Gynecology USMLE Part 2

251.A 25-year-old woman, gravida 2 para 1, presents to your office at 20 weeks' gestation for a routine prenatal check-up. This pregnancy has been uncomplicated thus far. She is known to be D (-) while her husband is D (+). Her obstetric history is significant for intrapartum placental abruption, which did not require caesarian delivery. She received a standard dose of anti-D immune globulin at 28 weeks of her first pregnancy and immediately postpartum. You decide to determine her anti-D antibody titers, and they turn out to be 1:34. Which of the following is the most likely explanation of the positive antibody screen in this patient?

252.A 15-year-old girl is being evaluated for primary amenorrhea. She has no other symptoms. She has not been sexually active. She has no other medical problems and does take any medication. Her family history is unremarkable. On examination, you note fully developed breasts and absent axillary and pubic hair. External genitalia have a normal appearance, but the vagina is abnormally short and blind ended. Initial work-up reveals no uterus on ultrasound, a testosterone level of 400 ng/dl (Normal is 20-80 for a female), and a 46 XY karyotype. Which of the following events is most likely to have caused the absence of in utero development of the internal reproductive organs?

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

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

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

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

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

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

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

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

261.A patient comes to your office with her last menstrual period 4 weeks ago. She denies any symptoms such as nausea, fatigue, urinary frequency, or breast tenderness. She thinks that she may be pregnant because she has not had her period yet. She is very anxious to find out because she has a history of a previous ectopic pregnancy and wants to be sure to get early prenatal care. Which of the following actions is most appropriate at this time? a. No action is needed because the patient is asymptomatic, has not missed her period, and cannot be pregnant.

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

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

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

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

266.A 28-year-old woman at 39 weeks gestation is admitted to the hospital. She has regular uterine contractions. Her blood pressure is 120/70mmHg, pulse is 80/min and respirations are 18/min. Fetal heart monitoring is placed and shows a baseline rate of 130 beats/min, without any associated abnormalities. Pelvic examination shows the cervix is 50% effaced and 3 cm dilated. Amniotomy is performed. Immediately after the rupture of membranes, the baseline fetal heart d. During the pregnancy, she should consume an additional 300 kcal/day versus prepregnancy, and her weight gain so far is appropriate for her gestational age. Rate increases to 160 beats/min and then drops to 70 beats/min with repetitive late decelerations. There is severe acute vaginal bleeding. Repeat vital signs of the patient shows a blood pressure of 130/70mmHg, pulse of 80/min and respirations of 18/min. Which of the following is the most likely cause of the current condition?

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

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

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

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

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

272.A 24-year-old woman, gravida 2, para 1, at 36 weeks' gestation is brought to the emergency department after passing out. She is drowsy and moaning, complaining of abdominal pain. Her husband accompanies her. He states that she has not experienced any trauma, but that she experienced the sudden onset of severe abdominal pain before she passed out. She has no significant past medical history. Her pregnancy has been uncomplicated thus far. She does not use tobacco, alcohol, or drugs. She takes supplemental vitamins, but no other medications. Her temperature is 36.9° C (98.4° F), blood pressure is 90/60 mm of Hg, and pulse is 130/min. Physical examination shows a cold and diaphoretic female. Examination shows a uterus consistent in size with a 36-week gestation; the cervical os is closed and no vaginal bleeding is noted. Which of the following is the most likely diagnosis?

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

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

275.A 38-year-old woman, gravida 2, para 1, at 10 weeks gestation comes to the physician's office for prenatal counseling of genetic disorders. She has a healthy 3-year-old child. Given her age, she is worried about the risk of Down syndrome, and if her baby test is positive for Down syndrome she would like to terminate the pregnancy. Ultrasonogram shows increased fetal nuchal fold lucency. Which of the following is the most appropriate next step in management?

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

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

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

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

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

281.A 28-year-old nulliparous woman is being evaluated for infertility. She has no other medical problems. Pelvic examination reveals abundant mucous and a clear cervical secretion, which 2.1 mg/dl when lifted vertically extends in a long thread; pH is 6.5. This visit took place at which of the following phases of the menstrual cycle?

282.A 28-year-old G1P0 presents to your office at 18 weeks gestational age for an unscheduled visit secondary to right-sided groin pain. She describes the pain as sharp and occurring with movement and exercise. She denies any change in urinary or bowel habits. She also denies any fever or chills. The application of a heating pad helps alleviate the discomfort. As her obstetrician, what should you tell this patient is the most likely etiology of this pain?

283.A 19-year-old G1P0 presents to her obstetrician’s office for a routine OB visit at 32 weeks gestation. Her pregnancy has been complicated by gestational diabetes requiring insulin for control. She has been noncompliant with diet and insulin therapy. She has had two prior normal ultrasounds at 20 and 28 weeks gestation. She has no other significant past medical or surgical history. During the visit, her fundal height measures 38 cm. Which of the following is the most likely explanation for the discrepancy between the fundal height and the gestational age?

284.A 43-year-old G1P0 who conceived via in vitro fertilization comes into the office for her routine OB visit at 38 weeks. She denies any problems since she was seen the week before. She reports good fetal movement and denies any leakage of fluid per vagina, vaginal bleeding, or regular uterine contractions. She reports that sometimes she feels crampy at the end of the day when she gets home from work, but this discomfort is alleviated with getting off her feet. The fundal height measurement is 36 cm; it measured 37 cm the week before. Her cervical examination is 2 cm dilated. Which of the following is the most appropriate next step in the management of this patient?

285.A pregnant woman who is 7 weeks from her LMP comes in to the office for her first prenatal visit. Her previous pregnancy ended in a missed abortion in the first trimester. The patient therefore is very anxious about the well-being of this pregnancy. Which of the following modalities will allow you to best document fetal heart action?

286.A 30-year-old G2P1001 patient comes to see you in the office at 37 weeks gestational age for her routine OB visit. Her first pregnancy resulted in a vaginal delivery of a 9-lb 8-oz baby boy after 30 minutes of pushing. On doing Leopold maneuvers during this office visit, you determine that the fetus is breech. Vaginal examination demonstrates that the cervix is 50% effaced and 1 to 2 cm dilated. The presenting breech is high out of the pelvis. The estimated fetal weight is about 7 lb. The patient denies having any contractions. You send the patient for a sonogram, which confirms a fetus with a double footling breech presentation. There is a normal amount of amniotic fluid present and the head is hyperextended in the “stargazer” position. Which of the following is the best next step in the management of this patient?

287.A 21-year-old nulligravid woman comes to her physician to discuss birth control options. She became sexually active for the first time 2 weeks ago. She is currently using condoms for contraception. Her past medical history is significant for asthma, which has been inactive for 2 years. She takes no medications and has no allergies to medications. She has no family history of cancer. Her examination is within normal limits. After a discussion with the physician, she chooses to take the oral contraceptive pill (OCP). She stays on the pill for the next 6 years. She now has most significantly decreased her risk of developing which of the following malignancies?

288.A 33-year-old woman presents to the physician because of a malodorous vaginal discharge that has been present for the past 3 days. She has no vaginal or vulvar irritation, and has no urinary complaints. Pelvic examination demonstrates a copious, gray discharge with a pH of 5.0. When 1 drop of potassium hydroxide (KOH) is added to a sample of the discharge there is an intense amine odor. A normal saline wet preparation is performed that demonstrates epithelial cells whose borders and nuclei are obscured by the presence of bacteria. Which of the following is the most likely pathogen?

289.A 62-year-old woman comes to the physician because of vaginal itch and pain with intercourse. She had her last menstrual period at age 52. She has no medical problems, takes no medications, and is allergic to penicillin. Pelvic examination demonstrates pale vaginal mucosa with no rugae present. The vagina is dry with no discharge. A potassium hydroxide (KOH) and normal saline wet preparation is negative. Which of the following is the most appropriate initial step in management?

290.A 32-year-old woman is brought to the operating room for diagnostic laparoscopy because of chronic pelvic pain and chronic right upper quadrant pain. She has had these pains for the past 2 years. Her bowel and bladder function are normal. Past medical history is significant for two episodes of gonorrhea. She drinks one beer per day. Laboratory studies show: Urine hCG: negative Haematocrit : 39% Leukocyte count: 8,000/mm3 Platelet count: 200,000/mm3 AST: 12U/L ALT: 14U/L Intraoperatively, the patient is noted to have dense adhesions involving her fallopian tubes, ovaries, and uterus. The fallopian tubes themselves appear clubbed and occluded. A survey of her upper abdomen is remarkable for perihepatic adhesions extending from the liver surface to the diaphragm. The liver otherwise appears unremarkable. Which of the following is the most likely diagnosis for her right upper quadrant pain?

291.A 24-year-old female presents to you for the evaluation of acne. Further questioning, reveals that she also has had irregular periods for a long time. She is single and not sexually active. On examination, her BMI is 31 Kg/m2 and she has evidence of hirsutism. Further evaluation reveals increase in serum free testosterone and LH/FSH ratio of 2.4. Glucose tolerance testing reveals two-hour blood glucose of 155 mg/dl. Apart from prescribing oral contraceptive pills, which of the following is indicated in this patient?

292.A 22-year-old primigravid woman at 10 weeks gestation is brought to the emergency department because of vaginal bleeding and lower abdominal pain. She was cleaning the house when she suddenly started feeling colicky pain in the suprapubic area. The pain did not subside after resting, and a few minutes later a tissue-like substance passed through her vagina along with moderate bleeding. The pain subsequently ceased, but she still has mild discomfort. Her temperature is 37.0° C (98.7° F), blood pressure is 120/70 mmHg, pulse is 90/min and respirations are 16/min. Physical examination shows a closed cervix and blood pooled in the vaginal vault. Ultrasonogram shows a vacant uterine cavity and free adnexae. Which of the following is the most likely diagnosis?

293.A 25-year-old female presents to the physician's office for evaluation of infertility. Her menstrual periods are regular. She has mild chronic pelvic pain. Her husband's semen analysis is within normal limits. She has no history of sexually transmitted diseases in the past. Her temperature is 37.2° C (98.9°F), and her blood pressure is 120/72 mmHg. Physical examination shows a normal sized uterus and enlarged left adnexae. Ultrasonography shows a homogeneous mass on the left ovary, but is otherwise normal. Which of the following is the most likely diagnosis?

294.A 14-year-old phenotypically female child is brought to your office by her mother who is concerned that her daughter has not had menstrual bleeding 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. Bilateral inguinal masses are 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?

295.A 30-year-old woman in her second pregnancy presents to your office at 36 weeks gestation complaining of dull, low back pain. The pain is minimal in the morning, but increases at the end of the day. She also noticed ankle edema that appears at the end of the day. Her past medical history is insignificant. Her temperature is 36.7° C (98° F), blood pressure is 120/80 mmHg, pulse is 90/min, and respirations are 18/min. Urinalysis is normal. Which of the following is the most likely cause of this patient's complaints?

296.A 26-year-old Caucasian female calls your office with a question about levothyroxine dosage during pregnancy. She is contemplating her first pregnancy very soon. You have been following her for primary hypothyroidism for several years. Her thyroid functions have been stable on a daily levothyroxine dose of 100μg. Her TSH level three months ago was 2.0 μU/ml (0.35 - 5.0 μU/ml is normal). What would be the most appropriate answer to this patient's question?

297.A 50-year-old woman presents to your office complaining of severe insomnia, hot flashes, and mood swings. She also states that her mother had a hip fracture at 65 years of age. She is afraid of developing osteoporosis and having a similar incident. Her last menstrual period was six months ago. Her past medical history is significant for hypothyroidism diagnosed seven years ago. She takes L-thyroxine and the dose of the hormone has been stable for the last several years. Her blood pressure is 120/70 mmHg and her heart rate is 75/min. Serum TSH level is normal. You consider estrogen replacement therapy for this patient. Which of the following is most likely concerning estrogen replacement therapy in this patient?

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

299.A 22-year-old primigravid woman comes for her initial prenatal visit at 6 weeks gestation. She has no complaints except mild nausea. She quit tobacco and alcohol use after she learned that she was pregnant. Vital signs are within normal limits. Physical examination shows no abnormalities. The screening VDRL test returns positive, as does the confirmatory FTA-ABS test. The patient has a history of an allergic reaction to penicillin. Which of the following is the 1.020 negative negative negative negative 5-10/hpf none best treatment for this patient?

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

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

302.A 23-year-old female comes to your office to review her daily prescription medications. She had a positive pregnancy test three days ago despite strict contraception. Her last menstrual period was 5 weeks ago. She is on albuterol and beclomethasone inhalers for bronchial asthma, isotretinoin for acne, and lithium for bipolar disorder. Her bipolar disorder has been stable for the past several years. She does not use tobacco, alcohol, or drugs. Physical examination shows no abnormalities; vital signs are stable. Which of the following is the most appropriate advice for this patient?

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

304.A 33-year-old, gravida 3, para 3 woman comes to the physician because of amenorrhea of 9- month duration. She denies symptoms of any kind. She had a tubal ligation after the birth of her last child 2 years ago. She did not breast feed. Her menarche was at the age of 13 years, and her menses were regular until 18 months ago. At that time, her menses skipped every other month, and then they stopped. She currently takes no medication. She weighs 120.2 kg (264lb) and is 160 cm (5'3") tall. Initial physical examination shows no abnormalities except for morbid obesity. In the initial blood work, serum TSH and prolactin levels are within normal limits. Follow-up laboratory test show: FSH: 20 mIU/mL (normal: 5-30 mIU/mL) LH: 15 mIU/mL (normal: 5-20 mIU/mL) Which of the following is the most likely explanation for this patient's amenorrhea?

305.A healthy 23-year-old G1P0 has had an uncomplicated pregnancy to date. She is disappointed because she is 40weeks gestational age by good dates and a first-trimester ultrasound. She feels like she has been pregnant forever, and wants to have her baby now. The patient reports good fetal movement; she has been doing kick counts for the past several days and reports that the baby moves about eight times an hour on average. On physical examination, her cervix is firm, posterior, 50% effaced, and 1 cm dilated, and the vertex is at a-1 station. As her obstetrician, which of the following should you recommend to the patient?

306.A 29-year-old G1P0 presents to the obstetrician’s office at 41weeks gestation. On physical examination, her cervix is 1 centimeter dilated, 0% effaced, firm, and posterior in position. The vertex is presenting at –3 station. Which of the following is the best next step in the management of this patient?

307.Your patient had an ultrasound examination today at 39weeks gestation for size less than dates. The ultrasound showed oligohydramnios with an amniotic fluid index of 1.5 centimeters. The patient’s cervix is unfavorable. Which of the following is the best next step in the management of this patient?

308.A healthy 30-year-old G1P0 at 41weeks gestational age presents to labor and delivery at 11:00 PM because she is concerned that her baby has not been moving as much as normal for the past 24 hours. She denies any complications during the pregnancy. She denies any rupture of membranes, regular uterine contractions, or vaginal bleeding. On arrival to labor and delivery, her blood pressure is initially 140/90 but decreases with rest to 120/75. Her prenatal chart indicates that her baseline blood pressures are 100 to 120/60 to 70 mm Hg. The patient is placed on an external fetal monitor. The fetal heart rate baseline is 180 beats per minute with absent variability. There are uterine contractions every 3 minutes accompanied by late fetal heart rate decelerations. Physical examination indicates that the cervix is long/closed/-2. Which of the following is the appropriate plan of management for this patient?

309.A 27-year-old G3P2002, who is 34 weeks gestational age, calls the on call obstetrician on a Saturday night at 10:00 PM complaining of decreased fetal movement. She says that yesterday her baby has moved only once per hour. For the past 6 hours she has felt no movement. She is healthy, has had regular prenatal care, and denies any complications so far during the pregnancy. Which of the following is the best advice for the on-call physician to give the patient?

310.Your patient complains of decreased fetal movement at term. You recommend a modified BPP test. Nonstress testing (NST) in your office was reactive. The next part of the modified BPP is which of the following?

311.You are seeing a patient in the hospital for decreased fetal movement at 36 weeks gestation. She is healthy and has had no prenatal complications. You order a BPP. The patient receives a score of 8 on the test. Two points were deducted for lack of fetal breathing movements. How should you counsel the patient regarding the results of the BPP?

312.An 18-year-old G2P1001 with the first day of her last menstrual period of May 7 presents for her first OB visit at 10 weeks. What is this patient’s estimated date of delivery?

313.A 28-year-old, G2 P1 woman presented to the hospital at 34weeks gestation because of midepigastric and right upper quadrant pain associated with nausea and vomiting. She has been closely followed for mild hypertension and mild proteinuria (250 mg/24hr) on an outpatient basis since the 28th week of gestation. Her previous pregnancy was without incident. Her temperature is 37.2 C (98.9 F), blood pressure is 160/94 mmHg and pulse is 80/min. Physical examination shows epigastric and right upper quadrant tenderness; her bowel sounds are slightly reduced. The extremities have Laboratory studies show: Hb: Platelets: Prothrombin time: Partial thromboplastin time: Serum creatinine: Total bilirubin: Direct bilirubin: Alkaline phosphatase: Aspartate aminotransferase: Alanine aminotransferase: Lipase: 2+ edema. Fetal heart sounds are audible on Doppler. 8.2g/dl 96,000/mm3 12.4 sec 23.6 sec 1.1 mg/dl 2.6 mg/dl 0.8 mg/dl 120 U/L 308 U/L 265 U/L 53 U/L Peripheral blood smear shows numerous red blood cell fragments. Which of the following is the most likely diagnosis?

314.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. Decreased thyroid function

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

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

317.A 36-year-old woman, gravida 3, para 2, comes to the physician for a prenatal checkup. According to the 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 26cm (9.8in). Fetal heart tones are heard by Doppler. Repeat ultrasonogram shows a biparietal diameter consistent with dates and an abdominal circumference below the 10th percentile. Which of the following could most likely be responsible for the observed fetal findings?

318.A new patient presents to your office for her first prenatal visit. By her last menstrual period she is 11 weeks pregnant. This is the first pregnancy for this 36-year-old woman. She has no medical problems. At this visit you observe that her uterus is palpable midway between the pubic symphysis and the umbilicus. No fetal heart tones are audible with the Doppler stethoscope. Which of the following is the best next step in the management of this patient?

319.A healthy 30-year-old G2P1001 presents to the obstetrician’s office at 34 weeks for a routine prenatal visit. She has a history of a cesarean section (low transverse) performed secondary to fetal mal presentation (footling breech). This pregnancy, the patient has had an uncomplicated prenatal course. She tells her physician that she would like to undergo a trial of labor during this pregnancy. However, the patient is interested in permanent sterilization and wonders if it would be better to undergo another scheduled cesarean section so she can have a bilateral tubal ligation performed at the same time. Which of the following statements is true and should be relayed to the patient?

320.A 16-year-old primigravida presents to your office at 35 weeks gestation. Her blood pressure is 170/110 mm Hg and she has 4+ proteinuria on a clean catch specimen of urine. She has significant swelling of her face and extremities. She denies having contractions. Her cervix is closed and uneffaced. The baby is breech by bedside ultrasonography. She says the baby’s movements have decreased in the past 24 hours. Which of the following is the best next step in the management of this patient?

321.While you are on call at the hospital covering labor and delivery, a 32-year-old G3P2002, who is 35 weeks of gestation, presents complaining of lower back pain. The patient informs you that she had been lifting some heavy boxes while fixing up the baby’s nursery. The patient’s pregnancy has been complicated by diet-controlled gestational diabetes. The patient denies any regular uterine contractions, rupture of membranes, vaginal bleeding, or dysuria. She denies any fever, chills, nausea, or emesis. She reports that the baby has been moving normally. She is afebrile and e. Schedule an ultrasound as soon as possible to determine the gestational age and viability of the fetus.@ e. If the patient desires a bilateral tubal ligation, it is safer for her to undergo a vaginal delivery followed by a postpartum tubal ligation rather than an elective repeat cesarean section with intrapartum bilateral tubal ligation. Her blood pressure is normal. On physical examination, you note that the patient is obese. Her abdomen is soft and nontender with no palpable uterine contractions. No costovertebral angle tenderness can be elicited. On pelvic examination her cervix is long and closed. The external fetal monitor indicates a reactive fetal heart rate strip; there are rare irregular uterine contractions demonstrated on the tocometer. The patient’s urinalysis comes back with trace glucose, but is otherwise negative. The patient’s most likely diagnosis is which of the following?

322.A 29-year-old G3P2 presents to the emergency center with complaints of abdominal discomfort for 2 weeks. Her vital signs are: blood pressure 120/70 mm Hg, pulse 90 beats per minute, temperature 36.94C, respiratory rate 18 breaths per minute. A pregnancy test is positive and an ultrasound of the abdomen and pelvis reveals a viable 16-week gestation located behind a normal- appearing 10*6*5.5 cm uterus. Both ovaries appear normal. No free fluid is noted. Which of the following is the most likely cause of these findings?

323.A 32-year-old G2P1 at 28 weeks gestation presents to labor and delivery with the complaint of vaginal bleeding. Her vital signs are: blood pressure 115/67 mm Hg, pulse 87 beats per minute, temperature 37.0C, respiratory rate 18 breaths per minute. She denies any contraction and states that the baby is moving normally. On ultrasound the placenta is anteriorly located and completely covers the internal cervical os. Which of the following would most increase her risk for hysterectomy?

324.A 29-year-old woman comes to the emergency department because of constant, severe lower abdominal pain. She also complains of fever and chills. Three weeks ago she had an intrauterine device (IUD) placed for contraception. Her temperature is 38.3 C (101 F), blood pressure is 110/76 mm Hg, pulse is 110/min, and respirations are 16/min. She has bilateral lower quadrant abdominal tenderness. On pelvic examination, she has cervical motion tenderness and bilateral adnexal tenderness. A urinalysis is negative. A pelvic ultrasound is negative, with normal uterus and adnexae and no free fluid. What is the most likely diagnosis?

325.A 14-year-old girl comes to the physician because of lower abdominal cramping. This cramping starts a few hours before, and lasts through, her menses, and then resolves completely. The cramping is primarily in the lower abdomen but also radiates to the back and thighs. She first noted this cramping approximately 6 months after her first menstrual period at age 12. She is not sexually active. Physical examination is unremarkable, including a normal pelvic examination. A pregnancy test is negative. Which of the following is the most appropriate next step in management?

326.A patient at 17 weeks gestation is diagnosed as having an intrauterine fetal demise. She returns to your office 5 weeks later and her vital signs are: blood pressure 110/72 mm Hg, pulse 93 beats per minute, temperature 36.38C, respiratory rate 16 breaths per minute. She has not had a miscarriage, although she has had some occasional spotting. Her cervix is closed on examination. This patient is at increased risk for which of the following?

327.A 24-year-old presents at 30 weeks with a fundal height of 50 cm. Which of the following statements concerning polyhydramnios is true?

328.A 20-year-old G1 at 32 weeks presents for her routine obstetric (OB) visit. She has no medical problems. She is noted to have a blood pressure of 150/96 mm Hg, and her urine dip shows 1+ protein. She complains of a constant headache and vision changes that are not relieved with rest or a pain reliever. The patient is sent to the hospital for further management. At the hospital, her blood pressure is 158/98 mm Hg and she is noted to have tonic-clonic seizure. Which of the following is indicated in the management of this patient?

329.During routine ultrasound surveillance of a twin pregnancy, twin A weighs 1200 g and twin B weighs 750g. Hydramnios is noted around twin A, while twin B has oligohydramnios. Which statement concerning the ultrasound findings in this twin pregnancy is true?

330.A 32-year-old G5P1 presents for her first prenatal visit. A complete obstetrical, gynecological, and medical history and physical examination is done. Which of the following would be an indication for elective cerclage placement?

332.A 20-year-old G1P0 presents to your clinic for follow-up for a suction dilation and curettage for an incomplete abortion. She is asymptomatic without any vaginal bleeding, fever, or chills. Her examination is normal. The pathology report reveals trophoblastic proliferation and hydropic degeneration with the absence of vasculature; no fetal tissue is identified. A chest x-ray is negative for any evidence of metastatic disease. Which of the following is the best next step in her management?

333.27-year-old G2P1 woman comes to the labor and delivery unit with nausea, vomiting, and right lower-quadrant pain. She is at 19 weeks gestation. The symptoms started 12 hours ago and have become progressively worse. She has no chills, dysuria, or urinary frequency and is uncertain if  she has had a fever. Her temperature is 38 C (100.4 F), blood pressure is 120/70 mm Hg, pulse is 98/min, and respirations are 18/min. Abdominal examination shows a gravid uterus just below the umbilicus. The fetal heart rate is 144/min. There is moderate tenderness to palpation in the right lower quadrant with guarding. Laboratory results are as follows: Hemoglobin: 12.4 g/L Leukocytes: 16,000/μL Which of the following is the most appropriate next step in management of this patient?

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

335.A 41-year-old woman, gravida 3, para 3, comes to the physician because of a 2-year history of dysmenorrhea and menorrhagia that has been increasing in intensity. She has no dyspareunia or any other symptoms. She has a history of chronic hypertension. She had a cesarean section in her 3rd pregnancy followed by surgical sterilization. Vital signs are normal. Bimanual examination shows a symmetrically enlarged and tender uterus with soft consistency and free adnexae. Which of the following is the most likely diagnosis?

336.A 22-year-old G1P0 presents to your clinic for follow-up of evacuation of a complete hydatidiform mole. She is asymptomatic and her examination is normal. Which of the following would be an indication to start single-agent chemotherapy?

337.A 32-year-old female presents to the emergency department with abdominal pain and vaginal bleeding. Her last menstrual period was 8 weeks ago and her pregnancy test is positive. On examination she is tachycardic and hypotensive and her abdominal examination findings reveal peritoneal signs, a bedside abdominal ultrasound shows free fluid within the abdominal cavity. The decision is made to take the patient to the operating room for emergency exploratory laparotomy. Which of the following is the most likely diagnosis?

338.A 19-year-old woman comes to the emergency department and reports that she fainted at work earlier in the day. She has mild vaginal bleeding. Her abdomen is diffusely tender and distended. In addition, she complains of shoulder and abdominal pain. Her temperature is 37.2C, pulse rate is 120 beats per minute, and blood pressure is 80/42 mm Hg. Which of the following is the best diagnostic procedure to quickly confirm your diagnosis?

339.A 22-year-old G1P0 woman who is 10 weeks pregnant with twins presents to the emergency department because of vomiting and dizziness. She has had “morning sickness” for the past month and would vomit once or twice a day. However, over the past week, she has been vomiting multiple times a day, and she has been unsuccessful at “keeping anything down” for the past 2 days. She denies fever or change in her bowel movements; her last bowel movement was that morning and was well formed. She has otherwise been healthy. Physical examination reveals a tired-appearing, pale woman with poor skin turgor; otherwise her examination is unremarkable. Her blood pressure is 110/75 mm Hg lying down and 90/45 mm Hg sitting up. Her pulse is 80/min lying down and 115/min sitting up. Her respiratory rate is 24/min, and her temperature is 37.2°C (99.0°F). Her original blood work results are: WBC count: 14,000/mm3 Platelet count: 350,000/mm3 Na+: 150 mEq/L K+: 4 mEq/L Cl-: 88 mEq/L HCO3-: 26 mEq/L Hemoglobin: 15 g/dL Hematocrit: 40% Aspartate aminotransferase: 80 U/L Alanine aminotransferase: 85 U/L What is this woman’s most likely diagnosis?

340.A 58-year-old woman with stage II epithelial ovarian cancer undergoes successful surgical debulking followed by chemotherapy with carboplatin and radiation therapy. Subsequently, she develops non-pitting edema of both legs and pain and numbness in her legs. Which of the following is the most likely cause of her pain and numbness?

341.A 26-year-old nulligravid patient presents to her physician seeking preconceptional advice. She plans to conceive in about 1 year. Her past medical history is significant for chickenpox as a child. She had an appendectomy 2 years ago. She takes no medications and is allergic to penicillin. Her complete physical examination, including a pelvic examination, is unremarkable. Which of the following is the most appropriate next step in diagnosis to prevent morbidity in this patient's offspring?

342.A 26-year-old black gravida 2, para 1, at 32 weeks' gestation presents to the physician for a prenatal visit. Her prenatal course has been remarkable for hyperemesis gravidarum in the first trimester. She also had a urine culture in the first trimester that grew out Group B Streptococcus. She has had type 1 diabetes for the past 2 years and has had good control of her blood glucose levels during this pregnancy. Her first pregnancy resulted in a low transverse cesarean section for dystocia. Other than insulin, she takes no medicines and has no known drug allergies. After a routine prenatal visit, the physician sends her to the antepartum fetal testing unit to undergo a non-stress test (NST). Which of the following characteristics makes this patient a good candidate for antepartum fetal testing with an NST?

343.A 19-year-old gravida 2, para 1 woman presents at her first prenatal visit complaining of a rash, hair loss, and spots on her tongue. Her temperature is 37 C (98.6 F), blood pressure is 112/74 mm Hg, pulse is 68/min, and respirations are 14/min. Physical examination is significant for a maculopapular rash on her trunk and extremities, including her palms and soles. She has "moth- eaten" alopecia and white patches on her tongue. Her uterus is 10-week size, which is consistent with her dating by last menstrual period. The rest of her examination is unremarkable. RPR and MHA-TP are positive. Which of the following is the most appropriate pharmacotherapy?

344.A 34-year-old woman with breast cancer presents to her physician complaining of increased weakness, lower back pain, and urinary incontinence. She was diagnosed with breast cancer 2 years ago and is undergoing radiation and chemotherapy. Her back pain developed 2 days ago. Physical examination shows lower extremity weakness and hyporeflexia. Which of the following is the most appropriate next step in this patient's care?

345.An otherwise healthy, 65-year-old woman comes to the physician because of bloody discharge from the right nipple for 2 weeks. On examination, no retraction, erosion, or other abnormal change is present. Palpation reveals an ill-defined, 1-cm nodule located deep in the right areola. Which of the following is the most appropriate next step in diagnosis?

346.A 73-year-old female presents to your office with lower abdominal discomfort. Physical examination reveals an adnexal mass on the right side. This patient is most likely to have elevated levels of which of the following?

347.A 39-year-old Caucasian female presents to your office with a palpable nodularity in the right breast. Pathologically, the lesion is composed of ducts distended by pleomorphic cells with prominent central necrosis. The lesion does not extend beyond the ductal basal membrane. Which of the following is the most likely diagnosis in this patient?

348.A 32-year-old female presents to your office complaining of a small amount of vaginal discharge. Wet mount preparation of the discharge shows few leukocytes. Application of KOH solution to the discharge yields a strong fishy odor. The most likely diagnosis is:

349.A 50-year-old woman presents with fatigue, insomnia, hot flashes, night sweats, and absence of menses for the last 5 months (secondary amenorrhea). Her urine hCG test is negative. Laboratory tests reveal decreased serum estrogen and increased serum FSH and LH levels. Which of the following is the most likely cause of this individual’s clinical signs and symptoms?

350.A 28-year-old woman presents 4 weeks after delivering her first child with a low-grade fever and pain in her right breast. She states that she has been breast feeding her newborn infant. Physical examination finds this breast to be tender, swollen, and erythematous. Microscopic examination of nipple smears from this woman would most likely reveal large numbers of which of the following types of cells?

351.During a routine breast self-examination, a 35-year-old woman is concerned because her breasts feel “lumpy.” She consults you as her primary care physician. After performing an examination, you reassure her that no masses are present and that the “lumpiness” is due to fibrocystic changes. Which of the following pathologic findings is a type of nonproliferative fibrocystic change?

352.A 23-year-old woman presents with a rubbery, freely movable 2-cm mass in the upper outer quadrant of the left breast. Which of the following histologic features is most likely to be seen when examining a biopsy specimen from this mass?

353.A 39-year-old woman presents with new onset of a bloody discharge from her right nipple. Physical examination reveals a 1-cm freely movable mass that is located directly beneath the nipple. Sections from this mass reveal multiple fibrovascular cores lined by several layers of epithelial cells. Atypia is minimal. The lesion is completely contained within the duct and no invasion into underlying tissue is seen. Which of the following is the most likely diagnosis?

354.A 48-year-old woman presents with a painless mass located in her left breast. Physical examination finds a firm, nontender, 3-cm mass in the upper outer quadrant of her left breast. There was retraction of the skin overlying this mass, and several enlarged lymph nodes were found in her left axilla. The mass was resected and histologic sections revealed an invasive ductal carcinoma. Biopsies from her axillary lymph nodes revealed the presence of metastatic disease to 4 of 18 examined axillary lymph nodes. Response to therapy with Trastuzumab is most closely associated with expression of which of the following?

355.A 48-year-old woman presents with a 1.5-cm firm mass in the upper outer quadrant of her left breast. A biopsy from this mass reveals many of the ducts to be filled with atypical cells. In the center of these ducts there is extensive necrosis. No invasion into the surrounding fibrous tissue is seen. Which of the following is the most likely diagnosis?

356.A 51-year-old woman presents with an ill-defined, slightly firm area in the upper outer quadrant of her right breast. The clinician thinks this area is consistent with fibrocystic change, but a biopsy from this area has a focus of lobular carcinoma in situ. Which of the following histologic features is most characteristic of this lesion?

357.A 46-year-old woman presents with a 4-month history of a discharge from the nipple. An excisional biopsy of the nipple area reveals infiltration of the nipple by large cells with clear cytoplasm. These cells are found both singly and in small clusters in the epidermis and are PAS- positive and diastase resistant. Which of the following is the most likely diagnosis?

358.59-year-old woman who had been diagnosed with infiltrating ductal carcinoma 2years prior presents with pain of her right breast. The breast is swollen, tender on palpation, and is diffusely indurated with a “peau d’orange” appearance. Multiple axillary lymph nodes are palpable in the lower axilla. A skin biopsy from her breast reveals extensive invasion of dermal lymphatics. What is the best diagnosis?

359.A 51-year-old man presents with bilateral enlargement of his breasts. Physical examination is otherwise unremarkable, and the diagnosis of gynecomastia is made. Which of the following histologic features is most likely to be seen when examining a biopsy specimen from this man’s breast tissue?

360.An 18-year-old woman presents to the physician's office complaining of vaginal pruritus and discharge. She has no nausea, vomiting, or abdominal pain. She has had 2 sexual partners in the past six months and takes oral contraceptive pills. She has no other medical problems and takes no other medications. She has no known drug allergies. Her temperature is 37.2° C (98.9° F) and blood pressure is 120/72 mm Hg. Pelvic examination reveals mucopurulent cervical discharge and friable cervical mucosa. The remainder of the physical examination is unremarkable. A gram stain of the discharge reveals numerous polymorphonuclear leukocytes filled with gram-negative diplococci. What is the most appropriate next step in management?

361.A 24-year-old primigravid woman at 35 weeks gestation comes to the emergency department with uterine contractions. She started these contractions six hours earlier, and they have not increased in intensity since then. The contractions started in the lower abdomen and are irregular. Her pregnancy has been uncomplicated. Her prenatal course, prenatal tests and fetal growth have been normal. She has no history of trauma. She does not use tobacco, alcohol or drugs. Vital signs are normal. Examination shows a firm, posterior and closed cervix. Ultrasonogram in the emergency department shows a gestational age of 35-weeks and the fetus in the vertex presentation. Fetal heart tones are heard. She feels better after mild sedation. Which of the following is the most appropriate next step in management?

362.A 26-year-old woman comes to the physician's office for evaluation of a vulvar ulcer that she noticed two days ago. Initially she had a small painless papule that later became ulcerated. Upon further questioning she reluctantly admits to using sex to obtain drugs. She also reports using oral contraceptives to prevent pregnancy. On vulvar examination there is a 2-cm ulcer with a non- exudative base and a raised, indurated margin. Painless bilateral inguinal lymphadenopathy is present. Which of the following is the most likely diagnosis?

363.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 2 cm 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. Non-stress 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?

364.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 37.0° C (98.7° F), 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?

365.A 22-year-old female comes to the physician complaining of pain during sexual activity. She is unable to have intercourse because her vagina becomes tense, resulting in intense pain upon penetration. She is living with her boyfriend and this is her first sexual relationship. She now avoids intercourse because of her fear of the pain. She has no history of serious illness. Speculum examination is not possible due to tense perineal musculature. Which of the following is the most appropriate next step in management?

366.A 23-year-old woman who is 26 weeks pregnant presents to the emergency department with sudden onset severe shortness of breath and inability to lie flat. She recently emigrated from Eastern Europe. Her medical history is significant for recurrent sore throats requiring tonsillectomy as a child. Presently, her blood pressure is 11 0/60 mmHg and her heart rate is 120/min. An EKG rhythm strip suggests atrial fibrillation. Which of the following is the most likely diagnosis?

367.A 14-year-old girl is being evaluated for short stature. She has not yet had any menstrual periods. She is not sexually active. She is at 6th percentile for height and 20th percentile for weight. Blood pressure is elevated in the upper extremities and low in the lower extremities. Lungs are clear to auscultation. If measured, which of the following is most likely to be present in this patient?

368.A 30-year-old woman, gravida 3, para 2, at 32 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?

369.A 34-year-old woman comes to the physician for infertility evaluation. Her cycles have been irregular for the past 12 months and she has had no periods for the past 3 months. Before that time, her cycles were quite regular. She also has hot flashes, dyspareunia, and mood disturbances. She has been married for 6 years and has a 3-year-old daughter. The patient has a history of Hashimoto's thyroiditis and is on thyroid replacement therapy. She smokes a pack of cigarettes a day. Both her father and mother have type 2 diabetes mellitus. Vital signs are normal. Pelvic examination reveals atrophic vaginal mucosa. Serum FSH is markedly elevated, serum prolactin is normal, and pregnancy test is negative. Serum TSH is within normal limits. Which of the following is the most appropriate treatment for her infertility?

370.A 24-year-old primigravid woman at 28 weeks gestation comes to the physician because she has not felt her baby's movements for the past two weeks. Fetal heart tones are not heard by Doppler. Ultrasound shows absence of fetal cardiac activity. Fetal demise is diagnosed. Laboratory studies show: Serum fibrinogen level: 160 mg/dl (normal is 150 - 450 mg/dL) Platelets: 150, 000/mm3 Prothrombin time: 14 sec Partial thromboplastin time: 28 sec First trimester platelets were: 250, 000/mm3 There are no signs of active bleeding. Which of the following is the most appropriate next step in management?

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

372.A 23-year-old female comes to the physician complaining of a 3-day history of intermittent lower abdominal pain and vaginal spotting. The pain is of mild to moderate intensity. Her last menstrual period was 6 weeks ago. A pregnancy test is performed, and the result is positive. Her temperature is 36.7° C (98° F), blood pressure is 11 0/80 mm Hg, pulse is 80/min, and respirations are 18/min. Physical examination shows unilateral adnexal tenderness. Transabdominal ultrasonogram does not reveal an intrauterine gestation. Quantitative beta-HCG is 1500 IU/L. Which of the following is the most appropriate next step in management?

373.A 28-year-old woman comes to the physician for routine physical examination and a Pap smear. She has had multiple sexual partners and uses barrier methods for contraception. She was treated for chlamydial cervicitis four months ago. She has no other medical problems. Pelvic examination is unremarkable and a Pap smear was performed. A week later the result came as "satisfactory for evaluation" and shows mild dysplasia (low grade intraepitheliallesion). Which of the following is the most appropriate next step in management?

374.A 25-year-old nulligravid woman comes to the physician because of constant pelvic and low sacral back pain for several months. The pain is usually worse premenstrually. She tried over the counter anti-inflammatory medications but had little relief. She has been in a monogamous relationship with her boyfriend for the past 4 years. She has no fever or abnormal vaginal discharge. Her temperature is 37.2 C (98.9 F), and blood pressure is 120/78 mm Hg. Physical examination shows tender posterior vaginal fornix and pain upon uterine motion. Complete blood count is normal. Pelvic ultrasonogram is normal. Which of the following is most appropriate diagnostic test in her management?

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

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

377.A 22-year-old primigravid woman comes for her initial prenatal visit at 6 weeks gestation. She has no complaints except mild nausea. She quit tobacco and alcohol use after she learned that she was pregnant. Vital signs are within normal limits. Physical examination shows no abnormalities. The screening VORL test returns positive, as does the confirmatory FTA-ABS test. The patient has a history of an allergic reaction to penicillin. Which of the following is the best treatment for this patient?

378.A 19-year-old nulligravid woman comes to the physician's office for a routine annual check-up. She complains of weight gain of about 10lbs over the last year. She feels this is related to her oral contraceptive pill use. She has no previous medical problems. She had her first sexual intercourse 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 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 this patient?

379.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?

380.A 28-year-old primigravid woman comes to the physician for a follow-up prenatal visit. According to prenatal records, ultrasound at 16 weeks gestation showed an intrauterine gestation consistent with dates and showed no abnormalities. She is now at 40 weeks gestation. Examination shows a fundal height consistent with dates and the cervix is not favorable. Fetal heart tracing is reassuring. She wishes to continue the pregnancy for two more weeks rather than undergoing induction. She should be closely monitored for which of the following?

381.A 24-year-old female presents to you for the evaluation of acne. Further questioning, reveals that she also has had irregular periods for a long time. She is single and not sexually active. On examination, her BMI is 31 Kg/m2 and she has evidence of hirsutism. Further evaluation reveals increase in serum free testosterone and LH/FSH ratio of 2.4. Glucose tolerance testing reveals two-hour blood glucose of 155 mg/dl. Apart from prescribing oral contraceptive pills, which of the following is indicated in this patient?

382.A 21-year-old woman at 36 weeks gestation is admitted for delivery. She has severe preeclampsia. Her blood pressure is 190/11 0 mmHg, pulse is 80/min and respirations are 16/min. Physical examination shows 3+ pitting edema of the legs and brisk deep tendon reflexes. Fundoscopic examination shows no abnormalities. Laboratory studies show elevated BUN, serum creatinine and serum transaminases. Urinalysis shows 4+ proteinuria. Intravenous hydralazine and magnesium sulfate was initiated on admission. After stabilization, intravenous oxytocin and artificial rupture of membranes (AROM) was administered for induction of labor. Two hours later, her blood pressure is 150/90 mmHg, pulse is 78/min and respirations are 9/min. Repeat examination shows hyporeflexia and a completely effaced cervix that is 5cm dilated. Which of the following is the most appropriate next step in management?

383.An 18-year-old woman presents to the physician's office complaining of vaginal pruritus and discharge. She has no nausea, vomiting, or abdominal pain. She has had 2 sexual partners in the past six months and takes oral contraceptive pills. She has no other medical problems and takes no other medications. She has no known drug allergies. Her temperature is 37.2 C (98.9 F) and blood pressure is 120/72 mm Hg. Pelvic examination reveals mucopurulent cervical discharge and friable cervical mucosa. The remainder of the physical examination is unremarkable. A gram stain of the discharge reveals numerous polymorphonuclear lymphocytes filled with gram-negative diplococci. What is the most appropriate next step in management?

384.A 22-year-old woman, gravida 2, para 1, at 39 weeks gestation is admitted to the hospital for delivery. She has had regular and painful uterine contractions occurring every 3 minutes for the past 10 hours. Her pregnancy has been uncomplicated. She had a normal vaginal delivery for her first pregnancy and required an episiotomy. A recent ultrasound at 37 weeks gestation showed a fetus in a cephalic presentation with an estimated fetal weight of 3,400 g (7.5 lb). Examination shows the cervix is soft, 50% effaced and 2 cm dilated. She is given epidural anesthesia per her request. Eight hours later, her cervix has not significantly changed, and uterine contractions are occurring every 5 minutes. Which of the following is the most likely cause of her current condition?

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

386.A 55-year-old woman has a palpable 2 cm mass in her left breast. She had found the mass on self-examination, but she says that she had not done self-breast exam for at least six months before she did this one. Physical examination confirms the presence of the lesion, which is hard, movable, and not painful. A mammogram confirms the presence of an opacity in that area, but it does not have any of the radiological characteristics of a breast cancer. The radiologist also does a sonogram, and comes up with the same opinion, I.e., that neither study is suggestive for cancer. Fine needle aspirate is read as negative. Which of the following is the most appropriate next step in management?

387.A 27-year-old primigravid woman at 30 weeks’ gestation comes to the emergency department complaining of abdominal pain, nausea, and vomiting. Earlier in the day she began to experience severe epigastric and later right upper quadrant pain. Until now her pregnancy has been uneventful and she has had regular prenatal care. Her past medical history and review of symptoms are unremarkable. On examination she is a pregnant woman in moderate distress, lying still on the hospital bed. Vital signs are: temperature 38.9 C (102.0 F), blood pressure 105/68 mm Hg, and pulse 108/min. Her abdomen is extremely tender to palpation in the right upper quadrant with guarding. There is no vaginal bleeding or discharge. Laboratory studies show:  Hematocrit: 36% Leukocytes: 15,000/mm3(88% neutrophils) Platelets: 158,000/mm3 Liver function tests, including transaminases, are normal. Prothrombin time is within normal limits. Urinalysis is unremarkable except for a few red blood cells on microscopy. X-ray is deferred out of concern for the fetus. Which of the following is the most likely cause of this patient’s symptoms?

388.A 19-year-old woman comes to the office because of irregular vaginal spotting. She always has had normal periods that occur every 28 days and last 5 days, and so this is particularly concerning. She is sexually active with her boyfriend of 3 years and has been taking oral contraceptive pills that you prescribed 2 months ago. She has no known medical problems besides seasonal allergies and has never had any surgery. She takes the oral contraceptive pill daily and loratadine intermittently, but takes no other medications. She has no known drug allergies. Physical examination, including pelvic examination, is unremarkable. Urine hCG is negative. Which of the following is the most appropriate next step in management?

389.A 38-year-old woman is 10 weeks pregnant with her second pregnancy and is found to have blood pressures exceeding the 150 to 160 mm Hg systolic range and 100 to 110mm Hg diastolic range at her first prenatal visit. She has no other medical problems. She had a cholecystectomy at the age of 20. She takes no medications and is allergic to sulfa drugs. Her family history is significant for hypertension on both her maternal and paternal sides. Physical examination is normal, including an obstetrical ultrasound demonstrating a 10-week intrauterine pregnancy. The patient is diagnosed with chronic hypertension. Which of the following should be used as first-line antihypertensive therapy for this patient?

390.A 29-year-old woman comes to your office because she has been feeling depressed. She states that at times over the past several years she has regular occurrences of depression, anxiety, tearfulness, anger, and difficulty with work and social relationships. These occurrences have been increasing over the past several months. She doesn’t remember when her symptoms start or end. “It’s all a blur,” she says. She has had several urinary tract infections in her life, but otherwise has no medical problems. She takes no medications and has no drug allergies. Physical examination is normal. Which of the following is the most appropriate next step in caring for this patient?

391.You examine a 28-year-old woman who is 2 days status post-cesarean delivery for a nonreassuring fetal heart rate tracing in labor. Her prenatal course was complicated by her developing acute tuberculosis in the days immediately before her delivery. When you diagnosed her with tuberculosis, she decided to hold off on therapy until after the baby was born. She was also found to be Group B Streptococcus–positive on a 36-week vaginal culture. She has a past medical history significant for chronic hepatitis B. Her past surgical history is significant for a breast reduction 4 years ago. Postpartum she is doing well, with no complaints, normal vital signs, and a normal postpartum physical examination. She wants to know if she is able to breast feed her infant. Which of the following conditions precludes this patient from breastfeeding?

392.A 20-year-old college student comes to the student health clinic concerned that she may be pregnant. She states that she has had a steady boyfriend for the last 2 years and that they regularly use condoms for birth control. Last night the condom broke, however, and the patient is extremely worried that she may have become pregnant. Although she has mixed feelings about terminating an advanced pregnancy, she is not opposed to terminating an early pregnancy, and wants to know if she can take an “abortion pill” that she has heard about in the news. Her last menstrual period was 14 days ago, and her last gynecologic examination, which included a negative Pap smear, was 10 months ago. She has no previous illnesses and has a negative review of systems. She does not smoke, drinks only rarely, and does not use any illicit substances. Vital signs are: temperature 37.0 C (98.6 F), blood pressure 118/78 mmHg, pulse 72/min, and respirations 20/min. Physical examination is unremarkable. A urine pregnancy test is negative. Given her request, which of the following is the most appropriate management?

393.A 33-year-old woman is very depressed about her recurrent pregnancy loss. She has had four pregnancies that all have ended in spontaneous abortion before 8 weeks. Her past medical history is otherwise unremarkable. She has never had surgery. She takes acetaminophen occasionally for headaches, but otherwise uses no medications and has no known drug allergies. Physical examination is normal. Laboratory evaluation demonstrates that she is positive for lupus anticoagulant and that she is positive for anticardiolipin IgG. These results are again positive 8 weeks later. Which of the following is the most appropriate management of this patient during her next pregnancy?

394.A 27-year-old woman, gravida 2, para 1, at 20 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her obstetric history is significant for a primary low transverse cesarean delivery because of a non-reassuring fetal tracing 3 years ago. She has no medical problems. She takes prenatal vitamins and has no known drug allergies. She is debating whether to have an elective repeat cesarean delivery or to attempt a vaginal birth after cesarean (VBAC). She wants to know her chances for a successful VBAC. Which of the following most accurately represents the patient's likelihood of having a successful vaginal delivery?

395.A 62-year-old woman comes to the physician because of bleeding from the vagina. She states that her last menstrual period came 11 years ago and that she has had no bleeding since that time. She has hypertension and type 2 diabetes mellitus. Examination shows a mildly obese woman in no apparent distress. Pelvic examination is unremarkable. An endometrial biopsy is performed that shows grade I endometrial adenocarcinoma. Which of the following is the most appropriate next step in management?

396.A 35-year-old woman, gravida 4, para 3, at 38 weeks' gestation comes to the labor and delivery ward after a gush of clear fluid from the vagina. After the gush, she has had increasing contractions. Sterile speculum examination shows a pool of clear fluid in the vagina that is nitrazine positive. Cervical examination shows that the patient is 5 cm dilated, with the fetal face presenting in a mentum anterior position. External uterine monitoring shows that the patient is contracting every 2 minutes, and external fetal monitoring shows that the fetal heart rate is in the 140s and reactive. Which of the following is the most appropriate next step in management?

397.A 36-year-old woman, gravida 3, para 2, at 33 weeks' gestation comes to the physician for a prenatal visit. She has some fatigue but no other complaints. Her current pregnancy has been complicated by a Group B Streptococcus urine infection at 16 weeks. Her past obstetric history is significant for a primary, classic cesarean delivery 5 years ago for a non-reassuring fetal tracing. Two years ago, she had a repeat cesarean delivery. Past surgical history is significant for an appendectomy 10 years ago. Which of the following is the major contraindication to a vaginal birth after cesarean (VBAC) in this patient?

398.A patient who has been taking tamoxifen to prevent breast cancer for the past 6 months presents complaining of irregular vaginal bleeding. An endometrial biopsy is performed that demonstrates atypical hyperplasia. Which of the following is the most appropriate next step in management?

399.An 18-year-old woman comes to the physician for an annual examination. She has no complaints. She has been sexually active for the past 2 years. She uses the oral contraceptive pill for contraception. She has depression for which she takes fluoxetine. She takes no other medications and has no allergies to medications. Her family history is negative for cancer and cardiac disease. Examination is unremarkable. Which of the following screening tests should this patient most likely have?

400.A patient is seen on the first postoperative day after a difficult abdominal hysterectomy complicated by hemorrhage from the left uterine artery pedicle. Multiple sutures were placed into this area to control bleeding. Her estimated blood loss was 500 mL. The patient now has fever, left back pain, left costovertebral angle tenderness, and hematuria. Her vital signs are temperature 38.2C (100.8F), blood pressure 110/80 mm Hg, respiratory rate 18 breaths per minute, and pulse 102 beats per minute. Her postoperative hemoglobin dropped from 11.2 to 9.8, her white blood cell count is 9.5, and her creatinine rose from 0.6 mg/dL to 1.8 mg/dL. What is next best step in the management of this patient?

401.A 44-year-old woman complains of urinary incontinence. She loses urine when she laughs, coughs, and plays tennis. Urodynamic studies are performed in the office with a multiple-channel machine. If this patient has genuine stress urinary incontinence, which of the following do you expect to see on the cystometric study?

402.A 59-year-old G4P4 presents to your office complaining of losing urine when she coughs, sneezes, or engages in certain types of strenuous physical activity. The problem has gotten increasingly worse over the past few years, to the point where the patient finds her activities of daily living compromised secondary to fear of embarrassment. She denies any other urinary symptoms such as urgency, frequency, or hematuria. In addition, she denies any problems with her bowel movements. Her prior surgeries include tonsillectomy and appendectomy. She has adult-onset diabetes and her blood sugars are well controlled with oral Metformin. The patient has no history of any gynecologic problems in the past. She has four children who were all delivered vaginally. Their weights ranged from 8 to 9 lb. Her last delivery was forceps assisted. She had a third-degree laceration with that birth. She is currently sexually active with her partner of 25 years. She has been menopausal for 4 years and has never taken any hormone replacement therapy. Her height is 5ft 6 in, and she weighs 190 lb. Her blood pressure is 130/80 mm Hg. Based on the patient’s history, which of the following is the most likely diagnosis?

403.A 49-year-old G4P4 presents to your office complaining of a 2-month history of leakage of urine every time she exercises. She has had to limit her physical activities because of the loss of urine. She has had burning with urination and some blood in her urine for the past few days. Which of the following is the best next step in the evaluation and management of this patient?

404.A 46-year-old woman presents to your office complaining of something bulging from her vagina for the past year. It has been getting progressively more prominent. She has started to notice that she leaks urine with laughing and sneezing. She still has periods regularly every 26 days. She is married. Her husband had a vasectomy for contraception. After appropriate evaluation, you diagnose a second-degree cystocele. She has no uterine prolapse or rectocele. Which of the following is the best treatment plan to offer this patient?

405.An obese 46-year-old G6P1051 with type 1 diabetes since age 12 presents to your office complaining of urinary incontinence. She has been menopausal since age 44. Her diabetes has been poorly controlled for years because of her noncompliance with insulin therapy. She often cannot tell when her bladder is full, and she will urinate on herself without warning. Which of the following factors in this patient’s history has contributed the most to the development of her urinary incontinence?

406.A 76-year-old woman presents for evaluation of urinary incontinence. She had a hysterectomy for fibroid tumors of the uterus at age 48. After complete evaluation, you determine that the patient has genuine stress urinary incontinence. On physical examination, she has a hypermobile urethra, but there is no cystocele or rectocele. There is no vaginal vault prolapse. Office cystometrics confirms genuine stress urinary incontinence. Which of the following surgical procedures should you recommend to this patient?

407.A patient presents to your office approximately 2 weeks after having a total vaginal hysterectomy with anterior colporrhaphy and Burch procedure for uterine prolapse and stress urinary incontinence. She complains of a constant loss of urine throughout the day. She denies any urgency or dysuria. Which of the following is the most likely explanation for this complaint?

408.A 90-year-old G5P5 with multiple medical problems is brought into your gynecology clinic accompanied by her granddaughter. The patient has hypertension, chronic anemia, coronary artery disease, and osteoporosis. She is mentally alert and oriented and lives in an assisted living facility. She takes numerous medications, but is very functional at the current time. She is a widow and not sexually active. Her chief complaint is a sensation of heaviness and pressure in the vagina. She denies any significant urinary or bowel problems. On performance of a physical examination, you note that the cervix is just inside the level of the introitus. Based on the physical examination, which of the following is the most likely diagnosis?

409.An 86-year-old woman presents to your office for her well-woman examination. She has no complaints. On pelvic examination performed in the supine and upright positions, the patient has second-degree prolapse of the uterus. Which of the following is the best next step in the management of this patient?

410.A 19-year-old primigravid woman at 42 weeks' gestation comes the labor and delivery ward for induction of labor. Her prenatal course was uncomplicated. Examination shows her cervix to be long, thick, closed, and posterior. The fetal heart rate is in the 140s and reactive. The fetus is vertex on ultrasound. Prostaglandin (PGE2) gel is placed intravaginally. One hour later, the patient begins having contractions lasting longer than 2 minutes. The fetal heart rate falls to the 70s. Which of the following is the most appropriate next step in management?

411.A 25-year-old primigravid woman comes to the physician for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had some nausea and vomiting but otherwise has no complaints. Past medical and surgical history are unremarkable. Her family history is significant for cystic fibrosis with an affected aunt. Her husband has an affected cousin. Physical examination is unremarkable. Given her family history, she is concerned about the risks of having a child with cystic fibrosis. She inquires about cystic fibrosis screening. Which of the following is the appropriate response?

412.A 52-year-old woman comes to the physician because of hot flashes. Her last menstrual period was 1 year ago. Over the past year, she has noted a persistence of her hot flashes, which come several times each day and are associated with a feeling of heat and flushing. They also awaken her at night and interfere with her sleep. She has no medical problems, takes no medications, and has no known drug allergies. She has a family history of cardiovascular disease and she does not smoke. Physical examination is unremarkable. She is started on estrogen and medroxyprogesterone acetate (Provera). The addition of a progestin is most likely to decrease her risk of which of the following?

413.A 21-year-old woman comes to the physician because of "bumps" on her vulva that she has just recently noticed. These bumps do not cause her symptoms, but she wants to know what they are and wants them removed. She has no medical problems, takes no medications, and has no allergies to medications. She smokes one-half pack of cigarettes per day. She is sexually active with 3 partners. Examination shows 3 cauliflower-like lesions on the right labia majora. Which of the following is the most appropriate next step in management?

414.A 29-year-old patient comes to the physician for an annual examination. She has normal menstrual periods every 30 days. She was 15 years old when she first began having intercourse. She uses condoms for contraception. Her past medical history is significant for multiple sclerosis. This condition has required her to use a wheelchair for the past 4 years, which makes pelvic examination somewhat difficult for her. She smokes one pack of cigarettes per day. Given her difficulty with the pelvic examination, she inquires as to how often she needs to have a Pap smear performed. Which of the following is the correct answer?

415.A 33-year-old woman comes to the physician for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had no bleeding or abdominal pain. She has no medical problems and takes no medications. She has no family history of congenital anomalies. Her husband is 55 years old. He is in good health and also has no family history of birth defects. The patient is concerned that her husband's age may place their fetus at increased risk of a chromosomal anomaly. She wishes to know the paternal age above which amniocentesis or chorionic villus sampling should be considered. Which of the following is the correct response?

416.A 14-year-old girl comes to the physician for an annual examination. She has no complaints. She became sexually active during the past year and uses condoms occasionally for contraception. She has asthma, for which she occasionally takes an albuterol inhaler. She had an appendectomy at age 9. Physical examination is unremarkable including a normal pelvic examination. When should this patient begin having Pap testing?

417.A 25-year-old nulliparous woman at 35 weeks' gestation comes to the labor and delivery ward complaining of contractions, a headache, and flashes of light in front of her eyes. Her pregnancy has been uncomplicated except for an episode of first trimester bleeding that completely resolved. She has no medical problems. Her temperature is 37 C (98.6 F), blood pressure is 160/110 mm Hg, pulse is 88/minute, and respirations are 12/minute. Examination shows that her cervix is 2 centimeters dilated and 75% effaced, and that she is contracting every 2 minutes. The fetal heart tracing is in the 140s and reactive. Urinalysis shows 3+ proteinuria. Laboratory values are as follows: leukocytes 9,400/mm3, hematocrit 35%, platelets 101,000/mm3. Aspartate aminotransferase (AST) is 200 U/L, and ALT 300 U/L. Which of the following is the most appropriate next step in management?

418.A 33-year-old primigravid woman at 18 weeks' gestation comes to the physician for a prenatal visit. Her prenatal course has been uncomplicated thus far. She has no complaints. She has had no loss of fluid, bleeding, or contractions. She has hypothyroidism, for which she takes thyroid hormone replacement. The patient states that a friend of hers recently had a preterm delivery. The patient is quite concerned about preterm delivery and wants to know whether home uterine activity monitoring (HUAM) is recommended. Which of the following is the most appropriate response?

419.A 32-year-old nulliparous woman at 38 weeks' gestation comes to the labor and delivery ward with regular painful contractions after a gush of fluid two hours ago. Her temperature is 98.6 F (37 C). She is found to have gross rupture of membranes and to have a cervix that is 6 centimeters dilated. The fetus is in breech position. The patient is then brought to the operating room for cesarean delivery. Which of the following represents the correct procedure for antibiotic administration?

420.A previously healthy 21-year-old woman has a profuse, malodorous vaginal discharge. Examination shows a greenish gray "frothy" discharge with a "fishy" odor and petechial lesions on the cervix. There is no cervical motion tenderness. Her temperature is 37.5 C (99.4 F), blood pressure is 120/80 mm Hg, pulse is 60/min, and respirations are 16/min. Microscopic evaluation of the discharge is most likely to show which of the following?

421.A 21-year-old primigravid woman at 39 weeks' gestation comes to the labor and delivery ward with painful contractions every three minutes. Her prenatal course was unremarkable. Examination shows her cervix to be 3 centimeters dilated and 90% effaced. The fetal heart rate tracing is in the 150s and reactive. 5 hours later cervical examination reveals that the patient is 9 centimeters dilated and at -1 station. The fetal heart rate tracing shows moderate variable decelerations with each contraction and decreased variability. Fetal scalp sampling is performed that yields fetal scalp pHs of 7.04, 7.05, and 7.06. Which of the following is the most appropriate next step in management?

422.A 31-year-old, HIV-positive woman, gravida 3, para 2, at 32-weeks' gestation comes to the physician for a prenatal visit. Her prenatal course is significant for the fact that she has taken zidovudine throughout the pregnancy. Otherwise, her prenatal course has been unremarkable. She has no history of mental illness. She states that she has been weighing the benefits and risks of cesarean delivery in preventing transmission of the virus to her baby. After much deliberation, she has decided that she does not want a cesarean delivery and would like to attempt a vaginal delivery. Which of the following is the most appropriate next step in management?

423.A 26-year-old nulligravid woman comes to the emergency department because of severe right lower quadrant pain. She states that the pain started last night. This morning she was awakened from sleep with severe pain in the same area. During the episode of pain, she also had nausea, vomiting, and diaphoresis. On admission to the emergency department she required 5 mg of morphine to control her pain. Examination is significant for right lower quadrant tenderness and a tender right adnexal mass on pelvic examination. Urine hCG is negative. Urinalysis is negative. Transvaginal ultrasound reveals an 8 cm right ovarian mass. Which of the following is the most likely diagnosis?

424.An 18-year-old woman comes to the physician for advice regarding birth control. She has been sexually active since the age of 15 and has had numerous sexual partners since that time. She has tried the oral contraceptive pill twice, for approximately two cycles each time, but stopped because of irregular bleeding. She has had gonorrhea once and Chlamydia twice. She does not smoke. Physical examination is unremarkable. Which of the following forms of birth control should be recommended for this patient?

425.A 44-year-old woman, gravida 4, para 3, at 8 weeks' gestation comes to the physician for her first prenatal visit. She has mild nausea and vomiting but no other complaints. Her obstetric history is significant for three full-term, normal vaginal deliveries of normal infants. She has no medical or surgical history and takes no medications. Physical examination reveals an 8-week- sized uterus, but is otherwise unremarkable. She wishes to have chromosomal testing of the fetus and wants to have chorionic villus sampling performed, as she did with her last pregnancy. Compared with amniocentesis, chorionic villus sampling may place the patient at greater risk for which of the following?

426.A pharmaceutical company sponsors a physician lecture concerning thrombotic complications of the oral contraceptive pill (OCP). At the start of the presentation, the company's representative makes a short presentation regarding their particular brand of OCP. He then proceeds to announce that his company would like to award a gift to the physician in the group who gives the largest number of prescriptions for this pill. Which of the following is the most appropriate action?

427.A 24-year old woman comes to the physician because of burning with urination. She states that every time she urinates there is pain and that she has a feeling that she constantly needs to urinate even though only a little comes out. She has never had any similar symptoms before. She has no medical problems and no known drug allergies. Examination is unremarkable. Urinalysis demonstrates that the urine is positive for leukocyte esterase and nitrites. Which of the following is the most appropriate pharmacotherapy?

428.A 21-year-old woman comes to the physician because of abdominal pain. She states that the pain is in her right lower quadrant and has been getting worse over the past 3 months. She has no other symptoms and a normal appetite. Examination demonstrates mild right lower quadrant abdominal tenderness. Pelvic examination reveals mild right adnexal enlargement and tenderness. Urine human chorionic gonadotropin (hCG) is negative. A pelvic ultrasound is obtained that shows a 4- centimeter, heterogeneous hyperechoic lesion in the right adnexa with cystic areas. On transvaginal ultrasound, hair and calcifications are demonstrated within the cystic areas. Which of the following is the most likely diagnosis?

429.An 18-year-old G2P1 presents to the emergency department with abdominal pain and vaginal bleeding for the past day. Her last menstrual period was 7 weeks ago. On examination she is afebrile with normal blood pressure and pulse. Her abdomen is tender in the left lower quadrant with voluntary guarding. On pelvic examination, she has a small anteverted uterus, no adnexal masses, mild left adnexal tenderness, and mild cervical motion tenderness. Labs reveal a normal white count, hemoglobin of 10.5, and a quantitative β-hCG of 2342. Ultrasound reveals a 10×5×6 cm uterus with a normal-appearing 1-cm stripe and no gestation sac or fetal pole. A 2.8-cm complex adnexal mass is noted on the left. In the treatment of this patient, laparoscopic salpingostomy has what advantage over salpingectomy via laparotomy?

430.A 27-year-old has just had an ectopic pregnancy. Which of the following events would be most likely to predispose to ectopic pregnancy?

431. A18-year-old G1 at 8 weeks gestation complains of nausea and vomiting over the past week occurring on a daily basis. Nausea and emesis are a common symptom in early pregnancy. Which of the following signs or symptoms would indicate a more serious diagnosis of hyperemesis gravidarum?

432.32-year-old G2P0101 presents to labor and delivery at 34 weeks of gestation, complaining of regular uterine contractions about every 5 minutes for the past several hours. She has also noticed the passage of a clear fluid per vagina. A nurse places the patient on an external fetal monitor and calls you to evaluate her status. The external fetal monitor demonstrates a reactive fetal heart rate tracing, with regular uterine contractions occurring about every 3 to 4 minutes. On sterile speculum examination, the cervix is visually closed. A sample of pooled amniotic fluid seen in the vaginal vault is fern and nitrazine-positive. The patient has a temperature of 38.8C, pulse 102 beats per minute, blood pressure 100/60 mm Hg, and her fundus is tender to deep palpation. Her admission blood work comes back indicating a WBC of 19,000. The patient is very concerned because she had previously delivered a baby at 35 weeks who suffered from respiratory distress syndrome (RDS). You perform a bedside sonogram, which indicates oligohydramnios and a fetus whose size is appropriate for gestational age and with a cephalic presentation. Which of the following is the most appropriate next step in the management of this patient?

433.A 30-year-old G1P0 with a twin gestation at 25 weeks presents to labor and delivery complaining of irregular uterine contractions and back pain. She reports an increase in the amount of her vaginal discharge, but denies any rupture of membranes. She reports that earlier in the day she had some very light vaginal bleeding, which has now resolved. On arrival to labor and delivery, she is placed on an external fetal monitor, which indicates uterine contractions every 2 to 4 minutes. She is afebrile and her vital signs are all normal. Her gravid uterus is non tender. The nurses call you to evaluate the patient. Which of the following is the most appropriate first step in the evaluation of vaginal bleeding in this patient?

434.A 30-year-old G1 with twin gestation at 28 weeks is being evaluated for vaginal bleeding and uterine contractions. A bedside ultrasound examination rules out the presence of a placenta previa. Fetal heart rate tracing is reactive on both twins, and the uterine contractions are every 2 to 3 minutes and last 60 seconds. A sterile speculum examination is negative for rupture membranes. A digital examination indicates that the cervix is 2 to 3 cm dilated and 50% effaced, and the presenting part is at −3 station. Tocolysis with magnesium sulfate is initiated and intravenous antibiotics are started for group B streptococcus prophylaxis. Betamethasone, a corticosteroid, is also administered. Which of the following statements regarding the use of betamethasone in the treatment of preterm labor is true?

435.A maternal fetal medicine specialist is consulted and performs an in-depth sonogram on a 30- year-old G1 at 28 weeks with a twin gestation. The sonogram indicates that the fetuses are both male, and the placenta appears to be diamniotic and monochorionic. Twin B is noted to have oligohydramnios and to be much smaller than twin A. Which of the following would be a finding most likely associated with twin A?

436.A 30-year-old G1 at 28 weeks gestation with a twin pregnancy is admitted to the hospital for preterm labor with regular painful contractions every 2 minutes. She is 3 cm dilated with membranes intact and a small amount of bloody show. Ultrasound reveals growth restriction of twin A and oligohydramnios, otherwise normal anatomy. Twin B has normal anatomy and has appropriate-for-gestational-age weight. Which of the following is a contraindication to the use of indomethacin as a tocolytic in this patient?

437.A healthy 42-year-old G2P1001 presents to labor and delivery at 30 weeks gestation complaining of a small amount of bright red blood per vagina which occurred shortly after intercourse. It started off as spotting and then progressed to a light bleeding. By the time the patient arrived at labor and delivery, the bleeding had completely resolved. The patient denies any regular uterine contractions, but admits to occasional abdominal cramping. She reports no pregnancy complications and a normal ultrasound done at 14 weeks of gestation. Her obstetrical history is significant for a previous low transverse cesarean section at term. Which of the following can be ruled out as a cause for her vaginal bleeding?

438.A 34-year-old G2P1 at 31 weeks gestation presents to labor and delivery with complaints of vaginal bleeding earlier in the day that resolved on its own. She denies any leakage of fluid or uterine contractions. She reports good fetal movement. In her last pregnancy, she had a low transverse cesarean delivery for breech presentation at term. She denies any medical problems. Her vital signs are normal and electronic external monitoring reveals a reactive fetal heart rate tracing and no uterine contractions. Which of the following is the most appropriate next step in the management of this patient?

439.A 34-year-old G2P1 at 31 weeks gestation with a known placenta previa presents to the hospital with vaginal bleeding. On assessment, she has normal vital signs and the fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. No uterine contractions are demonstrated on external tocometer. Heavy vaginal bleeding is noted. Which of the following is the best next step in the management of this patient?

440.A 34-year-old G2P1 at 31 weeks gestation with a known placenta previa is admitted to the hospital for vaginal bleeding. The patient continues to bleed heavily and you observe persistent late decelerations on the fetal heart monitor with loss of variability in the baseline. Her blood pressure and pulse are normal. You explain to the patient that she needs to be delivered. The patient is delivered by cesarean section under general anesthesia. The baby and placenta are easily delivered, but the uterus is noted to be boggy and atonic despite intravenous infusion of Pitocin. Which of the following is contraindicated in this patient for the treatment of uterine atony?

441.A 20-year-old G1P0 at 30 weeks gestation with a known placenta previa is delivered by cesarean section under general anesthesia for vaginal bleeding and nonreassuring fetal heart rate tracing. The baby is easily delivered, but the placenta is adherent to the uterus and cannot be completely removed, and heavy uterine bleeding is noted. Which of the following is the best next step in the management of this patient?

442.A 40-year-old G2P1001 presents to your office for a routine OB visit at 30 weeks gestational age. Her first pregnancy was delivered 10 years ago and was uncomplicated. She had a normal vaginal delivery at 40 weeks and the baby weighed 7 lb. During this present pregnancy, she has not had any complications, and she reports no significant medical history. She is a nonsmoker and has gained about 25 lb to date. Despite being of advanced maternal age, she declined any screening or diagnostic testing for Down syndrome. Her blood pressure range has been 100 to 120/60 to 70. During her examination, you note that her fundal height measures only 25 cm. Which of the following is a likely explanation for this patient’s decreased fundal height?

443.A 38-year-old G4P3 at 33 weeks gestation is noted to have a fundal height of 29 cm on routine obstetrical visit. An ultrasound is performed by the maternal-fetal medicine specialist. The estimated fetal weight is determined to be in the fifth percentile for the estimated gestational age. The biparietal diameter and abdominal circumference are concordant in size. Which of the following is associated with symmetric growth restriction?

444.A 37-year-old G4P2 presents to your office for new OB visit at 8 weeks. In a prior pregnancy, the fetus had multiple congenital anomalies consistent with trisomy 18, and the baby died shortly after birth. The mother is worried that the current pregnancy will end the same way, and she wants testing performed to see whether this baby is affected. Which of the following can be used for chromosome analysis of the fetus?

445.A 26-year-old G1 at 37 weeks presents to the hospital in active labor. She has no medical problems and has a normal prenatal course except for fetal growth restriction. She undergoes an uncomplicated vaginal delivery of a female infant weighing 1950 g. The infant is at risk for which of the following complications?

446.A 38-year-old G1P1 comes to see you for her first prenatal visit at 10 weeks gestational age. She had a previous term vaginal delivery without any complications. You detect fetal heart tones at this visit, and her uterine size is consistent with dates. You also draw her prenatal labs at this visit and tell her to follow up in 4 weeks for a return OB visit. Two weeks later, the results of the patient’s prenatal labs come back. Her blood type is A–, with an anti-D antibody titer of 1:4. Which of the following is the most appropriate next step in the management of this patient?

447.A 23-year-old G3P1011 at 6 weeks presents for routine prenatal care. She had a cesarean delivery 3 years ago for breech presentation after a failed external cephalic version. Her daughter is Rh- negative. She also had an elective termination of pregnancy 1 year ago. She is Rh-negative and is found to have a positive anti-D titer of 1:8 on routine prenatal labs. Failure to administer RhoGAM at which time is the most likely cause of her sensitization?

448.A 27-year-old G2P1 at 29 weeks gestational age, who is being followed for Rh isoimmunization presents for her OB visit. The fundal height is noted to be 33 cm. An ultrasound reveals fetal ascites and a pericardial effusion. Which of the following can be another finding in fetal hydrops?

449.A 39-year-old G1P0 at 39 weeks gestational age is sent to labor and delivery from her obstetrician’s office because of a blood pressure reading of 150/100 mm Hg obtained during a routine OB visit. Her baseline blood pressures during the pregnancy were 100 to 120/60 to 70. On arrival to labor and delivery, the patient denies any headache, visual changes, nausea, vomiting, or abdominal pain. The heart rate strip is reactive and the tocodynamometer indicates irregular uterine contractions. The patient’s cervix is 3 cm dilated. Her repeat blood pressure is 160/90 mm Hg. Hematocrit is 34.0, platelets are 160,000, SGOT is 22, SGPT is 15, and urinalysis is negative for protein. Which of the following is the most likely diagnosis?

E. Gestational hypertension@ 450.A 21-year-old woman presents to the clinic in tears. She states that she recently found out she was pregnant at 10 weeks’ gestation. She is a recovering alcoholic but recently relapsed, consuming several drinks a day. She is nervous about the effects of her drinking on her fetus. For which of the following is the patient at greatest risk?

451.A 28-year-old G1P0 woman at 12 weeks’ gestation presents for routine follow-up with her obstetrician. She complains of mild nausea and occasional vomiting, but otherwise is doing well and reports no other symptoms or complications. Her physical examination is unremarkable and fetal ultrasound is normal for gestational age. Laboratory tests show: Free triiodothyronine: 180 ng/dL Free thyroxine: 2.2 ng/dL Total thyroxine: 12 μg/dL Thyroid-stimulating hormone: 0.1 μU/mL (normal: 0.4–4 μU/mL) Results of a thyroid-stimulating hormone receptor antibody test are negative. Which of the following best explains these findings?

452.A 27-year-old G1P0 woman at 27 weeks’ gestation presents to the emergency department after a motor vehicle accident. The patient denies any abdominal pain or cramping, contractions, or vaginal bleeding. Examination reveals a gravid, non-tender abdomen and a closed, non- effaced cervix with no evidence of vaginal bleeding. Fetal heart monitoring shows a fetal heart rate of 145/min, with variable accelerations and no decelerations. The patient is Rh negative with no history of blood transfusion, while the father is of unknown Rh status and unavailable. The results of the Kleihauer-Betke test, in which maternal blood is exposed to acid, shows a combination of pale and stained RBCs. Which of the following is the best next step in management?

453.A 27-year-old G1 woman is 20 weeks pregnant. She is currently in her third year of a family practice residency and would like to travel to Africa and Asia as part of an outreach mission with her program. She has received all of her childhood immunizations. She presents to the obstetric clinic inquiring about the safety of immunizations during pregnancy. Which of the following vaccines is contraindicated in pregnancy?

454.A 28-year-old G0 woman presents to the clinic complaining of inability to conceive and amenorrhea. She has been taking a low-dose oral contraceptive pill for the past 6 years, which she discontinued 3 months ago when she and her husband decided they wanted to have children. They have been sexually active with each other two to three times per week over the past 3 months, but the patient has not become pregnant. The patient denies a history of sexually transmitted disease and states that until recently she has always had regular menstrual cycles. She has not had a period since discontinuation of the oral contraceptive. Which of the following is the most appropriate next step?

455.A 31-year-old G3P2 woman at 37 weeks’ gestation presents to the labor and delivery floor after 2 hours of contractions of increasing frequency and intensity. An epidural anesthetic is requested on admission and placed. The patient continues to have contractions for the next 15 hours, during which time her membranes rupture spontaneously. Vaginal examination at that time reveals a cervix that is soft, 3 cm dilated, in an anterior position, and 80% effaced. The fetal head is at the -1 station. Fetal heart tracings reveal a baseline heart rate of 156/min, with variable accelerations and no significant decelerations. Which of the following is the best next step in management?

456.A 24-year-old G2P2 woman presents to the emergency department complaining of vaginal bleeding and abdominal cramping. She is sexually active in a monogamous relationship with her husband. Her last menstrual period was 6 weeks ago. The patient is afebrile, and vital signs are within normal limits. Pelvic examination is notable for a dilated cervix, fetal tissue in the vaginal vault, and no cervical motion tenderness. Which of the following is the most likely cause of this patient’s abortion?

457.A 30-year-old G3P2 woman at 25 weeks’ gestation has a history of gestational diabetes in her previous pregnancy. Her fasting blood glucose level at her initial 10-week screening visit was 110 mg/dL and urinalysis was negative for glucose in the urine. The patient has not been taking her own blood sugars at home, but she has been adhering to a low-carbohydrate diet. Over the past several weeks, she has noticed increased fatigue and polyuria. Which of the following is the next most appropriate step?

458.A 31-year-old woman with systemic lupus erythematosus who is 4 weeks pregnant presents to her obstetrician for her first prenatal visit. She is very concerned that the lupus will affect her baby. She was diagnosed with systemic lupus erythematosus 5 years ago and her symptoms have been well controlled with low-dose prednisone. She has baseline renal insufficiency, with a creatinine level of 1.3 mg/dL that has been stable for the past 6 months. This is her first pregnancy. For which of the following is the baby at increased risk?

459.A 30-year-old G0 woman with a past medical history of dysmenorrhea presents to an infertility clinic with her husband for a follow-up visit. The couple has been trying to get pregnant for the past 3 years with no success. Their infertility work-up thus far has included a semen analysis, hysterosalpingogram, and estrogen, progesterone, and follicle-stimulating hormone blood levels, all of which were normal. Currently the woman feels well; her only complaint is frustration regarding her inability to conceive. A pelvic ultrasound done last week demonstrated a 3-cm well-circumscribed mass on the patient’s left ovary. Her last menstrual period was 3 weeks ago. The ovarian mass most likely represents which of the following?

460.A 34-year-old G1P0 woman at 29 weeks’ gestation presents to the emergency department complaining of 2 hours of vaginal bleeding. The bleeding recently stopped, but she was diagnosed earlier with placenta previa by ultrasound. She denies any abdominal pain, cramping, or contractions associated with the bleeding. Her temperature is 36.8°C (98.2°F), blood pressure is 118/72 mm Hg, pulse is 75/min, and respiratory rate is 13/min. She reports she is Rh positive, her hemoglobin is 11.1 g/dL, and coagulation tests, fibrinogen, and D-dimer levels are all normal. On examination her gravid abdomen is non-tender. Fetal heart monitoring is reassuring, with a heart rate of 155/min, variable accelerations, and no decelerations. Two large-bore peripheral intravenous lines are inserted and two units of blood are typed and crossed. What is the most appropriate next step in management? Fi

461.A 32-year-old G3P2 woman at 35 weeks’ gestation has a past medical history significant for hypertension. She was well-controlled on hydrochlorothiazide and lisinopril as an outpatient, but these drugs were discontinued when she found out that she was pregnant. Her blood pressure has been relatively well controlled in the 120–130 mm Hg systolic range without medication, and urinalysis has consistently been negative for proteinuria at each of her prenatal visits. She presents now to the obstetric clinic with a blood pressure of 142/84 mm Hg. A 24-hour urine specimen yields 0.35 g of proteinuria. Which of the following is the most appropriate next step?

462.A 32-year-old G2P1 woman at 35 weeks’ gestation presents to her obstetrician for a routine prenatal check-up. The mother has been previously diagnosed with mild preeclampsia, which the obstetrician has chosen to manage expectantly. During the visit, a biophysical profile is performed and the amniotic fluid index is found to be <5 cm, indicating the development of oligohydramnios. The biophysical profile is otherwise normal, with a total score of 8/10 and reassuring fetal heart tracings. How should oligohydramnios be managed in this patient?

463.At 38 weeks’ gestation, a 4030-g (8.9-lb) boy is delivered by spontaneous vaginal delivery. During the first minute of life he is limp, cyanotic, lacks respiratory effort, has a heart rate of 95/min, flexes his extremities, and grimaces to nasal suctioning. By 5 minutes, he continues to grimace to nasal suctioning, has a weak cry, is well perfused with a heart rate of 160/min, and (D) Restricted activity and close monitoring as an outpatient following initial inpatient evaluation is kicking both legs. Based on his Apgar scores, when will the child need to be resuscitated?

464.A 23-year-old G1P0 woman at 28 weeks’ gestation presents to her obstetrician for a prenatal examination. She has received poor prenatal care up to this point, but is confident about dating the pregnancy. She denies use of alcohol and illicit drugs but has continued to smoke during the pregnancy. The mother has gained only 9 kg (20 lb) during the course of the pregnancy. The mother’s temperature is 36.8°C (98.2°F), pulse is 94/min, blood pressure is 138/84 mm Hg, and respiratory rate is 12/min. The fundal height is 23 cm above the pubic symphysis. Further examination with ultrasound reveals the fetus is <10% of the expected weight for the gestational age with symmetric growth anomalies. What is the most likely cause for the intrauterine growth restriction of this fetus?

465.A 22-year-old obese woman presents to the obstetrics-gynecology clinic complaining of mild abdominal pain and vaginal bleeding. The patient states that she is sexually active with her boyfriend and uses condoms “basically all the time.” She states that her last menstrual period was 7 weeks ago and insists that her periods have always been irregular, occurring every 3 to 4 months. She denies any past medical history but states that she used to have a problem with excess facial hair prior to starting low-dose oral contraceptive pills. Which of the following is the best next step in diagnosis?

466.A full-term 2200-g (4.9-lb) boy was born to a 30-year-old G4P3 woman whose pregnancy was complicated by a seizure disorder for which she inconsistently took carbamazepine. The pregnancy was also notable for an abnormal triple screen for which an amniocentesis was declined. His Apgar scores are 7 and 9 at 1 and 5 minutes, respectively. His temperature is 37.0°C (98.6°F), blood pressure is 65/45 mm Hg, heart rate is 110/min, and respiratory rate is 30/min. His head circumference is <5th percentile. There is a small fleshy sac protruding from the sacral spine. His reflexes are 2+ throughout, and his strength is 5/5 in all extremities. His fingernails are very small. Which of the following is the most likely diagnosis?

467.A 24-year-old G1P0 woman at 31 weeks’ gestation presents to the emergency department with a 4-hour history of abdominal cramping and contractions. The contractions have been regularly spaced at 10 minutes, but seem to be increasing in intensity. She has had a small amount of vaginal discharge, but is unable to definitively say whether her water has broken. She has not had any vaginal bleeding. Her temperature is 36.8°C (98.3°F), blood pressure is 137/84 mm Hg, pulse is 87/min, and respiratory rate is 12/min. Physical examination reveals a non-tender abdomen with palpable contractions every 8 minutes. Which of the following is the best next step in management?

468.20-year-old G1 at 36 weeks is being monitored for preeclampsia; she rings the bell for the nurse because she is developing a headache and feels funny. As you and the nurse enter the room, you witness the patient undergoing a tonic-clonic seizure. You secure the patient’s airway, and within a few minutes the seizure is over. The patient’s blood pressure monitor indicates a pressure of 160/110 mm Hg. Which of the following medications is recommended for the prevention of a recurrent eclamptic seizure?

469.You are doing postpartum rounds on a 22-year-old G1P1, who vaginally delivered an infant male at 36 weeks after an induction for severe preeclampsia. During her labor she required hydralazine to control her blood pressures. She is on magnesium sulfate for seizure prophylaxis. Her vital signs are: blood pressure 154/98 mm Hg, pulse 93 beats per minute, respiratory rate 24 breaths per minute, and temperature 37.3C. She has adequate urine output at greater than 40 cc/h. On examination, she is oriented to time and place, but she is somnolent and her speech is slurred. She has good movement and strength of her extremities, but her deep tendon reflexes are absent. Which of the following is the most likely cause of her symptoms?

470.A 28-year-old woman and her husband present to her obstetrician. They have been married for 7 years and have been trying to become pregnant for the past 2 years. Prior to this the woman used an intrauterine device for contraception, which she had in place for 5 years. Both are healthy without any medical problems, and both deny a history of sexually transmitted diseases. The woman states that her menstrual cycles have always been regular (every 28 days, lasting for 5 days) since she was 14 years old. She also denies menorrhagia and dysmenorrhea. Which of the following is the most likely cause of this couple’s infertility?

471.A woman brings her 15-year-old daughter to her pediatrician for concerns about hair growth. The child has always had a lot of body hair and has been shaving her legs since she was 12 years old. The mother reports that her daughter has recently been noticing more hair, especially along the upper lip and on the chest and abdomen. The child is clearly distressed about her appearance. Further questioning reveals that although the girl had her first menses at 11 years old, her menstrual cycles are irregular, and she sometimes skips cycles for months at a time. Physical examination reveals a young, heavy-set, olive-skinned teenager with moderate acne and dark hair growth along her upper lip, across her chest, and over her lower abdomen. She exercises regularly. Which of the following is the most appropriate treatment for this child’s hirsutism?

472.A 28-year-old teacher presents to the clinic complaining of 5 months of polyuria, polydipsia, and weight loss. Additionally, her menses, which have always been irregular, have stopped altogether. She is concerned because both her mother and maternal aunt suffer from noninsulin- dependent diabetes, and they told her they had similar symptoms before they were diagnosed. Upon questioning she reveals that she is in a committed relationship and has no desire to have children, so she uses barrier protection during intercourse. Physical examination reveals an obese woman with hirsutism currently in no acute distress. Testing for β-human chorionic gonadotropin level, random blood sugar level, cholesterol panel, and a luteinizing hormone/follicle-stimulating hormone ratio suggests the patient has polycystic ovarian syndrome (PCOS). Although no one in her family has had cancer, she is concerned that her symptoms are a harbinger of cancer or that she might be likely to suffer from cancer in the future. This diagnosis would most raise her risk for which kind of cancer?

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

474.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 99.4° F (37.4° C). What is the most likely diagnosis?

475.A 32-year-old woman comes to your office for re-evaluation of her birth control method. She wants her intrauterine device (IUD) removed because it is causing her pelvic pain. She wants to be placed on oral contraceptive pills (OCPs). She has had hypertension for the past five years controlled with hydrochlorothiazide and atenolol. She has a family history of diabetes mellitus and ovarian carcinoma. Her body mass index (BMI) is 34 kg/m2. Physical examination is unremarkable. If she starts taking oral contraceptive pills, which of the following statement is most correct?

476.A 21-year-old woman at 36 weeks gestation is admitted for delivery. She has severe preeclampsia. Her blood pressure is 190/110 mmHg, pulse is 80/min and respirations are 16/min. Physical examination shows 3+ pitting edema of the legs and brisk deep tendon reflexes. Fundoscopic examination shows no abnormalities. Laboratory studies show elevated BUN, serum creatinine and serum transaminases. Urinalysis shows 4+ proteinuria. Intravenous hydralazine and magnesium sulfate was initiated on admission. After stabilization, intravenous oxytocin and artificial rupture of membranes (AROM) was administered for induction of labor. Two hours later, her blood pressure is 150/90 mmHg, pulse is 78/min and respirations are 9/min. Repeat examination shows hyporeflexia and a completely effaced cervix that is 5 cm dilated. Which of the following is the most appropriate next step in management?

477.An 18-year-old woman comes to the physician for her annual physical examination. Her past medical history is unremarkable and she takes no medications. Her last menstrual period was 2 weeks ago, and she has regular menses lasting 4-5 days every 28 days. The patient became sexually active at age 16 and has had 3 partners since then. She is currently in a monogamous relationship with her boyfriend of a year and uses condoms regularly. The patient has no vaginal discharge, urinary complaints, or weight changes. Vital signs and general physical examination are within normal limits. She inquires about cervical cancer screening and human papillomavirus vaccine, which she has not received. What is the most appropriate next step in management of this patient?

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

479.A 28-year-old G1A1 woman presents to a gynecology clinic with a chief complaint of reduced menstrual flow for the past 6 months, especially last month. She denies any pain with menstruation or irregularity in her cycle. She says that she had an elective termination by dilation and curettage approximately 9 months ago. She is sexually active with one partner and always uses condoms. Review of her records indicates a past history of abnormal Papanicolaou (Pap) smears, but she has not been followed recently. She denies any history of irregular menses, and says that age of menarche was 13 years. She takes no medications. Physical examination reveals a normally developed 68-kg (150lb) woman who is 183 cm (6') tall. She is in no acute distress. A β-human chorionic gonadotropin test from her original visit 1 week ago is negative. Which of the following is the most likely diagnosis?

480.A 21-year-old G0 woman presents for a well-woman examination. Menarche began at age 12 years, and her periods occur every 26–30 days and last 4–5 days. She has had two sexual partners since becoming sexually active last year. She uses condoms for contraception and denies a history of sexually transmitted disease. Her physical examination is within normal limits. She has never had a pelvic exam before, and asks why it is necessary for her to get a Pap smear. Which of the following statements about cervical cancer screening is true?

81.A 42-year-old postmenopausal woman presents to the clinic complaining of vague abdominal pain, early satiety, and a 9-kg (20-lb) unintended weight loss. She has a history of normal Pap smears. On physical examination her abdomen is firm, with evidence of ascites and a firm, irregular, and fixed left adnexal mass palpated on vaginal examination. CT scan of the abdomen and pelvis confirms the presence of an ovarian mass that has features that are highly suspicious for cancer. What is the best means to correctly diagnose and stage this mass?

482.A 55-year-old woman is brought to the emergency department by fi re and rescue personnel because of intractable back and thigh pain for the past 3 hours. Upon presentation she says that the pain is 9 of 10 in severity and localized to her lower back. She lives with her sister, and she has no primary care physician. She denies any complaints aside from fatigue, which she attributes to her multiple jobs and caring for her sister’s children. She has a pulse of 110/min, blood pressure of 140/88 mm Hg, respiratory rate of 20/min, and temperature of 37.8°C (100.1°F). On physical examination she is exquisitely tender over the L2–3 area of the spine. She also has point tenderness over the anterior right thigh. Sensation is intact over the lower extremities bilaterally and she has 5/5 strength in the lower extremities bilaterally. Breast examination reveals a retracted nipple and dimpling of the right breast. What will likely represent the mainstay of treatment for this patient’s symptoms?

483.A 57-year-old G3P3 woman presents to her gynecologist with complaints of vaginal pruritus and increased vaginal discharge. The patient has no history of gynecologic surgery or sexually transmitted diseases; she is not currently sexually active. A bimanual examination and Pap smear are performed. The Pap smear is positive for malignant squamous cells. Follow up colposcopy shows no cervical lesions, but a small lesion is noted on the lower vagina. Biopsy of this lesion confirms the diagnosis of vaginal squamous cell cancer, while cross-sectional imaging excludes invasion of surrounding tissues. What is the most appropriate course of treatment?

484.A 33-year-old G1P1 woman presents to her gynecologist for a Pap smear. It has been several years since she last saw a physician. She is not currently sexually active, but takes oral contraceptives. Her vaginal examination is normal, but her Pap smear shows moderate-grade cervical intraepithelial neoplasia. The patient undergoes colposcopy and biopsies, which confirm the diagnosis. What is the most appropriate management of this patient?

485.A 48-year-old woman presents to her gynecologist because of vaginal bleeding. She states that after a year of hot flashes and irregular cycles, she finally stopped menstruating 4 months ago. Two days ago she began having some vaginal bleeding that was very similar to her prior menses. She is concerned because she heard that the first sign of endometrial cancer in postmenopausal women is vaginal bleeding. She is an otherwise healthy woman with no medical problems. She exercises three times a week and takes multivitamins. She had three children when she was 29–35 years old. She used oral contraceptive pills for contraception from the time she was 18 until she got married at the age of 28. Which of the following is the most appropriate next step in managing this woman’s vaginal bleeding?

486.A 35-year-old G4P4 obese woman is referred to her gynecology clinic by her primary care physician for heavy menstruation and irregular cycles. She has noticed these symptoms for several months. She reports being a “late bloomer,” with onset of menses at age 13 years. She is sexually active and monogamous with her partner of 2 years. She is taking oral contraceptive pills and has a 5-year smoking history. An endometrial biopsy is read as “endometrial hyperplasia, cannot rule out intraepithelial carcinoma.” Β -Human chorionic gonadotropin testing is negative. Which of the following most likely contributed to this abnormality?

487.An 18-year-old woman presents to the clinic because of 6 hours of severe abdominal pain, nausea, and vomiting. She describes 6 days of mild lower abdominal pain, low-grade fever, and abnormal vaginal discharge. She is sexually active with two male partners, and her last menstrual period was 10 days ago. Her temperature is 39.5°C (103.2°F), blood pressure is 100/60 mm Hg, heart rate is 110/min, and respiratory rate is 18/min. Physical examination reveals involuntary abdominal guarding. The patient will not allow a pelvic examination. Which of the following is the most appropriate management?

488.A 65-year-old G2P2 postmenopausal woman presents to a gynecologist for the first time in many years complaining of vaginal bleeding, pelvic pain, and increased urinary frequency. She reports she is sexually active with her husband. After an appropriate work-up, a diagnosis of locally invasive squamous cell carcinoma of the cervix is made. The tumor has extended approximately 9 mm into the cervical stroma, grading the cancer as stage IB. The patient is informed of the diagnosis and wishes to undergo definitive therapy. What is the definitive therapy for this patient’s disease?

489.A 29-year-old African-American woman comes to the physician after discovering a mass on breast self-examination. Her last menstrual period was 2 weeks ago. She reports occasional bilateral gray nipple discharge that has not changed since menarche. She has no significant past medical history and does not take any medications. Examination reveals a 1.5-cm fluctuant mass in the upper and outer quadrant of the left breast. Which of the following is the best next step in management?

490.A 26-year-old G0 woman is seen in her gynecologist’s office for a routine examination. She reports that she has been sexually active with four partners and has been treated for gonorrhea once in the past year. She has otherwise been healthy. Physical examination is unremarkable. Results of a Pap smear suggest a low-grade squamous intraepithelial lesion. What is the most appropriate next step in management?

491.During routine breast examination of a 28-yearold woman with no significant family or past medical history, a firm 2-cm mass is detected in the patient’s right breast. It is freely mobile and non-tender. Ultrasound reveals a solid, well-circumscribed mass, which is later found to be benign by biopsy. Which of the following statements is true?

492.A 52-year-old postmenopausal woman who was diagnosed with advanced ovarian cancer presents to the clinic to discuss her treatment options. She has had a CT of the abdominalpelvic region that showed extensive disease extending from her left ovary and involving her uterus along with large pelvic nodes. What is the best treatment for this patient?

493.An 18-year-old female college student presents to student health services with a complaint of a burning sensation while urinating and abdominal pain. She denies urinary urgency or increased frequency. She has no significant past medical history. She is currently sexually active with a new partner. She does not use barrier contraception. She denies any previous history of sexually transmitted diseases. On examination she is afebrile, heart rate is 70/min, and blood pressure is 120/60 mm Hg. Examination reveals no peritoneal signs but there is tenderness to palpation over the suprapubic region. On pelvic examination the cervix appears edematous and friable with a small amount of discharge from the os. A urine sample reveals numerous WBCs but no organisms on Gram stain. A cervical swab is sent for Gram stain and culture. Which of the following is the most likely explanation for these findings?

494.A 13-year-old girl had growth of breast buds at 11 years, followed by the appearance of pubic hair between the ages of 11 1/2 and 12 years. Which pubertal event is most likely to occur next?

495.A 17-year-old G1P1001 is now 5 weeks postpartum after a routine vaginal delivery. She calls your office to report a 3-week history of difficulty sleeping and “feeling blue.” On further questioning, she reports difficulty concentrating, very poor appetite, occasional wishes that she had never become pregnant, and feelings of guilt about those wishes. She has not left her home in more than a week because she “just can’t find the energy to go anywhere.” This patient’s symptoms are most consistent with:

496. Labor and vaginal delivery occur successfully in a 29-year-old woman after administration of oxytocin (Pitocin) for 9 hours. Spontaneous onset of labor at term is the result of which of the following?

497. A 31-year-old pregnant woman 6–7 weeks from her last menses comes to the emergency department of your hospital complaining of lower abdominal pain for 3 hours. The pain is diffused in the lower abdomen but worse on the right side. Her serum human chorionic gonadotropin (hCG) concentration is 9600 mIU/mL. Which of the following is the strongest evidence that she has a tubal ectopic pregnancy?

498.A 22-year-old primiparous woman is in premature labor at 30 weeks’ gestation. Despite administration of tocolytic agents, it seems she will deliver soon. Pulmonary maturity might be enhanced by the administration of which of the following drugs?

499.A 28-year-old woman with 28-day menstrual cycle is attempting to conceive and is considering the use of a home ovulation predictor kit to time intercourse at ovulation. She asks you what day of her menstrual cycle her luteinizing hormone (LH) peak is most likely to occur. What should you tell her?

500.48-year-old woman with five children complains of urinary incontinence with coughing and stair climbing. She likely has genuine stress urinary incontinence if which of the following is true?