OBGY USS 4st

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

A 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?

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?

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?

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?

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?

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?

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?

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?

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 2+ edema. Fetal heart sounds are audible on Doppler. Laboratory studies show: Hb: 8.2g/dl Platelets: 96,000/mm3 Prothrombin time: 12.4 sec Partial thromboplastin time: 23.6 sec Serum creatinine: 1.1 mg/dl Total bilirubin: 2.6 mg/dl Direct bilirubin: 0.8 mg/dl Alkaline phosphatase: 120 U/L Aspartate aminotransferase: 308 U/L Alanine aminotransferase: 265 U/L Lipase: 53 U/L Peripheral blood smear shows numerous red blood cell fragments. Which of the following is the most likely diagnosis?

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 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?

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?

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?

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?

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?

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?

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?

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?

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?

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

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?

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?

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?

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?

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

A 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?

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?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?

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?

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?

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?

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?

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?

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?

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?

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?

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?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?

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?

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: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:

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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:

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?

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?

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?

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?

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?

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

A 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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?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?

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?

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?

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?

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?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?