Gyn Management P1 q 51 to 100

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

52) A 16-year-old girl presents for evaluation of acne, which has been getting progressively worse over the past 2 weeks. Her medical history is significant for systemic lupus erythematosus (SLE) for which she has been taking prednisone for a recent exacerbation. Hydroxychloroquine is her only other medicine. She does not use tobacco, alcohol or drugs and her menstrual cycle is regular. On physical examination, her blood pressure is 110/76 mmHg and her pulse is 72/min. Her BMI is 22 kg/m2. Distributed over the face, arms and trunk are monomorphous erythematous papules. There are no open or closed comedones. The remainder of the physical examination is unremarkable. Which of the following is the most likely cause of her acne?

53) You are asked to consult on a 23-year-old woman who is 18hours status-post cesarean delivery. She presented 20 hours ago, at 32 weeks’ gestation, with vaginal bleeding and contractions and a nonreassuring fetal heart rate tracing. She was rushed to the operating room for an emergent cesarean delivery. The placenta had a large retroplacental clot. The infant is in the neonatal intensive care unit. On examination, the patient has a temperature of 37.7C (99.9 F), blood pressure of 110/60 mm Hg, pulse of 124/min, and respirations of 14/min. The patient has bleeding from her abdominal incision and her intravenous sites. Laboratory studies show: Hematocrit: 18%; Leuckocytes: 16,000/mm3; Platelets: 62,000/mm3; Prothrombin time: 60sec; Partial thromboplastin time: 100sec. Appropriate management includes which of the following?

54) A 27-year-old woman, gravida 3, para 0 (termination of pregnancy ´ 3) comes to your office for an annual examination. Over the past year she has been in good health except for recurrent upper respiratory tract infections. She smokes ½ pack of cigarettes per day. She has tried to stop smoking three times but is not ready to try again to stop now. She takes a combined oral contraceptive pill (OCP) with 35μg of estrogen in it. She takes no other medications and has no known drug allergies. Physical examination, including breast and pelvic exams, is significant for intermittent wheezes on chest auscultation. Regarding her birth control choice, which of the following is the most appropriate counseling?

55) A 20-year-old female comes to the physician because she has never had a period. She has no medical problems, has never had surgery, and takes no medications. Examination shows that she is a tall female with long extremities. She has normal size breasts, although the areolas are pale. She has little axillary hair. Pelvic examination is significant for scant pubic hair and a short, blind-ended vaginal pouch. Which of the following is the most appropriate next step in the management of this patient?

56) A 22-year-old woman comes to the physician for an annual examination. She has been sexually active since the age of 15 and has not had regular Pap smears or examinations. She is currently sexually active with multiple partners and intermittently uses condoms. She has no medical problems and takes no medications. Her examination is unremarkable. Her Pap smear is described as satisfactory but limited by the absence of endocervical cells. It is otherwise within normal limits. Which of the following is the most appropriate next step in management?

57) A 19-year-old female comes to the physician because of left lower quadrant pain for 2 months. She states that she first noticed the pain 2 months ago but now it seems to be growing worse. She has had no changes in bowel or bladder function. She has no fevers or chills and no nausea, vomiting, or diarrhea. The pain is intermittent and sometimes feels like a dull pressure. Pelvic examination is significant for a left adnexal mass that is mildly tender. Urine hCG is negative. Pelvic ultrasound shows a 6 cm complex left adnexal mass with features consistent with a benign cystic teratoma (dermoid). Which of the following is the most appropriate next step in management?

58) A 25-year-old woman, gravida 2, para 1, at 22 weeks' gestation comes to the physician with complaints of burning with urination and frequent urination. Her prenatal course has been uncomplicated except for a urinary tract infection (UTI) with E. Coli at 12 weeks' gestation, which was treated at that time. Physical examination is unremarkable. Urine culture demonstrates greater than 100,000 colony-forming units per milliliter of E. coli. After treating this patient for her current infection, which of the following is the most appropriate next step in management?

59) A 22-year-old woman in labor progresses to 7 cm dilation, and then has no further progress. She therefore undergoes a primary cesarean section. Examination 2 days after the section shows a temperature of 39.1 C (102.4 F), blood pressure of 110/70 mm Hg, pulse of 90/min, and respirations of 14/min. Lungs are clear to auscultation bilaterally. Her abdomen is moderately tender. The incision is clean, dry, and intact, with no evidence of erythema. Pelvic examination demonstrates uterine tenderness. Which of the following is the most appropriate pharmacotherapy?

60) A 64-year-old woman undergoes a total abdominal hysterectomy and bilateral salpingo-oophorectomy for uterine prolapse. On postoperative day 1, a complete blood count shows the following: Leukocytes: 5500/mm3; Hematocrit: 36%; Platelets: 245,000/mm3. By postoperative day 2, the patient is alert and able to ambulate without difficulty. She has no complaints. She has not taken in nutrition orally but is receiving IV fluids. She is voiding without difficulty and has passed flatus. Her temperature is 37 C (98.6 F), blood pressure is 124/72 mm Hg, pulse is 86/min, and respirations are 12/min. Examination shows her abdomen to be soft, nontender, and non distended. The incision is clean, dry, and intact. The rest of the examination is unremarkable. Which of the following is a reason for keeping this patient hospitalized for a longer period of time?

61) A 39-year-old woman, gravida 3, para 2, at 40 weeks' gestation comes to the labor and delivery ward after a gush of fluid with regular, painful contractions every two minutes. She is found to have rupture of the membranes and to have a cervix that is 5 centimeters dilated, a fetus in vertex presentation, and a reassuring fetal heart rate tracing. She is admitted to the labor and delivery ward. Two hours later she states that she feels hot and sweaty. Temperature is 38.3 C (101 F). She has mild uterine tenderness. Her cervix is now 8 centimeters dilated and the fetal heart tracing is reassuring. Which of the following is the most appropriate management of this patient?

62) A 43-year-old primigravid woman at 10 weeks' gestation comes to the physician for a prenatal visit. She is feeling well except for some occasional nausea. She has had no bleeding from the vagina, abdominal pain, dysuria, frequency, or urgency. She has asthma for which she occasionally uses an inhaler. Examination is normal for a woman at 10 weeks gestation. Urine dipstick is positive for nitrites and leukocyte esterase and a urine culture shows 50,000 colony forming units per milliliter of Escherichia coli. Which of the following is the most appropriate next step in management?

63) A 29-year-old primigravid woman at 34 weeks' gestation comes to the physician for a prenatal visit. At 28 weeks, she failed her 50-g, 1-hour oral glucose-loading test. She also failed her follow-up 100-g, 3-hour oral glucose tolerance test, with a normal fasting glucose, but abnormal 1, 2, and 3-hour values. Over the past several weeks, she has maintained good control of her fasting and 2-hour postprandial glucose levels by adhering to the diet recommendations of her physician. She asks the physician what effect her type of diabetes can have on her or her fetus. Which of the following is the most appropriate response?

64) A 32-year-old, HIV-positive, primigravid woman comes to the physician for a prenatal visit at 30 weeks. Her prenatal course has been notable for her use of zidovudine (ZDV) during the pregnancy. Her viral load has remained greater than 1000 copies per milliliter of plasma throughout the pregnancy. She has no other medical problems and has never had surgery. Examination is appropriate for a 30-week gestation. She wishes to do everything possible to prevent the transmission of HIV to her baby. Which of the following is the most appropriate next step in management?

65) A 29-year-old G1P0 patient at 24 weeks gestational age presents to your office complaining of some shortness of breath that is more intense with exertion. She has no significant past medical history and is not on any medication. The patient denies any chest pain. She is concerned because she has always been very athletic and cannot maintain the same degree of exercise that she was accustomed to prior to becoming pregnant. On physical examination, her pulse is 72 beats per minute. Her blood pressure is 90/50 mm Hg. Cardiac examination is normal. The lungs are clear to auscultation and percussion. Which of the following is the most appropriate next step to pursue in the workup of this patient?

66) A 24-year-old primigravid woman at 10 weeks gestation is brought to the emergency department because of vaginal bleeding. She has colicky pain in the suprapubic region radiating to her back. Her temperature is 37.0C (98.7F), blood pressure is 110/76 mm Hg, pulse is 84/min, and respirations are 14/min. Physical examination shows a dilated cervix and the products of conception are seen through it. Blood is sent to the laboratory for type and antibody screen. The patient is treated with dilation and curettage and all products of conception are evacuated. She is stabilized and transferred to the ward. Her laboratory results are as follows: Hematocrit: 32%; Leukocyte count: 8,000 cells/μL; Blood type: AB; Rh-negative; Anti-Rh antibody titer: 1:4. Which of the following is the most appropriate next step in management?

67) A 29-year-old woman presents for a routine prenatal visit She is 24 weeks pregnant by last menstrual period and ultrasound. She does not have any medical problems and does not take any medications. She does not use tobacco, alcohol or illicit drugs. She works as a financial advisor in a local firm. She and her husband have been monogamous since getting married 5 years ago. Vital signs are normal. Physical examination shows no abnormalities. At the end of the visit she tells you that her newborn niece recently had a group B streptococcal infection and she is afraid that her child might develop the same. Which of the following is the most appropriate response?

68) The labor nurse calls you in your office regarding your patient who is 30 weeks pregnant and complaining of decreased fetal movement. The fetus is known to have a ventricular septal defect of the heart. The nurse has performed a nonstress test on the fetus. No contractions are seen. She thinks the tracing shows either a sinusoidal or saltatory fetal heart rate (FHR) pattern. Without actually reviewing the FHR tracing what can you tell the nurse?

69) You are counseling a 24-year-old woman who is a G2P1 at 36 weeks gestation. She delivered her first baby at 41 weeks gestation by cesarean section as a result of fetal distress that occurred during an induction of labor for mild preeclampsia. She would like to know if she can have a trial of labor with this pregnancy. Which of the following is the best response to this patient?

70) A 24-year-old woman with chronic hypothyroidism presents to her gynecologist for her annual examination. She recently got married, and she and her husband would like to conceive. Her hypothyroidism is well controlled and stable on thyroxine, and she has no other medical conditions. She is healthy and does not smoke or drink alcohol. She would like to know if she should keep taking her thyroxine. Which of the following is the best advice to give this patient?

71) A 32-year-old G3P3 woman is postoperative day 5 after an emergent cesarean section due to fetal distress. The patient progressed rapidly through passive labor without incident, but after her membranes were ruptured manually, a fetal scalp probe was placed in the active phase secondary to several runs of mid-late decelerations. Cesarean section was ultimately performed after 2 hours of active labor secondary to fetal distress. The patient presents now with a fever to 38.7C (101.7F) and uterine tenderness. Laboratory tests reveal a WBC count of 14,000/mm3, with 70% neutrophils and 4% bands. Which of the following is the most appropriate treatment?

72) A 32-year-old G3P3 woman presents to her obstetrician for help conceiving. She states her menstrual cycles have not been regular since the birth of her third child 3 years ago. Furthermore, although she readily became pregnant with her other three children, she has failed to become pregnant despite trying over the past 2 years. She has no significant past medical history and takes only prenatal vitamins. Although she says she has not been ill lately, she reports feeling “tired and cold all the time.” She also reports she has had trouble sleeping over the past several months. Her physical examination is normal. Laboratory tests show: WBC count: 9000/mm3; Hemoglobin: 8.0 g/dL; Platelet count: 300,000/mm3; Hematocrit: 40%; Thyroid-stimulating hormone level: 0.5 μU/mL; Free thyroxine: 2.0 ng/dL; Luteinizing hormone: 0.5 mU/mL; Follicle-stimulating hormone: 0.5 mU/mL. Which of the following will this woman likely need to take to conceive?

73) A 64-year-old woman undergoes left radical mastectomy for breast cancer. A 4-cm infiltrating ductal carcinoma is found on pathologic examination. Four of 20 axillary lymph nodes are positive for malignancy. Neoplastic cells are immunoreactive for estrogen and progesterone receptors. No evidence of metastatic disease is found on bone scanning with 99mTc-labeled phosphate or chest x-ray films. The patient receives appropriate radiation therapy and multidrug chemotherapy. Which of the following is the most appropriate adjunctive therapy in this setting?

74) A 23-year-old gravida 3, para 2 is admitted to the hospital at 31 weeks' gestation with painful uterine contractions. Her cervix is initially 3 cm dilated. Magnesium sulfate is started. Over the next 5 hours she progresses to full dilation. After a 1-hour second stage, she delivers a 2013-g (4-lb, 7-oz) newborn. In the neonatal intensive care unit, the infant develops respiratory distress and pneumonia. Over the following days the infant develops septicemia. Preliminary blood cultures demonstrate gram-positive cocci in chains. Treatment with which of the following would most likely have prevented this neonatal outcome?

75) A 32-year-old woman, gravida 3, para 2, at 30 weeks’ gestation comes to the hospital because of new onset painful, regular uterine contractions that began 5 hours ago. Her pregnancy has been uncomplicated. Her second pregnancy was complicated by preterm labor at 28 weeks’ gestation. She has no discharge, leakage of fluid or bleeding from the vagina; she has no dysuria or urgency. Her temperature is 37.0 C (98.7 F), blood pressure is 125/70 mmHg, pulse is 80/min and respirations are 18/min. Pelvic examination shows a soft, partially effaced and posterior cervix dilated to 2 cm. A Nitrazine test is negative. Non-stress test shows a reassuring fetal heart pattern and uterine contractions occurring every 7 minutes. Which of the following is the most appropriate next step in management?

76) A 17-year-old female comes to the physician's office for a routine physical examination. She has no complaints and has no previous medical problems. She has been having sex since the age of 14 and has had 3 sexual partners so far. Vital signs are stable and physical examination is unremarkable. Pap smear is performed and the report came back as "satisfactory for evaluation" and shows mild dysplasia (low grade intraepithelial lesion). Which of the following is the most appropriate next step in management?

77) A 33-year-old woman, gravida 1, para 0, comes for a routine prenatal visit. According to her history, she is at 18-weeks gestation. Her family history is significant for Down syndrome on her maternal side. She does not use tobacco, alcohol or drugs. Vital signs are normal, and physical examination is unremarkable. Initial laboratory studies show a decreased maternal serum alpha-fetoprotein (MSAFP). Which of the following is the most appropriate next step in management?

78) A 76-year-old woman presents with complaints of severe vulvar itching for the past six months. She has tried over-the-counter topical lubricants without relief. Physical examination reveals numerous vulvar excoriations. The vulvar skin is thin, dry and white in color. The labia minora are difficult to visualize. Which of the following is the most appropriate next step in management?

79) A 30-year-old G2 P 1woman at 38 weeks gestation presents to the hospital complaining of regular and painful uterine contractions that started two hours earlier. Pelvic examination reveals bulging membranes, and her cervix is 50% effaced and dilated to 3 cm. Her pregnancy was complicated by first trimester hemorrhage of unknown cause. Her past medical history is unremarkable. After placing a fetal heart monitor and an external tocometer on the patient, you note 3 separate 15 beat/min decreases in the fetal heart rate not coinciding with uterine contractions, each lasting for 25 seconds. Which of the following is the most appropriate next step in the management of this patient?

80) A 26-year-old G1 P1 woman requests contraception after delivering a healthy baby three weeks ago. She is breastfeeding the child and plans to continue for at least six months. She does not want to get pregnant for at least one year. She has no medical problems and does not take any medication. She does not use tobacco, alcohol or drugs. Physical examination shows no abnormalities. Which of the following is the most preferred method of contraception you can advise for this patient?

81) A Caucasian couple presents to your office for infertility evaluation. They are unable to conceive after 14 months of unprotected sex. The woman is 23 years of age. Her menstrual periods are regular, occurring every 26 days. She denies perimenstrual pain or pelvic discomfort. Her last menstrual period was six days ago. Her past medical history is insignificant, and bimanual examination is normal. The man is 27 years old, He is not taking any medications, Physical examination, including external genitals, is normal. What is the best next step in the management of this couple?

82) A 24-year-old, gravida 0, para 0 woman comes to the physician because of an 8-week history of amenorrhea. She is sexually active and uses oral contraceptive pills for contraception. Her only other complaints are moderate fatigue and a decline in mood. She denies headaches, visual disturbances, and gastrointestinal symptoms. She has no other medical problems. She socially drinks alcohol and does not use tobacco or illicit drugs. She denies stress at home or work. She walks 1-2 miles every day. Her BMI is 24 kg/m2. Visual field test is within normal limits. Examination shows no hirsutism. Breast examination reveals a white, milky secretion upon expression of both nipples. Pelvic examination reveals a uterus of normal size. Initial investigations reveal a negative serum β-human chorionic gonadotropin (hCG) level. According to these findings, which of the following is the most appropriate next step in management?

83) 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 (98.7F), 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?

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

85) An 81-year-old woman presents to your office complaining that her uterus fell out 2 months ago. She has multiple medical problems, including chronic hypertension, congestive heart failure, and osteoporosis. She is limited to sitting in a wheelchair because of her health problems. Her fallen uterus causes significant pain. On physical examination, the patient is frail and requires assistance with getting on the examination table. She has complete procidentia of the uterus. Which of the following is the most appropriate next step in the management of this patient?

86) A 78-year-old woman with chronic obstructive pulmonary disease, chronic hypertension, and history of myocardial infarction requiring angioplasty presents to your office for evaluation of something hanging out of her vagina. She had a hysterectomy for benign indications at age 48. For the past few months, she has been experiencing the sensation of pelvic pressure. Last month she felt a bulge at the vaginal opening. Two weeks ago something fell out of the vagina. On pelvic examination, the patient has total eversion of the vagina. There is a superficial ulceration at the vaginal apex. Which of the following is the best next step in the management of this patient?

87) A 38-year-old woman presents to your office complaining of urinary incontinence. Her symptoms are suggestive of urge incontinence. She admits to drinking several large glasses of iced tea and water on a daily basis because her mother always told her to drink lots of liquids to lower her risk of bladder infections. Urinalysis and urine culture are negative. After confirming the diagnosis with physical examination and office cystometrics, which of the following treatments should you recommend to the patient as the next step in the management of her problem?

88) A 45-year-old woman with previously documented urge incontinence continues to be symptomatic after following your advice for conservative self-treatment. Which of the following is the best next step in management?

89) A 23-year-old G3POA2 female presents to your clinic at an estimated 12 weeks of gestational age. She is a new patient and has come to your clinic to seek an elective abortion. She has had two elective abortions in the past because of unplanned pregnancy. She has no past medical history and takes no medications. Her physical examination is within normal limits and a limited ultrasound examination was able to detect fetal heart tones. You and your partners have a strict policy against performing abortions because some members of the group object to the procedure. You decide it would be best to stick to this policy; however, the patient becomes angry and tells you that she will sue you if you do not perform the procedure. What is the best response to this patient?

90) A 24-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the physician complaining of aching and swelling in both legs. The aching of her legs is worst at night. She has no shortness of breath or chest pain. She has no past medical history. Her temperature is 36.9 C (98.2F), blood pressure is 110/70 mm Hg, and pulse is 78/min. Physical examination shows symmetrical pitting edema of both calves with no tenderness of either calf. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

91) A 32-year-old woman presents to your office with dysuria, urinary frequency, and urinary urgency for 24 hours. She is healthy but is allergic to sulfa drugs. Urinalysis shows large blood, leukocytes, and nitrites in her urine. Which of the following medications is the best to treat this patient’s condition?

92) You are seeing a patient in the emergency room who complains of fever, chills, flank pain, and blood in her urine. She has had severe nausea and started vomiting after the fever developed. She was diagnosed with a urinary tract infection 3 days ago by her primary care physician. The patient never took the antibiotics that she was prescribed because her symptoms improved after she started drinking cranberry juice. The patient has a temperature of 38.8C (102F). She has severe right-sided CVA tenderness. She has severe suprapubic tenderness. Her clean-catch urinalysis shows a large amount of ketones, RBCs, WBCs, bacteria, and squamous cells. Which of the following is the most appropriate next step in the management of this patient?

93) A 22-year-old woman has been seeing you for treatment of recurrent urinary tract infections over the past 6 months. She married 6 months ago and became sexually active at that time. She seems to become symptomatic shortly after having sexual intercourse. Which of the following is the most appropriate recommendation for this patient to help her with her problem?

94) A 17-year-old married girl comes to see you, complaining of “feeling tired all the time,” vomiting in the morning, and weight gain. Examination shows signs of pregnancy that is confirmed by laboratory studies. When informed of this, the girl is visibly distraught. “How could this happen?” she says, “I’ve been on the pill!” Mentioning that she and her husband live with her parents, she declares that she wants an immediate abortion. Which of the following is the best reply?

95) A 32-year-old woman comes to the physician because of amenorrhea. She had menarche at age 13 and has had normal periods since then. However, her last menstrual period was 8 months ago. She also complains of an occasional milky nipple discharge. She has no medical problems and takes no medications. She is particularly concerned because she would like to become pregnant as soon as possible. Examination shows a whitish nipple discharge bilaterally, but the rest of the examination is unremarkable. Urine human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is normal. Prolactin is elevated. Head MRI scan is unremarkable. Which of the following is the most appropriate pharmacotherapy?

96) A 32-year-old woman, gravida 3, para 2, at 14 weeks' gestation comes to the physician for a prenatal visit. She has some mild nausea, but otherwise no complaints. She has no significant medical problems and has never had surgery. She takes no medications and has no known drug allergies. She is concerned for two reasons. First, the "flu season" is coming, and she seems to get sick every year. Second, a child at her son's daycare center recently broke out with welts and was sent home. Which of the following vaccinations should this patient most likely be given?

97) A 35-year-old woman, gravida 3, para 2, at 39 weeks' gestation, comes to the labor and delivery ward with contractions. Past obstetric history is significant for two normal spontaneous vaginal deliveries at term. Examination shows the cervix to be 4 centimeters dilated and 50% effaced. The patient is contracting every 4 minutes. Over the next 2 hours the patient progresses to 5-centimeters dilation. An epidural is placed. Artificial rupture of membranes is performed, demonstrating copious clear fluid. 2 hours later the patient is still at 5centimeters dilation and the contractions have spaced out to every 10 minutes. Which of the following is the most appropriate next step in management?

98) A 54-year-old female comes to the physician because of involuntary loss of urine. She states "Doc, whenever I laugh, cough, or sneeze, I am unable to hold my urine. I am afraid to leave the house." She has no involuntary loss of urine while sleeping. She had a hysterectomy four years ago. She has had no trauma to her head or back. She has no other medical problems and takes no medications. Physical examination shows a relaxed anterior vaginal wall. Neurological examination shows no abnormalities. A cotton-tipped swab test reveals a urethral straining angle of 45 degrees when intra-abdominal pressure is increased. Urinalysis shows no abnormalities. Which of the following is most beneficial long-term management for this patient?

99) 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?

100) 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?