DES 2016. Final (Part 38)

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

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

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

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

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

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

167) A 20-year-old primigravid woman at 32 weeks gestation comes to the physician because of swelling in her hands and ankles. She has no headache, visual disturbances or epigastric pain. She has no previous medical problems. She does not use tobacco, alcohol or illicit drugs. Her previous prenatal check-up at 28 weeks gestation was normal. Her medical records show no preexisting hypertension or proteinuria. Her blood pressure is 156/100 mmHg, and after 15 minutes of lateral rest, a repeat reading is 154/98 mmHg. Physical examination shows 2+ pitting edema in both legs and hands. Deep tendon reflexes are normal. Fundoscopic examination shows no abnormalities. Fetal heart tones are audible by Doppler. Laboratory studies show: Hb: 13.0 g/dl, Hct: 50%, Platelets: 300,000/mm3, Creatinine: 1.1 mg/dl. 24-hours urine protein excretion is 1gm, which is new. Which of the following is the most likely diagnosis?

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

169) A 38-year-old G1P0 presents to the obstetrician’s office at 37 weeks gestational age complaining of a rash on her abdomen that is becoming increasingly pruritic. The rash started on her abdomen, and the patient notes that it is starting to spread downward to her thighs. The patient reports no previous history of any skin disorders or problems. She denies any malaise or fever. On physical examination, she is afebrile and her physician notes that her abdomen, and most notably her stretch marks, is covered with red papules and plaques. No excoriations or bullae are present. The patient’s face, arms, and legs are unaffected by the rash. Which of the following is this patient’s most likely diagnosis?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

191) A 22-year-old G1 at 34 weeks is tested for tuberculosis because her father, with whom she lives, was recently diagnosed with tuberculosis. Her skin test is positive and her chest x-ray reveals a granuloma in the upper left lobe. Which of the following is true concerning infants born to mothers with active tuberculosis?

192) A 21-year-old G1 at 40 weeks, who underwent induction of labor for severe preeclampsia, delivered a 3900-g male infant via vaginal delivery after pushing for 21/2 hours. A second-degree midline laceration and sidewall laceration were repaired in the usual fashion under local analgesia. The estimated blood loss was 450 cc. Magnesium sulfate is continued postpartum for the seizure prophylaxis. Six hours after the delivery, the patient has difficulty voiding. Which is the most likely cause of her problem?

193) Three days ago you delivered a 40-year-old G1P1 by cesarean section following arrest of descent after 2 hours of pushing. Labor was also significant for prolonged rupture of membranes. The patient had an epidural, which was removed the day following delivery. The nurse pages you to come to see the patient on the postpartum floor because she has a fever of 38.8C (102F) and is experiencing shaking chills. Her blood pressure is 120/70 mm Hg and her pulse is 120 beats per minute. She has been eating a regular diet without difficulty and had a normal bowel movement this morning. She is attempting to breast-feed, but says her milk has not come in yet. On physical examination, her breasts are mildly engorged and tender bilaterally. Her lungs are clear. Her abdomen is tender over the fundus, but no rebound is present. Her incision has some serous drainage at the right apex, but no erythema is noted. Her pelvic examination reveals uterine tenderness but no masses. Which of the following is the most likely diagnosis?

194) A 34-year-old G1P1 who delivered her first baby 5 weeks ago calls your office and asks to speak with you. She tells you that she is feeling very overwhelmed and anxious. She feels that she cannot do anything right and feels sad throughout the day. She tells you that she finds herself crying all the time and is unable to sleep at night. Which of the following is the most likely diagnosis?

195) A 40-year-old G4P5 at 39 weeks gestation has progressed rapidly in labor with a reassuring fetal heart rate pattern. She has had an uncomplicated pregnancy with normal prenatal labs, including an amniocentesis for advanced maternal age. The patient begins the second stage of labor and after 15 minutes of pushing starts to demonstrate deep variable heart rate accelerations. You suspect that she may have a fetus with a nuchal cord. You expediently deliver the baby by low-outlet forceps and hand the baby over to the neonatologists called to attend the delivery. As soon as the baby is handed off to the pediatric team, it lets out a strong spontaneous cry. The infant is pink with slightly blue extremities that are actively moving and kicking. The heart rate is noted to be 110 on auscultation. What Apgar score should the pediatricians assign to this baby at 1 minute of life?

196) A 32-year-old G2P1 at 41 weeks is undergoing an induction of oligohydramnios. During the course of her labor, the fetal heart rate tracing demonstrates severe variable decelerations that do not respond to oxygen, fluid, or amnioinfusion. The patient’s cervix is dilated to 4 cm. A low-transverse cesarean delivery is performed for nonreassuring fetal heart tones. After delivery of the fetus you send a cord gas, which comes back with the following arterial blood values: pH 7.29, Pco2: 50, and Po2: 20. What condition does the cord blood gas indicate?

197) A 25-year-old G1P1 comes to see you 6 weeks after an uncomplicated vaginal delivery for a routine postpartum examination. She denies any problems and has been breast-feeding her newborn without any difficulties since leaving the hospital. During the bimanual examination, you note that her uterus is irregular, firm, nontender, and about a 15-week size. Which of the following is the most likely etiology for this enlarged uterus?

198) A 74-year-old woman presents to your office for well-woman examination. Her last Pap smear and mammogram were 3 years ago. She has hypertension, high cholesterol, and osteoarthritis. She stopped smoking 15 years ago, and denies alcohol use. Based on this patient’s history which of the following medical conditions should be this patient’s biggest concern?

199) A 16-year-old G0 female presents to your office for a routine annual gynecologic examination. She reports that she has previously been sexually active, but currently is not dating anyone. She has had three sexual partners in the past and says she diligently used condoms. She is a senior in high school and is doing well academically and has many friends. She lives at home with her parents and a younger sibling. She denies any family history of medical problems, but says her 80-year-old grandmother was recently diagnosed with breast cancer. She denies any other family history of cancer. She says she is healthy and has no history of medical problems or surgeries. She reports having had chicken pox. She smokes tobacco and drinks beer occasionally, but denies any illicit drug use. She had her first Pap smear and gynecologic examination last year with another doctor and reports that everything was normal. Her menses started at age 13 and are regular and light. She denies any dysmenorrhea. Her blood pressure is 90/60 mm Hg. Her height is 5ft 6 in and she weighs 130 lb. Based on this patient’s history, what would be the most likely cause of death if she were to die at age 16?

200) A married 41-year-old G5P3114 presents to your office for a routine examination. She reports being healthy except for a history of migraine headaches. All her Pap smears have been normal. She developed gestational diabetes in her last pregnancy. She drinks alcohol socially, and admits to smoking occasionally. Her grandmother was diagnosed with ovarian cancer when she was in her fifties. Her blood pressure is 140/90 mm Hg; height is 5ft 5 in; weight is 150 lb. Which of the following is the most common cause of death in women of this patient’s age?

201) A 34-year-old woman comes to the physician for evaluation of vulvar lesions. Examination reveals multiple small teardrop shaped growths at the vestibule of the vulva. Application of trichloroacetic acid results incomplete resolution of the lesions. Which of the following is the most likely cause of her lesions?

202) A 36-year-old G2P2 presents for her well-woman examination. She has had two spontaneous vaginal deliveries without complications. Her largest child weighed 3500 g at birth. She uses oral contraceptive pills and denies any history of an abnormal Pap smear. She does not smoke, but drinks about four times per week. Her weight is 70 kg. Her vital signs are normal. After placement of the speculum, you note a clear cyst approximately 2.5 cm in size on the lateral wall of the vagina on the right side. The cyst is nontender and does not cause the patient any dyspareunia or discomfort. Which of the following is the most likely diagnosis of this mass?

203) A 24-year-old nullipara is being evaluated for infertility. On pelvic examination, she has a single cervix. A diagnostic laparoscopy shows a double uterine fundus. Which of the following is the most likely diagnosis of her uterine anomaly?

204) A 58-year-old G6P4Ab2 diabetic woman who weighs 122.6 kg (270 lb) has her first episode of vaginal bleeding in 5 years. Her physician performs an outpatient operative hysteroscopy and dilatation and curettage (D&C). Which of the following is an indication for the procedure and the most likely diagnosis?

205) A 53-year-old obese, postmenopausal woman presents to your office for a routine annual examination. Her last menstrual period was one year ago. Upon further questioning, she says that she sometimes experiences hot flashes of mild intensity. She is sexually active and denies vaginal dryness or dyspareunia. She has mild hypertension managed with hydrochlorothiazide and a salt-reduced diet. Her obstetrical history is significant for an elective termination of pregnancy at 35 years of age because of an abnormal MSAFP. Physical examination is normal. What is the most likely cause of the mild nature of the symptoms the patient is having?

206) 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 2cm 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?

207) A 19-year-old primigravid woman at 39 weeks’ gestation is in active labor, and her cervix is 4 cm dilated, 90% effaced. Her amniotic membranes have been ruptured for 4 hours. Contractions are strong at 2- to 3-minute intervals and of 60- to 70-second duration. For the past 30 minutes, repetitive variable decelerations of the fetal heart rate have occurred. They have lasted 60–90 seconds, and the fetal heart rate has dropped as low as 60 beat per minute (BPM). You explain that there is a risk that the baby will become hypoxic and recommend a cesarean section. She refuses. Which of the following is the most appropriate course of action?

208) A 24-year-old woman has a MSAFP of 0.5 MOM (multiples of the median) at 17 weeks’ gestation. Which of the following fetal abnormalities is most likely to occur with this MSAFP?

209) A 69-year-old woman with diabetes mellitus complains of urinary incontinence. Her diabetes is well controlled with oral hypoglycemic agents. She has no complaints other than the wetness. Which of the following tests is most likely to demonstrate the cause?

210) A 48-year-old G5P5 woman has genuine stress incontinence (GSI). Kegel exercises have not helped, and her incontinence is gradually worsening. Her urethrovesical junction (UVJ) is prolapsed into the vagina, and her urethral closure pressure is normal. Which of the following procedures will most likely cure her incontinence?

211) A 51-year-old woman comes to your office for a routine health maintenance examination. She says that she has been having irregular menses and occasional hot flashes for the past eight months. She has a very stressful job and drinks two to three cups of coffee every morning. She does not smoke, but drinks two to three ounces of alcohol daily. She eats a pure vegetarian diet and walks two miles on a treadmill each day. Her vital signs are within normal limits. Her BMI is 31 kg/m2 Physical examination is unremarkable. You inform her that she is probably reaching menopause, and that she will be at an increased risk of developing osteoporosis. Which of the following is the most significant risk factor for the development of osteoporosis in this patient?

212) A 16-year-old female presents to the ER complaining of left lower quadrant abdominal pain that started suddenly 24 hours ago. The pain does not radiate and is 5/ 10 in severity. She denies having fevers, vomiting, dysuria, diarrhea or vaginal bleeding. Her last menstrual period was two weeks ago. She takes no medications. On physical examination, her temperature is 37.20C (98.9.F), blood pressure is 11 0/65 mmHg, pulse is 80/min and respirations are 14/min. There is mild left lower quadrant tenderness without rebound or rigidity, and the remainder of the examination is unremarkable. Which of the following is the most likely diagnosis?

213) 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?

214) A 26-year-old woman complains of a vaginal discharge causing burning and itching of the perineum. The pH of the discharge is 4.5. Which of the following is the most likely cause of her discharge?

215) A 45-year-old woman has bilateral breast pain that is most severe premenstrually. On palpation, there is excessive nodularity, tenderness, and cystic areas that diminish in size after menses. Which of the following is the most likely diagnosis?

216) A 19-year-old nulligravid woman at 38 weeks' gestation comes to her physician because she has passed bloody mucus discharge. Her prenatal course was unremarkable including a normal 19-week ultrasound. On speculum examination, there are no vaginal or cervical lesions. On vaginal examination, the cervix is 2 cm dilated and 100% effaced, and the fetus is at +1 station. The fetal heart rate has a baseline of 140 and is reactive. She has painful contractions every 2 minutes. One hour later the patient's cervix is 3 cm dilated, and a small amount of bloody mucus is noted on the examining glove. Which of the following is the most likely diagnosis?

217) A 33-year-old, white woman, gravida 3, para 2, at 37 weeks' gestation comes to the emergency department because of painful uterine contractions and heavy vaginal bleeding that started after she used intranasal cocaine. The patient's prenatal course was significant because she conceived while on the oral contraceptive pill, she occasionally used cocaine and heroin during the pregnancy, and she was found to be positive for group B Streptococcus colonization at 35 weeks. Fetal monitoring is not reassuring. The patient undergoes cesarean section, at which the uterus has a bluish hue. On inspection, the placenta is noted to have an adherent, retroplacental clot on 50% of its surface. Which of the following is the most likely initiating factor for this patient's presentation?

218) A 64-year-old woman comes to the physician because she is "leaking" urine. She states that, over the past 3 years, she has had incontinence several times daily. She describes these episodes as small squirts of urine that come out whenever she laughs, coughs, sneezes, or engages in physical activity. Physical examination shows mild uterine prolapse and a moderate cystocele. Urine culture is negative. Postvoid residual is 25 ml (normal <50 mL) Cystometrogram is normal. Which of the following is the most likely diagnosis?

219) A 50-year-old woman is diagnosed with cervical cancer. Which lymph node group would be the first involved in metastatic spread of this disease beyond the cervix and uterus?

220) A 51-year-old woman is diagnosed with invasive cervical carcinoma by cone biopsy. Pelvic examination and rectal-vaginal examination reveal the parametrium to be free of disease, but the upper portion of the vagina is involved with tumor. Intravenous pyelography (IVP) and sigmoidoscopy are negative, but a computed tomography (CT) scan of the abdomen and pelvis shows grossly enlarged pelvic and periaortic nodes. This patient is classified at which of the following stages?

221) A 70-year-old woman presents for evaluation of a pruritic lesion on the vulva. Examination shows a white, friable lesion on the right labia majora that is 3 cm in diameter. No other suspicious areas are noted. Biopsy of the lesion confirms squamous cell carcinoma. In this patient, lymphatic drainage characteristically would be first to which of the following nodes?

222) A postmenopausal woman presents with pruritic white lesions on the vulva. Punch biopsy of a representative area is obtained. Which of the following histologic findings is consistent with the diagnosis of lichen sclerosus?

223) At the time of annual examination, a patient expresses concern regarding possible exposure to sexually transmitted diseases. During your pelvic examination, a single, indurated, nontender ulcer is noted on the vulva. Venereal Disease Research Laboratory (VDRL) and fluorescent treponemal antibody (FTA) tests are positive. Without treatment, the next stage of this disease is clinically characterized by which of the following?

224) A 7-year-old girl is brought to your office by her parents after they noticed the development of axillary and pubic hair 3 months ago. The girl has also experienced a significant growth spurt over the past year. There has been no change in her behavior or school performance. The girl denies headaches, vomiting or visual disturbances. Her personal and family medical histories are unremarkable. On examination, you note the presence of axillary hair, pubic hair at Tanner stage 2, and breast development at Tanner stage 3. Abdominal, genital and neurologic examinations reveal nothing abnormal. Her bone age is more than two standard deviations above normal. Serum FSH and LH levels are elevated. MRI of the brain is normal. Which of the following is the most likely cause of her symptoms?

225) 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?

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

227) 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 3cm dilated. Amniotomy is performed and a bloody show is noted. Immediately after the rupture of membranes, the baseline fetal heart rate increases to 160 beats/min and then drops to 70 beats/min. As labor progresses, repetitive late decelerations are noted, as well as an increase in 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?

228) A 20-year-old woman, gravida 1, para 0, at 36 weeks gestation comes to the physician because of diffuse headache, blurry vision and epigastric pain. She has no previous history of hypertension, renal disease or neurologic disease. Her mother has a history of migraine headaches. Her temperature is 37.2 C (98.9 F), blood pressure is 200/126 mmHg and pulse is 80/min. Physical examination shows bilateral lower extremity edema. Deep tendon reflexes are exaggerated. Laboratory studies show: Blood urea nitrogen (BUN) 23 mg/dl, Serum creatinine 1.6 mg/dl, Blood glucose 98 mg/dl. Urinalysis: Protein: 4+, Blood: negative, Glucose: negative, WBC: 1-2/hpf, RBC: 1-2/hpf, Casts: none. Fetal heart tones are heard by Doppler. While evaluating her, she suddenly develops generalized tonic-clonic convulsions. Which of the following is the most accurate diagnosis of this new event?

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

230) A 23-year-old woman, gravida 2, para 1, at 38 weeks' gestation was admitted to the delivery room for management of labor. On admission 6-hours ago, the patient was in the active phase of labor and the cervix was 4cm dilated. She was then placed under external tocometer and epidural anesthesia. Contractions were regular, occurring 2-3 minutes apart and lasting 40-60 seconds. She progressed well to 7cm. However, she has remained at 7cm the past 4 hours. The fetus is in the Left Occipita Anterior (LOA) position and at +1 station. Internal pelvic assessment shows prominent ischial spines. Electronic fetal heart monitoring shows 140 bpm with normal beat-to-beat and long term variability. Prenatal ultrasound at 37-weeks showed no abnormalities. Which of the following is the most likely cause of this patient's anomaly of labor?

231) 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 (98.4F), 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?

232) A 28-year-old male comes for evaluation of infertility. He has been healthy and otherwise has no complaints. He says the he eats a high protein diet and exercises daily in order to be muscular. He weighs 85 kg (187 1b) and is 175cm (70 in) tall. His temperature is 37.2 C (98.9 F), and his blood pressure is 130/82 mmHg. Physical examination shows small testes. The remainder of the examination is unremarkable. Initial laboratory studies show: Hemoglobin: 16.0 g/L, Platelets: 200,000/mm3, Leukocyte count: 4,500/mm3, Serum creatinine: 1.4 mg/dl, Serum LH: low, Serum testosterone: low. Which of the following is the most likely cause of his infertility?

233) A 14-year-old female is brought to the physician's office for evaluation of excessive menstrual bleeding. She experienced menarche at age 13, and since then her menses have been irregular and unpredictable. Her last menstrual period was 6 weeks ago and for the past week she has been having heavy menstrual bleeding. She has never been sexually active. Vital signs are stable. Her external genitalia are normal. She refused pelvic examination, and a pregnancy test is negative. Which of the following is the most likely cause of her symptoms?

234) 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?

235) 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 36.7C (98F), 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?

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

237) A 24-year-old female and her husband come to the physician's office for evaluation of infertility. They have not been able to conceive after 12 months of frequent intercourse without contraception. She has no other medical problems and takes no medication. Physical examination shows an obese woman with excess thick hair over her chin and along the linea alba of the lower abdomen. There is no increase in muscles mass. When asked about the excess hair, she states that she has had it for a long time. Serum testosterone levels are elevated. Which of the following is the most likely cause of her infertility?

238) 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?

239) A 24-year-old G0 presents to your office complaining of vulvar discomfort. More specifically, she has been experiencing intense burning and pain with intercourse. The discomfort occurs at the vaginal introitus primarily with penile insertion into the vagina. The patient also experiences the same pain with tampon insertion and when the speculum is inserted during a gynecologic examination. The problem has become so severe that she can no longer have sex, which is causing problems in her marriage. She is otherwise healthy and denies any medical problems. She is experiencing regular menses and denies any dysmenorrhea. On physical examination, the region of the vulva around the vaginal vestibule has several punctate, erythematous areas of epithelium measuring 3 to 8 mm in diameter. Most of the lesions are located on the skin between the two Bartholin glands. Each inflamed lesion is tender to touch with a cotton swab. Which of the following is the most likely diagnosis? Obstetric gynecology pretest 12th 319?

240) A 29-year-old G0 comes to your office complaining of a vaginal discharge for the past 2 weeks. The patient describes the discharge as thin in consistency and of a grayish white color. She has also noticed a slight fishy vaginal odor that seems to have started with the appearance of the discharge. She denies any vaginal or vulvar pruritus or burning. She admits to being sexually active in the past, but has not had intercourse during the past year. She denies a history of any sexually transmitted diseases. She is currently on no medications with the exception of her birth control pills. Last month she took a course of amoxicillin for treatment of a sinusitis. On physical examination, the vulva appears normal. There is a discharge present at the introitus. A copious, thin, whitish discharge is in the vaginal vault and adherent to the vaginal walls. The vaginal pH is 5.5. The cervix is not inflamed and there is no cervical discharge. Wet smear of the discharge indicates the presence of clue cells. Which of the following is the most likely diagnosis?

241) A 20-year-old G2P0020 with an LMP 5 days ago presents to the emergency room complaining of a 24-hour history of increasing pelvic pain. This morning she experienced chills and a fever, although she did not take her temperature. She reports no changes in her urine or bowel habits. She has had no nausea or vomiting. She is hungry. She denies any medical problems. Her only surgery was a laparoscopy performed last year for an ectopic pregnancy. She reports regular menses and denies dysmenorrhea. She is currently sexually active. She has a new sexual partner and had sexual intercourse with him just prior to her last menstrual period. She denies a history of any abnormal Pap smears or sexually transmitted diseases. Urine pregnancy test is negative. Urinalysis is completely normal. WBC is 18,000. Temperature is 38.8C (102F). On physical examination, her abdomen is diffusely tender in the lower quadrants with rebound and voluntary guarding. Bowel sounds are present but diminished. Which of the following is the most likely diagnosis?

242) A 43-year-old G2P2 comes to your office complaining of an intermittent right nipple discharge that is bloody. She reports that the discharge is spontaneous and not associated with any nipple pruritus, burning, or discomfort. On physical examination, you do not detect any dominant breast masses or adenopathy. There are no skin changes noted. Which of the following conditions is the most likely cause of this patient’s problem?

243) A 20-year-old G0, LMP 1 week ago, presents to your gynecology clinic complaining of a mass in her left breast that she discovered during routine breast self-examination in the shower. When you perform a breast examination on her, you palpate a 2-cm firm, nontender mass in the upper inner quadrant of the left breast that is smooth, well-circumscribed, and mobile. You do not detect any skin changes, nipple discharge, or axillary lymphadenopathy. Which of the following is the most likely diagnosis?

244) A mother brings her 12-year-old daughter in to your office for consultation. She is concerned because most of the other girls in her daughter’s class have already started their period. She thinks her daughter hasn’t shown any evidence of going into puberty yet. Knowing the usual first sign of the onset of puberty, you should ask the mother which of the following questions?

245) A 9-year-old girl presents for evaluation of regular vaginal bleeding. History reveals thelarche at age 7 and adrenarche at age 8. Which of the following is the most common cause of this condition in girls?

246) A 55-year-old woman presents to your office for consultation regarding her symptoms of menopause. She stopped having periods 8 months ago and is having severe hot flushes. The hot flushes are causing her considerable stress. What should you tell her regarding the psychological symptoms of the climacteric?

247) An 18-year-old patient presents to you for evaluation because she has not yet started her period. On physical examination, she is 5ft 7 in tall. She has minimal breast development and no axillary or pubic hair. On pelvic examination, she has a normally developed vagina. A cervix is visible. The uterus is palpable, as are normal ovaries. Which of the following is the best next step in the evaluation of this patient?

248) A mother brings her daughter in to see you for consultation. The daughter is 17 years old and has not started her period. She is 4ft 10 in tall. She has no breast budding. On pelvic examination, she has no pubic hair. By digital examination, the patient has a cervix and uterus. The ovaries are not palpable. As part of the workup, serum FSH and LH levels are drawn and both are high. Which of the following is the most likely reason for delayed puberty and sexual infantilism in this patient?

249) A 30-year-old female comes to your office for her first prenatal visit. She has been married for 3-years and has been trying to conceive for the past year. She had been unsuccessful; however, she now has a 2-month history of amenorrhea. She has been experiencing morning sickness and has had abdominal distension and breast fullness over the past two weeks. She states that her home urine pregnancy test is positive. She seems happy and excited about this long awaited pregnancy. She has no previous medical problems. She has been taking prenatal vitamins for the past 3 weeks after she first missed her period. Physical examination shows a tympanic abdomen. Ultrasonogram shows a normal endometrial stripe. Pregnancy testing in the office is negative. Which of the following is the most likely diagnosis?

250) 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 not 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?

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

252) Select the most likely diagnosis. A. Child abuse B. Foreign body C. Trichomonas vaginitis D. Bacterial vaginosis E. Candidiasis A 25-year-old woman presents to the physician's office for evaluation of foul-smelling vaginal discharge. She has been sexually active with a new partner for the past month. Physical examination reveals a thin, whitish-gray vaginal discharge. There is no discharge from the cervical os, and there is no adnexal or cervical motion tenderness. The remainder of the examination is normal. The pH of the vaginal fluid is 5.0. When KOH is added to vaginal discharge on a slide, an amine-like ("fishy") odor is perceived. A wet mount of the fluid reveals many epithelial cells with adherent bacteria. No polymorphonuclear cells are seen.

253) A 24-year-old woman comes to the physician for her third prenatal check-up at 12 weeks gestation. She has been feeling well for the last 4 weeks because she no longer has nausea and vomiting. She had a small dark brown discharge 4 weeks ago, but it stopped spontaneously. Physical examination shows the cervix is closed and fetal heart tones are not heard. Real-time ultrasonogram shows a collapsed gestational sac with absent fetal heart motion. Urine pregnancy test is positive. Which of the following is the most likely diagnosis?

254) A 21-year-old G0 presents to your office because her menses is 2 weeks late. She states that she is taking her birth control pills correctly; she may have missed a day at the beginning of the pack, but took it as soon at she remembered. She denies any medical problems, but 3 or 4 weeks ago she had a “viral stomach flu” and missed 2 days of work for nausea, vomiting, and diarrhea. Her cycles are usually regular even without contraceptive pills. She has been on the pill for 5 years and recently developed some midcycle bleeding, which usually lasts about 2 days. She has been sexually active with the same partner for the past 3 months and has a history of chlamydia 3 years ago. She has had a total of 10 sexual partners. A urine pregnancy test is positive. Which of the following is the major cause of unplanned pregnancies in women using oral contraceptives?

255) A 15-year-old girl is being evaluated for primary amenorrhea. She is otherwise healthy and has no previous medical problems. Vital signs are within normal limits. Physical examination reveals normal breast development, normal pubic and axillary hair, and a blind vagina; the uterus and adnexae could not be appreciated. Pelvic ultrasonography reveals 2 ovaries and no uterus is seen. The karyotype is 46 XX. Which of the following is the most likely diagnosis?

256) A 23-year-old woman presents to your office with the complaint of a red splotchy rash on her chest that occurs during intercourse. It is nonpuritic and painless. She states that it usually resolves within a few minutes to a few hours after intercourse. Which of the following is the most likely cause of the rash?

257) A 62-year-old woman presents for annual examination. Her last spontaneous menstrual period was 9 years ago, and she has been reluctant to use postmenopausal hormone replacement because of a strong family history of breast cancer. She now complains of diminished interest in sexual activity. Which of the following is the most likely cause of her complaint?

258) 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?

259) A 34-year-old sexually active female comes to your office because of urinary frequency and dysuria for two days. She has had two such episodes in the past, each treated with oral antibiotics. Physical examination reveals suprapubic tenderness and her urinalysis is positive for nitrite, leukocyte esterase, many WBC, and a moderate amount of bacteria. Which of the following is the most common reason for the higher incidence of urinary tract infections in females than in males?

260) A 31-year-old woman comes to the physician because she has not had a menstrual period for 7 months. She previously had normal cycles. She also states that over the past year she has felt increasingly weak and tired. She notes that she always feels cold and that her hair has been thinning over the course of the year. She also complains of constipation, weight gain, and depression. Her temperature is 36.7 C (98 F), blood pressure is 100/60 mmHg, pulse is 56/minute, and respirations are 10/minute. Examination is significant for brittle hair and delayed deep tendon reflexes. Urine human chorionic gonadotropin (hCG) is negative. Thyroid stimulating hormone (TSH) is 20 μU/mL. Prolactin is normal. Which of the following is the most likely cause of this patient's amenorrhea?