( New ) Part 7 (1530-1563 ) (1530- 1784) Pogba KH 1

A 25-year-old G2 P1 woman at 12 weeks gestation comes to the physician because of foul smelling vaginal discharge. She is sexually active and reports no previous problems. Speculum examination reveals a grayish, foul smelling discharge, but no erythema or edema is noted on the vaginal walls or the vulva. There is no cervical or adnexal tenderness. A saline wet mount examination reveals numerous epithelial cells coated with bacteria. No white blood cells are seen. Which of the following is the most appropriate pharmacotherapy for this patient?

A 20-year-old woman presents with complaints of vaginal discharge and vulvar pruritus. She has no other medical problems. Physical examination reveals a thin, malodorous vaginal discharge and erythema of the vulva and vaginal mucosa. No other exam abnormalities are noted. Wet-mount preparation of the discharge shows motile pear-shaped organisms. Which of the following management options is most appropriate?

A 28-year-old woman comes to the physician's office at 30 weeks gestation because she has not felt her baby's movements for the past week. Fetal heart tones are not heard by Doppler. An ultrasound shows an absence of fetal cardiac activity. Fetal demise is diagnosed. She underwent a cesarean section for her previous delivery to avoid a post-term pregnancy. She has no other medical problems. Vital signs are normal and physical examination shows no abnormalities. Her cervix is 3 cm dilated and 70 percent effaced. Laboratory studies show a platelet count of 230,000/mm and a fibrinogen level of 480 mg/dl(normal: 150-450mg/dl). Both the patient and her husband are shocked after hearing the news of fetal demise. Which of the following is the most appropriate next step in management?

An intrauterine pregnancy of approximately 10 weeks gestation is confirmed in a 30-year-old G5P4 woman with an IUD in place. The patient expresses a strong desire for the pregnancy to be continued. On examination, the string of the IUD is noted to be protruding from the cervical os. Which of the following is the most appropriate course of action?

A 34-year-old G1P1 with a history of pulmonary embolism presents to your office to discuss contraception. Her cycles are regular. She has a history of pelvic inflammatory disease last year, for which she was hospitalized. She has currently been sexually active with the same partner for the past year. She wants to use condoms and a spermicide. You counsel her on the risks and benefits. Which of the following statements is true regarding spermicides found in vaginal foams, creams, and suppositories?

A 32-year-old woman presents to your office for her well-woman examination. She is also worried because she has not been able to achieve orgasm with her new partner, with whom she has had a relationship for the past 3 months. She had three prior sexual partners and achieved orgasm with them. She is taking a combined oral contraceptive pill for birth control and an antihypertensive medication for chronic hypertension. She has also been on fluoxetine for depression for the past 2 years. She smokes one pack per day and drinks one drink per week. She had a cervical cone biopsy for severe cervical dysplasia 6 months ago. Which of the following is the most likely cause of her sexual dysfunction?

A 19-year-old woman presents for voluntary termination of pregnancy 6 weeks after her expected (missed) menses. She previously had regular menses every 28 days. Pregnancy is confirmed by β-human chorionic gonadotropin (β-hCG), and ultrasound confirms expected gestational age. Which of the following techniques for termination of pregnancy would be safe and effective in this patient at this time?

A 35-year-old female complains of nipple discharge. The discharge is from both breasts, brown in color and occurs intermittently. She has two children who are 5 and 8 years old. She has not been recently pregnant. Her last menstrual period was one week ago. She describes no other symptoms. Examination shows normal breasts without palpable lumps or nipple abnormalities. Brownish discharge is expressed from the nipples, and it is guaiac negative. Which of the following is the most appropriate next step in management?

A 27-year-old female comes to the physician's office for evaluation of infertility. She has not been able to conceive for 12 months despite frequent intercourse. Her menses started at age 12 and have always been irregular. She uses over the counter acne medications. She is also obese and has been unsuccessful with weight loss. Physical examination shows an obese woman with sparse hair over the upper lip. There is no galactorrhea, thyromegaly or clitoromegaly. Which of the following is the most appropriate therapy for this patient's infertility?

A 20-year-old, gravida 1, para 0, at 10 weeks gestation is brought to the emergency department because of moderate vaginal bleeding. She has a colicky suprapubic pain radiating to the back and denies the passage of tissue through her introitus. She does not use tobacco, alcohol or drugs. She has no history of trauma or serious illness. Her temperature is 37.0C (98.7 F), blood pressure is 100/65 mm of Hg, pulse is 90/min and respirations are 17/min. Physical examination shows a dilated cervix and the products of conception can be seen through it. Her blood type is AB Rh negative and her antibody titer is 1:2. Ultrasonogram shows a ruptured gestational sac with no fetal heart motion. Which of the following is the most appropriate next step in management?

A 29-year-old woman, gravida 3, para 2, at 37 weeks gestation is rushed to the emergency department because of bright red vaginal bleeding. She has had no uterine contractions. She does not take any medications and has no history of trauma. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week of gestation showed an intrauterine gestation consistent with dates. Her temperature is 37.0C (98.7F), blood pressure is 120/80 mmHg, pulse is 80/min and respirations are 16/min. Ultrasonogram in the emergency department shows complete placenta previa. After initial resuscitation, bleeding is stopped. Nonstress test is performed, and the strip is reactive and reassuring. Which of the following is the most appropriate next step in management?

A 24-year-old primigravid woman comes to the physician because of recent onset amenorrhea. Her last menstrual period was 7 weeks ago, and she has had nausea for the past 2 weeks. A urine pregnancy test is positive. She is being evaluated for dysphagia, and one-week ago she had a barium swallow examination. She is concerned for the baby because of her recent exposure to radiation. Which of the following is the most appropriate next step in management?

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

A 31-year-old woman, gravida 1, para 0, at 36-weeks' gestation with twins comes to the physician for a prenatal visit. The patient has had no contractions, bleeding from the vagina, or loss of fluid, and the babies are moving well. An ultrasound that was performed today shows that the presenting fetus is vertex and the non-presenting fetus is breech. Both fetuses are appropriately grown and greater than 2000 g. The patient wants to know if she should have a vaginal or cesarean delivery. Which of the following is the proper counseling for this patient?

A 27-year-old woman comes to the physician because of fevers and back pain. She states that a few days ago she had burning with urination. Over the next few days she developed fevers and chills and a pain on the right side of her back. She has no medical problems and takes no medications. Her temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, pulse is 102/minute, and respirations are 16/minute. Examination shows a patient in mild distress with shaking chills and right costovertebral angle tenderness. Leukocyte count is 18,000/mm3. Urinalysis shows 100 leukocytes/high powered field. Which of the following is the most appropriate next step in management?

A 24-year-old patient comes to the doctor because she has concerns regarding her sexuality. She states that for as long as she can remember she has been sexually attracted to other women. She was raised in a family where homosexuality is considered "unacceptable," so she has never discussed these feelings before. Now, however, she feels that she can no longer hide her feelings, but she is concerned that she will cause deep and irreparable harm to her relationship with her parents if she tells them. Which of the following is the most appropriate next step in the management of this patient?

A 21-year-old woman, gravida 2, para 1, at 28 weeks' gestation comes to the physician because of spotting after intercourse and a foul-smelling vaginal discharge. Her prenatal course has, up to now, been uncomplicated, and she has no medical problems. Speculum examination shows inflammation of the cervix with a mucopurulent cervical discharge. A gonorrhea and Chlamydia test is performed which comes back positive for chlamydia. Which of the following is the most appropriate pharmacotherapy?

A 32-year-old woman, gravida 4, para 3, at 39 weeks' gestation comes the labor and delivery ward with painful contractions. Her prenatal course was unremarkable. Examination shows that her cervix is 5 cm dilated, 100% effaced and the fetal heart rate is in the 130s and reactive. She is given meperidine for pain control. She progresses rapidly and less than 2 hours later she delivers a 7-pound, 6-ounce (3,345g) male fetus. The one-minute APGAR score is 1 and the infant is making little respiratory effort. Which of the following is the most appropriate next step in management?

A 38-year-old woman comes to the physician for an annual examination and Pap smear. She has no complaints. She has a regular period every month. She is sexually active with her husband. She has migraine headaches and is status post a tubal ligation. She states that she uses numerous alternative medications for mood, sleep, and disease prevention. Examination, including pelvic and breast examination, is unremarkable. Which of the following is an appropriate question to ask this patient?

A mother brings her 12-year-old daughter to the physician because the mother is concerned that her child has delayed physical development. In particular, the mother is concerned because her daughter has not yet had a menstrual period. The daughter began developing breasts at age 10, but has not had her first period. The daughter has no medical problems and takes no medications. Examination shows developing breasts and normal external female genitalia. Which of the following is the most appropriate response to the mother??

A 23-year-old woman, gravida 2, para 1, at 6 weeks' gestation comes to the emergency department because of lower abdominal pain and fevers. She states that her symptoms began 2 days ago and have steadily worsened since. Past medical history is significant for 2 episodes of gonorrhea and 1 episode of chlamydia. Temperature is 38.9 C (102.1 F), blood pressure is 110/76 mm Hg, pulse is 102/min, and respirations are 12/minute. Abdominal examination demonstrates significant lower abdominal tenderness. Pelvic examination shows a mucopurulent cervical discharge and bimanual examination reveals cervical motion tenderness and adnexal tenderness. Complete blood count shows leukocytes 18,000/mm3. Pelvic ultrasound shows a 6-week intrauterine gestation with no adnexal findings. Which of the following is the most appropriate management?

A 26-year-old primigravid woman at 35 weeks' gestation comes to the labor and delivery ward because of painful uterine contractions and a gush of fluid. Sterile speculum examination reveals a pool of clear fluid in the vagina that is nitrazine positive. When the fluid is examined under the microscope, a "ferning" pattern is seen. Cervical examination shows the patient to be 4 cm dilated, 100% effaced, and at 0 station. Fetal fingers can be felt along side the fetal head. External uterine monitoring shows contractions every 2 minutes. External fetal monitoring shows the fetal heart rate to be in the 130s and reactive. Which of the following is the most appropriate next step in management?

A 25-year-old woman comes to the physician for an annual examination. She has been feeling well over the past year. Her past medical and surgical histories are unremarkable. Past obstetrical history is significant for the term vaginal delivery two years ago of a male infant with spina bifida. Examination is within normal limits. The patient states that she would like to try to become pregnant within the next few months and wants to know if she needs to start taking any vitamins or medications. Which of the following supplements should this patient take?

A 41-year-old woman, gravida 4, para 3, at term is admitted to the labor and delivery ward with regular contractions every 2 minutes. Examination shows that her membranes are grossly ruptured and that her cervix is 5cm dilated. Over the following 3 hours, she progresses to full dilation and +2 station. A fetal bradycardia develops, and the decision is made to proceed with vacuum-assisted vaginal delivery. A 7 pound, 8ounce boy is delivered. APGAR scores are 8 at 1 minute and 9 at 5 minutes. Which of the following best represents an advantage of vacuum extraction over the forceps for expediting delivery?

A 22-year-old woman, gravida 3, para 2, at 22 weeks' gestation comes to the physician because of an ulcer near her vagina. She noted this a few days ago and it has not improved. The ulcer is painless. The patient has no history of medical problems and takes no medications. She is allergic to penicillin. Examination is significant for a 22 week-sized uterus and a 1 cm, raised, nontender lesion on the distal portion of the vagina. A rapid plasma reagin (RPR) test is sent; the result is positive. A microhemagglutination assay for Treponema pallidum (MHA-TP) is also read as positive. Which of the following is the most appropriate management for this patient?

A 32-year-old woman comes to the physician because of recurrent painful outbreaks on her labia and vagina. Her first outbreak was six years ago. At that time she developed what she thought was a bad "flu" with malaise and a fever, along with a painful rash on her labia. This initial outbreak resolved, but since then she has had approximately 8 -10 outbreaks each year. Each outbreak is preceded by burning in her perineal area. A few days later she develops vesicles, then shallow, painful ulcers that resolve in about 10 days. Which of the following is the most appropriate pharmacotherapy?

A 34-year-old primigravid woman at 30 weeks' gestation comes to the physician with regular contractions every 6 minutes. Her prenatal course was significant for type 1 diabetes, which she has had for 10 years. Over the course of 1 hour, she continues to contract, and her cervix advances from closed and long to a fingertip of dilation with some effacement. The patient is started on magnesium sulfate, penicillin, and betamethasone. Which of the following is the most likely side effect from the administration of corticosteroids to this patient?

A pregnant patient of yours goes to the emergency room at 20 weeks gestational age with complaints of hematuria and back pain. The emergency room physician orders an intravenous pyelogram (IVP) as part of a workup for a possible kidney stone. The radiologist indicates the absence of nephrolithiasis but reports the presence of bilateral hydronephrosis and hydroureter, which is greater on the right side than on the left. Which of the following statements is true regarding this IVP finding?

A 24-year-old woman presents to the emergency department complaining of right lower quadrant pain and vaginal spotting. Her last menstrual period was 5 weeks ago. Her temperature is 37 C (98.6 F), blood pressure is 112/70 mm Hg, pulse is 74/min, and respirations are 14/min. The abdomen is soft and non-tender. Pelvic examination reveals scant blood in the vagina, a closed cervical os, no pelvic masses, and right pelvic tenderness. Her leukocyte count is 8000/mm3, hematocrit is 38%, and a platelet count is 250,000/mm3. Which of the following is the most appropriate step next in diagnosis?

A 34-year-old female comes to your office for an infertility evaluation. She has been having irregular menstrual cycles for the past five years, stating that her menstrual periods come on average once every two to three months. Her past medical history is not significant. She is not taking any medications currently. Her blood pressure is 145/96 mmHg and heart rate is 72/min. Her BMI is 33 kg/m2. Physical examination reveals facial acne and excessive hair growth over the upper lip and chin. Which of the following is the most likely pathologic finding in this patient?

A 32-year-old female is being evaluated for abnormal uterine bleeding. A urine pregnancy test is negative. Pelvic ultrasound reveals endometrial hyperplasia and a right-sided adnexal mass. In this patient, the adnexal mass is most likely to be a?

A 28-year-old nulligravid patient complains of bleeding between her periods and increasingly heavy menses. Over the past 9 months, she has had two dilation and curettages (D&Cs), which have failed to resolve her symptoms, and oral contraceptives and antiprostaglandins have not decreased the abnormal bleeding. Which of the following options is most appropriate at this time?

A patient presents to you for evaluation of infertility. She is 26 years old and has never been pregnant. She and her husband have been trying to get pregnant for 2 years. Her husband had a semen analysis and was told that everything was normal. The patient has a history of endometriosis diagnosed by laparoscopy at age 17. At the time she was having severe pelvic pain and dysmenorrhea. After the surgery, the patient was told she had a few small implants of endometriosis on her ovaries and fallopian tubes and several others in the posterior cul-de-sac. She also had a left ovarian cyst, filmy adnexal adhesions, and several subcentimeter serosal fibroids. You have recommended that she have a hysterosalpingogram as part of her evaluation for infertility. Which of the patient’s following conditions can be diagnosed with a hysterosalpingogram?

A 29-year-old woman presents with severe pain during menstruation (dysmenorrhea). During workup, an endometrial biopsy is obtained. The pathology report from this specimen makes the diagnosis of chronic endometritis. Based on this pathology report, which of the following was present in the biopsy sample of the endometrium?

A couple presents for evaluation of primary infertility. The evaluation of the woman is completely normal. The husband is found to have a left varicocele. If the husband’s varicocele is the cause of the couple’s infertility, what would you expect to see when evaluating the husband’s semen analysis?

A 30-year-old woman presents for a physical examination for work. She denies any medical problems or surgeries in the past. She has had no pregnancies. She is sexually active and has been using oral contraceptive pills for the past 6 years. She denies any allergies to medications. On examination, her weight is 62 kg, blood pressure 120/78 mm Hg, pulse 76 beats per minute, respiratory rate 15 breaths per minute, temperature 36.8C (98.4F). Her physical examination is normal. Laboratory evaluation is also done. Which direct effect of birth control pills could be noted in the laboratory results?

A 27-year-old woman comes to the physician for preconception counseling. She takes no medication. Her menses are regular, are moderate in amount, and last 5-6 days. Her diet is well balanced. Her grandparents are from Greece. Her husband's family is also of Mediterranean ancestry. Her mother and sister have been diagnosed with anemia, but she does not know the types. The presence of thalassemia anemia in her family is suspected. Which of the following is the most appropriate initial screening test?

A 27-year old woman comes to the physician for evaluation of infertility. She and her 31-year-old husband have not been able to conceive after 12 months of unprotected and frequent intercourse. She has regular 28-day menstrual cycles and during the menstrual cycles she develops mild pelvic pain and bilateral breast tenderness. She has no pain during sexual intercourse. Her blood pressure is 128/76 mm Hg and pulse is 82/min. Physical examination is completely unremarkable. Which of the following could most likely be abnormal in this patient?

A 22-year-old woman comes to your office at 10 weeks gestation for her first prenatal visit. Her obstetrical history is significant for a spontaneous abortion at 12 weeks gestation one year ago. She states that her mother has hypothyroidism, and she asks you to order thyroid function tests for her. She denies any symptoms, and her physical examination is unremarkable. Ultrasound reveals an intrauterine gestation with normal fetal cardiac activity. Which of the following results is most likely to be expected in this patient?

A 35-year-old female complains of nipple discharge. The discharge is from both breasts, brown in color and occurs intermittently. She has two children who are 5 and 8 years old. She has not been recently pregnant. Her last menstrual period was one week ago. She describes no other symptoms. Examination shows normal breasts without palpable lumps or nipple abnormalities. Brownish discharge is expressed from the nipples, and it is guaiac negative. Which of the following is the most appropriate next step in management?

A 22-year-old woman is being followed by her family physician during her first pregnancy. She is currently at 28 weeks' gestation, feeling well, and gaining an appropriate amount of weight. She has not had sexual intercourse for the past 15 weeks. Her first prenatal exam was at 12 weeks' gestation, at which time her HIV, chlamydia, gonorrhea, Rh(D)-antibody, and urine cultures were negative. Her blood type is A negative. She does not know who the father of the child is but is excited to raise the child with the help of her mother. She is unable to recall or confirm her immunization status for a number of vaccines. Which of the following measures is warranted at this time?

A 16-year-old girl is brought to your office by her mother for evaluation of primary amenorrhea. Her older sister had her first period at age 13. Vitals signs are within normal limits. Physical examination shows absence of breast development and external genitalia at Tanner stage 1. Examination shows no other abnormalities. Which of the following is the most appropriate next step in management?

A 31-year-old woman comes to the clinic for a preoperative evaluation. She is undergoing an infertility workup and a laparoscopy is planned. She and her husband have been trying to have a child for the last 5 years, but have not had any success. Over that time period, this woman has suffered three miscarriages. Her past medical history is remarkable for anemia, a history of depression, and a deep venous thrombus suffered during her first pregnancy. Her review of systems reveals diffuse arthralgias, but is otherwise unremarkable. She is currently not taking any medications, though she does report having a drug reaction to prenatal vitamins. Early in pregnancy, she had a red facial rash across her face that spared her nasolabial folds. Physical examination today is unremarkable. Laboratory studies, with the exception of a prothrombin time elevated to two times greater than normal, are unremarkable. Which of the following studies will most likely explain this patient’s laboratory abnormality?

A 30-year old woman has irregular menses. She reports that her last menstrual period (LMP) was 8 weeks ago. She has been experiencing vaginal spotting and left lower quadrant pain. She is afebrile. She has a normal size uterus and mild tenderness in the right lower quadrant with no rebound tenderness. A human chorionic gonadotropin (hCG) beta-subunit level of 1400 mIU/ml is reported in her records from an obstetrics visit 2 days ago. Which of the following is the appropriate management?

During a routine return OB visit, an 18-year-old G1P0 patient at 23 weeks gestational age undergoes a urinalysis. The dipstick done by the nurse indicates the presence of trace glucosuria. All other parameters of the urine test are normal. Which of the following is the most likely etiology of the increased sugar detected in the urine?

A 32-year-old Caucasian primigravida presents to your office in her 30'" week of pregnancy. On review of systems, she complains of leg swelling and occasional heartburn. She denies abdominal pain or vaginal discharge. She eats a balanced diet and takes folic acid supplements. Her blood pressure is 165/100 mmHg and her heart rate is 90/min. Which of the following additional findings is most likely in this patient?

A healthy, 32-year-old, primigravid woman at 12 weeks of gestation comes to the physician for a routine prenatal visit. She has no complaints. She does not use tobacco or alcohol. She has blood group O, Rh(O)+, and her husband has blood group AB, Rh(O)+. She is concerned about the risk of alloimmunization because her mother had that problem during her second pregnancy. Although the child will have a different blood group from the patient, alloimmunization is of little concern due to which of the following?

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?

A 22-year-old woman presents with complaints of vaginal discharge and severe vulvar pruritus. She is otherwise healthy. Physical examination reveals a thin, malodorous vaginal discharge and marked vulvar and vaginal erythema. The pH of the vaginal discharge is 5.5. Microscopic examination of the discharge is most likely to reveal which of the following?

A 22-year-old woman (G2POA1) is being followed by her family physician for pregnancy. She is currently at 28 weeks' gestation, feeling well, and gaining an appropriate amount of weight. She has not had sexual intercourse during her pregnancy. Her first prenatal exam at 12 weeks' gestation showed a negative HIV, Chlamydia, gonorrhea, and urine cultures. Her blood type is A negative and Rh (D) negative. She has not communicated with the father of the child during the pregnancy but is excited to raise the child with the help of her mother. She is unable to recall or confirm her immunization status for a number of vaccines. Which of the following measures is warranted at this time?

A 29-year-old woman presents for her first prenatal visit. She is 10 weeks pregnant as determined by her last menstrual period. She does not have any medical problems and does not take any medications. She is devoutly religious and has been in a monogamous relationship with her husband since getting married 5 years ago. They live in a house built in 1983 where she works as a homemaker. Her husband is an accountant. She does not smoke cigarettes or drink alcohol. Her physical exam is within normal limits. Which of the following screening tests is indicated at this time?

A 17-year-old teenage girl presents to your office with a 10-month history of lower abdominal pain that radiates to the upper thighs and back. The pain is colicky in nature and usually starts a few hours prior to menses, lasting 3-4 days. Menses have occurred at regular 28-day intervals over the past 2 years. She has no inter-menstrual bleeding. She became sexually active 6-months ago and does not use contraception. Physical examination shows healthy genitalia and well-developed secondary sexual characteristics; the uterus is normal in size and freely mobile. Examination shows no other abnormalities. Which of the following is the most likely cause of her pelvic pathology?

A 28-year-old woman presents to your office with symptoms of a urinary tract infection. This is her second infection in 2 months. You treated the last infection with Bactrim DS for 3 days. Her symptoms never really improved. Now she has worsening lower abdominal discomfort, dysuria, and frequency. She has had no fever or flank pain. Physical examination shows only mild suprapubic tenderness. Which of the following is the best next step in the evaluation of this patient?

A 23-year-old G1PO female presents for her first prenatal visit at 14 weeks gestation. A pap smear is done at that time and a high grade squamous intraepitheliallesions (HSIL) is seen at cytology. A test for HPV discloses the presence of a strain with high oncogenic risk. A satisfactory colposcopy is done and shows no site of abnormalities. At this time the next best step is?

A 28-year-old G3P2 woman at 32 weeks gestation comes to the physician because she has felt only 2 or 3 fetal movements in the past 12 hours. As in her previous pregnancies, she has gestational diabetes, which is under good control with diet and mild exercise. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. Physical examination is unremarkable. Fetal heart tones are heard by Doppler. Which of the following is the most appropriate next step in management of this patient?

An 18-year-old woman comes to your office because of abdominal pain. She states that the pain started yesterday afternoon and has been worsening. The pain is in the right lower quadrant and does not radiate. She rates it a 7 on a scale of 1 to 10. She has had some nausea but no vomiting. Nothing seems to improve or worsen the pain. She has a history of hypothyroidism for which she takes thyroid hormone replacement, and no other medical problems. She has never had surgery. She is allergic to penicillin. Physical examination is significant for right lower quadrant tenderness. Bimanual examination reveals right adnexal tenderness. Which of the following is the most appropriate next step in the diagnostic workup of this patient?

A 45-year-old woman presents to her physician's office complaining of night sweats and insomnia. She states that for the past month she has woken up completely soaked with perspiration on several occasions. She has had irregular menstrual periods for the past six months. She consumes one ounce of alcohol nightly before going to the bed, and quit smoking 5 years ago. She has a history of hypertension controlled with hydrochlorothiazide. She denies illicit drug use. Her temperature is 36.7C (98F), blood pressure is 140/90 mmHg, pulse is 80/min, and respirations are 14/min. Physical examination shows no abnormalities. Which of the following is the best next step in management?

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

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

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

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

A patient comes to your office with her last menstrual period 4 weeks ago. She denies any symptoms such as nausea, fatigue, urinary frequency, or breast tenderness. She thinks that she may be pregnant because she has not had her period yet. She is very anxious to find out because she has a history of a previous ectopic pregnancy and wants to be sure to get early prenatal care. Which of the following actions is most appropriate at this time?

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

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

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

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

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

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?

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 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 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?

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 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?

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

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

A 23-year-old female comes to the physician complaining of a 3-day history of intermittent lower abdominal pain and vaginal spotting. The pain is of mild to moderate intensity. Her last menstrual period was 6 weeks ago. A pregnancy test is performed, and the result is positive. Her temperature is 36.7 C (98 F), blood pressure is 110/80 mm Hg, pulse is 80/min, and respirations are 18/min. Physical examination shows unilateral adnexal tenderness. Transabdominal ultrasonogram does not reveal an intrauterine gestation. Quantitative beta-HCG is 1500 IU/L. Which of the following is the most appropriate next step in management?

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 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?

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

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

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

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

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

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

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

A 23-year-old woman, gravida 1, para 0, at 25 weeks’ gestation comes to the physician because of right upper quadrant pain, nausea and vomiting, and malaise for the past 2 days. Her temperature is 37 C (98.6 F), blood pressure is 104/72 mm Hg, pulse is 92/min, and respirations are 16/min. Physical examination reveals right upper quadrant tenderness to palpation. The cervix is long, closed, and posterior. There is generalized edema. Laboratory values are as follows: Leukocyte count 10,500/mm3, Platelet count 62,000/mm3, Hematocrit: 26%, Sodium: 140 mEq/L, Chloride: 100 mEq/L, Potassium: 4.5 mEq/L, Bicarbonate: 26 mEq/L. A peripheral blood smear reveals hemolysis. Which of the following laboratory findings would be most likely in this patient?

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

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

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

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

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

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

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

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