Gynéco khme teacher (Part 3)

A 29-year-old woman presents for her first prenatal visit. She is 1 0 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 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 absense 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 17 -year-old female comes to the physician's office for a routine physical examination. She has no complaints and has no previous medical problems. She has been having sex since the age of 14 and has had 3 sexual partners so far. Vital signs are stable and physical examination is unremarkable. Pap smear is performed and the report came back as "satisfactory for evaluation" and shows mild dysplasia (low grade intraepithelial lesion) Which of the following is the most appropriate next step in management?

A 57 -year-old woman comes to the physician's office for evaluation of vaginal dryness, burning and dyspareunia. She also has dysuria and increased urinary frequency. The symptoms have been present for several months but have intensified recently. She has tried over-the-counter lubricants with little relief. Her last menstrual period was seven years ago. She takes hydrochlorothiazide for hypertension and pravastatin for hypercholesterolemia. Physical examination shows scarce pubic hair and reduced elasticity and turgor of the vulvar skin. Pale, dry and smooth vaginal epithelium is noted. Urine dipstick is normal. Which of the following is the most appropriate next step in management?

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

A 24-year-old woman presents to your office with a self-palpated breast lump. She discovered the mass 2 days ago while taking a shower and noted that it is mildly tender. Her menstrual periods are regular, occurring every 26 days. Her last menstrual period (LMP) was 3 weeks ago. Her past medical history is insignificant. She has no family history of breast cancer. Physical examination reveals a lump in the superior outer quadrant of the right breast without palpable lymphadenopathy. Which of the following is the most reasonable next step in the management of this patient?

A 24-year-old woman presents to your office with a self-palpated breast lump. She discovered the mass 2 days ago while taking a shower and noted that it is mildly tender. Her menstrual periods are regular, occurring every 26 days. Her last menstrual period (LMP) was 3 weeks ago. Her past medical history is insignificant. She has no family history of breast cancer. Physical examination reveals a lump in the superior outer quadrant of the right breast without palpable lymphadenopathy. Which of the following is the most reasonable next step in the management of this patient?

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. Item 1 of2 Which of the following is the most appropriate next step in management?

Item 2 of2 A diagnosis of lichen sclerosus is made. Which of the following is the most appropriate next step in management?

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

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?

A 24-year-old woman delivered a healthy baby by vaginal delivery at 36 weeks gestation. She had a prolonged premature rupture of the membranes, and mid forceps application was required during delivery. On the second postpartum day she complained of fever and chills. She cannot breast-feed because her "nipples are tender". Her temperature is 38.5C (101 .3F), blood pressure is 120/55 mmHg and pulse is 92/min. Bimanual examination shows tender uterus and foul-smelling lochia. Her nipples are cracked but without surrounding erythema or warmth. Physical examination otherwise shows no abnormalities.Item 1 of3 Which of the following is the most likely diagnosis?

A 24-year-old woman delivered a healthy baby by vaginal delivery at 36 weeks gestation. She had a prolonged premature rupture of the membranes, and mid forceps application was required during delivery. On the second postpartum day she complained of fever and chills. She cannot breast-feed because her "nipples are tender". Her temperature is 38.5C (101 .3F), blood pressure is 120/55 mmHg and pulse is 92/min. Bimanual examination shows tender uterus and foul-smelling lochia. Her nipples are cracked but without surrounding erythema or warmth. Physical examination otherwise shows no abnormalities.Item 2 of3 Which of the following pathogens is most likely responsible for this patient's current condition?

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 initial therapy for this patient?

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

A 20-year-old, G 1 PO, woman at 35 weeks gestation comes to the hospital because of regular uterine contractions and passage of clear fluid per vagina. She has no other symptoms. Her pregnancy thus far has been uncomplicated Her temperature is 38.2 C ( 1 DO. 7 F), blood pressure is 120/68 mmHg, pulse is 11 0/min and respirations are 17/min. Speculum examination shows a closed cervix and clear fluid pooling in the vaginal fornix. The pH of the fluid is 7.5. F eta I heart monitoring shows a rate of 165/min and uterine contractions occurring every 3-4 minutes. Initial laboratory studies show: Hemoglobin 10.2 g/L Platelets 198 ,OOO/mm3 Leukocyte count 18 ,500/mm3 Neutrophils 86% Lymphocytes 14% Which of the following is the most likely diagnosis?

A 20-year-old, G 1 PO, woman at 35 weeks gestation comes to the hospital because of regular uterine contractions and passage of clear fluid per vagina. She has no other symptoms. Her pregnancy thus far has been uncomplicated Her temperature is 38.2 C ( 1 DO. 7 F), blood pressure is 120/68 mmHg, pulse is 11 0/min and respirations are 17/min. Speculum examination shows a closed cervix and clear fluid pooling in the vaginal fornix. The pH of the fluid is 7.5. F eta I heart monitoring shows a rate of 165/min and uterine contractions occurring every 3-4 minutes. Initial laboratory studies show: Hemoglobin 10.2 g/L Platelets 198 ,OOO/mm3 Leukocyte count 18 ,500/mm3 Neutrophils 86% Lymphocytes 14% Which of the following is the most appropriate next step in management?

A 23-year-old G 1 PO 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 25-year-old primiparous woman comes to your office 12 weeks after vaginal delivery of a healthy female baby. She has not had a menstrual period since delivery. She is nursing, and is using barrier methods for contraception. Examination shows no abnormalities. Which of the following is the most likely mechanism for this patient's amenorrhea?

A 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 13-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 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. F eta I heart tracing is reassuring. She wishes to continue the pregnancy for two more weeks rather than undergoing induction. She should be closely monitored for which of the following?

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

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

A 1 9-year-old woman comes to the emergency department because of a 2-day history of fever, shaking chills and lower abdominal pain. She had an abortion at an outside clinic 3 days ago. Her temperature is 39 .SC ( 1 03. 7F), blood pressure is 1 00/65mmHg, pulse is 114/min and respirations are 26/min. Physical examination shows mild rigidity and guarding. Fundal height is at 12 weeks gestation, the adnexae are free and no mass is noted. Bimanual examination shows uterine tenderness with purulent, offensive vaginal discharge coming out of a dilated cervical os. Which of the following is the most appropriate sequence in management?

A 28-year-old woman, gravida 2, para 0, aborta 1 , at 30 weeks' gestation comes to the physician because of a decrease in fetal movements. She has felt no fetal movements the past 18-hours. Her prenatal course, prenatal tests, and fetal growth have been normal up to this point. Triple test was performed at 14-weeks and showed no abnormalities. Her first pregnancy was terminated because her fetus was diagnosed with Down's syndrome. She does not use tobacco, alcohol, or drugs. F eta I heart tones are heard by Doppler. Non-stress test is non-reactive; therefore, biophysical profile is performed and shows a score of 8. Which of the following is the most appropriate next step in management?

A 25-year-old woman at 28 weeks gestation comes to the ER because of strong, regular and painful uterine contractions that started 4 hours earlier with the passage of clear fluid from her vagina. She denies any vaginal bleeding. She has had no prenatal care. Vital signs are normal. A sterile speculum examination shows pooling of amniotic fluid within the vagina, and a cervix that is 4 em dilated and 80% effaced. Ultrasonogram in the emergency department shows an amniotic fluid index of 4 and bilateral renal agenesis in the fetus. 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?

A 32-year-old woman, gravida 1 , is in active labor. Lumbar epidural anesthesia is being used for pain control. She is having contractions every two to three minutes. The cervix is 4 em dilated. F eta I heart rate is reassuring. Her blood pressure is 90/55 mmHg and heart rate is 120/min. What is the most probable cause of her hypotension?

A 23-year-old woman complains of breast pain two days after delivering her first child. The delivery was complicated by mild postpartum bleeding. On exam, both breasts are tense, warm, and tender to touch. Her blood pressure is 130/70 mmHg, heart rate is 100/min, and temperature is 994•F (374.C). What is the most likely diagnosis?

A 34-year-old obese female returns to the physician's office for a follow-up appointment at 16 weeks gestation. She was diagnosed with gestational diabetes at 12 weeks gestation and since then has been following dietary recommendations. She eats a balanced diabetic diet three times a day and avoids snacks. Her fasting blood sugars for the past two weeks have been in between 120 to 150 mg/dl. Her temperature is 37.0C (98.7F), blood pressure is 130/88 mmHg, pulse is 76/min and respirations are 14/min. Physical examination is unremarkable.Which of the following is the most appropriate therapy for this patient?

A 25-year-old female comes to the physician because of abdominal bloating, headache, fatigue, weight gain, anxiety, and decreased libido. She experiences these symptoms seven to ten days before the start of each menstrual cycle. She has a past history of postpartum depression, but she denies any recent feelings of hopelessness or guilt. Physical examination shows no abnormalities. Complete blood count, serum chemistries and thyroid stimulating hormone levels are within normal limits. Which of the following is the most appropriate next step in management

A 23-year-old, gravida 2, para 1 woman at 30 weeks gestation comes to the ER after she noticed a sudden gush of clear fluid coming from her vagina. She has had no uterine contractions or vaginal bleeding. Her pregnancy has been uncomplicated; she has had consistent prenatal care. Vital signs are normal. Sterile speculum examination shows the cervix is minimally effaced and 2 em dilated; there is pooling of clear fluid in the vaginal fornix, and when pressure is applied to the fundus, clear fluid comes out of the cervix. Emergency ultrasound shows a fetus of average size in the vertex presentation and an Amniotic Fluid Index (AFI) of 15. Nonstress test shows a baseline of 120 bpm and frequent accelerations. Amniotic fluid analysis shows lecithin/sphingomyelin ratio of 1 0 Which of the following is the most appropriate next step in management?A 23-year-old, gravida 2, para 1 woman at 30 weeks gestation comes to the ER after she noticed a sudden gush of clear fluid coming from her vagina. She has had no uterine contractions or vaginal bleeding. Her pregnancy has been uncomplicated; she has had consistent prenatal care. Vital signs are normal. Sterile speculum examination shows the cervix is minimally effaced and 2 em dilated; there is pooling of clear fluid in the vaginal fornix, and when pressure is applied to the fundus, clear fluid comes out of the cervix. Emergency ultrasound shows a fetus of average size in the vertex presentation and an Amniotic Fluid Index (AFI) of 15. Nonstress test shows a baseline of 120 bpm and frequent accelerations. Amniotic fluid analysis shows lecithin/sphingomyelin ratio of 1 0 Which of the following is the most appropriate next step in management?

A 93-year-old woman is sentto your office from the nursing home for evaluation of vaginal bleeding. She is a poor historian and history is provided by her caregiver. Per her caregiver, she has a history of cerebrovascular accident with residual weakness, myocardial infarction, hypertension, type 2 diabetes mellitus and chronic renal insufficiency. She has been wheelchair-bound and living in the nursing home since her stroke five years ago. She takes multiple medications. Her temperature is 37.2 C (98.9 F), blood pressure is 176/76, pulse is 74/min and respirations are 14/min. She is awake, alert, and oriented to person, place and time. Physical examination reveals a friable, bleeding vaginal mass 3 em in si ze, and a malodorous vaginal discharge. The remainder of the examination reveals left-sided spasticity and weakness. Biopsy of the mass reveals squamous cell carcinoma of the vagina, that does not extend to the pelvic wall. CT scan of the abdomen and pelvis shows no evidence of metastasis. You call the patient's daughter, who is the power of attorney, and she requests that you do the best you can. Which of the following is the most appropriate next step in management?

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. F eta I 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?

A 28-year-old woman, gravida 3, para 2, at 28 weeks gestation comes to the physician because she has only felt 2-3 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. She does not use tobacco, alcohol or drugs. Vital signs are normal. Physical examination is unremarkable. F eta I heart tones are heard. Which of the following is the next most appropriate step in management?

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 1 00/70 mm Hg, pulse is 90/min and respirations are 16/min. F eta I heart monitoring is reassuring. Which of the following is the most likely diagnosis

A 27 -year-old woman, gravida 2, para 1 , at 12 weeks gestation comes to the physician because of a dark brown vaginal discharge. She had a mild brown vaginal discharge 3 weeks ago, which resolved without any intervention. She noticed similar discharge again two days ago. For the past two weeks, she has not had nausea or breast tenderness, which she used to have before. She does not use tobacco, alcohol or drugs. Her temperature is 37.0C (98.7F), blood pressure is 110/60 mmHg, pulse is 85/min and respirations are 15/min. Physical examination shows a soft uterus and a closed cervix. F eta I heart tones are not present.Which of the following is the most appropriate next step in management?

A 27 -year-old woman, gravida 2, para 1 , at 12 weeks gestation comes to the physician because of a dark brown vaginal discharge. She had a mild brown vaginal discharge 3 weeks ago, which resolved without any intervention. She noticed similar discharge again two days ago. For the past two weeks, she has not had nausea or breast tenderness, which she used to have before. She does not use tobacco, alcohol or drugs. Her temperature is 37.0C (98.7F), blood pressure is 110/60 mmHg, pulse is 85/min and respirationsQuantitative beta-HCG level is similar to her previous value, which was obtained 4 weeks ago. Pelvic ultrasonogram reveals absent fetal cardiac activity and small gestational sac. Coagulation studies are within normal limits Which of the following is the most appropriate next step in management?

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?

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?

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?

A 32-year-old, gravida 3, para 2 woman at 35 weeks gestation comes to the hospital because of regular and painful uterine contractions occurring every 5 - 6 minutes. She also has continuous leakage of clear fluid from her vagina that started 1 0 hours earlier. She has chronic hypertension and was prescribed methyldopa throughout pregnancy but has been noncompliant. She also has a history of drug abuse and has missed two previous antenatal appointments. Her temperature is 37.0C (98.7F), blood pressure is 160/100 mmHg, pulse is 80/min and respirations are 16/min. Sterile speculum examination shows pooling of amniotic fluid in the vagina; the cervix is 80% effaced and 3 em dilated. Ultrasound shows a small for gestational age fetus in the vertex presentation with a decreased amniotic fluid index. F eta I heart monitoring shows repetitive late decelerations. Uterine contractions are now occurring every 4 minutes. Which of the following is the most appropriate next step in management?

A 24-year-old primigravid woman comes for her initial prenatal visit at 24 weeks' gestation. Her only complaint is low back pain. She has no significant past medical history, and she has had no complications of pregnancy thus far. She does not use tobacco, alcohol, or drugs. Her vital signs are within normal limits. Complete physical examination shows no abnormalities. During the interview she requests screening for diabetes because her friend was diagnosed with gestational diabetes at 26-weeks of gestation. Which of the following is the most appropriate screening procedure for this patient?

A 29-year-old woman, gravida 3, para 2, at 37 weeks gestation is rushed to the emergency department because of gushing 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 37.0 C (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. She is anxious and concerned about her baby. Which of the following is the most appropriate next step in management?

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?

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?

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

A 28-year-old primigravid woman at 34 weeks gestation is brought to the emergency department following a motor vehicle accident. She had intense abdominal pain and became agitated and restless in the ambulance. She has mild vaginal bleeding and diffuse abdominal pain. She is on continuous fetal heart monitoring. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. Her blood pressure is 11 0/60mmHg, pulse is 11 0/min and respirations are 32/min. Physical examination shows hyperventilation, cold extremities and a distended abdomen with irregular contours. F eta I heart monitoring shows repetitive late decelerations and a long-term variability of 2 cycles/min. Which of the following is the most likely diagnosis?

A 28-year-old primigravid woman at 34 weeks gestation is brought to the emergency department following a motor vehicle accident. She had intense abdominal pain and became agitated and restless in the ambulance. She has mild vaginal bleeding and diffuse abdominal pain. She is on continuous fetal heart monitoring. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. Her blood pressure is 11 0/60mmHg, pulse is 11 0/min and respirations are 32/min. Physical examination shows hyperventilation, cold extremities and a distended abdomen with irregular contours. F eta I heart monitoring shows repetitive late decelerations and a long-term variability of 2 cycles/min.Which of the following is the most likely diagnosis?

A 28-year-old primigravid woman at 34 weeks gestation is brought to the emergency department following a motor vehicle accident. She had intense abdominal pain and became agitated and restless in the ambulance. She has mild vaginal bleeding and diffuse abdominal pain. She is on continuous fetal heart monitoring. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. Her blood pressure is 11 0/60mmHg, pulse is 11 0/min and respirations are 32/min. Physical examination shows hyperventilation, cold extremities and a distended abdomen with irregular contours. F eta I heart monitoring shows repetitive late decelerations and a long-term variability of 2 cycles/minWhich of the following is the most appropriate next step in management?

A 28-year-old nulliparous woman presents to your office complaining of fatigue, low mood, and amenorrhea. She says that it all started two months ago and progressively worsened. She is sexually active and uses condoms for contraception. Her medical history is unremarkable, and she denies taking any drugs or medications. Examination reveals dry skin, short eyebrows, a painless and enlarged thyroid gland, and galactorrhea. The uterus has a normal size, and the adnexae are not palpable. Initial investigations reveal the following: Serum pregnancy test Free T4 Serum TSH Prolactin Antimicrosomal antibodies Negative 2.5 IJg/dL (N= 5- 12) 11 .0 IJU/ml (N= 0.5-5.0) 30 ng/ml ( < 20 ng/ml) Positive Of the following, which represents the association between hypothyroidism and hyperprolactinemia in the above patient?

A newborn rnale has srnall body size, srnall eye openings, low-set ears, a sunken nasal bridge, flat philtrum and a thin upper lip. Which of the following is the most likely cause of the fetal condition?

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

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

A 34-year-old primigravida develops severe postpartum bleeding requiring aggressive volume resuscitation and transfusion of 5 units of packed red blood cells. Her pregnancy was complicated by mild hypertension and trace proteinuria that was treated with low-dose methyldopa. Her mother suffered from premature menopause and severe osteoporosis. Seven days after giving birth, she has failed to lactate. Her urinalysis is insignificant and her blood pressure has ranged from 95 to 110 mmHg systolic and 69 to 75 mmHg diastolic. Fundoscopy shows no retinal changes. Which of the following is most likely deficient in 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 em 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 24-year-old primigravid woman at 28 weeks gestation comes to the physician because she has not felt her baby's movements for the past two weeks. Fetal heart tones are not heard by Doppler. Ultrasonogram shows absence of fetal cardiac activity. Fetal demise is diagnosed. Laboratory studies show: Serum fibrinogen level 250 mg/dl (normal is 150 - 450 mg/dl ) Platelets 130 ,OOO/mm3 Prothrombin time Partial thromboplastin time 15 sec 33 sec There are no signs of active bleeding. Which of the following is the most appropriate next step in management?

A 37-year-old G4 P3 woman delivered a 4,100 gram (9 .02 1bs) infant by spontaneous vaginal delivery one hour ago. This pregnancy has been complicated by gestational diabetes for which she is being treated with insulin. The patient is currently on magnesium sulfate for elevated blood pressures and proteinuria. You are called to evaluate her because she began to have very heavy vaginal bleeding and is feeling lightheaded. Her blood pressure is 90/60 mmHg and pulse is 98/min. On physical examination you see heavy vaginal bleeding and numerous blood clots. Her cervix is closed and the uterus can be palpated 3 em above the umbilicus. The uterus feels boggy.The next best step in management is:

A 37-year-old G4 P3 woman delivered a 4,100 gram (9 .02 1bs) infant by spontaneous vaginal delivery one hour ago. This pregnancy has been complicated by gestational diabetes for which she is being treated with insulin. The patient is currently on magnesium sulfate for elevated blood pressures and proteinuria. You are called to evaluate her because she began to have very heavy vaginal bleeding and is feeling lightheaded. Her blood pressure is 90/60 mmHg and pulse is 98/min. On physical examination you see heavy vaginal bleeding and numerous blood clots. Her cervix is closed and the uterus can be palpated 3 em above the umbilicus. The uterus feels boggy.What is the most likely cause of her current condition?

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

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

A 15-year-old girl is being evaluated for primary amenorrhea. Her previous medical history is unremarkable and she denies taking any medications. Examination reveals absent breasts as well as pubic and axillary hair. Vaginal examination could not be performed. Olfactory exam reveals an inability to identify different odors. Ultrasound shows a uterus and two ovaries; serum FSH level is 2 U/L (Normal is 4-30). Which of the following is the most likely karyotype to be found in this patient?

34-year-old woman presents to the physician's office for infertility evaluation. Her cycles have been irregular for the past 12 months and she hasn't had any periods for the past 3 months. Previously, her cycles were quite regular. She also has hot flashes, dyspareunia and mood disturbances. She has been married for 6 years and has a three-year-old daughter. She has a history of Hashimoto thyroiditis and is on thyroid replacement therapy. She smokes one pack of cigarettes daily. Vital signs are normal. Pelvic examination reveals atrophic vaginal mucosa. Serum FSH is markedly elevated, and serum prolactin is normal. Serum TSH is within normal limits Which of the following is the most appropriate treatment for her infertility?

A 36-year-old woman comes to your office complaining of a 12-month history of inter-menstrual bleeding and heavy menses. She has had type-2 diabetes for the past 4-years, managed with glipizide and metformin. She has no family history of gynecological malignancies. She does not use tobacco or alcohol. Her temperature is 37.2 C (98.9 F), and blood pressure is 126/76 mm Hg. Her BMI is 30 Kg/m2. Physical examination shows pale mucus membranes. Pelvic examination is within normal limits; no vaginal lesions are noted. Urine pregnancy test is negative. Her hemoglobin is 1 0.8 g/dl and platelet count is 223 ,OOO/mm3. Coagulation studies are within normal limits. Which of the following is the most appropriate next step in management?

99. A 16-yea r-ol d pri mi gra vi da pres ents to your office a t 38 weeks ges ta 􀆟on. Her firs t tri mes ter bl ood pres s ure wa s 100/72. Toda y I t I s 170/110 mm Hg a nd s he ha s 4+ protei nuri a on a cl ea n ca tch s peci men of uri ne. She ha s s I gni fica nt s wel l I ng of her fa ce a nd extremi 􀆟es . She deni es ha vi ng contra c􀆟ons . Her cervi x I s cl os ed a nd uneffa ced. The ba by I s breech by beds I de ul tra s onogra phy. She s a ys the ba by’s movements ha ve decrea s ed I n the pa s t 24 hours . Whi ch of the fol l owi ng I s the bes t next s tep I n the ma na gement of thi s pa ti ent?

A new pa 􀆟ent pres ents to your office for her firs t prena ta l vi s I t. By her l a s t mens trua l peri od s he I s 11 weeks pregna nt. Thi s I s the firs t pregna ncy for thi s 36-yea r-ol d woma n. She ha s no medi ca l probl ems . At thi s vi s I t you obs erve tha t her uterus I s pa l pa bl e mi dwa y between the pubi c s ymphys I s a nd the umbi l I cus . No feta l hea rt tones a re a udi bl e wi th the Doppl er s tethos cope. Whi ch of the fol l owi ng I s the bes t next s tep I n the ma na gement of thi s pa ti ent?

98. A hea l thy 30-yea r-ol d G2P1001 pres ents to the obs tetri ci a n’s office a t 34 weeks for a rou􀆟ne prena ta l vi s I t. She ha s a hi s tory of a ces a rea n s ec􀆟on (l ow tra ns vers e) performed s econda ry to feta l ma l pres enta 􀆟on (footl I ng breech). Thi s pregna ncy, the pa 􀆟ent ha s ha d a n uncompl I ca ted prena ta l cours e. She tel l s her phys I ci a n tha t s he woul d l I ke to undergo a tri a l of l a bor duri ng thi s pregna ncy. However, the pa 􀆟ent I s I nteres ted I n perma nent s teri l I za 􀆟on a nd wonders I f I t woul d be be􀆩er to undergo a nother s chedul ed ces a rea n s ec􀆟on s o s he ca n ha ve a bi l a tera l tuba l l I ga ti on performed a t the s a me ti me. Whi ch of the fol l owi ng s ta tements I s true a nd s houl d be rel a yed to the pa ti ent?

Whi l e you a re on ca l l a t the hos pi ta l coveri ng l a bor a nd del I very, a 32-yea r-ol d G3P2002, who I s 35 weeks of ges ta 􀆟on, pres ents compl a I ni ng of l ower ba ck pa I n. The pa ti ent I nforms you tha t s he ha d been l I fti ng s ome hea vy boxes whi l e fi xi ng up the ba by’s nurs ery. The pa ti ent’s pregna ncy ha s been compl I ca ted by di et-control l ed ges ta 􀆟ona l di a betes . She deni es a ny regul a r uteri ne contra c􀆟ons , rupture of membra nes , va gi na l bl eedi ng, or dys uri a . She deni es a ny fever, chi l l s , na us ea , or emes I s . She reports tha t the ba by ha s been movi ng norma l l y. She I s a febri l e a nd her bl ood pres s ure I s norma l . On phys I ca l exa mi na 􀆟on, you note tha t the pa 􀆟ent I s obes e. Her a bdomen I s s o􀅌 a nd nontender wi th no pa l pa bl e contra c􀆟ons or uteri ne tendernes s . No cos tovertebra l a ngl e tendernes s ca n be el I ci ted. On pel vi c exa mi na 􀆟on her cervi x I s l ong a nd cl os ed. The externa l feta l moni tor I ndi ca tes a rea c􀆟ve feta l hea rt ra te s tri p; there a re ra re I rregul a r uteri ne contra c􀆟ons demons tra ted on the tocometer. The pa ti ent’s uri na l ys I s comes ba ck wi th tra ce gl ucos e, but I s otherwi s e nega ti ve. The pa ti ent’s mos t l I kel y di a gnos I s I s whi ch of the fol l owi ng?

77. A 26-yea r-ol d G1P0 pa tient a t 34 weeks ges ta tion I s bei ng eva l ua ted wi th Doppl er ul tra s ound s tudi es of the feta l umbi l I ca l a rteri es . The pa tient I s a hea l thy s moker. Her fetus ha s s hown evi dence of I ntra uteri ne growth res tri c􀆟on (IUGR) on previ ous ul tra s ound exa mi na 􀆟ons . The Doppl er s tudi es currentl y s how tha t the s ys tol I c to di a s tol I c ra 􀆟o (S/D) I n the umbi l I ca l a rteri es I s much hi gher tha n I t wa s on her l a s t ul tra s ound 3 weeks a go a nd there I s now revers e di a s tol I c fl ow. Whi ch of the fol l owi ng I s correct I nforma ti on to s ha re wi th the pa ti ent?

A 17-yea r-ol d pri mi pa ra pres ents to your office a t 41 weeks . Her pregna ncy ha s been uncompl I ca ted. Beca us e her cervi x I s unfa vora bl e for I nduc􀆟on of l a bor, s he I s bei ng fol l owed wi th bi ophys I ca l profil e (BPP) tes 􀆟ng. Whi ch of the fol l owi ng I s correct I nforma 􀆟on to s ha re wi th the pa ti ent rega rdi ng BPPs ?

79. A pa 􀆟ent comes to your office wi th her l a s t mens trua l peri od 4 weeks a go. She deni es a ny s ymptoms s uch a s na us ea , fa 􀆟gue, uri na ry frequency, or brea s t tendernes s . She thi nks tha t s he ma y be pregna nt beca us e s he ha s not ha d her peri od yet. She I s very a nxi ous to find out beca us e s he ha s a hi s tory of a previ ous ectopi c pregna ncy a nd wa nts to be s ure to get ea rl y prena ta l ca re. Whi ch of the fol l owi ng a c􀆟ons I s mos t a ppropri a te a t thi s ti me?

80. A pa 􀆟ent pres ents for her firs t I ni 􀆟a l OB vi s I t a 􀅌er ha vi ng a pos I 􀆟ve home pregna ncy tes t. She reports a l a s t mens trua l peri od of a bout 8 weeks a go. She s a ys s he I s not en􀆟rel y s ure of her da tes , however, beca us e s he ha s a l ong hi s tory of I rregul a r mens es . Her uri ne pregna ncy tes t I n your offi ce I s pos I ti ve. Whi ch of the fol l owi ng I s the mos t a ccura te wa y of da ti ng thi s pa ti ent’s pregna ncy?

81. 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 fol lowing tests is not part of the recommended first trimester blood testing for this patient?

83. A hea l thy 31-year-ol d G3P2002 pa ti ent pres ents to the obs tetri ci a n’s offi ce a t 34 weeks ges ta ti ona l a ge for a routi ne return vi s I t. She ha s ha d a n uneven􀆞ul pregna ncy to da te. Her ba s el I ne bl ood pres s ures were 100 to 110/60 to 70 I n the firs t tri mes ter, a nd s he ha s ga I ned a tota l of 20 l b s o far. During the visit, the patient complains of swelling I n both feet a nd a nkl es that ometimes ca us es her feet to a che a t the end of the da y. Her urine dip indicates trace protein, and her blood pressure in the office is currently 115/75. She deni es a ny other s ymptoms or complaints . On physical examination, there is piting edema of both feet and ankles extending to the lower one-half of the legs . There is no calf tendernes s . Which of the following is the mos t appropriate respons e to the patient’s concern?

84. A 28-yea r-ol d G1P0 pres ents to your office a t 24 weeks ges ta 􀆟ona l a ge for a n uns chedul ed vi s I t s econda ry to ri ght-s I ded groi n pa I n. She des cri bes the pa I n a s s ha rp a nd occurri ng wi th movement a nd exerci s e. She deni es a ny cha nge I n uri na ry or bowel ha bi ts . She a l s o deni es a ny fever or chi l l s . The a ppl I ca 􀆟on of a hea 􀆟ng pa d hel ps a l l evi a te the di s comfort. As her obs tetri ci a n, wha t s houl d you tel l thi s pa 􀆟ent I s the mos t l I kel y eti ol ogy of thi s pa I n?

85. A 19-yea r-ol d G1P0 pres ents to her obs tetri ci a n’s office for a rou􀆟ne OB vi s I t a t 32 weeks ges ta 􀆟on. Her pregna ncy ha s been compl I ca ted by ges ta 􀆟ona l di a betes requi ri ng I ns ul I n for control . She ha s been noncompl I a nt wi th di et a nd I ns ul I n thera py. She ha s ha d two pri or norma l ul tra s ound exa mi na 􀆟ons a t 20 a nd 28 weeks ges ta 􀆟on. She ha s no other s I gni fica nt pa s t medi ca l or s urgi ca l hi s tory. Duri ng the vi s I t, her funda l hei ght mea s ures 38 cm. Whi ch of the fol l owi ng I s the mos t l I kel y expl a na 􀆟on for the di s crepa ncy between the funda l hei ght a nd the ges ta 􀆟ona l a ge?