Gyn Test Q71 to Q 136

71) 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?

72) 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?

73) 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?

74) A 35-year-old woman comes to the clinic because of a left breast “thickness.” She noted this 5months ago and it has not receded. She has no family history of breast cancer. There is no drainage. She denies any pain. She has no other medical issues. She takes no birth control pills or any other medication. Examination shows a palpable mass in the left breast at 9 o’clock. A mammogram is nondiagnostic. Which of the following is the appropriate course of action?

75) A patient in your practice calls you in a panic because her 14-yearold daughter has been bleeding heavily for the past 2 weeks and now feels a bit dizzy and light-headed. The daughter experienced menarche about 6 months ago, and since that time her periods have been irregular and very heavy. You instruct the mother to bring her daughter to the emergency room. When you see the daughter in the emergency room, you note that she appears very pale and fatigued. Her blood pressure and pulse are 110/60 mm Hg and 70 beats per minute, respectively. When you stand her up, her blood pressure remains stable, but her pulse increases to 100. While in the emergency room, you obtain a more detailed history. She denies any medical problems or prior surgeries and is not taking any medications. She reports that she has never been sexually active. On physical examinations, her abdomen is benign. She will not let you perform a speculum examination, but the bimanual examination is normal. She is 5ft 4in tall and weighs 95 lb. Which of the following blood tests is not indicated in the evaluation of this patient?

76) A 53-year-old postmenopausal woman, G3P3, presents for evaluation of troublesome urinary leakage 6 weeks in duration. Which of the following is the most appropriate first step in this patient’s evaluation?

77) A 29-year-old woman comes to the physician for follow-up of a right breast lump. The patient first noticed the lump 4 months ago. It was aspirated at that time, and cytology was negative, but the cyst recurred about 1 month later. The cyst was re-aspirated 2 months ago and, again, the cytology was negative. The lump has recurred. Examination reveals a mass at 10 o'clock, approximately 4 cm from the areola. Ultrasound demonstrates a cystic lesion. Which of the following is the most appropriate next step in management?

78) A 43-year-old African American woman comes to the physician because of her concern regarding breast cancer. She has no complaints at present. In past years, she had noted bilateral breast tenderness prior to her menses, but this has since abated. She has no medical problems. She had two cesarean deliveries, but no other surgeries. She takes a low-dose oral contraceptive pill and has no known drug allergies. She does not smoke, and her family history is negative. Physical examination is normal. All mammograms (yearly since age 40) have been negative to date. She wants to know whether BRCA1 and BRCA2 screening would be appropriate for her. Which of the following is the correct response?

79) A 28-year-old primigravid woman at term comes to the labor and delivery ward with a gush of fluid and regular contractions. Her prenatal course was remarkable for her being Rh negative and antibody negative. Her husband is Rh positive. Over the following 10 hours, she progresses in labor and delivers a 3600-g boy via a normal spontaneous vaginal delivery. The placenta does not deliver spontaneously, and a manual removal is required. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send?

80) A 33-year-old woman, gravida 3, para 3, comes to the physician for an annual examination. She has no complaints. Past medical history is significant for two episodes of Chlamydia and one episode of gonorrhea. Obstetric history is significant for three normal spontaneous vaginal deliveries with gestational diabetes during the last two pregnancies. She takes no medications. Family history is significant for paternal coronary artery disease. Physical examination is unremarkable. Which of the following interventions should this patient most likely have?

81) A 40-year-old woman comes to the physician for an annual examination. She has no complaints. She has menses every 28-30 days that last for 3 days. She has no intermenstrual bleeding. She has asthma, for which she uses an occasional inhaler. She had a tubal ligation 10 years ago. She has no known drug allergies. Examination is unremarkable, including a normal pelvic examination. One of her friends was recently diagnosed with endometrial cancer, and the patient wants to know when and if she needs to be screened for this. Which of the following is the most appropriate response?

82) A 53-year-old woman comes to the physician for an annual examination. She has no complaints. She has hypertension, for which she takes a thiazide diuretic, but no other medical problems. Her past gynecologic history is significant for normal annual Pap tests for many years, her last being 2 months ago. A recent mammogram was negative. Heart, lung, breast, abdomen, and pelvic examination are unremarkable. Which of the following procedures or tests should most likely be performed on this patient?

83) A 22-year-old woman, gravida 2, para 0, at 8 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her first pregnancy resulted in a 22-week loss when she presented to her physician with bleeding from the vagina, was found to be fully dilated, and delivered the fetus. Examination of the patient today is unremarkable. She declines to have a cerclage placed. When should this patient begin having regular cervical examinations?

84) A 25-year-old woman who is “about 5 months” pregnant with her first child presents for the first time to an obstetrician. She has had no prenatal care. When asked about her medical history, she states she sometimes takes medicine for “depression,” and she produces a prescription bottle with lithium tablets in it. She is otherwise healthy and her pregnancy has been uncomplicated to date. The fundus of her uterus is 22 cm from the pubic symphysis, fetal movement is felt, and fetal heart tones are present at 130/min. Which of the following tests should be advised given the patient’s lithium ingestion?

85) A 23-year-old primigravid woman at 9 weeks gestation presents to the emergency room because of generalized weakness and lightheadedness. For the past 4 weeks she has not been able to keep anything down and over the past week her nausea and vomiting have worsened. She has no fever, abdominal pain, diarrhea, headache, dysuria, polyuria, tremor, or heat intolerance. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2C (98.9 F); orthostatic vitals are as follows: BP 136/86 mm Hg and pulse 98/min supine, and 11 0/70 mm Hg and 115/min standing. Physical examination shows dry mucus membranes. The remainder of the examination is unremarkable. Laboratory studies show: Hematocrit: 50 %, Platelets: 200,000/mm3, Serum sodium: 130 mEq/L, Serum potassium: 2.8 mEq/L, Chloride: 86 mEq/L, Bicarbonate: 30 mEq/L, Blood urea nitrogen (BUN): 30mg/dl, Serum creatinine: 1.6 mg/dl, Blood glucose: 98 mg/dl. Which of the following is the most appropriate next step in management?

86) 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?

87) A 27-year-old healthy woman comes to the office 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. Her husband is healthy and takes no medications. He has a normal semen analysis. She has regular 28-day menstrual cycles. The patient has mid-cycle pelvic pain and an egg white like consistency to her discharge mid-cycle. She has no pain during sexual intercourse. The patient does report having been hospitalized with a pelvic infection in her late teens, during which time she had pain with intercourse, discharge, and fever. Her sister was diagnosed with polycystic ovarian disease. Her blood pressure is 128/76 mm Hg and pulse is 82/min. Physical examination shows no abnormalities. Which of the following is most likely to be abnormal in this patient?

89) One of your obstetric patients presents to the office at 25 weeks complaining of severe left calf pain and swelling. The area of concern is slightly edematous, but no erythema is apparent. The patient demonstrates a positive Homans sign, and you are concerned that she may have a deep vein thrombosis. Which of the following diagnostic modalities should you order?

90) On postpartum day 2 after a vaginal delivery, a 32-year-old G2P2 develops acute shortness of breath and chest pain. Her vital signs are blood pressure 120/80 mm Hg, pulse 130 beats per minute, respiratory rate 32 breaths per minute, and temperature 37.6C (99.8F). She has new onset of cough. She appears to be in mild distress. Lung examination reveals clear bases with no rales or rhonchi. The chest pain is reproducible with deep inspiration. Cardiac examination reveals tachycardia with 2/6 systolic ejection murmur. Pulse oximetry reveals an oxygen saturation of 88% on room air and oxygen supplementation is initiated. Which of the following is the best diagnostic tool to confirm the diagnosis?

91) A 75-year-old G2P2 presents to your gynecology office for a routine examination. She tells you that she does not have an internist and does not remember the last time she had a physical examination. She says she is very healthy and denies taking any medication, including hormone replacement therapy. She has no history of abnormal Pap smears. She is a nonsmoker and has an occasional cocktail with her dinner. She does not have any complaints. In addition, she denies any family history of cancer. The patient tells you that she is a widow and lives alone in an apartment in town. Her grown children have families of their own and live far away. She states that she is self-sufficient and spends her time visiting friends and volunteering at a local museum. Her blood pressure is 140/70 mm Hg. Her height is 5ft 4 in and she weighs 130 lb. Her physical examination is completely normal. Which of the following are the most appropriate screening tests to order for this patient?

92) A 65-year-old G3P3 presents to your office for annual checkup. She had her last well-woman examination 20 years before when she had a hysterectomy for fibroids. She denies any medical problems, except some occasional stiffness in her joints early in the morning. She takes a multivitamin daily. Her family history is significant for cardiac disease in both her parents and breast cancer in a maternal aunt at the age of 42 years. Her physical examination is normal. Which of the following is the most appropriate set of laboratory tests to order for this patient?

93) You are following up on the results of routine testing of a 68-year-old G4P3 for her well-woman examination. Her physical examination was normal for a postmenopausal woman. Her Pap smear revealed parabasal cells, her mammogram was normal, lipid profile was normal, and the urinalysis shows hematuria. Which of the following is the most appropriate next step in the management of this patient?

94) A 17-year-old G1P1 presents to your office for her yearly wellwoman examination. She had an uncomplicated vaginal delivery last year. She has been sexually active for the past 4 years and has had six different sexual partners. Her menses occurs every 28 days and lasts for 4 days. She denies any intermenstrual spotting, postcoital bleeding, or vaginal discharge. She denies tobacco, alcohol, or illicit drug use. Which of the following are appropriate screening tests for this patient?

95) A 15-year-old woman presents to your office for her first well-woman examination. She has a history of asthma, for which she uses an inhaler as needed. She denies any prior surgeries. Her menses started at the age of 13 and are regular. She has recently become sexually active with her 17-year-old boyfriend. She states that they use condoms for contraception, but she is interested in something more effective. Which of the following is the most appropriate instrument to use when performing the Pap smear test in this patient?

96) A 40-year-old G3P2012 presents for her well-woman examination. She has had two vaginal deliveries and her largest baby weighed 4000 g. She had a postpartum bilateral tubal ligation. Her menstrual cycles are regular every 28 days and last 5 days. She states that with cough she may occasionally lose some urine; otherwise she has no complaints. She denies any medical problems. On examination she weighs 56 kg and her blood pressure is 132/81 mmHg. What type of speculum would be most appropriate to use when performing this patient’s Pap test?

97) A 50-year-old G4P4 presents for her well-woman examination. She had one cesarean delivery followed by three vaginal deliveries. Her menses stopped 1 year ago and she occasionally still has a hot flash. She tells you that about 10 years ago she was treated with a laser conization for carcinoma in situ of her cervix. Since that time, all of her Pap tests have been normal. What recommendation should you make regarding how frequently she should undergo Pap smear testing?

98) A 45-year-old G3P3 presents for her yearly examination. She last saw a doctor 7 years ago after she had her last child. She had three vaginal deliveries, the last of which was complicated by gestational diabetes and preeclampsia. She has not been sexually active in the past year. She once had an abnormal Pap smear for which she underwent cryotherapy. She denies any medical problems. Her family history is significant for coronary artery disease in her dad and a maternal aunt who developed ovarian cancer at the age of 67. Which of the following is best screening approach for this patient?

99) A pregnant woman is being followed by a nephrologist for chronic glomerulonephritis. Which of the following findings is normal at 28 weeks’ gestation?

100) A 37-year-old pregnant woman with type 2 diabetes mellitus and chronic hypertension is 35 weeks’ pregnant. Which of the following is the best test to screen for fetal well-being?

101) A 28-year-old G2, P 1woman in her 26th week of gestation comes to the office due to intermittent episodes of abdominal pain. She has been having these episodes for the past 4 days, and thinks that her fetus may be in distress. She points to her right flank when asked about the location of the pain, and says that it occasionally radiates to the groin area. She cannot identify any exacerbating or relieving factors. Her pregnancy has been uncomplicated so far. Her past medical history is significant for pelvic inflammatory disease. Her temperature is 37.5 C (99.5 F), blood pressure is 130/80 mm Hg, and pulse is 88/min. She is in considerable pain at the moment. Deep palpation of the right flank reveals tenderness. There is no CVA tenderness. Urinalysis shows: Specific gravity: 1.020, Blood: ++, Glucose: negative, Ketones: negative, Protein: negative, Leukocyte esterase: negative, Nitrites: negative. What is the best next step in the management of this patient?

102) 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?

103) 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 10.8 g/dl and platelet count is 223,000/mm3. Coagulation studies are within normal limits. Which of the following is the most appropriate next step in management?

104) 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 36.7 C (98 F), 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?

105) A 14-year-old girl is being evaluated for short stature. She has not yet had any menstrual periods. She is not sexually active. She is at 6th percentile for height and 20th percentile for weight. Blood pressure is elevated in the upper extremities and low in the lower extremities. Lungs are clear to auscultation. If measured, which of the following is most likely to be present in this patient?

106) A 32-year-old multiparous African-American woman comes for her initial prenatal visit at 14 weeks gestation. She complains of the recent appearance of facial hair and acne. The beta-HCG level is consistent with gestational age. Examination shows hirsutism. Ultrasonogram shows an intrauterine gestation consistent with dates and bilateral solid nodular masses in both ovaries. Which of the following is the most appropriate next step in management?

107) A 16-year-old girl comes to the emergency department because of abdominal pain and vaginal bleeding. She has been sexually active with her boyfriend for the past year; they occasionally use condoms. This is their only means of contraception. Her last menstrual period was eight weeks ago. Previous menses occurred at regular 28-day intervals. She has had two episodes of pelvic inflammatory disease in the past year. Which of the following is the most appropriate next step in management?

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

109) Which feature of fibrocystic disease of the breast is associated with the greatest risk of developing breast cancer?

110) A 25-year-old woman, gravida 2 para 1, presents to your office at 20 weeks' gestation for a routine prenatal check-up. She is known to be 0 (-) while her husband is 0 (+). Her obstetric history is significant for intrapartum placental abruption, which did not require caesarian delivery. She received a standard dose of anti-0 immune globulin at 28 weeks of her first pregnancy and immediately postpartum. You decide to determine her anti-0 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?

111) A 75-year-old woman comes to the physician complaining of vulvar itch that has been worsening for the past 2 years. She has had no bleeding from the vagina since she underwent menopause at the age of 52. She smokes five cigarettes per day. On physical examination she has a raised, pigmented lesion on the right labia majora. The rest of her physical examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?

112) A premenopausal, 48-year-old woman undergoes a routine mammographic screening. Physical examination is normal. Mammography identifies a suspicious focus with clustered micro-calcifications located deeply in the lateral upper quadrant of the right breast. No abnormality can be detected in this area on breast examination. Which of the following is the most appropriate next step in diagnosis?

113) A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy of the cervix shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. How should you classify or stage this patient’s disease?

114) An intravenous pyelogram (IVP) shows hydronephrosis in the workup of a patient with cervical cancer otherwise confined to a cervix of normal size. This indicates which one of the following stages?

115) A 24-year-old woman presents with new-onset right lower quadrant pain, and you palpate an enlarged, tender right adnexa. Which of the following sonographic characteristics of the cyst in this patient suggests the need for surgical exploration now instead of observation for one menstrual cycle?

116) A 20-year-old woman presents complaining of bumps around her vaginal opening. The bumps have been there for several months and are getting bigger. Her boyfriend has the same type of bumps on his penis. On physical examination the patient has multiple 2- to 10-mm lesions around her introitus consistent with condyloma. Her cervix has no gross lesions. A Pap smear is done. One week later, the Pap smear returns showing atypical squamous cells of undetermined significance (ASCUS). Reflex HPV typing showed no high-risk HPV. Which of the following viral types is most likely responsible for the patient’s condyloma?

117) A 24-year-old patient recently emigrated from the tropics. Four weeks ago she noted a small vulvar ulceration that spontaneously healed. Now there is painful inguinal adenopathy associated with malaise and fever. You are considering the diagnosis of lymphogranuloma venereum (LGV). The diagnosis can be established by which of the following?

118) A 33-year-old woman, gravida 1, para 0, comes for a routine prenatal visit, for the first time. 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?

119) A 15-year-old girl is brought to the physician by her mother because she has not begun menstruating. She is otherwise healthy and has no medical problems. Vitals signs are within normal limits. Physical examination shows absence of breast development and no pubic hair is seen. Examination shows no other abnormalities. Ultrasound confirms the presence of a uterus. Which of the following is the most appropriate next step in management?

120) A 24-year-old woman, G1 P1, comes to your office because she has been amenorrheic for two months. She has been taking low dose combined oral contraceptive pills (OCPs) for the past three months. She had withdrawal bleeding after the first month, but has had no bleeding over the past two months. Over the past few days, she has had nausea, vomiting and abdominal bloating. She does not use alcohol, tobacco, or drugs. Menarche occurred at the age of 14; menses have always been irregular. She is requesting a change in her contraception regimen because of these problems. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

121) 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. Fetal heart tones are heard. Which of the following is the next most appropriate step in management?

122) 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. Fetal heart tones are not present. Which of the following is the most appropriate next step in management?

123) A 22-year-old woman comes to the physician for an annual examination. She has normal periods every month and has no complaints. She has no medical problems but does smoke one pack of cigarettes per day. She has intercourse with more than one partner. Examination is unremarkable, including a normal pelvic examination. A Papanicolaou smear shows a high-grade squamous intraepithelial lesion. Which of the following is the most appropriate next step in management?

124) A 22-year-old woman presents for her first Pap smear. She has been sexually active with only one boyfriend since age 19. Her physical examination is completely normal. However, 2 weeks later her Pap smear results return showing HGSIL. There were no endocervical cells seen on the smear. Which of the following is the most appropriate next step in the management of this patient?

125) A 32-year-old woman consults with you for evaluation of an abnormal Pap smear done by a nurse practitioner at a family planning clinic. The Pap smear shows evidence of a high-grade squamous intraepithelial lesion (HGSIL). You perform colposcopy in the office. Your colposcopic impression is of acetowhite changes suggestive of human papilloma virus infection (HPV). Your biopsies show chronic cervicitis but no evidence of dysplasia. Which of the following is the most appropriate next step in the management of this patient?

126) A 55-year-old postmenopausal female presents to her gynecologist for a routine examination. She denies any use of hormone replacement therapy and does not report any menopausal symptoms. She denies the occurrence of any abnormal vaginal bleeding. She has no history of any abnormal Pap smears and has been married for 30 years to the same partner. She is currently sexually active with her husband on a regular basis. Two weeks after her examination, her Pap smear comes back as atypical glandular cells of undetermined significance (AGUS). Which of the following is the most appropriate next step in the management of this patient?

127) A 55-year-old G3P3 with a history of fibroids presents to you complaining of irregular vaginal bleeding. Until last month, she had not had a period in over 9 months. She thought she was in menopause, but because she started bleeding again last month she is not sure. Over the past month she has had irregular, spotty vaginal bleeding. The last time she bled was 1 week ago. She also complains of frequent hot flushes and emotional lability. She does not have any medical problems and is not taking any medications. She is a nonsmoker and denies any alcohol or drug use. Her gynecologic history is significant for cryotherapy of the cervix 10 years ago for moderate dysplasia. She has had three cesarean sections and a tubal ligation. On physical examination, her uterus is 12 weeks in size and irregularly shaped. Her ovaries are not palpable. A urine pregnancy test is negative. Which of the following is the most reasonable next step in the evaluation of this patient?

128) A 25-year-old nulligravid woman comes to the physician because of chronic 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. Urine pregnancy test is negative. Which of the following is most appropriate diagnostic test in her management?

129) A 23-year-old G1POfemale presents for her first prenatal visit at 14 weeks gestation. A pap smear is done at that time and a high grade squamous intraepithelial lesions (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?

130) A 26-year-old woman, gravida 3, para 2, comes to the physician for the first time for a prenatal checkup. She changed her physician and in the interim has missed two prenatal checkups. She states that she is at 7months gestation. According to her prenatal records and an ultrasound performed at 16 weeks gestation, she is now at 30 weeks, but her fundal height is only 26 cm (10.2 inches). Fetal heart tones are heard by Doppler. Blood pressure is 140/90 mm Hg. You suspect fetal growth restriction (FGR) and order a repeat ultrasonogram. Which of the following is the single most useful parameter for predicting fetal weight by ultrasonogram in suspected FGR?

131) A 75-year-old woman comes to the physician because of irregular vaginal bleeding. She has been menopausal for the past 25 years, but has noted on-and-off spotting for the past 2 years, which she finds intolerable. She has a complicated past medical history including hypertension, diabetes, and severe chronic obstructive pulmonary disease. Examination is unremarkable. An endometrial biopsy is performed that demonstrates an endometrial polyp with atypical cells that are difficult to grade. Which of the following is the most appropriate next step in management?

132) A 68-year-old woman comes to the physician because of a painful lump in her vagina. She states that the lump has been there for a few months, but has recently begun to cause her pain. She has hypertension, for which she takes a diuretic, but no other medical problems. Examination shows a 4 cm cystic mass near the patient's introitus by the right labia. The mass is mildly tender. The remainder of the pelvic examination is normal. Which of the following is the most appropriate next step in management?

133) A 28-year-old primigravid woman at 8 weeks' gestation comes to the physician for her first prenatal visit. A home pregnancy test was positive. She has no complaints. She is concerned, however, because she is a carrier of the fragile X mutation. Her husband is also known to be a carrier. This is a highly desired pregnancy. She wants to know whether there is a way to determine whether the fetus is affected. Which of the following is the most appropriate next step in management?

134) A 23-year-old woman calls her physician for the results of her Pap test. She has a history of Chlamydia. She has never had an abnormal Pap. She occasionally has unprotected intercourse. The physician informs her that the Pap was normal. The patient is relieved, but wants to know whether this result could be wrong. The physician explains that a Pap test detects abnormal cells in roughly 4 of every 5 women who have abnormal cervical cells. Which of the following represents the sensitivity of the Papanicolaou test?

135) A 34-year-old woman, gravida 3, para 2 at term comes to the labor and delivery ward with a gush of blood, abdominal pain, and irregular, painful contractions. Her prenatal course was significant for her being Rh negative and antibody negative. Her temperature is 37 C (98.6 F), pulse is 110/minute, blood pressure is 110/70 mm Hg, and respirations are 12/minute. Abdominal examination shows a tender abdomen and cervical examination shows the cervix to be closed and long with a significant amount of blood in the vagina. The fetal heart rate is in the 170s with moderate to severe variable decelerations with contractions. The diagnosis of placental abruption is made and an emergent cesarean delivery is performed. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send?

136) A 23-year-old primigravid woman comes to the physician because of vaginal bleeding. Her last menstrual period was 6 weeks ago. She has no other symptoms. Examination shows a 10-week sized uterus, but is otherwise unremarkable. Pelvic ultrasound reveals a snowstorm pattern consistent with a complete mole. Serum beta-hCG is markedly elevated over normal pregnant values. A chest x-ray film is negative. A dilation and evacuation is performed and the pathologic diagnosis is complete hydatidiform mole. Which of the following is the most appropriate next step in management?