DES 2016. Final (Part 36)

79) A 31-year-old primigravid woman comes to the physician for a prenatal visit. She is known to be HIV positive. She also has asthma, for which she uses an inhaler. She had a diagnostic laparoscopy at age 20 for pelvic pain and has had no other surgeries. She has no known drug allergies. Extensive counseling is given to the patient regarding vertical transmission of HIV to the fetus. It is recommended to her that she take antiretroviral therapy during the pregnancy to decrease the vertical transmission rate. It is also recommended to her that she have a scheduled cesarean delivery. After consideration of these options, the patient chooses not to take the antiretrovirals and opts for a vaginal delivery. Which of the following represents the approximate risk of vertical transmission (from the mother to the fetus) for this patient?

80) A 36-year-old woman, gravida 5, para 4, at 30 weeks' gestation comes to the physician for a prenatal visit. She feels the baby moving and has not had bleeding per vagina, contractions, or loss of fluid. The prenatal course has been uncomplicated thus far. The patient is interested in having a postpartum tubal ligation. She has many questions regarding the procedure, including whether there is a risk of failure. Which of the following represents the closest estimate for the likelihood of failure of a postpartum tubal ligation?

81) A 23-year-old primigravid woman at 29-weeks' gestation comes to the physician because of contractions. She states that they have been occurring every 3-5 minutes for the past few hours and that they are worsening in intensity. Examination reveals that the patient is afebrile and her abdomen is nontender. Her cervix is 3 cm dilated, and the fetus is in vertex position. The patient is started on IV magnesium sulfate and penicillin and given an intramuscular injection of betamethasone. Which of the following represents the most significant consequence of this patient's preterm labor?

82) A 22-year-old G1 at 14 weeks gestation presents to your office with a history of recent exposure to her 3-year-old nephew who had a rubella viral infection. In which time period does maternal infection with rubella virus carry the greatest risk for congenital rubella syndrome in the fetus?

83) A 22-year-old has just been diagnosed with toxoplasmosis. You try to determine what her risk factors were. The highest risk association is which of the following?

84) A 30-year-old class D diabetic is concerned about pregnancy. She can be assured that which of the following risks is the same for her as for the general population?

85) A 37-year-old G3P2 presents to your office for her first OB visit at 10 weeks gestation. She has a history of Graves’ disease and has been maintained on propylthiouracil (PTU) as treatment for her hyperthyroidism. She is currently euthyroid but asks you if her condition poses any problems for the pregnancy. Which of the following statements should be included in your counseling session with the patient?

86) A 23-year-old G1 at 40 weeks gestation presents to the hospital with the complaint of contractions. She states they are occurring every 4 to 8 minutes and each lasts approximately 1 minute. She reports good fetal movement and denies any leakage of fluid or vaginal bleeding. The nurse places an external tocometer and fetal monitor and reports that the patient is having contractions every 2 to 10 minutes. The nurse states that the contractions are mild to palpation. On examination the cervix is 2 cm dilated, 50% effaced, and the vertex is at −1 station. The patient had the same cervical examination in your office last week. The fetal heart rate tracing is 140 beats per minute with accelerations and no decelerations. Which of the following stages of labor is this patient in?

87) A 38-year-old G3P3 begins to breast-feed her 5-day-old infant. The baby latches on appropriately and begins to suckle. In the mother, which of the following is a response to suckling?

88) A 26-year-old G1P1 is now postoperative day (POD) 6 after a low transverse cesarean delivery for arrest of active phase. On POD 2, the patient developed a fever of 39C (102.2F) and was noted to have uterine tenderness and foul-smelling lochia. She was started on broad-spectrum antibiotic coverage for endometritis. The patient states she feels fine now and wants to go home, but continues to spike fevers each evening. Her lung, breast, and cardiac examinations are normal. Her abdomen is nontender with firm, nontender uterus below the umbilicus. On pelvic examination her uterus is appropriately enlarged, but nontender. The adnexa are nontender without masses. Her lochia is normal. Her white blood cell count is 12 with a normal differential. Blood, sputum, and urine cultures are all negative for growth after 3 days. Her chest x-ray is negative. Which of the following statements is true regarding this patient’s condition?

89) A 32-year-old G2P2 develops fever and uterine tenderness 2 days after cesarean delivery for nonreassuring fetal heart tones. She is placed on intravenous penicillin and gentamicin for her infection. After 48 hours of antibiotics she remains febrile, and on examination she continues to have uterine tenderness. Which of the following bacteria is resistant to these antibiotics and is most likely to be responsible for this woman’s infection?

90) A patient was induced for being postterm at 421/2 weeks. Immediately following the delivery, you examine the baby with the pediatricians and note the following on physical examination: a small amount of cartilage in the earlobe, occasional creases over the anterior two-thirds of the soles of the feet, 4-mm breast nodule diameter, fine and fuzzy scalp hair, and a scrotum with some but not extensive rugae. Based on this physical examination, what is the approximate gestational age of this male infant?

91) A 30-year-old G3P3 is postoperative day 4 after a repeat cesarean delivery. During the surgery she received 2 units of packed red blood cells for a hemorrhage related to uterine atony. She is to be discharged home today. She complains of some yellowish drainage from her incision and redness that just started earlier in the day. She states that she feels feverish. She is breast-feeding. Her past medical history is significant for type 2 diabetes mellitus and chronic hypertension. She weighs 110 kg. Her vital signs are temperature 37.8C (100.1F), pulse 69 beats per minute, respiratory rate 18 breaths per minute, and blood pressure is 143/92 mm Hg. Breast, lung, and cardiac examinations are normal. Her midline vertical skin incision is erythematous and has a foul-smelling purulent discharge from the lower segment of the wound. It is tender to touch. The uterine fundus is not tender. Which of the following is not a risk factor for her condition?

92) A 44-year-old G6P3215 presents for her well-woman examination. She tells you that all of her deliveries were vaginal and that her largest child weighed 2900 g at birth. How many full-term pregnancies did this patient have?

93) A 30-year-woman presents to your office with the fear of developing ovarian cancer. Her 70-year-old grandmother recently died from ovarian cancer. You discuss with her the risks factors and prevention for ovarian cancer. Which of the following can decrease a woman’s risk of ovarian cancer?

94) Which of the following statements is true regarding contraception?

95) A 31-year-old primigravida develops gestational diabetes mellitus and is managed appropriately during pregnancy. She asks you about the consequences of gestational diabetes to her and her fetus. Which one of the following statements is correct?

96) A 23-year-old G1P0010 woman complains of severe dysmenorrhea (i.e., pain with menses). She misses work for the first 3 days of her menstrual cycle almost every month and states that this has been a problem for about 3 years, now getting worse. She is not currently sexually active and is not using any hormonal contraception. She complains of occasional deep abdominal pain after bowel movements. Subsequent laparoscopic evaluation reveals endometriosis. Which of the following is a true statement regarding this condition?

97) A 21-year-old woman presents with left lower quadrant pain. An anterior 7-cm firm adnexal cyst is palpated. Ultrasound confirms a complex left adnexal mass with solid components that appear to contain bone and teeth. What percentage of these tumors are bilateral?

98) A patient is receiving external beam radiation for treatment of metastatic endometrial cancer. The treatment field includes the entire pelvis. Which of the following tissues within this radiation field is the most radiosensitive?

99) A pregnant 35-year-old patient is at highest risk for the concurrent development of which of the following malignancies?

100) A 17-year-old girl is seen by her primary care physician for the evaluation of left lower quadrant pain. The physician felt a pelvic mass on physical examination and ordered a pelvic ultrasound. You are consulted because an ovarian neoplasm is identified by the ultrasound. Which of the following is the most common ovarian tumor in this type of patient?

101) A 41-year-old woman undergoes exploratory laparotomy for a persistent adnexal mass. Frozen section diagnosis is serous carcinoma. Assuming that the other ovary is grossly normal, what is the likelihood that the contralateral ovary is involved in this malignancy?

102) A 21-year-old woman returns to your office for evaluation of an abnormal Pap smear. The Pap smear showed a squamous abnormality suggestive of a high-grade squamous intraepithelial lesion (HGSIL). Colposcopy confirms the presence of a cervical lesion consistent with severe cervical dysplasia (CIN III). Which of the following human papilloma virus (HPV) types is most often associated with this type of lesion?

103) One day after a casual sexual encounter with a bisexual man recently diagnosed as antibody-positive for human immunodeficiency virus (HIV), a patient is concerned about whether she may have become infected. A negative antibody titer is obtained. To test for seroconversion, when is the earliest you should reschedule repeat antibody testing after the sexual encounter?

104) After reading an article titled: "The Risk of Cancer in Patients with Diethylstilbestrol (DES) Exposed Mothers", a 23-year old female comes to your office with her mother for assessment of possible risks. Her mother had been given DES while pregnant. Which of the following cancers is this patient most at risk of developing?

105) A 24-year-old female comes to the physician because of increasing facial acne and recent menstrual irregularities. She has no significant past medical history and she takes no medications. She does not use tobacco, alcohol or drugs. She weighs 170 lb (77 Kg) and is 62 in (155cm) tall. Physical examination shows moderate acne on her face and prominent hair on the upper lip. For which of the following conditions is she at greater risk than the general population?

106) You have a 32-year-old G1P0 patient who has undergone a routine obstetrical ultrasound screening at 20 weeks of gestation. The patient phones you immediately following the ultrasound because during the procedure the ultrasonographer commented that she noted several small fibroid tumors in the patient’s uterus. As this is the patient’s first pregnancy, she is concerned regarding the possible effects that the fibroid tumors may have on the outcome of her pregnancy. As her obstetrician, which of the following should you tell her?

107) A 58-year-old Caucasian woman comes in to your office for advice regarding her risk factors for developing osteoporosis. She is 5ft 1 in tall and weighs 195 lb. She stopped having periods at age 49. She is healthy but smokes one pack of cigarettes per day. She does not take any medications. She has never taken hormone replacement for menopause. Her mother died at age 71 after she suffered a spontaneous hip fracture. Which of the following will have the least effect on this patient’s risk for developing osteoporosis?

108) While evaluating a 30-year-old woman for infertility, you diagnose a bicornuate uterus. You explain that additional testing is necessary because of the woman’s increased risk of congenital anomalies in which organ system?

109) 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?

110) A 20-year-old G0 and her partner, a 20-year-old man, present for counseling for sexual dysfunction. Prior to their relationship, neither had been sexually active. Both deny any medical problems. In medical experience, which type of male or female sexual dysfunction has the lowest cure rate?

111) A 28-year-old G3P3 presents to your office for contraceptive counseling. She denies any medical problems or sexually transmitted diseases. You counsel her on the risks and benefits of all contraceptive methods. Which of the following is the most common form of contraception used by reproductive-age women in the United States?

112) A 20-year-old woman presents to your office for her well-woman examination. She has recently become sexually active and desires an effective contraceptive method. She has no medical problems, but family history is significant for breast cancer in a maternal aunt at the age of 42. She is worried about getting cancer from taking birth control pills. You discuss with her the risks and benefits of contraceptive pills. You tell her that which of the following neoplasms has been associated with the use of oral contraceptives?

113) A 39-year-old G3P3 presents for her postpartum examination and desires a long-term contraceptive method, but is unsure if she wants sterilization. She has been happily married for 15 years and denies any sexually transmitted diseases. Her past medical history is significant for mild hypertension, for which she takes a low-dose diuretic. She is considering an intrauterine device and wants to know how it works. Which of the following is the best explanation for the mechanism of the action of the intrauterine device (IUD)?

114) A 14-year-old girl is brought to the physician's office because of irregular menstrual periods. She had her menarche at age 13, and since then her periods have been irregular with the cycles varying from 3 to 6 weeks. She has no other symptoms. Physical examination is unremarkable. She has age appropriate secondary sexual characteristics. A urine pregnancy test is negative. Serum prolactin and thyroid stimulating hormone levels are normal. Administration of micronized oral progesterone results in withdrawal bleeding in 3 days. Which of the following most likely explains her irregular periods?

115) A 20-year-old woman presents to your office for a well-woman examination. She has been sexually active with one male partner for the past year. She has not achieved orgasm with her partner. On further questioning, she has never achieved orgasm with other partners or with masturbation or the use of a vibrator. Which of the following statements is true regarding her condition?

116) A 48-year-old woman presents to your office with the complaint of vaginal dryness during intercourse. She denies any medical problems or prior surgeries and does not take any medications. She still has regular menstrual cycles every 28 days. She denies any sexually transmitted diseases. She describes her sexual relationship with her husband as satisfying. Her physical examination is normal. Components of the natural lubrication produced by the female during sexual arousal and intercourse include which of the following?

117) A wealthy American executive donates five million dollars for the prevention of intrauterine growth restriction in the local county. Spending this money on which of the following programs would prevent the greatest number of cases of fetal growth restriction (FGR) in the population?

118) A 33-year-old woman comes to the physician because she has not had a menstrual period for 8 months. She had menarche at the age of 12 and, after a few years of irregular menses, has since had normal monthly menses. She has no medical problems and takes no medications. Examination reveals a normal-appearing female with no abnormalities noted. Urine human chorionic gonadotropin (hCG) is negative. Serum thyroid stimulating hormone (TSH) and prolactin are also normal. The patient is given a 10-day course of medroxyprogesterone acetate. Upon completing the 10 days, she has a heavy menstrual period. This patient's withdrawal bleeding in response to the progesterone provides good evidence for which of the following?

1) A 16-year-old girl presents to the emergency department complaining of fever, chills, abdominal pain, and vaginal bleeding. She gives a history of unprotected sexual activity with her 17-year-old boyfriend over the past several months. Her last menstrual period was 8 weeks ago. She reports having a dilatation and curettage procedure at an unlicensed abortion clinic recently to try to abort the pregnancy. Her temperature is 38.7C (101.7F), heart rate is 120/min, and blood pressure is 100/70 mmHg. Pelvic examination reveals cervical motion tenderness, tissue in the internal os, and foul-smelling vaginal discharge. Urine is positive for β-human chorionic gonadotropin. Which of the following is the most likely diagnosis?

2) A 19-year-old G0 woman presents to her family physician complaining of dysmenorrhea for the past year. She reports severe right-sided pain that coincides with days 1–5 of her menstrual cycle. Her menses occur regularly every 28 days, and she requires three to four pads per day for the first 2 days of her bleeding and one to two pads per day for the remainder. She has never had surgery. She is not sexually active and does not smoke. Her last menstrual period was 1 week ago. Her temperature is 36.7C (98.1F), blood pressure is 121/74 mmHg, heart rate is 80/min, and respiratory rate is 14/min. Physical examination reveals a thin, healthy-appearing young woman. Pelvic examination reveals a normal sized uterus and no cervical motion tenderness. Which of the following is the most likely diagnosis?

3) After an appropriate diagnostic evaluation, a 59-year-old woman with postmenopausal bleeding had a total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH-BSO). The pathologic diagnosis is adenocarcinoma of the endometrium. An endometrial adenocarcinoma that is confined to the uterus and extends more than 50% through the myometrium is at which stage?

4) A 39-year-old woman at 16 weeks’ gestation complains of headaches, blurred vision, and epigastric pain. Her blood pressure is now 156/104 mmHg. Her uterine fundus is palpable 22 cm above her symphysis pubis. Fetal heart tones could not be heard with a handheld Doppler. She has 3+proteinuria. Which of the following is the most likely diagnosis?

5) A 39-year-old G3P3 complains of severe, progressive secondary dysmenorrhea and menorrhagia. Pelvic examination demonstrates a tender, diffusely enlarged uterus with no adnexal tenderness. Results of endometrial biopsy are normal. Which of the following is the most likely diagnosis?

6) A 28-year-old G3P0 has a history of severe menstrual cramps, prolonged, heavy periods, chronic pelvic pain, and painful intercourse. All of her pregnancies were spontaneous abortions in the first trimester. A hysterosalpingogram (HSG) she just had as part of the evaluation for recurrent abortion showed a large uterine septum. You have recommended surgical repair of the uterus. Of the patient’s symptoms, which is most likely to be corrected by resection of the uterine septum?

7) A 22-year-old woman presents with mouth sores, sore throat, vaginal discharge, fever, and myalgia. She has no other medical problems. She takes oral contraceptive pills. She is in a monogamous relationship and states that her partner occasionally uses barrier contraception. Physical examination reveals a temperature of 38.3 C (101 F), cervical and inguinal lymphadenopathy, exudative pharyngitis, and multiple ulcers on the oral mucosa, the labia, and cervix. The vaginal discharge is profuse, and Gram stain indicates many neutrophils. Which of the following is the most likely diagnosis?

8) A 14-year-old Caucasian female presents to clinic for a routine check-up. She complains that her menstrual cycles are irregular and that her menses last seven to ten days. She underwent menarche one year ago and her last menstrual period was two weeks ago. She eats a balanced diet and works out in a gym on weekends. Her past medical history is insignificant and her BMI is 25 kg/m2. Which of the following is the most likely cause of this patient's complaints?

9) A 32-year-old female with a history of amenorrhea develops white nipple discharge. She eats a balanced diet and exercises regularly. She is not sexually active. Her family history is significant for her mother dying of breast cancer at age 50. The most likely diagnosis in this patient is:

10) A 37-year-old female presents to your clinic complaining of lower abdominal discomfort. On bimanual examination the uterus is enlarged. Biopsy reveals normal appearing endometrial glands within the myometrium. The most likely diagnosis is:

11) A 75-year-old woman presents with a pruritic vulvar lesion. Physical examination reveals an irregular white, rough area involving her vulva. Biopsies from this area reveal a combination of squamous hyperplasia of the epidermis (acanthosis) with hyperkeratosis and mild dermal inflammation. No atrophy or dysplasia of the epidermis is seen. What is the best diagnosis?

12) A 65-year-old woman presents with a pruritic red, crusted, sharply demarcated map-like lesion involving a large portion of her labia majora. Histologic sections from this lesion reveal individual anaplastic tumor cells infiltrating the epidermis. Distinctive clear spaces are noted between these anaplastic cells and the surrounding normal epithelial cells. These malignant cells stain positively for mucin and negatively with S100. Which of the following is the most likely diagnosis?

13) A 39-year-old woman presents with severe menorrhagia and colicky dysmenorrhea. A hysterectomy including resection of the fallopian tubes and ovaries is performed. Examination by the pathologist finds a right adnexal cyst measuring approximately 2.3 cm in diameter and filled with clotted blood. Microscopic examination reveals the presence in the wall of the cyst of endometrial glands, stroma, and hemosiderin pigment. What is the best diagnosis?

14) A 23-year-old woman presents with urinary frequency and abnormal uterine bleeding. A careful medical history finds that her abnormal menstrual bleeding is characterized by excessive bleeding at irregular intervals. A pelvic examination finds a single mass in the anterior wall of the uterus, this being confirmed by ultrasonography. Which one of the following clinical terms best describes the abnormal uterine bleeding in this woman?

15) A 25-year-old woman presents with lower abdominal pain, fever, and a vaginal discharge. Pelvic examination reveals bilateral adnexal (ovarian) tenderness and pain when the cervix is manipulated. Cultures taken from the vaginal discharge grow Neisseria gonorrhoeae. Which of the following is the most likely cause of this patient’s adnexal pain?

16) 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 110/60mmHg, pulse is 110/min and respirations are 32/min. Physical examination shows hyperventilation, cold extremities and a distended abdomen with irregular contours. Fetal heart monitoring shows repetitive late decelerations and a long-term variability of 2 cycles/min. Which of the following is the most likely diagnosis?

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

18) A 32-year-old woman, gravida 3, para 2, at 38 weeks gestation is admitted to the hospital for labor pains. 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. In her second pregnancy, she had to undergo cesarean section. The woman is admitted to the delivery room and fetal heart and uterine contraction monitoring is started. Her blood pressure is 100/60mmHg, pulse is 115/min and respirations are 26/min. Pelvic examination shows the cervix is 60% effaced and 6cm dilated. Uterine contractions are regular and occurring every 4 minutes. Fetal heart tracing shows no abnormalities. Suddenly, the patient starts complaining of an intense lower abdominal pain. She is restless and vaginal bleeding is noted. Fetal heart monitoring shows variable decelerations, and the fetus has shifted to the ‘-2' station from '0' station Which of the following is the most likely diagnosis?

19) A 25-year-old woman, gravida 2, para 1, at 32 weeks gestation is brought to the emergency department because of acute onset severe uterine contractions and moderate vaginal bleeding. Her first pregnancy was uncomplicated. She has a history of cocaine addiction but she is now participating in a drug rehabilitation program. Ultrasonogram performed at the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. Her temperature is 37.0 C (98.7F), blood pressure is 130/80 mmHg, pulse is 90/min and respirations are 15/min. Physical examination shows uterine tenderness, hyperactivity, and increased uterine tone. Fetal heart tracing shows 140/min with good long-term and beat-to-beat variability. Which of the following is the most likely diagnosis?

20) During the evaluation of infertility in a 25-year-old female, a hysterosalpingogram showed evidence of Asherman syndrome. Which one of the following symptoms would you expect this patient to have?

21) A 29-year-old woman presents with complaints of a vaginal discharge. She has had two sexual partners over the past 4 weeks, and she reports that she uses oral contraceptives and that her partners were not using condoms. Examination shows she is afebrile, with no lymphadenopathy. Pelvic examination shows no ulcers, but a thick white discharge is noted at the cervical os on speculum examination. A Gram stain of the discharge reveals gram negative diplococci. A sample of the discharge is also sent out for culture. The patient is appropriately treated and returns unhappily 3 weeks later with identical symptoms. A Gram stain of the discharge is again done, and this time reveals no organisms. Which of the following is the most likely cause of her symptoms?

22) An 18-year-old woman presents with amenorrhea and is found to have normal secondary sex characteristics and normal-appearing external genitalia. Her first menstrual period was at age 13, and her cycle has been unremarkable until now. She states that her last menstrual period was 8 weeks prior to this visit. A urine test for hCG is positive. Which of the following is the most likely diagnosis?

23) A 24-year-old woman delivers a normal 8-lb baby boy at 40 weeks of gestation. She has no history of drug abuse, and her pregnancy was unre-markable. Examination had revealed the placenta to be located normally, but following delivery the woman fails to deliver the placenta and subsequently develops massive postpartum hemorrhage and shock. Emergency surgery is performed to stop the bleeding. Which of the following is the most likely cause of her postpartum bleeding?

24) A 26-year-old woman develops acute lower abdominal pain and vaginal bleeding. While in the bathroom she passes a cast of tissue composed of clot material and then collapses. She is brought to the hospital, where a physical examination reveals a soft, tender mass in right adnexa and pouch of Douglas. Histologic examination of the tissue passed in the bathroom reveals blood clots and decidualized tissue. No chorionic villi or trophoblastic tissue are present. Which of the following conditions is most likely present in this individual?

25) A 26-year-old woman in the third trimester of her first pregnancy develops persistent headaches and swelling of her legs and face. Early during her pregnancy, a physical examination was unremarkable; however, now her blood pressure is 170/105 mmHg and urinalysis reveals slight proteinuria. Which of the following is the most likely diagnosis?

26) A 22-year-old nulliparous woman has recently become sexually active. She consults you because of painful coitus, with the pain located at the vaginal introitus. It is accompanied by painful involuntary contraction of the pelvic muscles. Other than confirmation of these findings, the pelvic examination is normal. Which of the following is the most common cause of this condition?

27) A 35-year-old African-American marathon runner presents to the gynecologist complaining of secondary amenorrhea that developed three months ago. Her cycles are normally 28 days long, and her menses last three to five days with moderate flow. One year ago, the woman adopted a vigorous exercise regimen that lasted between three and five hours every day. Since then, her BMI has declined from 23.4 to 16.5. She has been winning many local races and is considering increasing the difficulty of her exercise regimen, but would like to address the issue of her amenorrhea first. Physical examination reveals a thin woman with well-defined musculature but is otherwise unremarkable. Pregnancy test is negative. What is the most likely etiology of her amenorrhea?

28) A 38-year-old Caucasian female presents to the office complaining of lethargy, weight gain and fatigue. She denies headaches, pruritus or urine discoloration. She just gave birth 2 months ago via vaginal delivery; her baby is in good health and receives formula nutrition. Her delivery was complicated by vaginal bleeding that required blood transfusion, and postpartum endometritis that rapidly responded to antibiotics. She has not had any menstrual periods following delivery. Physical examination shows sparse pubic hair, dry skin and delayed tendon reflexes. Urinalysis shows no glucose or ketones. Which of the following is most likely to be responsible for this patient's condition?

29) A 24-year-old gravida 2, para 1, African American woman at 12 weeks gestation comes for her first prenatal visit. Except for early morning mild headaches and nausea she has no other symptoms. Physical examination shows mild bilateral ankle edema. Blood pressure is measured twice 15 minutes apart and is 150/96 mmHg on both occasions. Blood is drawn for laboratory tests and the patient is sent home with a follow-up appointment 3 days later. She returns 3 days later and repeat blood pressure is the same. Laboratory studies show: Urinalysis: Protein: negative; Blood: negative; Glucose: negative; Ketones: negative; Leukocyte esterase: negative; Nitrites: negative; WBC:1-2/hpf; RBC: 1-2/hpf. Chemistry panel: Serum sodium: 150 mEq/L; Serum potassium: 2.5 mEq/L; Chloride: 100 mEq/L; Bicarbonate: 23 mEq/L; Blood urea nitrogen (BUN): 14 mg/dL; Serum creatinine: 0.8 mg/dL. Ultrasonogram reveals intrauterine gestation consistent with dates; no abnormalities noted. Which of the following is the most likely diagnosis?

30) A 27-year-old female at 30 weeks gestation complains of difficulty hearing, especially on the right side. She denies any ear pain or discharge. Her pregnancy was complicated by acute pyelonephritis at 22 weeks gestation, which was treated with antibiotics. She does not smoke or consume alcohol, and she eats a balanced diet. She has no preexisting medical problems and takes no medications aside from a multivitamin. Her blood pressure is 160/100 mmHg and heart rate is 75/min. Cardiac and pulmonary examinations are unremarkable. No focal abnormalities are found on neurologic examination. When a tuning fork is placed on the right mastoid process, she appreciates the tone louder than when it is held near the external auditory meatus. Audiometry shows right low-frequency hearing loss. Which of the following is the most likely cause of this patient's complaints?

31) You are asked to consult on a 31-year-old woman who is at 26 weeks’ gestation and who has had fever for 2 days. She states that she starting feeling fevers and chills approximately 3 days ago. These symptoms have worsened since that time and she has also experienced myalgias, back pain, malaise, and upper respiratory complaints. She was initially diagnosed with the flu, but her condition seems to be worsening. Her prenatal course has been otherwise uncomplicated. She has no past medical or surgical history. Her past obstetric history is significant for a normal spontaneous vaginal delivery 3 years ago. She takes no medications and is allergic to sulfa drugs. Her physical examination is significant for a temperature of 38.3 C (101.0 F) and mild abdominal tenderness. Her urine culture is negative. Her obstetrician performed an amniocentesis yesterday that demonstrated gram-positive rods. Which of the following is the most likely causative organism?

32) A 54-year-old woman comes to the physician for an annual examination. She has no complaints. For the past year, she has been taking tamoxifen for the prevention of breast cancer. She was started on this drug after her physician determined her to be at high risk on the basis of her strong family history, nulliparity, and early age at menarche. She takes no other medications. Examination is within normal limits. Which of the following is this patient most likely to develop while taking tamoxifen?

33) A 24-year-old woman comes to the physician because of right lower quadrant abdominal pain. She has had the pain off and on for the past month, but it is now increasing. She has no other symptoms and no medical problems. Examination reveals a mildly tender, right adnexal mass. Pelvic ultrasound shows a 7 cm right adnexal complex cyst. Urine hCG is negative. The patient is taken to the operating room for laparotomy and right ovarian cystectomy. Microscopically the cyst has cartilage, adipose tissue, intestinal glands, hair, and a calcification that appears to be a tooth. There is also a large amount of thyroid tissue. Which of the following is the most likely diagnosis?

34) A 60-year-old woman comes to the physician for an annual examination. She has no complaints. She had her last menstrual period at age 55 and has had no vaginal bleeding since. She has no medical problems and has never had surgery. She takes no medications and has no allergies to medications. The physical examination is unremarkable. She is concerned about cancer and wants to know which type is the major cause of cancer death in women. Which of the following is the correct response?

35) A 36-year-old primigravid woman at 36 weeks' gestation comes to the physician for a prenatal visit. She is experiencing good fetal movement and has had no loss of fluid, bleeding from the vagina, or contractions. She has no complaints. Her past medical history is significant for mitral stenosis, which she developed after an episode of rheumatic fever as a child. She also has asthma for which she uses an albuterol inhaler daily. She has herpes outbreaks approximately once a year. At her last visit she was found to be positive for Group B Streptococcus colonization. For which of the following disease processes would this patient benefit by having a forceps-assisted vaginal delivery at the time of delivery?

36) A 14-year-old girl comes to the office for a health maintenance evaluation. She is concerned that she has not yet started her menstrual cycle. Her height has increased by 3 inches since her last visit 1 year ago, and her weight is up by 10 pounds. On physical examination, the physician notes a general enlargement of her breasts and areola. Examination of her genital area reveals pubic hair that is coarse and dark and extends past the medial border of the labia. Which of the following is the most likely diagnosis?

37) A 27-year-old primigravid woman at 10 weeks gestation is brought to the emergency department because of vaginal bleeding and cramping lower abdominal pain. She continues to have cramping in the ER. Her temperature is 37.0 C (98.7 F), blood pressure is 100/76 mmHg, pulse is 84/min and respirations are 14/min. Physical examination shows an effaced and dilated cervix. Gestational tissue is visualized through the internal cervical os. Bimanual examination shows the uterus is soft and enlarged, and vaginal bleeding is seen. Which of the following is the most likely diagnosis?

38) A 30-year-old G2P2 woman comes to the physician with fatigue, mood swings, irritability, breast tenderness, abdominal bloating, and headaches that occur monthly. The symptoms are worse just before her menses and resolve by the third day of her menstrual cycle. The symptoms interfere with her daily activities, including her proficiency at work. The patient's only current medication is a multivitamin. She uses spermicidal foam and condoms for birth control. Her menses are regular. Her sister was diagnosed with hypothyroidism and takes levothyroxine. Examination shows no abnormalities. Which of the following is the most likely cause of her symptoms?

39) At a follow-up routine prenatal visit, the uterine fundus of a healthy 23-year-old pregnant woman is palpated halfway between her symphysis pubis and umbilicus. Which of the following is the most appropriate test to order at this stage of her pregnancy?

40) A 25-year-old woman in her 15th week of pregnancy presents with uterine bleeding and passage of a small amount of watery fluid and tissue. She is found to have a uterus that is much larger than estimated by her gestational dates. Her uterus is found to be filled with cystic, avascular, grapelike structures that do not penetrate the uterine wall. No fetal parts are found. Immunostaining for p57 was negative in the cytotrophoblasts and villi mesenchyme. Which of the following is the best diagnosis?

41) 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. Which of the following is the most likely diagnosis?

42) A 20-year-old, G1 PO, woman at 35 weeks gestation comes to the hospital because of regular uterine contractions. She noticed a passage of clear fluid per vagina for the past 24 hours. She has no other symptoms. Her pregnancy thus far has been uncomplicated. Her temperature is 38.2 C (100.7 F), blood pressure is 120/68 mmHg, pulse is 110/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. Fetal 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: 198,000/mm3; Leukocyte count: 18,500/mm3; Neutrophils: 86%; Lymphocytes: 14%. Which of the following is the most likely diagnosis?

43) A 37-year-old woman comes to the physician for evaluation of infertility. She and her 39-year-old husband have not been able to conceive after 13 months of unprotected and frequent intercourse. She has 28-day regular menstrual cycles. The patient had a pregnancy with her husband at age 31. She has no other genitourinary complaints such as menorrhagia, dyspareunia or pelvic pain. She has no previous history of sexually transmitted diseases or abdominal surgery. The patient does not use tobacco, alcohol, or illicit drugs. She is an aerobics instructor and teaches 230-minute classes daily. Her blood pressure is 130/80 mm Hg and pulse is 84/min. Her body mass index is 23 kg/m2. Complete physical examination is unremarkable. Which of the following is the most likely cause of her condition?

44) A 20-year-old, G1PO, 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 (100.7 F), blood pressure is 120/68 mmHg, pulse is 110/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. Fetal 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 198,000/mm3; Leukocyte count 18,500/mm3; Neutrophils 86%; Lymphocytes 14%. Which of the following is the most likely diagnosis?

45) A 40-year-old G3P3 comes to your office for a routine annual GYN examination. She tells you that she gets up several times during the night to void. On further questioning, she admits to you that during the day she sometimes gets the urge to void, but sometimes cannot quite make it to the bathroom. She attributes this to getting older and is not extremely concerned, although she often wears a pad when she goes out in case she loses some urine. This patient is very healthy otherwise and does not take any medication on a regular basis. She still has regular, monthly menstrual periods. She has had three normal spontaneous vaginal deliveries of infants weighing between 7 and 8 lb. An office dipstick of her urine does not indicate any blood, bacteria, WBCs, or protein. Her urine culture is negative. Based on her office presentation and history, which of the following is the most likely diagnosis?

46) An 18-year-old G0 comes to see you complaining of a 3-day history of urinary frequency, urgency, and dysuria. She panicked this morning when she noticed the presence of bright red blood in her urine. She also reports some midline lower abdominal discomfort. She had intercourse for the first time 5 days ago and reports that she used condoms. On physical examination, there are no lacerations of the external genitalia, there is no discharge from the cervix or in the vagina, and the cervix appears normal. Bimanual examination is normal except for mild suprapubic tenderness. There is no flank tenderness, and the patient’s temperature is normal. Which of the following is the most likely diagnosis?

47) 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 external 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?

48) You have diagnosed a healthy, sexually active 24-year-old female patient with an uncomplicated acute urinary tract infection. Which of the following is the likely organism responsible for this patient’s infection?

49) 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?

50) A previously healthy 50-year-old gravida 5, para 4, Caucasian woman comes to the physician complaining of passing small amounts of urine while sneezing or coughing for the past five months. She denies any episodes of weakness, numbness or fecal incontinence. There is no history of dysuria, increased frequency of urination, or hematuria. Her symptoms are progressively getting worse. Her other medical problems include diabetes mellitus type 2 diagnosed 3 years ago, treated with glyburide 2.5mg/day. She does not use tobacco, alcohol, or drugs, and has no known drug allergies. She mentions that she is an avid jogger, but her problem causes her significant embarrassment. She now has to wear absorbent pads while jogging. Her vital signs are within normal limits. On examination, the abdomen is soft. Neurological examination is within normal limits. Pelvic examination shows a cystocele. The patient's labs reveal: Urine: Specific gravity: 1.020, Blood: negative, Glucose: negative, Leukocyte esterase: negative, Nitrites: negative, WBC: 5-10/hpf, Bacteria: none. Random blood sugar is 120 mg/dl. Which of the following is the most likely cause of her symptoms?

51) 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 to110 mmHg systolic and 69 to 75 mmHg diastolic. Fundoscopy shows no retinal changes. Which of the following is most likely deficient in this patient?

52) A 35-year-old African-American marathon runner presents to the gynecologist complaining of secondary amenorrhea that developed three months ago. Her cycles are normally 28 days long, and her menses last three to five days with moderate flow. One year ago, the woman adopted a vigorous exercise regimen that lasted between three and five hours every day. Since then, her BMI has declined from 23.4 to 16.5 Kg/m2. She has been winning many local races and is considering increasing the difficulty of her exercise regimen, but would like to address the issue of her amenorrhea first. Physical examination reveals a thin woman with well-defined musculature but is otherwise unremarkable. Pregnancy test is negative. What is the most likely etiology of her amenorrhea?

53) A 26-year-old primigravid woman at 32 weeks gestation comes to the physician because of swelling of her hands and feet. Her previous prenatal check-up was normal. Blood pressure is 150/95 mmHg, and five minutes later following lateral rest her blood pressure is 140/95 mmHg. Physical examination shows 2+ pitting edema of the legs and a macular eruption on the cheekbones. Optic fundi show no abnormalities. Laboratory studies are as follows: Urinalysis: 4+ protein, RBC casts, Urine protein: 8 g/24hr, Uric acid: 5 mg/dl, BUN: 28 mg/dl, Serum creatinine: 2.1 mg/dl, Serum electrolytes, liver function tests and coagulation studies are within normal limits. A serum antinuclear antibody (ANA) test is positive in high titers Which of the following is the most likely diagnosis?

54) A 28-year-old G1P0 presents to your office at 18 weeks gestational age for an unscheduled visit secondary to right-sided groin pain. She describes the pain as sharp and occurring with movement and exercise. She denies any change in urinary or bowel habits. She also denies any fever or chills. The application of a heating pad helps alleviate the discomfort. As her obstetrician, what should you tell this patient is the most likely etiology of this pain?

55) A 30-year-old G2P1001 patient comes to see you in the office at 37 weeks gestational age for her routine OB visit. Her first pregnancy resulted in a vaginal delivery of a 9-lb 8-oz baby boy after 30 minutes of pushing. On doing Leopold maneuvers during this office visit, you determine that the fetus is breech. Vaginal examination demonstrates that the cervix is 50% effaced and 1 to 2 cm dilated. The presenting breech is high out of the pelvis. The estimated fetal weight is about 7 lb. The patient denies having any contractions. You send the patient for a sonogram, which confirms a fetus with a double footling breech presentation. There is a normal amount of amniotic fluid present and the head is hyperextended in the “stargazer” position. Which of the following is the best next step in the management of this patient?

56) A 33-year-old woman presents to the physician because of a malodorous vaginal discharge that has been present for the past 3 days. She has no vaginal or vulvar irritation, and has no urinary complaints. Pelvic examination demonstrates a copious, gray discharge with a pH of 5.0. When 1 drop of potassium hydroxide (KOH) is added to a sample of the discharge there is an intense amine odor. A normal saline wet preparation is performed that demonstrates epithelial cells whose borders and nuclei are obscured by the presence of bacteria. Which of the following is the most likely pathogen?

57) A 32-year-old woman is brought to the operating room for diagnostic laparoscopy because of chronic pelvic pain and chronic right upper quadrant pain. She has had these pains for the past 2 years. Her bowel and bladder function are normal. Past medical history is significant for two episodes of gonorrhea. She drinks one beer per day. Laboratory studies show: Urine hCG: negative, Haematocrit: 39%, leukocyte count: 8,000/mm3, platelet count: 200,000/mm3, AST: 12U/L, ALT:14U/L. Intraoperatively, the patient is noted to have dense adhesions involving her fallopian tubes, ovaries, and uterus. The fallopian tubes themselves appear clubbed and occluded. A survey of her upper abdomen is remarkable for perihepatic adhesions extending from the liver surface to the diaphragm. The liver otherwise appears unremarkable. Which of the following is the most likely diagnosis for her right upper quadrant pain?

58) A 22-year-old primigravid woman at 10 weeks gestation is brought to the emergency department because of vaginal bleeding and lower abdominal pain. She was cleaning the house when she suddenly started feeling colicky pain in the suprapubic area. The pain did not subside after resting, and a few minutes later a tissue-like substance passed through her vagina along with moderate bleeding. The pain subsequently ceased, but she still has mild discomfort. Her temperature is 37.0 C (98.7 F), blood pressure is 120/70 mmHg, pulse is 90/min and respirations are 16/min. Physical examination shows a closed cervix and blood pooled in the vaginal vault. Ultrasonogram shows a vacant uterine cavity and free adnexae. Which of the following is the most likely diagnosis?

59) A 26-year-old Caucasian female calls your office with a question about levothyroxine dosage during pregnancy. She is contemplating her first pregnancy very soon. You have been following her for primary hypothyroidism for several years. Her thyroid functions have been stable on a daily levothyroxine dose of 100μg. Her TSH level three months ago was 2.0 μU/ml (0.35 - 5.0 μU/ml is normal). What would be the most appropriate answer to this patient's question?

60) 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?