Génico page 1321-1354

82) A 59-year-old woman who had been diagnosed with infiltrating ductal carcinoma 2years prior presents with pain of her right breast. The breast is swollen, tender on palpation, and is diffusely indurated with a “peau d’orange” appearance. Multiple axillary lymph nodes are palpable in the lower axilla. A skin biopsy from her breast reveals extensive invasion of dermal lymphatics. What is the best diagnosis?

83) A 26-year-old woman comes to the physician's office for evaluation of a vulvar ulcer that she noticed two days ago. Initially she had a small painless papule that later became ulcerated. Upon further questioning she reluctantly admits to using sex to obtain drugs. She also reports using oral contraceptives to prevent pregnancy. On vulvar examination there is a 2-cm ulcer with a non-exudative base and a raised, indurated margin. Painless bilateral inguinal lymphadenopathy is present. Which of the following is the most likely diagnosis?

84) A 23-year-old woman who is 26 weeks pregnant presents to the emergency department with sudden onset severe shortness of breath and inability to lie flat. She recently emigrated from Eastern Europe. Her medical history is significant for recurrent sore throats requiring tonsillectomy as a child. Presently, her blood pressure is 110/60 mmHg and her heart rate is 120/min. An EKG rhythm strip suggests atrial fibrillation. Which of the following is the most likely diagnosis?

85) A 47-year-old woman presents to your office with complaints of lower abdominal pain, nocturia, urinary urgency and frequency relieved with urination. She states the symptoms have been worsening this past month and she recently experienced dyspareunia. She is sexually active with her husband, but this is causing her a great amount of pain. She has four children and had uncomplicated pregnancies. She denies fevers or chills. On examination, she has diffuse lower abdominal pain with no rebound or guarding. Her external genitalia appear normal. On bimanual examination, palpation of the anterior vaginal wall elicits extreme pain. No cervical motion tenderness is present. No other abnormalities are noted. A urinalysis is negative. The most likely diagnosis is:

86) A 22-year-old woman, gravida 2, para 1, at 39 weeks gestation is admitted to the hospital for delivery. She has had regular and painful uterine contractions occurring every 3 minutes for the past 10 hours. Her pregnancy has been uncomplicated. She had a normal vaginal delivery for her first pregnancy and required an episiotomy. A recent ultrasound at 37 weeks gestation showed a fetus in a cephalic presentation with an estimated fetal weight of 3,400 g (7.5 lb). Examination shows the cervix is soft, 50% effaced and 2 cm dilated. She is given epidural anesthesia per her request. Eight hours later, her cervix has not significantly changed, and uterine contractions are occurring every 5 minutes. Which of the following is the most likely cause of her current condition?

87) 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: trace, 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?

88) A 27-year-old primigravid woman at 30 weeks’ gestation comes to the emergency department complaining of abdominal pain, nausea, and vomiting. Earlier in the day she began to experience severe epigastric and later right upper quadrant pain. Until now her pregnancy has been uneventful and she has had regular prenatal care. Her past medical history and review of symptoms are unremarkable. On examination she is a pregnant woman in moderate distress, lying still on the hospital bed. Vital signs are: temperature 38.9 C (102.0 F), blood pressure 105/68 mm Hg, and pulse 108/min. Her abdomen is extremely tender to palpation in the right upper quadrant with guarding. There is no vaginal bleeding or discharge. Laboratory studies show: Hematocrit: 36%, Leukocytes: 15,000/mm3 (88% neutrophils), Platelets: 158,000/mm3. Liver function tests, including transaminases, are normal. Prothrombin time is within normal limits. Urinalysis is unremarkable except for a few red blood cells on microscopy. X-ray is deferred out of concern for the fetus. Which of the following is the most likely cause of this patient’s symptoms?

89) A 29-year-old woman comes to your office because she has been feeling depressed. She states that at times over the past several years she has regular occurrences of depression, anxiety, tearfulness, anger, and difficulty with work and social relationships. These occurrences have been increasing over the past several months. She doesn’t remember when her symptoms start or end. “It’s all a blur,” she says. She has had several urinary tract infections in her life, but otherwise has no medical problems. She takes no medications and has no drug allergies. Physical examination is normal. Which of the following is the most appropriate next step in caring for this patient?

90) You examine a 28-year-old woman who is 2 days status post-cesarean delivery for a nonreassuring fetal heart rate tracing in labor. Her prenatal course was complicated by her developing acute tuberculosis in the days immediately before her delivery. When you diagnosed her with tuberculosis, she decided to hold off on therapy until after the baby was born. She was also found to be Group B Streptococcus–positive on a 36-week vaginal culture. She has a past medical history significant for chronic hepatitis B. Her past surgical history is significant for a breast reduction 4 years ago. Postpartum she is doing well, with no complaints, normal vital signs, and a normal postpartum physical examination. She wants to know if she is able to breast feed her infant. Which of the following conditions precludes this patient from breastfeeding?

91) A 36-year-old woman, gravida 3, para 2, at 33 weeks' gestation comes to the physician for a prenatal visit. She has some fatigue but no other complaints. Her current pregnancy has been complicated by a Group B Streptococcus urine infection at 16 weeks. Her past obstetric history is significant for a primary, classic cesarean delivery 5 years ago for a non-reassuring fetal tracing. Two years ago, she had a repeat cesarean delivery. Past surgical history is significant for an appendectomy 10 years ago. Which of the following is the major contraindication to a vaginal birth after cesarean (VBAC) in this patient?

92) A 59-year-old G4P4 presents to your office complaining of losing urine when she coughs, sneezes, or engages in certain types of strenuous physical activity. The problem has gotten increasingly worse over the past few years, to the point where the patient finds her activities of daily living compromised secondary to fear of embarrassment. She denies any other urinary symptoms such as urgency, frequency, or hematuria. In addition, she denies any problems with her bowel movements. Her prior surgeries include tonsillectomy and appendectomy. She has adult-onset diabetes and her blood sugars are well controlled with oral Metformin. The patient has no history of any gynecologic problems in the past. She has four children who were all delivered vaginally. Their weights ranged from 8 to 9 lb. Her last delivery was forceps assisted. She had a third-degree laceration with that birth. She is currently sexually active with her partner of 25 years. She has been menopausal for 4 years and has never taken any hormone replacement therapy. Her height is 5 ft 6 in, and she weighs 190 lb. Her blood pressure is 130/80 mmHg. Based on the patient’s history, which of the following is the most likely diagnosis?

93) A 49-year-old G4P4 presents to your office complaining of a 2-month history of leakage of urine every time she exercises. She has had to limit her physical activities because of the loss of urine. She has had burning with urination and some blood in her urine for the past few days. Which of the following is the best next step in the evaluation and management of this patient?

94) An obese 46-year-old G6P1051 with type 1 diabetes since age 12 presents to your office complaining of urinary incontinence. She has been menopausal since age 44. Her diabetes has been poorly controlled for years because of her noncompliance with insulin therapy. She often cannot tell when her bladder is full, and she will urinate on herself without warning. Which of the following factors in this patient’s history has contributed the most to the development of her urinary incontinence?

95) A 76-year-old woman presents for evaluation of urinary incontinence. She had a hysterectomy for fibroid tumors of the uterus at age 48. After complete evaluation, you determine that the patient has genuine stress urinary incontinence. On physical examination, she has a hypermobile urethra, but there is no cystocele or rectocele. There is no vaginal vault prolapse. Office cystometrics confirms genuine stress urinary incontinence. Which of the following surgical procedures should you recommend to this patient?

96) A patient presents to your office approximately 2 weeks after having a total vaginal hysterectomy with anterior colporrhaphy and Burch procedure for uterine prolapse and stress urinary incontinence. She complains of a constant loss of urine throughout the day. She denies any urgency or dysuria. Which of the following is the most likely explanation for this complaint?

97) A 90-year-old G5P5 with multiple medical problems is brought into your gynecology clinic accompanied by her granddaughter. The patient has hypertension, chronic anemia, coronary artery disease, and osteoporosis. She is mentally alert and oriented and lives in an assisted living facility. She takes numerous medications, but is very functional at the current time. She is a widow and not sexually active. Her chief complaint is a sensation of heaviness and pressure in the vagina. She denies any significant urinary or bowel problems. On performance of a physical examination, you note that the cervix is just inside the level of the introitus. Based on the physical examination, which of the following is the most likely diagnosis?

98) A 52-year-old woman comes to the physician because of hot flashes. Her last menstrual period was 1 year ago. Over the past year, she has noted a persistence of her hot flashes, which come several times each day and are associated with a feeling of heat and flushing. They also awaken her at night and interfere with her sleep. She has no medical problems, takes no medications, and has no known drug allergies. She has a family history of cardiovascular disease and she does not smoke. Physical examination is unremarkable. She is started on estrogen and medroxyprogesterone acetate (Provera). The addition of a progestin is most likely to decrease her risk of which of the following?

99) A previously healthy 21-year-old woman has a profuse, malodorous vaginal discharge. Examination shows a greenish gray "frothy" discharge with a "fishy" odor and petechial lesions on the cervix. There is no cervical motion tenderness. Her temperature is 37.5 C (99.4 F), blood pressure is 120/80 mm Hg, pulse is 60/min, and respirations are 16/min. Microscopic evaluation of the discharge is most likely to show which of the following?

100) A 26-year-old nulligravid woman comes to the emergency department because of severe right lower quadrant pain. She states that the pain started last night. This morning she was awakened from sleep with severe pain in the same area. During the episode of pain, she also had nausea, vomiting, and diaphoresis. On admission to the emergency department she required 5 mg of morphine to control her pain. Examination is significant for right lower quadrant tenderness and a tender right adnexal mass on pelvic examination. Urine hCG is negative. Urinalysis is negative. Transvaginal ultrasound reveals an 8 cm right ovarian mass. Which of the following is the most likely diagnosis?

101) A 21-year-old woman comes to the physician because of abdominal pain. She states that the pain is in her right lower quadrant and has been getting worse over the past 3 months. She has no other symptoms and a normal appetite. Examination demonstrates mild right lower quadrant abdominal tenderness. Pelvic examination reveals mild right adnexal enlargement and tenderness. Urine human chorionic gonadotropin (hCG) is negative. A pelvic ultrasound is obtained that shows a 4-centimeter, heterogeneous hyperechoic lesion in the right adnexa with cystic areas. On transvaginal ultrasound, hair and calcifications are demonstrated within the cystic areas. Which of the following is the most likely diagnosis?

102) A 27-year-old has just had an ectopic pregnancy. Which of the following events would be most likely to predispose to ectopic pregnancy?

103) A healthy 42-year-old G2P1001 presents to labor and delivery at 30 weeks gestation complaining of a small amount of bright red blood per vagina which occurred shortly after intercourse. It started off as spotting and then progressed to a light bleeding. By the time the patient arrived at labor and delivery, the bleeding had completely resolved. The patient denies any regular uterine contractions, but admits to occasional abdominal cramping. She reports no pregnancy complications and a normal ultrasound done at 14 weeks of gestation. Her obstetrical history is significant for a previous low transverse cesarean section at term. Which of the following can be ruled out as a cause for her vaginal bleeding?

104) A 23-year-old G3P1011 at 6 weeks presents for routine prenatal care. She had a cesarean delivery 3 years ago for breech presentation after a failed external cephalic version. Her daughter is Rh-negative. She also had an elective termination of pregnancy 1 year ago. She is Rh-negative and is found to have a positive anti-D titer of 1:8 on routine prenatal labs. Failure to administer RhoGAM at which time is the most likely cause of her sensitization?

105) A 39-year-old G1P0 at 39 weeks gestational age is sent to labor and delivery from her obstetrician’s office because of a blood pressure reading of 150/100 mm Hg obtained during a routine OB visit. Her baseline blood pressures during the pregnancy were 100 to 120/60 to 70. On arrival to labor and delivery, the patient denies any headache, visual changes, nausea, vomiting, or abdominal pain. The heart rate strip is reactive and the tocodynamometer indicates irregular uterine contractions. The patient’s cervix is 3 cm dilated. Her repeat blood pressure is 160/90 mm Hg. Hematocrit is 34.0, platelets are 160,000, SGOT is 22, SGPT is 15, and urinalysis is negative for protein. Which of the following is the most likely diagnosis?

106) A 21-year-old woman presents to the clinic in tears. She states that she recently found out she was pregnant at 10 weeks’ gestation. She is a recovering alcoholic but recently relapsed, consuming several drinks a day. She is nervous about the effects of her drinking on her fetus. For which of the following is the patient at greatest risk?

107) A 24-year-old G2P2 woman presents to the emergency department complaining of vaginal bleeding and abdominal cramping. She is sexually active in a monogamous relationship with her husband. Her last menstrual period was 6 weeks ago. The patient is afebrile, and vital signs are within normal limits. Pelvic examination is notable for a dilated cervix, fetal tissue in the vaginal vault, and no cervical motion tenderness. Which of the following is the most likely cause of this patient’s abortion?

108) A 31-year-old woman with systemic lupus erythematosus who is 4 weeks pregnant presents to her obstetrician for her first prenatal visit. She is very concerned that the lupus will affect her baby. She was diagnosed with systemic lupus erythematosus 5 years ago and her symptoms have been well controlled with low-dose prednisone. She has baseline renal insufficiency, with a creatinine level of 1.3 mg/dL that has been stable for the past 6 months. This is her first pregnancy. For which of the following is the baby at increased risk?

109) A 30-year-old G0 woman with a past medical history of dysmenorrhea presents to an infertility clinic with her husband for a follow-up visit. The couple has been trying to get pregnant for the past 3 years with no success. Their infertility work-up thus far has included a semen analysis, hysterosalpingogram, and estrogen, progesterone, and follicle-stimulating hormone blood levels, all of which were normal. Currently the woman feels well; her only complaint is frustration regarding her inability to conceive. A pelvic ultrasound done last week demonstrated a 3-cm well-circumscribed mass on the patient’s left ovary. Her last menstrual period was 3 weeks ago. The ovarian mass most likely represents which of the following?

110) At 38 weeks’ gestation, a 4030-g (8.9-lb) boy is delivered by spontaneous vaginal delivery. During the first minute of life he is limp, cyanotic, lacks respiratory effort, has a heart rate of 95/min, flexes his extremities, and grimaces to nasal suctioning. By 5 minutes, he continues to grimace to nasal suctioning, has a weak cry, is well perfused with a heart rate of 160/min, and is kicking both legs. Based on his Apgar scores, when will the child need to be resuscitated?

111) A 23-year-old G1P0 woman at 28 weeks’ gestation presents to her obstetrician for a prenatal examination. She has received poor prenatal care up to this point, but is confident about dating the pregnancy. She denies use of alcohol and illicit drugs but has continued to smoke during the pregnancy. The mother has gained only 9 kg (20 lb) during the course of the pregnancy. The mother’s temperature is 36.8C (98.2F), pulse is 94/min, blood pressure is 138/84 mm Hg, and respiratory rate is 12/min. The fundal height is 23 cm above the pubic symphysis. Further examination with ultrasound reveals the fetus is <10% of the expected weight for the gestational age with symmetric growth anomalies. What is the most likely cause for the intrauterine growth restriction of this fetus?

112) A 22-year-old obese woman presents to the obstetrics-gynecology clinic complaining of mild abdominal pain and vaginal bleeding. The patient states that she is sexually active with her boyfriend and uses condoms “basically all the time.” She states that her last menstrual period was 7 weeks ago and insists that her periods have always been irregular, occurring every 3 to 4 months. She denies any past medical history but states that she used to have a problem with excess facial hair prior to starting low-dose oral contraceptive pills. Which of the following is the best next step in diagnosis?

113) A full-term 2200-g (4.9-lb) boy was born to a 30-year-old G4P3 woman whose pregnancy was complicated by a seizure disorder for which she inconsistently took carbamazepine. The pregnancy was also notable for an abnormal triple screen for which an amniocentesis was declined. His Apgar scores are 7 and 9 at 1 and 5 minutes, respectively. His temperature is 37.0C (98.6F), blood pressure is 65/45 mm Hg, heart rate is 110/min, and respiratory rate is 30/min. His head circumference is <5th percentile. There is a small fleshy sac protruding from the sacral spine. His reflexes are 2+ throughout, and his strength is 5/5 in all extremities. His fingernails are very small. Which of the following is the most likely diagnosis?

114) A 28-year-old woman and her husband present to her obstetrician. They have been married for 7 years and have been trying to become pregnant for the past 2 years. Prior to this the woman used an intrauterine device for contraception, which she had in place for 5 years. Both are healthy without any medical problems, and both deny a history of sexually transmitted diseases. The woman states that her menstrual cycles have always been regular (every 28 days, lasting for 5 days) since she was 14 years old. She also denies menorrhagia and dysmenorrhea. Which of the following is the most likely cause of this couple’s infertility?

115) A 28-year-old teacher presents to the clinic complaining of 5 months of polyuria, polydipsia, and weight loss. Additionally, her menses, which have always been irregular, have stopped altogether. She is concerned because both her mother and maternal aunt suffer from noninsulin-dependent diabetes, and they told her they had similar symptoms before they were diagnosed. Upon questioning she reveals that she is in a committed relationship and has no desire to have children, so she uses barrier protection during intercourse. Physical examination reveals an obese woman with hirsutism currently in no acute distress. Testing for β-human chorionic gonadotropin level, random blood sugar level, cholesterol panel, and a luteinizing hormone/follicle-stimulating hormone ratio suggests the patient has polycystic ovarian syndrome (PCOS). Although no one in her family has had cancer, she is concerned that her symptoms are a harbinger of cancer or that she might be likely to suffer from cancer in the future. This diagnosis would most raise her risk for which kind of cancer?

116) 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?

117) 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 99.4 F (37.4 C). What is the most likely diagnosis?

118) A 32-year-old woman comes to your office for re-evaluation of her birth control method. She wants her intrauterine device (IUD) removed because it is causing her pelvic pain. She wants to be placed on oral contraceptive pills (OCPs). She has had hypertension for the past five years controlled with hydrochlorothiazide and atenolol. She has a family history of diabetes mellitus and ovarian carcinoma. Her body mass index (BMI) is 34 kg/m2. Physical examination is unremarkable. If she starts taking oral contraceptive pills, which of the following statement is most correct?

119) A 28-year-old G1A1 woman presents to a gynecology clinic with a chief complaint of reduced menstrual flow for the past 6 months, especially last month. She denies any pain with menstruation or irregularity in her cycle. She says that she had an elective termination by dilation and curettage approximately 9 months ago. She is sexually active with one partner and always uses condoms. Review of her records indicates a past history of abnormal Papanicolaou (Pap) smears, but she has not been followed recently. She denies any history of irregular menses, and says that age of menarche was 13 years. She takes no medications. Physical examination reveals a normally developed 68-kg (150lb) woman who is 183 cm (6') tall. She is in no acute distress. A β-human chorionic gonadotropin test from her original visit 1 week ago is negative. Which of the following is the most likely diagnosis?

120) An 18-year-old female college student presents to student health services with a complaint of a burning sensation while urinating and abdominal pain. She denies urinary urgency or increased frequency. She has no significant past medical history. She is currently sexually active with a new partner. She does not use barrier contraception. She denies any previous history of sexually transmitted diseases. On examination she is afebrile, heart rate is 70/min, and blood pressure is 120/60 mm Hg. Examination reveals no peritoneal signs but there is tenderness to palpation over the suprapubic region. On pelvic examination the cervix appears edematous and friable with a small amount of discharge from the os. A urine sample reveals numerous WBCs but no organisms on Gram stain. A cervical swab is sent for Gram stain and culture. Which of the following is the most likely explanation for these findings?

121) A 13-year-old girl had growth of breast buds at 11 years, followed by the appearance of pubic hair between the ages of 11.5 and 12 years. Which pubertal event is most likely to occur next?

122) A 17-year-old G1P1001 is now 5 weeks postpartum after a routine vaginal delivery. She calls your office to report a 3-week history of difficulty sleeping and “feeling blue.” On further questioning, she reports difficulty concentrating, very poor appetite, occasional wishes that she had never become pregnant, and feelings of guilt about those wishes. She has not left her home in more than a week because she “just can’t find the energy to go anywhere.” This patient’s symptoms are most consistent with:

123) A 48-year-old woman with five children complains of urinary incontinence with coughing and stair climbing. She likely has genuine stress urinary incontinence if which of the following is true?

124) An 18-year-old nullipara has suddenly stopped menstruating. She recently lost 8.6 kg when she started long-distance running. The laboratory test most consistent with her cause of secondary amenorrhea is which of the following?

125) On the first pelvic examination of an 18-yearold nulligravida, a soft, fluctuant mass is found in the superior aspect of the right labia majora. This is asymptomatic. She tells you it has been present for several years and seems to be enlarging slightly. There is no defect in the inguinal ring. Which of the following is the most likely diagnosis?

126) Your patient has just had twins and wonders if there is any way to determine whether the twins are identical. You correctly tell her which of the following?

127) A 42-year-old woman comes to the physician because of vaginal itch and discharge, dysuria, and dyspareunia. These symptoms have been steadily worsening over the past 3 days. Pelvic examination reveals an erythematous vagina and a thin, green, frothy vaginal discharge with a pH of 6. Microscopic examination of the discharge demonstrates the presence of a pear-shaped, motile organism. Which of the following is the most likely pathogen?

128) A 22-year-old professional tennis player presents to your office with a 5-month history of amenorrhea. She describes an intense schedule of regular exercise, and says that she eats a balanced diet but avoids fatty foods. She does not smoke or consume alcohol. Her mother suffers from long-standing hypertension. The patient's BMI is 22.5 kg/mm2. Pregnancy test is negative. The patient is at greatest risk for which of the following?

129) 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 38.5 C (101.3 F), 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?

130) A seven-year-old girl is brought to the physician's office because of a sudden onset of growth spurt, pubic hair development, and breast enlargement. Her family history is not significant. She has no other medical problems. On examination, there is no hirsutism or acne. Her weight is 70th percentile and her height is 98th percentile. Examination showed a pelvic mass. Pelvic ultrasonogram showed a right ovarian mass. Initial evaluation showed elevated estrogen levels. Which of the following is the most likely diagnosis?

131) A 36-year-old woman, gravida 3, para 2, comes to the physician for a prenatal checkup. According to her last menstrual period and an ultrasonography performed at 16 weeks gestation, she is at 30 weeks gestation. She missed two antenatal appointments. She does not use tobacco, alcohol, or drugs. Examination shows a fundal height of 26 cm (9.8 in). Fetal heart tones are heard by Doppler. Repeat ultrasound shows a fetal biparietal diameter consistent with 30 weeks and an abdominal circumference below the 10th percentile. Which of the following could most likely be responsible for the observed fetal findings?

132) A 19-year-old primigravid woman at 34 weeks gestation comes to the physician because of diffuse headache, right upper quadrant pain and visual disturbances. During her last visit two weeks ago she was found to have an elevated blood pressure and 1+ proteinuria. She was advised to follow-up closely and sent home on bed rest. Her blood pressure today is 176/120 mm Hg and pulse is 86/min. Physical examination shows 2+ pitting edema in both legs and right upper quadrant tenderness. Fetal heart tones are audible by Doppler. Urinalysis shows 3+ proteinuria. Serum aspartate aminotransferase (AST) is 88 U/L and alanine aminotransferase (ALT) is 80 U/L. Serum creatinine now is 1.4 mg/dl. Which of the following is the most likely cause of her right upper quadrant pain?

133) A 26-year-old woman presents to her physician because of pain in her breast. She gave birth 3 months ago and is breast-feeding. Soon after she began lactating she developed cracks in the nipples, and for the past 5 days her left breast has become progressively more tender. On physical examination, her affected breast is red, hot, swollen, and painful to palpation. Her temperature is 38.3 C (101 F), and her white cell count is 13,000/mm3. Which of the following is the most likely diagnosis?

134) A 32-year-old G3P2 woman at 38 weeks gestation is admitted to the hospital for labor pains. Her prenatal course, prenatal tests, and fetal growth have been normal. Ultrasound at the 16th week showed no abnormalities and an intrauterine gestation consistent with dates. In her second pregnancy, she underwent a cesarean section. The woman is admitted to the delivery room and fetal heart and uterine contraction monitoring is started. Her blood pressure is 100/60 mm Hg, pulse is 115/min, and respirations are 26/min. Pelvic examination shows that the cervix is 60% effaced and 6 cm dilated. Uterine contractions are regular and occur every 4 minutes. Fetal heart tracing shows no abnormalities. The patient suddenly complains of intense lower abdominal pain. She is restless and vaginal bleeding is noted. Fetal heart monitoring shows repetitive variable decelerations, and the fetus has shifted from 0 to -2 station. Which of the following is the most likely diagnosis?

135) A 16-year-old female presents to the ER complaining of left lower quadrant abdominal pain that started suddenly 24 hours ago. The pain does not radiate and is 5/10 in severity. She denies having fevers, vomiting, dysuria, diarrhea or vaginal bleeding. Her last menstrual period was two weeks ago. She takes no medications. On physical examination, her temperature is 37.2 C (98.9 F), blood pressure is 110/65 mmHg, pulse is 80/min and respirations are 14/min. There is mild left lower quadrant tenderness without rebound or rigidity, and the remainder of the examination is unremarkable. Which of the following is the most likely diagnosis?

136) A 53-year-old obese, menopausal woman comes to the physician for a routine annual examination. Her last menstrual period was one year ago. Upon further questioning, she says that she sometimes experiences hot flashes of mild intensity. She is sexually active and denies vaginal dryness or dyspareunia. Her medical problems include mild hypertension managed with hydrochlorothiazide and a salt-reduced diet. Her obstetrical history is significant for an elective termination of pregnancy at 35 years of age because of an abnormal maternal serum alpha-fetoprotein. Physical examination is normal. Which of the following is a possible cause of the comparatively milder nature of the symptoms the patient is having compared to many other menopausal women with more severe symptoms?

137) A 39-year-old G5P5 woman delivered a 4.1-kg (9-lb) healthy male infant 20 minutes ago. She is now experiencing heavy vaginal bleeding, with the passage of large blood clots. She had an uncomplicated pregnancy, with a 15.9-kg (35-lb) weight gain. The patient had spontaneous onset of labor and spontaneous rupture of the membranes at 5 cm dilation. Labor lasted 3 hours, including 10 minutes of pushing. She did not have an episiotomy. The placenta delivered spontaneously 5 minutes after the infant, was normal in appearance, and was intact with a 3-vessel cord. The patient's previous 4 pregnancies and deliveries were normal. Her blood pressure is 110/60 mm Hg, pulse is 106/min, and respirations are 20/min. The uterine fundus is soft and at the level of the umbilicus. The patient's peri-pad is saturated with blood, and there are clots extruding from the vagina. Which of the following is the most likely cause of this patient's symptoms?

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

139) A 37-year-old woman presents for evaluation of infertility. She and her 39-year-old husband have not been able to conceive after 9 months of unprotected and frequent intercourse. She had one pregnancy with her husband when she was 31. She has 28-day regular menstrual cycles and enjoys frequent sexual intercourse. She has no other complaints. She denies any previous history of sexually transmitted diseases or abdominal surgery. She does not use tobacco, alcohol or drugs. She has been working as an aerobic teacher and teaches two 30 minute classes every day. Her blood pressure is 130/80 mmHg and her pulse is 84/min. Her BMI is 23 Kg/m2. Complete physical examination is unremarkable. Which of the following is most likely cause of her condition?

140) 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 4cm dilated. Fetal 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?

141) 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 0F (37,4 0C). What is the most likely diagnosis?

142) An 18-year-old woman arrives in your clinic with primary amenorrhea, sexual infantilism, and clitoromegaly. She has a history of ambiguous external genitalia noted at birth. Reviewing her records, you see that laparotomy performed at 17 months of age revealed normal internal female genitalia and ovarian biopsy performed at that time revealed normal-appearing primordial follicles. Laboratory studies today reveal a normal female karyotype and high serum testosterone and androstenedione concentrations. Estradiol and estrone are undetectable in the serum. Serum FSH and LH concentrations are high. Pelvic imaging shows multiple ovarian cysts. What is the most likely diagnosis?

143) A 26-year-old G0P0 comes to your office with a chief complaint of being too hairy. She reports that her menses started at age 13 and have always been very irregular. She has menses every 2 to 6 months. She also complains of acne and is currently seeing a dermatologist for the skin condition. She denies any medical problems. Her only surgery was an appendectomy at age 8. Her height is 5ft 5 in., her weight is 180 lb, and her blood pressure is 100/60 mm Hg. On physical examination, there is sparse hair around the nipples, chin, and upper lip. No galactorrhea, thyromegaly, or temporal balding is noted. Pelvic examination is normal and there is no evidence of clitoromegaly. Which of the following is the most likely explanation for this patient’s problem?

144) A 29-year-old woman comes to the office for a periodic health maintenance examination. She has no complaints. Her past medical history is significant for irritable bowel syndrome. She has never had any surgery. She has been taking the oral contraceptive pill for the past 12 years, ever since she became sexually active. She has no known drug allergies. Physical examination, including pelvic examination, is unremarkable. By taking the oral contraceptive pill, this patient is decreasing her risk most significantly for which of the following?

145) A 36-year-old woman comes to your office because of back pain. She states that the pain started around the time of her cesarean delivery 8 weeks ago. The pain is located in the lower back and does not radiate. It improves with rest and worsens with prolonged standing. She cannot stand for more than 30 minutes without what she describes as debilitating pain. She has no significant past medical history. She had a cesarean delivery 8 weeks ago for arrest of dilation during labor. She had epidural anesthesia for labor and surgery. Otherwise she has never had surgery. She takes ibuprofen for the pain. She is allergic to sulfa drugs. Physical examination is within normal limits, including a normal neurologic examination. The patient is most interested in knowing what caused her to start having this back pain. Which of the following is the most appropriate response?

146) A 65-year-old woman comes to the physician because of bleeding from the vagina. She states that her last menstrual period was at age 50 and that she has had no bleeding since. She has no medical problems and takes no medications. She is not sexually active. Examination is unremarkable, including a normal pelvic examination. After informed consent is obtained, an endometrial biopsy is performed. The patient complains of discomfort during and after the procedure but feels well enough to go home. Later that night, with her abdominal pain worsening, the patient comes to the emergency department. An ultrasound is performed that shows a normal uterus and adnexae but a complex fluid collection posterior to the uterus. Which of the following is the most likely diagnosis?

147) A 23-year-old female comes to the physician because of a swelling in her vagina. She states that the swelling started about 3 days ago and has been growing larger since. The swelling is not painful, but it is uncomfortable when she jogs. She has asthma for which she uses an albuterol inhaler, but no other medical problems. Examination shows a cystic mass 4 cm in diameter near the hymen by the patient's left labia minora. The mass is nontender and there is no associated erythema. The mass is freely mobile. The rest of the pelvic examination is unremarkable. Which of the following is the most likely diagnosis?

148) A 32-year-old morbidly obese diabetic woman presents to your office complaining of prolonged vaginal bleeding. She has never been pregnant. Her periods were regular, monthly, and light until 2 years ago. At that time, she started having periods every 3 to 6 months. Her last normal period was 5 months ago. She started having vaginal bleeding again 3 weeks ago, light at first. For the past week she has been bleeding heavily and passing large clots. On pelvic examination, the external genitalia is normal. The vagina is filled with large clots. A large clot is seen protruding through the cervix. The uterus is in the upper limit of normal size. The ovaries are normal to palpation. Her urine pregnancy test is negative. Which of the following is the most likely diagnosis?

149) A 25-year-old woman, gravida 2, para 2 is 4days status post cesarean section and develops a temperature to 100.7 F (38.2 C). She had her cesarean section when she went into unstoppable preterm labor with a breech fetus. She had an uncomplicated postoperative course until this temperature elevation. Her pulse is 100/min, blood pressure is 110/70 mm Hg, and respirations are 16/min. There is discoloration and cyanosis around the incision. The area around the incision is completely numb. There is no uterine tenderness on bimanual exam. Which of the following is of the most concern in this patient?

150) A 27-year-old woman, gravida 2, para 2, comes to the physician to have her staples removed after an elective repeat cesarean delivery. Her pregnancy course was uncomplicated. She states that she is doing well except that since the delivery she has noticed some episodes of sadness and tearfulness. She is eating and sleeping normally and has no strange thoughts or thoughts of hurting herself or others. Physical examination is within normal limits for a patient who is status post cesarean delivery. Which of the following is the most likely diagnosis?

151) A 26-year-old primigravid woman at 42 weeks' gestation comes to the labor and delivery ward for induction of labor. The prenatal course was significant for a positive group B Streptococcus culture performed at 35 weeks. Antenatal testing over the past 2 weeks has been unremarkable. The patient is started on lactated Ringer's IV solution. Sterile vaginal examination shows that the patient's cervix is long, thick, and closed. Prostaglandin (PGE2) gel is placed into the vagina, and electronic fetal heart rate monitoring is continued. In approximately 60 minutes, the fetal heart rate falls to the 90s, as the tocodynamometer shows the uterus to be contracting every 1 minute with essentially no rest in between contractions. Which of the following was most likely the cause of the uterine hyperstimulation?

152) A 16-year-old female comes to the physician because of an increased vaginal discharge. She developed this symptom 2 days ago. She also complains of dysuria. She is sexually active with one partner and uses condoms intermittently. Examination reveals some erythema of the cervix but is otherwise unremarkable. A urine culture is sent which comes back negative. Sexually transmitted disease testing is performed and the patient is found to have gonorrhea. While treating this patient's gonorrhea infection, treatment must also be given for which of the following?

153) A 12-year-old female comes to the physician because of a vaginal discharge. The discharge started about 2 months ago and is whitish in color. There is no odor. The patient has no complaints of itching, burning, or pain. The patient started breast development at 9 years of age and her pubertal development has proceeded normally to this point. She has not had her first menses and she is not sexually active. She has no medical problems. Examination is normal for a 12-year-old female. Microscopic examination of the discharge shows no evidence of pseudohyphae, clue cells, or trichomonads. Which of the following is the most likely diagnosis?

154) A 50-year-old woman complains of leakage of urine. After genuine stress urinary incontinence, which of the following is the most common cause of urinary leakage?

155) A 65-year-old woman complains of leakage of urine. Which of the following is the most common cause of this condition in such patients?

156) A healthy 59-year-old woman with no history of urinary incontinence undergoes vaginal hysterectomy and anteroposterior repair for uterine prolapse, large cystocele, and rectocele. Two weeks postoperatively, she presents to your office with a new complaint of intermittent leakage of urine. What is the most likely cause of this complaint following her surgery?

157) A postmenopausal woman is undergoing evaluation for fecal incontinence. She has no other diagnosed medical problems. She lives by herself and is self-sufficient, oriented, and an excellent historian. Physical examination is completely normal. Which of the following is the most likely cause of this patient’s condition?

158) A 30-year-old G3P3 is being evaluated for urinary urgency, urinary frequency, and dysuria. She also complains of pain with insertion when attempting intercourse. She frequently dribbles a few drops of urine after she finishes voiding. She has had three full-term spontaneous vaginal deliveries. Her last baby weighed more than 9 lb. She had multiple sutures placed in the vaginal area after delivery of that child. She also has a history of multiple urinary tract infections since she was a teenager. On pelvic examination, she has a 1-cm tender suburethral mass. With palpation of the mass, a small amount of blood-tinged pus is expressed from the urethra. Which of the following is the most likely cause of this patient’s problem?

159) A 22-year-old woman, gravida 4, para 3, at 38 weeks' gestation comes to the labor and delivery ward with a gush of fluid. Sterile speculum examination reveals a pool of fluid that is nitrazine positive and forms ferns when viewed under the microscope. The fetal heart rate is in the 150s and reactive. An ultrasound demonstrates that the fetus is in the breech position. A cesarean delivery is performed. During the operation, the physician, who has received no recent immunizations, is stuck with a needle that had been used on the patient. Which of the following is this physician at greatest risk of contracting?

160) A 67-year-old woman comes to the physician because of pain with urination and frequent urination. She has hypertension for which she takes a beta-blocker, but no other medical problems. She states that she is not sexually active. She does not smoke and drinks cranberry juice daily. Examination shows mild suprapubic tenderness and genital atrophy but is otherwise unremarkable. Urinalysis shows 50 to 100 leukocytes/high powered field (hpf) and 5 to 10 erythrocytes/hpf. Which of the following is the most likely cause of the infection?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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