Gyneco- us (1-120)

A 29-year-old Caucasian primigravida patient is 20 weeks pregnant with twins. She found out today on her routine ultrasound for fetal anatomy that she is carrying two boys. In this patient’s case, which of the following statements about twinning is true?

2. A 24-year-old primigravida with twins presents for routine ultrasonography at 20 weeks gestation. Based on the ultrasound findings, the patient is diagnosed with dizygotic twins. Which of the following is true regarding the membranes and placentas of dizygotic twins?

3.After delivery of a term infant with Apgar scores of 2 at 1 minute and 7 at 5 minutes, you ask that umbilical cord blood be collected for pH. The umbilical arteries carry which of the following?

4. During the routine examination of the umbilical cord and placenta after a spontaneous vaginal delivery, you notice that the baby had only one umbilical artery. Which of the following is true regarding the finding of a single umbilical artery?

5. A 22-year-old G1P0 at 28 weeks gestation by LMP presents to labor and delivery complaining of decreased fetal movement. She has had no prenatal care. On the fetal monitor there are no contractions. The fetal heart rate is 150 beats per minute and reactive. There are no decelerations in the fetal heart tracing. An ultrasound is performed in the radiology department and shows a 28-week fetus with normal-appearing anatomy and size consistent with dates. The placenta is implanted on the posterior uterine wall and its margin is well away from the cervix. A succenturiate lobe of the placenta is seen implanted low on the anterior wall of the uterus. Doppler flow studies indicate a blood vessel is traversing the cervix connecting the two lobes. This patient is most at risk for which of the following?

6. A healthy 25-year-old G1P0 at 40 weeks gestational age comes to your office to see you for a routine obstetric (OB) visit. The patient complains to you that on several occasions she has experienced dizziness, light-headedness, and feeling as if she is going to pass out when she lies down on her back to take a nap. What is the most appropriate plan of management for this patient?

7. A 22-year-old primigravida presents to your office for a routine OB visit at 34 weeks gestational age. She voices concern because she has noticed an increasing number of spidery veins appearing on her face, upper chest, and arms. She is upset with the unsightly appearance of these veins and wants to know what you recommend to get rid of them. Which of the following is the best advice to give this patient?

8. A 32-year-old G2P1001 at 20 weeks gestational age presents to the emergency room complaining of constipation and abdominal pain for the past 24 hours. The patient also admits to bouts of nausea and emesis since eating a very spicy meal at a new Thai restaurant the evening before. She denies a history of any medical problems. During her last pregnancy, the patient underwent an elective cesarean section at term to deliver a fetus in the breech presentation. The emergency room doctor who examines her pages you and reports that the patient has a low-grade fever of 37.7C (100F), with a normal pulse and blood pressure. She is minimally tender to deep palpation with hypoactive bowel sounds. She has no rebound tenderness. The patient has a WBC of 13,000, and electrolytes are normal. Which of the following is the most appropriate next step in the management of this patient?

9. A healthy 34-year-old G1P0 patient comes to see you in your office for a routine OB visit at 12 weeks gestational age. She tells you that she has stopped taking her prenatal vitamins with iron supplements because they make her sick and she has trouble remembering to take a pill every day. A review of her prenatal labs reveals that her hematocrit is 39%. Which of the following statements is the best way to counsel this patient?

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

11. A 14-year-old G1P0 girl who is 29 weeks’ pregnant with twins presents to the emergency department following a seizure. She was watching television and stood up to go to the bathroom when she “fell down and started shaking.” The patient has no history of seizures and is otherwise healthy. She missed her last obstetrician’s appointment, and her aunt states that her niece has had a lot of headaches and swelling over the past 2 days. On examination the patient is somnolent and difficult to arouse, and has edema of her hands and face. Her blood pressure is 205/120 mm Hg, pulse is 80/ min, and respiratory rate is 16/min. The fetal heart rate is 130/min. Which of the following is the most correct advice for the patient’s aunt?

12. A 19-year-old woman at 32 weeks’ gestation was the driver in a front-end motor vehicle crash. The air bags did not inflate, and the patient sustained blunt trauma to the abdomen. The patient is taken to a nearby emergency department in stable condition, where she notes a small amount of bright red blood on her underwear. Maternal vital signs are significant for a heart rate of 110/min and blood pressure of 110/55 mm Hg. What is most appropriate next step in management?

13. A 19-year-old G1P0 woman presents to the emergency department in active labor and delivers a full-term male infant. The infant appears healthy with the exception of jaundice (bilirubin 10 mg/dL [>95th percentile]). The mother does not speak English, but a cousin who does states that he has seen the mother taking pills prescribed by her doctor, although he does not know the reason she was taking medication. Based on the newborn’s jaundice, which drug was the mother most likely taking?

14. 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 38.7°C (101.7°F), heart rate is 120/min, and blood pressure is 100/70 mm Hg. 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?

15. A 30-year-old obese G3P2 woman is in active labor at 41 weeks’ gestation. She has no significant past medical history, and had an uncomplicated pregnancy with appropriate prenatal evaluation. The patient ruptured membranes spontaneously 30 minutes ago. Contractions occur regularly every 2–3 minutes. Early decelerations are noted on the fetal heart rate monitor with each of the past five contractions. Which is the most appropriate next step in management?

16. A 25-year-old G2P1 woman who is 36 weeks pregnant presents to her obstetrician complaining of restlessness and weakness for the past month. She says her boyfriend recently left her and their 2-year-old son, and she feels overwhelmed with this pregnancy. She denies feeling depressed but does report that she has trouble sleeping. She had an upper respiratory infection last month, “caught from my son,” and states she still has a sore throat. Laboratory tests show: WBC count: 8000/mm3; Hemoglobin: 11.0 g/dL; Hematocrit: 40% Platelet count: 250,000/mm3; Thyroid-stimulating hormone: 0.5μU/mL; Free thyroxine: 4.0 ng/dL. Which of the following is the best next step in management?

17. 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 36.7°C (98.1°F), blood pressure is 121/74 mm Hg, 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?

18. A 36-year-old G1P0 woman pregnant with twins presents to her obstetrician for her routine 32- week appointment. She has gained 5.4kg (12-lb) in the past 2 weeks. When questioned about her weight gain, she states she has had headaches and some blurred vision for the past 2 weeks, which she thinks is secondary to dehydration. To circumvent this, she has been drinking a lot of water, which she claims “is making me swell, even my hands.” She also has had some epigastric pain for the past 2 weeks, which she attributes to “all the water I’ve been drinking.” Her blood pressure is 142/90 mm Hg, pulse is 105/min, and respiratory rate is 18/min. Urinalysis reveals 1+ glycosuria and 4+ proteinuria. Which of the following is the best next step in management?

19. A 27-year-old woman has used oral contraceptives (OCs) without problems for 5 years. However, she just read an article about complications of OCs in a popular women’s magazine and asks you about the risks and hazards of taking OCs. You correctly tell her which of the following?

20. 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?

21. 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?

22. A 23-year-old woman develops painful vulvar vesicles that contain intranuclear inclusions on cytologic examination. She is 22 weeks’ pregnant. Which of the following statements about genital herpes is correct?

23. A 63-year-old woman has a 3-cm pruritic lesion on her right labia majora that she has noted for approximately 9 months. She has been treated with various topical creams and ointments for vulvar candidiasis without resolution of her symptoms or lesion. When you examine this woman, the lesion is still present. Which of the following is the most appropriate intervention?

24. A 35-year-old G3P3 woman has been experiencing bilateral breast pain for the past year. Breast examination and mammography are normal. Conservative measures have failed. Which of the following medications is most likely to bring relief?

25. 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?

26. 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?

27. In an amenorrheic patient who has had pituitary ablation for a craniopharyngioma, which of the following regimens is most likely to result in an ovulatory cycle?

28. In the evaluation of a 26-year-old patient with 4 months of secondary amenorrhea, you order serum prolactin and β-hCG assays. The β-hCG test is positive, and the prolactin level is 100 ng/mL (normal is <25 ng/mL in nonpregnant women in this assay). This patient requires which of the following?

29. A 23-year-old married woman consults you because she and her husband have never consummated their marriage because she has severe pain with attempts at vaginal penetration. Her pelvic examination is normal except for involuntary tightening of her vaginal muscles when you attempt to insert a speculum. Which of the following conditions would best be treated with the use of vaginal dilators?

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

31. A 35-year-old African American woman presents to a physician complaining of irregular menstrual periods. She had her first menses at age 15 and states that her periods come irregularly every 2 to 6 months. She has been in a monogamous relationship with her husband for 15 years; for 10 years they have been trying unsuccessfully to conceive. She gets yearly Pap smears, which have been normal. Her height is 5 feet 2 inches (157.5 cm), and her weight is 200 pounds (90.9 kg). Her temperature is 37 C (98.6 F), blood pressure is 118/78 mm Hg, pulse is 80/min, and respirations are 14/min. She has acne, as well as excess hair, on her face and between her breasts. Her abdomen is obese. Examination is otherwise within normal limits. This patient is at greatest risk for developing which of the following diseases?

32. A 32-year-old Hispanic woman presents to the emergency department complaining of heavy vaginal bleeding. Her temperature is 37 C (98.6 F), blood pressure is 80/50 mm Hg, pulse is 110/min, and respirations are 18/min. Her abdomen is soft, non-tender and non-distended. Her pelvic examination reveals approximately 200 mL of clotted blood in the vagina, an open cervical os with tissue protruding from it, and a 10-week-sized, non-tender uterus. Leukocyte count is 9000/mm3, hematocrit is 22%, and platelet count is 275,000/mm3. Quantitative hCG is 100,000mIU/L (normal: 5-200,000mIU/L). Pelvic ultrasound shows echogenic material within the uterine cavity consistent with blood or tissue, no adnexal masses, and no free fluid. No viable pregnancy is seen. Which of the following is the most appropriate next step in management?

33. A 25-year-old Caucasian woman, gravida 1, para 0, at 26 weeks' gestational age presents to her physician's office complaining of spotting from the vagina. She has no contractions and reports normal fetal movement. She denies any history of a bleeding disorder. Her temperature is 37.3 C (99.1 F), blood pressure is 100/60 mm Hg, pulse is 75/min, and respirations are 14/min. Her abdomen is gravid and benign, with a fundal height of 26 cm. A placenta previa is ruled out by ultrasound examination. Pelvic examination reveals some scant blood in the vagina, a closed os, and no uterine tenderness. Leukocyte count is 12,000/mm3, hematocrit is 33%, and platelet count is 140,000/mm3. Her blood type is A, Rh negative. Which of the following is the most appropriate pharmacotherapy?

34. A 29-year-old primigravid woman is admitted to the labor and delivery ward with strong contractions every 2 minutes and cervical change from 3 to 4 cm. Over the next 5 hours she progresses to full dilation. After 3 hours of pushing, the physician cuts a mediolateral episiotomy, and the woman delivers a 3770-g (8-lb, 4-oz) boy. Which of the following is the main advantage of a mediolateral episiotomy over a median (midline) episiotomy?

35. 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?

36. A 34-year-old woman, gravida 3, para 2, at 38 weeks gestation presents to the labor and delivery ward complaining of headache. She has no contractions. Her prenatal course was unremarkable until she noted the onset of swelling in her face, hands, and feet this week. Her obstetric history is significant for two normal spontaneous vaginal deliveries. She has no significant past medical or surgical history. Her temperature is 37 C (98.6 F), blood pressure is 160/92 mm Hg, pulse is 78/min, and respirations are 16/min. Examination reveals 3+ patellar reflexes bilaterally. A cervical examination reveals that her cervix is 3 cm dilated and 50% effaced and soft, and that the fetus is at 0 station and vertex. The fetal heart rate has a baseline of 140/min and is reactive. The results from a 24-hour urine collection show 5200 mg of protein (normal <300 mg/24 hours). The patient is given magnesium sulfate intravenously for seizure prophylaxis. Which of the following is the most appropriate next step in the management of this patient?

37. 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?

38. An ovarian mass removed from a 49-year-old female has yellow coloration of its cut surface. The pathologist describes it as a granulosa-theca cell tumor. Based on this pathology report, the tumor is most likely to secrete:

39. 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:

40. A 38-year-old Caucasian female presents to your office complaining of a small amount of vaginal discharge that appears following sexual intercourse. There is no associated abdominal pain or urinary symptoms. Her menstrual cycles occur with regular 28-day cycles; her last menstrual period was 2 weeks ago. She has never been pregnant. Menarche occurred at age 10, and she has been sexually active with 10 different partners over the last 20 years. She smokes two packs of cigarettes per day and consumes alcohol regularly. She admits that her diet is poor in vegetables and fruit. Her mother died of breast cancer at age 54, and her father, who is living, has hypertension. Cervical biopsy reveals cervical intraepithelial neoplasia Ill (CIN Ill). Which of the following is the strongest risk factor for this condition?

41. 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:

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

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

44. 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?

45. 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?

46. You have just performed diagnostic laparoscopy on a patient with chronic pelvic pain and dyspareunia. The patient had multiple implants of endometriosis on the uterosacral ligaments and ovaries and several on the rectosigmoid colon. At the time of the procedure, you ablated all of the visible lesions on the peritoneal surfaces with the CO2 laser. But because of the extent of the patient’s disease, you recommend postoperative medical treatment. Which of the following medications is the best option for the treatment of this patient’s endometriosis?

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

48. You are treating a 31-year-old woman with danazol for endometriosis. You should warn the patient of potential side effects of prolonged treatment with the medication. When used in the treatment of endometriosis, which of the following changes should the patient expect?

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

50. A 30-year-old woman with a genetic disorder characterized by a deficiency of phenylalanine hydroxylase is planning a first pregnancy. Her physician explains the increased risk of mental retardation, as well congenital heart disease, in the infant. Which of the following should also be recommended?

51. A 19-year-old woman comes to the physician because of irregular vaginal bleeding. She has asthma and has never had surgery. She takes albuterol for her asthma and has been taking the oral contraceptive pill for 2 years. She has no allergies to medications. On examination she is found to have a vaginal lesion, which is biopsied. The biopsy shows clear cell adenocarcinoma of the vagina. This patient's malignancy is most likely associated with which of the following types of exposure?

52. A 22-year-old woman, gravida 2, para 1, comes to the physician for her first prenatal visit She had a previous full-term, normal vaginal delivery 2 years ago. She has no medical problems and has never had surgery. She takes no medications and has no known drug allergies. Pelvic examination reveals a mucopurulent cervical discharge, no cervical motion tenderness, and an 8- week-sized, non-tender uterus. A cervical swab is performed. Two days later, the laboratory calls to notify the physician that the patient is positive for Chlamydia trachomatis. Which of the following is the most appropriate pharmacotherapy?

53. A 39-year-old nulligravid woman comes to the physician because of a persistent vaginal itch, vaginal discharge, and dysuria. She has had these same symptoms several times over the past 2 years and each time has been diagnosed with Candida vulvovaginitis. On physical examination, she has a thick, white vaginal discharge and significant vulvar and vaginal erythema. A potassium hydroxide (KOH) smear shows pseudohyphae; the normal saline smear is negative. Which of the following is the most appropriate next step in management?

54. A 25-year-old woman being evaluated for infertility is found to have an abnormal ridge of red, moist granules located in the upper third of her vagina. Pertinent medical history is that her mother was treated with diethylstilbestrol (DES) during her pregnancy. A biopsy from the abnormal vaginal ridge reveals the presence of benign glands underneath stratified squamous epithelium. Which of the following is the most serious long-term complication of this abnormality?

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

56. 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?

57. 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?

58. A 60-year-old postmenopausal woman presents with the new onset of uterine bleeding. An endometrial biopsy is diagnosed as atypical hyper-plasia. Which of the following histologic changes is most characteristic of this abnormality?

59. Prolonged unopposed estrogen stimulation in an adult woman increases the risk of development of endometrial hyperplasia and subsequent carcinoma. Which of the following is the most common histologic appearance for this type of cancer?

60. A 46-year-old woman undergoes an abdominal hysterectomy for a “fibroid” uterus. The surgeon requests a frozen section on the tumor, which is deferred because of the lesion’s degree of cellularity. Which of the following histologic criteria will be used by the pathologist to determine if this tumor is benign or malignant?

61. A 23-year-old G3POA2 female presents to your clinic at an estimated 12 weeks of gestational age. She is a new patient and has come to your clinic to seek an elective abortion. She has had two elective abortions in the past because of unplanned pregnancy. She has no past medical history and takes no medications. Her physical examination is within normal limits and a limited ultrasound examination was able to detect fetal heart tones. You and your partners have a strict policy against performing abortions because some members of the group object to the procedure. You decide it would be best to stick to this policy; however, the patient becomes angry and tells you that she will sue you if you do not perform the procedure. What is the best response to this patient?

62. A 65-year-old woman is found to have osteoporosis on DEXA scan. She underwent right knee surgery five years ago and developed post-operative deep venous thrombosis, for which she was treated with 6 months of warfarin therapy. She also has severe gastroesophageal reflux disease and takes lansoprazole daily. Her mother died of breast cancer, her maternal aunt has endometrial cancer, and her paternal aunt has a history of ovarian cancer. She does not want to use bisphosphonates because of her reflux symptoms, and would like to consider raloxifene. Which of the following is a contraindication to raloxifene in this patient?

63. A 22-year-old nulliparous woman comes to the physician with lower abdominal pain, nausea, and vomiting. She is unable to keep anything down. She is sexually active and uses oral contraceptive pills. The patient's last menstrual period was 15 days ago. Her temperature is 39°C (102.2°F), blood pressure is 11 0/70 mm Hg, and pulse is 11 O/min. Physical examination shows dry mucous membranes, soft and symmetrical abdomen, and diffuse tenderness over the lower quadrants. External genitalia show no abnormalities; speculum examination shows purulent discharge from the cervical os. The uterus is normal in size but is tender to palpation and motion. The adnexae are markedly tender but no palpable mass is noted. Cervical cultures are pending. Urine pregnancy test is negative. Which of the following is the most appropriate next step in management of this patient?

64. A 25-year-old woman presents to your office complaining of a seven-week history of amenorrhea. She also states that she has had nausea and vomiting for five weeks. She is sexually active. Her medical and obstetrical histories are unremarkable. Serum hCG level is elevated. Which of the following is the most important direct role of hCG in pregnancy?

65. 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?

66. A 29-year-old woman, gravida 2, para 0, comes for a routine prenatal visit. According to her history, she is at 16-weeks gestation. She had a first trimester miscarriage during her previous pregnancy. She does not take any vitamin supplementation. Vital signs are stable and physical examination is unremarkable. Initial laboratory studies show increased maternal serum alpha- fetoprotein (MSAFP) levels. Which of the following is the most likely cause of the abnormal laboratory finding?

67. 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?

68. A 25-year-old primigravid woman at 37 weeks gestation is brought to the emergency department because of severe uterine contractions and moderate vaginal bleeding. She has been followed for pre-eclampsia since her 32nd week of gestation. She is currently having intermittent bleeding. Ultrasonogram in the emergency department shows placental abruption and an intrauterine gestation consistent with dates. Placenta previa is ruled out. Her temperature is 37.0° C (98.7° F), blood pressure is 90/60 mmHg, pulse is 99/min and respirations are 20/min. Physical examination shows uterine tenderness and hyperactivity, increased uterine tone and vaginal bleeding. Her cervix is 1cm dilated and 10% effaced at the time of admission. Fetal heart tracing shows a rate of 11 O/min, a long-term variability of 4 cycles/min and a beat-to-beat variability of 20/min. Which of the following is the most appropriate next step in management?

69. A healthy 28-year-old woman comes to the physician for an annual physical examination. Her past medical history is unremarkable. Menses occur every 28 days and last 4-5 days. Her last menstrual period was 2 weeks ago. She became sexually active at age 18 and has had 3 sexual partners since then. The patient is in a relationship with her boyfriend of one year and uses oral contraceptives. She does not use tobacco, alcohol, or illicit drugs. Vital signs and general physical examination are within normal limits. Pelvic examination shows no cervical motion tenderness, adnexal masses, or cervical discharge. Pap smear is performed in the office. The results show adequate cellularity with transformation zone present and atypical squamous cells of undetermined significance. Which of the following is the most appropriate next step in management of this patient?

70. A 28-year-old G2, P1 woman in her 26th week of gestation comes to the office due to intermittent episodes of abdominal pain. She has been having these episodes for the past 4 days, and thinks that her fetus may be in distress. She points to her right flank when asked about the location of the pain, and says that it occasionally radiates to the groin area. She cannot identify any exacerbating or relieving factors. Her pregnancy has been uncomplicated so far. Her past medical history is significant for pelvic inflammatory disease. Her temperature is 37.5° C (99.5° F), blood pressure is 130/80 mm Hg, and pulse is 88/min. She is in considerable pain at the moment. Deep palpation of the right flank reveals tenderness. There is no CVA tenderness. Urinalysis shows: Specific gravity: 1.020 Blood: ++ Glucose: negative Ketones: negative Protein: negative Leukocyte esterase: negative Nitrites: negative What is the best next step in the management of this patient?

71. A 36-year-old woman comes to your office complaining of a 12-month history of inter-menstrual bleeding and heavy menses. She has had type-2 diabetes for the past 4-years, managed with glipizide and metformin. She has no family history of gynecological malignancies. She does not use tobacco or alcohol. Her temperature is 37.2° C (98.9° F), and blood pressure is 126/76 mm Hg. Her BMI is 30 Kg/m2. Physical examination shows pale mucus membranes. Pelvic examination is within normal limits; no vaginal lesions are noted. Urine pregnancy test is negative. Her hemoglobin is 10.8 g/dl and platelet count is 223,000/mm3. Coagulation studies are within normal limits. Which of the following is the most appropriate next step in management?

72. A 34-year-old woman, gravida 4, para 3, at 32 weeks gestation is brought to the emergency department because of vaginal bleeding. Her prenatal course, prenatal tests and fetal growth have been normal. Prenatal ultrasound at the 12th week showed an intrauterine gestation consistent with dates. Her temperature is 37.0°C (98.7° F), blood pressure is 90/70 mm of Hg, pulse is 98/min and respirations are 18/min. Physical examination shows continuous bright red vaginal bleeding. Ultrasonogram in the emergency department shows complete placenta previa. Fetal heart tracing shows repetitive late decelerations. The patient's vital signs are stabilized with fluids, but the bleeding continues. Which of the following is the most appropriate next step in management?

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

74. A 24-year-old woman presents for her first prenatal visit at 12 weeks gestation. She was diagnosed with HIV two years ago, and her most recent CD4 count three months ago was 600cells/mm3. She does not use tobacco, alcohol, or illicit drugs. Physical examination is within normal limits. Which of the following is the single most important intervention for reducing maternal-fetal transmission of HIV infection?

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

76. A 32-year-old woman who presents with menometrorrhagia is found to have a 4.0-cm mass within her left ovary. This mass is resected surgically and a histologic section reveals the tumor to be composed of small polygonal cells growing sheets and anastomosing cords. Rare Call-Exner bodies are present. The tumor cells are found to stain positively with an immunoperoxidase stain against inhibin. Which one of the following is most likely to be secreted by these tumor cells?

77. 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?

78. 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?

79. A 16-year-old teenage girl presents to your office with her mother complaining of primary amenorrhea. Her past medical history is not significant. Her family history is significant for hypothyroidism in her mother. Her vital signs are normal. Examination reveals absent breasts, as well as pubic and axillary hair. The uterus and gonads are visualized on ultrasound, and the FSH level is increased. Which of the following is the most appropriate next step in the management of this patient?

80. A 24-year-old woman, gravida 2, para 1, at 34 weeks' gestation comes for a routine prenatal visit. Her dates were confirmed by first trimester ultrasonogram. She has no painful uterine contractions. Her previous pregnancy was uncomplicated and ended with a normal vaginal delivery. Her vitals are stable and fetal heart tones are reassuring. Physical examination shows a closed cervix, vertex is palpable at the fundus, and the presenting part is not engaged. Which of the following is the appropriate next step in management?

81. 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?

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

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

84. 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?

85. A 39-year-old woman presents with increasing abdominal distention and pelvic pain. A CT scan finds a slight amount of fluid in the pleural cavity and also a 3.5-cm tumor of the right ovary. The tumor is resected and histologic sections reveal the tumor to be composed of spindle-shaped cells. These cells did not stain with an oil red O special stain. Which of the following types of ovarian tumor is most likely to produce this constellation of findings?

86. 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?

87. During the evaluation of secondary amenorrhea in a 24-year-old woman, hyperprolactinemia is diagnosed. Which of the following conditions could cause increased circulating prolactin concentration and amenorrhea in this patient?

88. A 36-year-old morbidly obese woman presents to your office for evaluation of irregular, heavy menses. An office endometrial biopsy shows complex hyperplasia of the endometrium without atypia. The hyperplasia is most likely related to the excess formation in the patient’s adipose tissue of which of the following hormones?

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

90. A 59-year-old patient with a 2-year history of metastatic breast cancer presents with the acute onset of severe low back pain. She underwent a radical mastectomy and lymphadenectomy 3 years ago. Four of seven nodes were positive at the time of her original diagnosis. One year ago she developed an asymptomatic metastasis to her right femur. On physical examination, she is in severe discomfort and finds movement extremely difficult. She has exquisite tenderness in the lumbar vertebral area, and any motion of her legs or lower back produces extreme pain. An emergent MRI reveals large lytic lesions in L3 and L4. Which of the following is the most appropriate next step in management?

91. A 22-year-old woman comes to the physician with her husband because of vaginal irritation and a malodorous vaginal discharge. Her symptoms started 4 days ago. She also notes pain with intercourse and dysuria. Pelvic examination reveals vaginal and cervical erythema and a copious greenish, frothy discharge. The pH of this discharge is 6.0. A wet preparation is done with normal saline, which shows numerous flagellated organisms that are slightly larger than the surrounding white blood cells. Which of the following is the most appropriate management?

92. A 24-year-old woman asks her physician about the possibility of genetic screening for BRCA1 mutations. Her mother died of breast carcinoma at age 44, and a sister had a diagnosis of in situ ductal carcinoma at age 38. Which of the following is the most appropriate advice to give this woman?

93. 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?

94. 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?

95. 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 unremarkable. 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?

96. 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?

A 29-year-old woman presents for a routine prenatal visit. She is 24 weeks pregnant by last menstrual period and ultrasound. She does not have any medical problems and does not take any medications. She does not use tobacco, alcohol or illicit drugs. She works as a financial advisor in a local firm. She and her husband have been monogamous since getting married 5 years ago. Vital signs are normal. Physical examination shows no abnormalities. At the end of the visit she tells you that her newborn niece recently had a group B streptococcal infection and she is afraid that her child might develop the same. Which of the following is the most appropriate response?

97. A 19-year-old woman presents to the physician's office for routine physical examination and Pap smear. She has no complaints. She has had 2 sexual partners in the past six months and takes oral contraceptive pills. She has no significant past medical history and takes no other medications. She has no known drug allergies. Her temperature is 37.2 C (98.9 F) and blood pressure is 120/72mm Hg. Complete physical exam including pelvic examination is unremarkable. Cervical swab is sent for nucleic acid amplification of Chlamydia trachomatis and Neisseria gonorrhoeae. One week later, the nucleic acid amplification test returns positive for Chlamydia infection. The patient is still asymptomatic. What is the most appropriate next step in the management?

98. A 25-year-old woman delivered a baby boy at 38 weeks gestation. The newborn has a small body size with microcephaly, hypoplasia of the distal phalanges of the fingers and toes, excess hair and a cleft palate. He weighs 2.5kg (5.5lb). Further history or evaluation of the mother would most likely reveal which of the following:

99. A 30-year-old obese white female comes to the physician with a six months history of oligomenorrhea. She never had this problem before. She has no galactorrhea. She has gained significant weight over the past two years despite a regular exercise program. She has also experienced hair loss during this time. She has had regular Pap smears since the age of 20; pap smears have shown no abnormalities. She takes no medications. She does not use tobacco, alcohol, or drugs. Her mother has a history of endometrial carcinoma and her grandmother had a history of ovarian carcinoma. Physical examination shows male pattern baldness. Abdominal and pelvic examination shows no abnormalities. A urine pregnancy test is negative. Serum prolactin level and thyroid function tests are normal. Which of the following is the most appropriate next step in management?

100.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 37.0C (98.7F), 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?

101.A 26-year-old woman comes to the physician for follow-up after a recent spontaneous abortion at 14 weeks gestation. She had one other spontaneous first trimester abortion two years ago. She has no other medical problems and does not use tobacco, alcohol or drugs. Review of systems reveals photosensitivity and occasional hematuria. On examination, you observe a bilateral malar rash. What is the most likely pathophysiology for her abortions?

102.A 29-year-old woman, gravida 2, para 0, comes for a routine prenatal visit. According to her history, she is at 16-weeks gestation. She had a first trimester miscarriage during her previous pregnancy. She does not take any vitamin supplementation. Vital signs are stable and physical examination is unremarkable. Initial laboratory studies show increased maternal serum alpha- fetoprotein (MSAFP) levels. Which of the following is the most likely cause of the abnormal laboratory finding?

103.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 mm Hg and urinalysis reveals slight proteinuria. Which of the following is the most likely diagnosis?

104.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?

105.A 39-year-old patient is contemplating discontinuing birth control pills in order to conceive. She is concerned about her fertility at this age, and inquires about when she can anticipate resumption of normal menses. You counsel her that by 3 months after discontinuation of birth control pills, what proportion of patients will resume normal menses?

106.A 36-year-old woman presents to your office for contraception. She has had three vaginal deliveries without complications. Her medical history is significant for hypertension, well- controlled with a diuretic, and a seizure disorder. Her last seizure was 12 years ago. Currently she does not take any antiepileptic medications. She also complains of stress-related headaches that are relieved with an over-the-counter pain medication. She denies any history of surgeries. She is divorced, smokes one pack of cigarettes per day, and has three to four alcoholic drinks per week. On examination, her vital signs include weight 90 kg, blood pressure 126/80 mm Hg, pulse 68 beats per minute, respiratory rate 16 breaths per minute, and temperature 36.4C (97.6F). Her examination is normal except for some lower extremity nontender varicosities. She has taken birth control pills in the past and wants to restart them because they help with her cramps. Which of the following would contradict the use of combination oral contraceptive pills in this patient?

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

108.A 32-year-old woman presents to your office to discuss contraception. She has recently stopped breast-feeding her 8-month-old son and wants to stop her progestin-only pill because her cycles are irregular on it. You recommend a combination pill to help regulate her cycle. You also mention that with estrogen added, the contraceptive efficacy is also higher. In combination birth control pills, which of the following is the primary contraceptive effect of the estrogenic component?

109.A 19-year-old primigravid woman at 12 weeks gestation comes to the physician for a routine prenatal visit. Her pregnancy has been uncomplicated to date, and her past medical history is unremarkable. Her medications include a multivitamin with iron and a folate supplement daily. She has no known drug allergies. Examination shows a uterus consistent in size with 12 weeks gestation. Clean-catch urine culture grows >100,000 colony-forming units/ml of Escherichia coli Sensitivity testing on the bacteria is pending. Which of the following is the most appropriate initial pharmacotherapy for this patient?

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

111.A 28-year-old woman at 30 weeks gestation comes to the physician because of 2 days of a near absence of fetal movements. This is only her second prenatal visit because she has skipped many appointments. She has a medical history significant for chronic hepatitis C infection and a MRSA skin abscess that was drained. She smokes cigarettes and uses heroin, cocaine and alcohol. She says that she is trying hard to be sober. Her temperature is 37.0° C (98.7° F), blood pressure is 138/85 mm Hg and pulse is 80/min. Physical examination shows a fundal height of 26 cm (10.2in). Fetal heart tones are heard by Doppler. Nonstress test (NST) shows no accelerations. After vibroacoustic stimulation, NST is still not reactive so a biophysical profile is ordered and shows a score of 2. Her lab work showed the following: Complete blood count: Hemoglobin: 8.0 g/L MCV: 105fl Platelets: 120,000/mm3 Leukocyte count: 3,500/mm3 Which of the following is the most appropriate next step in management?

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

113.A 24-year-old woman, gravida 2, para 1, at 16 weeks' gestation comes to you for a routine prenatal visit. She has had mild constipation. She has had no nausea, vomiting, fever, burning urination, back pain, or other complaints. She has no history of urinary tract infections. She takes iron and folic acid supplements. She does not use tobacco, alcohol, or drugs. She is afebrile; her blood pressure is 124/74 mm Hg and pulse is 78/min. Examination shows a uterus consistent in size with a 16-week gestation. Physical examination shows no abnormalities. Urinalysis is within normal limits. A routine clean-catch urine culture grows greater than 100,000 colonies/ml of Escherichia coli. Which of the following is the most appropriate next step in management?

114.A 22-year-old woman presents to your office for her well-woman examination and contraception. She has no medical problems or prior surgeries. She does not smoke or drink. Her vital signs and physical examination are normal. You explain the risks and benefits of combination oral contraceptive pills to the patient. She wants to know how they will keep her from getting pregnant. Which of the following mechanisms best explains the contraceptive effect of birth control pills that contain both synthetic estrogen and progestin?

115.A 45-year-old white female has undergone a right mastectomy for a node-negative, estrogen and progesterone receptor-positive tumor. She is scheduled to begin adjuvant therapy with tamoxifen. Her menstrual cycles are regular and her last menstrual period was 15 days ago. She has many concerns about tamoxifen therapy and would like to know its risks and benefits. Which of the following is she at risk for?

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

117.A 25-year-old G2 P 1woman at 12 weeks gestation comes to the physician because of foul smelling vaginal discharge. She is sexually active and reports no previous problems. Speculum examination reveals a grayish, foul-smelling discharge, but no erythema or edema is noted on the vaginal walls or the vulva. There is no cervical or adnexal tenderness. A saline wet mount examination reveals numerous epithelial cells coated with bacteria. No white blood cells are seen. Which of the following is the most appropriate pharmacotherapy for this patient?

118.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?

119.A 23-year-old primigravid woman comes to your office for her first prenatal visit. She is working as an aerobics instructor and is concerned about the effect her exercise schedule might have on the pregnancy. She teaches 30 minutes daily in the morning and does not feel fatigued. She does not use tobacco, alcohol or drugs. Vital signs are normal and physical examination is unremarkable. Which of the following is the best advice to give this patient?

120.A 25-year-old primigravid woman at 37 weeks gestation is brought to the emergency department because of severe uterine contractions and moderate vaginal bleeding. She has been followed for pre-eclampsia since her 32nd week of gestation. She is currently having intermittent bleeding. Ultrasonogram in the emergency department shows placental abruption and an intrauterine gestation consistent with dates. Placenta previa is ruled out. Her temperature is 37.0 C (98.7F), blood pressure is 90/60 mmHg, pulse is 99/min and respirations are 20/min. Physical examination shows uterine tenderness and hyperactivity, increased uterine tone and vaginal bleeding. Her cervix is 1em dilated and 10% effaced at the time of admission. Fetal heart tracing shows a rate of 11 0/min, a long-term variability of 4 cycles/min and a beat-to-beat variability of 20/min. Which of the following is the most appropriate next step in management?