B4E3 - Practice Exam
A 17-year-old woman with lower abdominal pain and spotting comes into the emergency department. She is noted to have an hCG level of 1000 mIU/mL and a progesterone level of 26 ng/mL. Which of the following is the most likely diagnosis? A. This is most likely a normal intrauterine pregnancy. B. This is most likely an ectopic pregnancy. C. This is most likely a nonviable intrauterine pregnancy. D. No clear conclusion can be drawn from this information.
A
Your patient progresses to complete dilation and delivers vaginally 1 hour later. Maternal antibiotics are discontinued following delivery, and the maternal temperature 2 hours after delivery is 37°C. On postpartum day 1, your patient complains of sore breasts from breastfeeding but no particular swelling of the breast (beyond what is expected postpartum), and her abdomen is sore "all over." She is having a moderate amount of lochia, and her temperature is 38.4°C. The most likely cause of the fever at this time is: A. Endometritis B. Mastitis C. Deep vein thrombosis D. Septic pelvic thrombophlebitis
A
Your patient wants to know how long she should use a backup method of contraception after starting the combination estrogen/progesterone OCP. You tell her the following regarding using a backup method: A. If she starts taking the pill during the first 5 days of her menstrual period, no backup method is needed B. If she starts taking the pill greater than 5 days after her the onset of her period, she needs a backup method for 30 days C. She should use a backup method for 2 months after starting the pill regardless of when she started it D. The OCP provides effective contraception immediately and no backup method is needed
A
In patients with PCOS whose primary concern is menstrual irregularity, who is not attempting pregnancy, which of the following is the initial therapeutic option after a trial of applicable lifestyle intervention? A. Metformin B. A combination oral contraceptive containing ethinyl estradiol and drospirenone C. LNG-IUS D. Letrozole
B
A 38-year-old premenopausal woman sees you for blood-tinged bilateral nipple discharge for 2 weeks. The discharge has to be expressed from her breasts, does not appear spontaneously, and appears from several ducts. She is concerned because she stopped lactating 6 months ago. Which is the most worrisome feature of this patient's history? A. Age B. Recent lactation C. Bloody discharge D. Bilateral nipple discharge E. Nonspontaneous discharge F. Discharge from multiple ducts
C
Where does fertilization most often occur? A. Cervix B. Ovary C. Oviduct D. Uterus
C
You offer your 12 week gestation patient the routine prenatal tests at this initial visit, which include all of the following EXCEPT: A. Syphilis testing B. HIV testing C. 1-hour glucose tolerance test D. Blood type and antibody screen E. Fetal nuchal translucency with maternal hCG and plasma-associated pregnancy protein A (PAPP-A)
C
A 24-year-old nulligravida female presents for her annual examination. Her gynecologic history is remarkable for irregular menses, menstruating every 4 to 8 weeks. She would like a more reliable form of contraception (currently using condoms) and would like to have predictable menses, but is very concerned regarding weight gain with various contraceptive methods. After reassuring her regarding the concerns of weight gain, you tell her about the additional potential benefit(s) of OCPs, which include: A. Improvement in acne B. Decreased dysmenorrhea C. Decreased menstrual flow D. Decreased risk of ovarian cancer E. All of the above
E
A gravida 4 para 4 (G4P4) 35-year-old woman has a remote history of an abnormal Pap test more than 10 years ago. She did not follow-up until now. Her age of first intercourse was 15, and she has had multiple (>10) sexual partners. Her clinical history is also significant for smoking and Human Immunodeficiency Virus (HIV) infection. A Pap test shows HSIL. Colposcopy is performed and shows a cervical mass. A biopsy is of the mass is taken and it is invasive squamous cell carcinoma. What is the most important risk factor in this patient for the development of squamous cell carcinoma? A. Multiple sexual partners B. Early age at first intercourse C. HIV infection D. Cigarette smoking E. Lack of regular Pap tests
E
A 19-year-old G1P0 woman at 39 weeks' gestation is diagnosed with preeclampsia based on a blood pressure of 150/90 mm Hg and urine protein-to-creatinine ratio of 0.7. She complains of a severe headache. The patient is placed on magnesium sulfate and develops flushing and fatigue. She asks about the need for the magnesium sulfate. You explain that it is to prevent the seizures that may complicate preeclampsia and may even cause death. Which of the following is the most common mechanism whereby eclampsia causes maternal death? A. Intracerebral hemorrhage B. Myocardial infarction C. Electrolyte abnormalities D. Aspiration
A
A 19-year-old woman has primary amenorrhea, Tanner stage V breast development, and a pelvic kidney. Which of the following is the most likely diagnosis? A. Müllerian agenesis B. Androgen insensitivity C. Gonadal dysgenesis D. Polycystic ovarian syndrome
A
A 21-year-old G1P0 woman at 11 weeks' gestation is seen in the emergency center complaining of nausea, vomiting, abdominal pain, and fatigue. The patient is a known diabetic since age 12 years and has had good glucose control. On examination, her blood pressure is 90/60 mm Hg, heart rate is 120 beats per minute, and respiratory rate is 28 breaths per minute. The arterial blood gas reveals a pH of 7.28, PaO2 of 100 mm Hg, PaCO2 of 22 mm Hg, and bicarbonate level of 12 mEq/L. Which of the following is the best management of this patient? A. Administer 2 L of normal saline intravenously (IV) B. Infuse two ampules of bicarbonate IV C. Obtain a spiral computed tomography scan to assess for pulmonary embolism D. Obtain an ultrasound for a possible concealed abruption
A
A 25-year-old G1P0 woman is at 28 weeks' gestation. She is noted to have regular uterine contractions, and her cervix is dilated at 2 cm and 80% effaced. Preterm labor is diagnosed. The clinician reviews the record and notes that the patient should not have tocolytic therapy. Which of the following is a contraindication for tocolysis? A. Suspected placental abruption B. Group B streptococcal bacteriuria C. Recent laparotomy D. Uterine fibroids
A
A 25-year-old woman is referred for a 4-cm simple cyst of the right ovary noted on abdominal ultrasound for suspected gallstones. She denies any abdominal pain, nausea, or vomiting. On examination, her vital signs are normal. The abdominal and pelvic exams reveal no tenderness or masses. The pregnancy test is negative. Which of the following is the next best step? A. Expectant management B. Laparoscopy C. Exploratory laparotomy D. Chemotherapy
A
A 28-year-old woman comes to see her physician with symptoms of weight gain and nausea. The physician diagnoses her as being at 24 weeks gestation. Her circulating estradiol is elevated due to its production by the placenta. Estradiol cannot be synthesized by the fetal adrenal gland due to its inability to produce what steroid hormone? The fetus is not capable of synthesizing what steroid hormone? A. Progesterone B. Pregnenolone C. DHEAS D. Cholesterol
A
A 35-year-old woman presents with AUB, pelvic pain, and fever. A urine pregnancy test is negative. An endometrial biopsy is performed and shows increased plasma cells. Which is the most likely additional clinical history? A. The patient recently delivered a full-term infant. B. The patient has endometriosis. C. The patient is on tamoxifen. D. The patient has hemophilia. E. The patient is obese.
A
A 36-year-old G2P1001 woman presents for her follow-up prenatal visit at 36 weeks' gestation. She has a 9-year history of type 2 diabetes mellitus, which is managed with oral metformin. Which of the following is the best indicator of fetal outcome of the pregnancy? A. Biophysical profile B. Blood glucose value in the office C. Hemoglobin A1C (HbA1C) value D. Placental grading
A
A 39-year-old woman is being seen in the office for feeling a new breast lump. On examination, she is noted to have a 1.5-cm mobile mass of the right breast. There is no adenopathy or nipple discharge. The patient has no family history of breast cancer. The mammogram shows no masses in either breast. Which of the following is the best next step in the management of this patient? A. Core-needle biopsy B. Observation C. Repeat mammogram in 6 months D. Tamoxifen use for 1 year
A
A 45-year-old woman has made an appointment to see you for an 8-week history of redness and thickening overlying the skin on her left breast. She stopped nursing 3 months ago. She initially received a course of antibiotics for mastitis, but the symptoms only partially improved. A diagnostic mammogram 4 weeks ago revealed dense breast tissue and skin thickening but no obvious mass. She has no other medical problems, and her family history is significant for a sister who was diagnosed with ovarian cancer at age 50 and a paternal aunt with breast cancer in her 60s. Which aspect of this patient's history is most consistent with a benign condition? A. Recent lactation B. Absence of mass on mammogram C. Partial response to antibiotics D. Family history of ovarian cancer
A
A 45-year-old woman is diagnosed with an early cervical cancer that is noted to be confined to the cervix and about 3 cm in diameter. Which of the following is the most significant risk factor for cervical cancer? A. Early age of coitus B. Nulliparity C. Obesity D. Late menopause E. Family history of cervical cancer
A
A 47-year-old G4P4 woman has a Pap smear that shows HSIL. Colposcopy is performed and is adequate, revealing cervical intraepithelial neoplasia (CIN) 3. An endocervical curettage is negative. The patient also has menorrhagia caused by uterine fibroids. Thus, the patient undergoes a total abdominal hysterectomy, including removal of the cervix. The patient asks whether Pap smears need to be performed now that her cervix has been surgically removed. Which of the following is the most accurate statement? A. The patient should continue to have annual Pap smears of the vaginal cuff. B. The patient should have Pap smears every 2 to 3 years, which may be discontinued if negative after 10 years. C. The patient does not need Pap smears any longer. D. The patient should have the HPV vaccine.
A
After a prolonged labor, delivery of an 8-lb baby is accomplished without operative vaginal assistance. The mere presence of the vacuum on the table was enough to entice the uterus to perform one last massive contraction—assisted by the infant clawing its way out when it saw the vacuum coming. Following spontaneous delivery of the intact placenta 15 minutes later, you note a large gush of blood. Which of the following is the most likely source of the bleeding? A. Uterine atony B. Vaginal laceration C. Cervical laceration D. Retained placenta
A
An 18-year-old nulliparous woman complains of not having started her menses. Her breast development is Tanner stage V. She has a blind vaginal pouch and no cervix. Her pregnancy test is negative. Which of the following describes the most likely diagnosis? A. Müllerian agenesis B. Kallmann syndrome C. Gonadal dysgenesis D. Polycystic ovarian syndrome
A
For the first 8 weeks of pregnancy, hCG doubles every how many days until it reaches a peak between 100,000 and 500,000 IU/L? A. 1.5 to 2 B. 3 to 5 C. 7 to 10 D. 10 to 15
A
Hyperkalemia is most likely to result from which of the following products used in the management of PCOS? A. A combination oral contraceptive containing ethinyl estradiol and drospirenone B. A combination oral contraceptive containing ethinyl estradiol and levonorgestrel C. Metformin 850 mg by mouth twice daily D. Injectable medroxyprogesterone acetate (MPA), 150 mg dosed every 12 weeks
A
Uterine leiomyomata: A. Are present in 20%-30% of women of reproductive age B. Are more common in Caucasian women than in those of African or Asian descent C. Often appear after menopause if estrogen supplements are not used D. Are usually monofocal, with a single tumor in the uterine wall E. Require treatment by hysterectomy
A
When your patient whose water broke at home arrives at the hospital, she alters her recollection of events (never happens in our practice) to say that the fluid soaking the bed sheets was blood-tinged and pink in color and first occurred 2 hours ago. She continues to have vaginal leakage but denies any bright red bleeding or contractions. Ultrasound reveals a fundal placenta (not a placenta previa) without any evidence of abruption. Fetal heart tones are in the 140s and reactive. Sterile speculum examination reveals fluid, which is nitrazine and ferning positive (both evidence of ruptured membranes). Her GBS culture performed 2 weeks ago is negative. She is still not feeling contractions, and there are no contractions on the monitor. What is the most appropriate next step in the management of this patient? A. Begin an induction of labor B. Send her home after 4 hours of reassuring fetal monitoring C. Treat her with IV penicillin for GBS prophylaxis D. Repeat her GBS test to confirm GBS status
A
Which of the following is the best management of an 18-year-old G1P0 woman at 28 weeks' gestation with a blood pressure of 160/110 mm Hg, normal liver function tests, and a platelet count of 160,000/mm3? A. Antihypertensive therapy B. Platelet transfusion C. Magnesium sulfate therapy and induction of labor D. Intravenous immunoglobulin (IVIG) therapy
A
Which of the following statements describes the primary utility of the transvaginal ultrasound in the assessment of an ectopic pregnancy? A. Assessment of an intrauterine pregnancy B. Assessment of adnexal masses C. Assessment of fluid in the peritoneal cavity D. Color Doppler flow in the adnexal region
A
Which one of the following statements about hCG and spontaneous abortion (miscarriage) is not true? A. A spontaneous abortion or nonviable pregnancy is associated with a slow rate of increase in hCG. B. hCG concentrations can be monitored after fetal loss until they are undetectable, to confirm complete expulsion of the products of conception. C. Up to 60 days may be required after fetal loss before the serum hCG concentrations are undetectable. D. Serial measurements of hCG concentration, along with other tests, are often important in the diagnosis of the spontaneous abortion.
A
A 17-year-old G1P0 adolescent presents to the outpatient surgical center for a surgical abortion at 6 weeks and 3 days' gestation under moderate sedation. At the end of the dilation and curettage, copious bright red blood is noted to be gushing rapidly from inside of the cervix. The patient's vital signs are within normal limits, and she is comfortably sedated. Physical exam reveals no lacerations or abrasions of the cervical stroma or vaginal mucosa. The uterus is found to be boggy on bimanual exam. Ultrasound examination does not reveal free fluid in the pelvis or any defect in the uterine wall. Which of the following is the most likely cause of the patient's bleeding? A. Infection B. Uterine atony C. Embolism D. Uterine perforation E. Cervical laceration
B
A 28-year-old parous woman at 16 weeks' gestation is noted to have a positive Chlamydia assay of the endocervix. She is asymptomatic. Which of the following is an acceptable treatment? A. Intramuscular ceftriaxone B. Oral amoxicillin C. Oral ciprofloxacin D. Oral doxycycline
B
A 29-year-old G0P0 woman with a diagnosis of PCOS is being counseled about the long-term complications of her condition. In particular, she is cautioned about the possibility of developing metabolic syndrome. Which of the following is the most significant consequence of metabolic syndrome? A. Hyperthyroidism B. Cardiovascular disease C. Breast cancer D. Renal insufficiency
B
A 30-year-old G2P1 woman is at 31 weeks with chronic hypertension using oral labetalol. Her blood pressure in the office is 160/95 mm Hg and 162/90 mm Hg. The urine protein is negative. A. Corticosteroids B. Antihypertensive agent C. Biophysical profile D. Magnesium sulfate and delivery E. Continued observation
B
A 34-year-old woman undergoes an elective termination of pregnancy at 12 weeks' gestation. She develops fever and uterine tenderness and is diagnosed with a septic abortion. Which of the following is the most likely mechanism of her infection? A. Instrumental contamination B. Ascending infection C. Skin organisms D. Urinary tract penetration E. Hematogenous infection
B
A 48-year-old healthy postmenopausal woman has a Pap smear performed, which reveals atypical glandular cells. She does not have a history of abnormal Pap smears. Which of the following is the best next step? A. Repeat Pap smear in 3 months B. Colposcopy, exocervical biopsy, endocervical curettage, endometrial sampling C. Hormone replacement therapy D. Vaginal sampling
B
A 48-year-old woman who presents with postcoital vaginal bleeding is noted to have a cervical exophytic mass. A biopsy of the mass confirms squamous cell carcinoma. If molecular analysis of the cancer is performed, which of the following human papillomavirus (HPV) subtypes is most likely to be found in the specimen? A. 6 and 11 B. 16 and 18 C. 55 and 57 D. 89 and 92
B
A 60-year-old woman presents with 2 months of progressive, crampy, lower abdominal pain and cyclical diarrhea. Which of the following features, if present, would be most concerning for endometrial cancer? A. Fever or chills B. Abnormal vaginal bleeding C. Dyspareunia D. Multiple sexual contacts
B
A 62-year-old woman is noted to have a 2-cm left breast mass detected on clinical examination. Stereotactic core-needle biopsy reveals infiltrating ductal carcinoma. The patient is noted to have a triple-negative tumor. Imaging does not demonstrate metastases. Which of the following is the best treatment for this patient? A. Partial mastectomy, local radiotherapy, and adjuvant hormonal therapy B. Partial mastectomy, sentinel node biopsy, local radiotherapy, and systemic chemotherapy C. Partial mastectomy, full axillary node dissection, and systemic chemotherapy D. Combination chemotherapy and radiation to breast lesion
B
A 65-year-old postmenopausal woman notes a 1-month history of a painless right breast mass. She denies nipple or skin changes. She has a history of hypertension, arthritis, and fibrocystic breast disease. She had a right breast biopsy 10 years ago for a breast lump, which revealed atypical ductal hyperplasia but no invasive or in situ cancer. She is on an antihypertensive, acetaminophen, and hormone replacement therapy (HRT). Her family history is significant for her mother, who had breast cancer in her 70s. Which of the following historical features does not increase the risk of breast cancer? A. Age B. History of fibrocystic disease C. Prior breast biopsy D. HRT use E. Breast cancer history in mother
B
Eight months later, the patient calls to speak with your nurse regarding nausea and vomiting. Apparently, she decided to stop taking her OCP. Her last menstrual period was 10 weeks earlier, and she had a positive home pregnancy test 5 weeks ago. Over the last week, she has been vomiting once every day, at various times, but is nauseated throughout most of the day. She wants to know if there is anything else that is "safe" that she can do to decrease the nausea. What is your most appropriate response? A. "This level of nausea and vomiting is abnormal and needs an immediate workup to rule out other pathology" B. "This level of nausea and vomiting is very common, and there are several modifications and over-the-counter medications that are safe" C. "This level of nausea and vomiting is very common; however, there are no medications that can be initiated in the first trimester" D. "This level of nausea and vomiting is very common. Metoclopramide, promethazine, and ondansetron are our first-line therapies" E. "Deal with it. You got yourself into this mess"
B
M.M. is a 32-year-old who started using a GnRH agonist 2 months ago to treat endometriosis. Today they report that the treatment has almost completely relieved their pain, but they have been experiencing uncomfortable hot flashes. What would be the most appropriate next step? A. Add a combined oral contraceptive pill B. Add a menopausal hormone replacement product C. Discontinue the GnRH agonist because its effects are long-lasting D. Switch to letrozole
B
Maintenance of the corpus luteum during the first 8 weeks of pregnancy is dependent on which of the following hormones? A. Estrogen B. hCG C. Progesterone D. DHEA-S
B
Sterile vaginal examination reveals a cervix that is 3 cm dilated, 2 cm long (effacement), soft, anterior, and vertex at a −1 station. The patient agrees to an induction of labor. The best induction method for this patient is to: A. Insert intracervical laminaria B. Begin IV oxytocin at 2 milliunits per minute C. Insert intravaginal dinoprostone (Prepidil, Cervidil) D. Have her partner sit on her abdomen E. Have her run a few laps around L&D (or walk around the hospital)
B
The Bishop score helps to determine: A. The health of the fetus B. The need for cervical ripening agents for induction and helps to predict labor induction success C. The maturity of the fetal lungs D. The risk of fetal demise in the post-term fetus E. The results of a Catholic intramural baseball game
B
Treatment of cervical carcinoma: A. Usually includes hysterectomy for microinvasive disease B. Consists of radiation therapy and chemotherapy for advanced disease C. Cannot preserve fertility in women with microinvasive disease D. Includes systemic therapy only for distant metastases E. Often requires radiation therapy for bone metastases
B
Your patient is at 41 weeks gestations and she is really (really, really) tired of being pregnant and wants "a natural way" to induce contractions. Which of the following nonpharmacologic methods of inducing or augmenting labor is LEAST likely to be effective? A. Stripping the amniotic membranes B. Prolonged walking C. Amniotomy D. Nipple stimulation
B
A 20-year-old G0P0 woman is told by her provider that there is a strong probability that her gonads will turn malignant. She has not had her menses yet. She has Tanner stage I breast development. Which of the following describes the most likely diagnosis? A. Müllerian agenesis B. Androgen insensitivity C. Gonadal dysgenesis D. Polycystic ovarian syndrome
C
A 22-year-old woman at 8 weeks' gestation has vaginal spotting. Her physical examination reveals no adnexal masses. The hCG level is 2200 mIU/mL, and the transvaginal ultrasound shows no pregnancy in the uterus and no adnexal masses. This is a desired pregnancy. Which of the following is the next best step in this patient's management? A. Laparoscopy B. Methotrexate C. Repeat the human chorionic gonadotropin (hCG) level in 48 hours D. Dilation and curettage
C
A 22-year-old woman presents with the complaint of a palpable, firm, mobile, 2-cm mass in the 12 o'clock position on her right breast. She states that it has been present for almost 6 months, does not change with her menstrual cycle, and is not painful. She smokes approximately 8 to 10 cigarettes daily, drinks three or four cups of caffeinated coffee daily, and rarely drinks alcohol. She has no personal or family history of breast cancer. Which of the following is the most appropriate initial evaluation of this mass? A. Surgical excision B. Mammogram C. Ultrasound D. Fine-needle aspiration
C
A 29-year-old woman presents with unilateral breast pain. Which of the following histories, if true, is most concerning for a malignant process? A. Associated symptoms include fever, chills, malaise, and erythema of the skin of the affected breast. The pain is severe enough that it prohibits her from breastfeeding her 3-month-old infant on that breast. B. She initially attributed the pain to bruising over the left breast secondary to trauma sustained in a recent motor vehicle accident in which she was the restrained driver, but she became concerned when she incidentally noted a new irregular mass in the breast tissue underlying the healing bruises. C. The pain is associated with erythema, swelling, warmth, and dimpling of the skin over the affected breast. She recently noted a nontender lump in the ipsilateral axilla. D. The pain is localized to a spot in the upper outer quadrant of the right breast. She recently also noted a well-circumscribed, mobile lump there that has grown in size over the past few weeks. She is especially concerned about her health because she is 6 months pregnant
C
A 30-year-old woman with previously normal menses presents to your clinic concerned about not having a period for 4 months following a dilation and curettage to treat heavy bleeding after a miscarriage. She reports having little energy, decreased appetite, and disturbed sleep patterns since the miscarriage. Which of the following is the first step in making the diagnosis? A. Check FSH levels B. Discuss her stress level in more detail C. Obtain a serum pregnancy test D. Perform hysteroscopy E. Order thyroid function levels
C
A 32-year-old G0P0 woman is seen in the office for irregular menses and excessive hair on the face and chest area. After evaluation, the clinician has a presumptive diagnosis of polycystic ovarian syndrome (PCOS). Which of the following is most suggestive of PCOS? A. Elevated 17-hydroxyprogesterone level B. Finding of a 9-cm right ovarian mass C. Vaginal bleeding after a 5-day course of progesterone oral therapy D. Dual-energy x-ray absorptiometry (DEXA) scan showing osteopenia
C
A 32-year-old G1P0 woman at 29 weeks' gestation presents to the obstetrical triage unit complaining of fever, chills, and nausea and vomiting of 3 days' duration. She also has myalgias. She denies leakage of fluid per vagina and states that she has been in good health. She has not been out of the country for 2 years. Questions about dietary habits reveal that she does not eat raw or uncooked foods, does not eat raw shellfish, but does eat a fair amount of soft goat cheese. Her temperature is 101 °F (38.3 °C), blood pressure is 100/80 mm Hg, and heart rate is 110 beats per minute. Her abdominal examination reveals tenderness of the uterine fundus. The fetal heart rate is 170 beats per minute. An ultrasound reveals a single, viable gestation that is consistent with 29 weeks' gestational age and a normal amniotic fluid volume. An amniocentesis reveals greenish, dark fluid, and a Gram stain of the amniotic fluid shows gram-positive rods. Which of the following is the most likely diagnosis? A. Group B Streptococcus infection B. Clostridial infection C. Listeria monocytogenes infection D. Pasteurella multiforme infection E. Meconium-stained amniotic fluid with bacterial skin contaminant
C
A 32-year-old G2P1 woman is at 35 weeks with chronic hypertension. The blood pressure is in the 140/95 mm Hg range. A. Corticosteroids B. Antihypertensive agent C. Biophysical profile D. Magnesium sulfate and delivery E. Continued observation
C
A 32-year-old G3P2002 woman presents for her 6-week postpartum visit. Her obstetrical history is significant for gestational diabetes mellitus (GDM) with her immediate past pregnancy, which ended in a term delivery of a 7-lb (3-kg) infant. She states that she is breastfeeding. Her current body mass index (BMI) is 24 kg/m2. Besides the routine examination and Pap smear, which of the following is your next step for this patient? A. Recommend a fasting glucose and HbA1C today B. Recommend a 3-hour, 100-g glucose tolerance test (GTT) if she has a first-degree relative with diabetes C. Recommend a 2-hour, 75-g GTT at this time D. No intervention is needed due to her optimal BMI
C
A 33-year-old woman has a Pap smear showing moderately severe cervical dysplasia (high-grade squamous intraepithelial neoplasia). She denies a smoking history and does not recall having any sexually transmitted infections. Which of the following is the best next step? A. Repeat Pap smear in 3 months B. Conization of the cervix C. Colposcopy-directed biopsies D. Radical hysterectomy E. CT scan of the abdomen and pelvis
C
A 34-year-old nulliparous woman presents with 1 month of bilateral milky nipple discharge. Review of systems is negative for breast, endocrine, or neurologic symptoms. She was prescribed risperidone 2 months ago for newly diagnosed schizophrenia. CBE reveals expressible milky discharge. The thyroid gland is not palpable. Urine pregnancy test is negative. Serum TSH and free T4 levels are within normal limits. Which of the following is the most accurate advice to give to this woman? A. The nipple discharge likely contains occult blood due to a benign breast disease. B. Her clinical presentation is highly suspicious for breast malignancy. C. This condition is likely attributable to her antipsychotic medication. D. Her normal examination and serologic testing are indicative of a physiologic process.
C
A 40-year-old woman is referred for a Pap smear showing high-grade squamous intraepithelial lesions (HSIL). Which of the following statements is most accurate? A. If HPV subtyping reveals no high-risk virus present, then routine cytology is recommended. B. If colposcopy demonstrates the entire transformation zone, then no further analysis is needed. C. If an endocervical curetting shows cervical dysplasia, then an excisional procedure of the cervix is appropriate. D. Cervical cancer is highly unlikely due to the Pap smear revealing only HSIL.
C
A 40-year-old woman undergoes a screening mammogram, which reveals a lesion of the right breast, showing an ill-defined mass with a cluster of calcifications. She recalls slipping and bruising her right breast from impact against a doorknob, which led to a bruise, approximately 1 year previously. Which of the following is the most likely diagnosis? A. Ductal carcinoma-in-situ B. Infiltrating intraductal carcinoma C. Fat necrosis D. Lobular carcinoma
C
A 51-year-old woman presents with oligomenorrhea and hot flushes. A. Gonadotropin receptor insensitivity B. Pituitary dysfunction C. Ovarian insufficiency D. Estrogen excess
C
A 52-year-old woman presents to her family health care provider with a palpable breast mass. Menarche occurred at age 10, and she had her first child at age 24. She takes low-dose oral contraceptive pills and calcium supplements daily. Her mother was diagnosed with breast cancer at age 45. She has never smoked tobacco and drinks alcohol socially. An attempt at FNA does not result in aspiration of fluid. Her mammogram is normal. Which of the following is the appropriate next step in evaluation of this patient? A. Repeat clinical examination in 4 to 6 weeks B. Repeat mammogram routinely in 1 year C. Refer for core-needle biopsy D. Discontinue her hormonal contraceptive medication
C
A 57-year-old postmenopausal woman with hypertension, diabetes, and a history of polycystic ovarian syndrome complains of vaginal bleeding for 2 weeks. The endometrial sampling shows a few fragments of atrophic endometrium. Estrogen replacement therapy is begun. The patient continues to have several episodes of vaginal bleeding 3 months later. Which of the following is the best next step? A. Continued observation and reassurance B. Unopposed estrogen replacement therapy C. Hysteroscopic examination with thorough biopsy of the endometrium D. Endometrial ablation E. Serum cancer antigen 125 (CA-125) testing
C
A 60-year-old woman presents to her provider's office with postmenopausal bleeding. She undergoes endometrial sampling and is diagnosed with endometrial adenocarcinoma. Which of the following is the most significant risk factor for type 1 endometrial cancer? A. Multiparity B. Herpes simplex infection C. Diabetes mellitus D. Oral contraceptive use E. Smoking
C
A NEGATIVE fetal fibronectin is associated with: A. Fetal lung immaturity B. Ruptured fetal membranes C. A decreased risk of preterm birth D. An increased risk of preterm birth
C
A pregnant woman has the following laboratory test results: a modest increase in AST and ALT; >0.3 g/L protein in a 24-hour urine specimen; and >1.0 g/L protein in a random urine specimen. She is also markedly hypertensive. Which one of the following abnormal pregnancy conditions does she likely have? A. HELLP syndrome B. Gestational trophoblast disease C. Preeclampsia D. Fatty liver of pregnancy
C
CO is a 30-year-old patient diagnosed with PMDD after charting symptoms for two cycles and attempting nonpharmacologic interventions for her symptoms without much relief. This patient is married and does not wish to use any form of birth control. Which of the following agents would be most appropriate for managing CO's PMDD? A. Continuous treatment with paroxetine B. Luteal phase treatment with fluoxetine C. Luteal phase treatment with sertraline D. 90-µg levonorgestrel and 20-µg ethinyl estradiol dosed continuously for 12 months
C
Fibrocystic condition of the breast is: A. Communicable disease B. Common in postmenopausal women C. Caused at least in part by estrogen stimulation of breast tissue D. Carries a threefold increased risk of breast cancer E. Does not actually include any cysts on histology
C
Implantation of the blastocyst into the endometrium usually occurs on which days after fertilization? A. 2-3 days B. 4-5 days C. 6-7 days D. 8-9 days
C
On postpartum day 1, a 28-year-old G1P1 woman reports a headache and problems with her vision bilaterally. Her blood pressure is 150/95 mm Hg and protein-to-creatinine ratio is 0.5. Her neurologic examination is normal, but her vision is "blurry" in both eyes, and this is a new symptom. Which of the following is the best next step? A. Antihypertensive agent B. Intravenous (IV) mannitol C. Magnetic resonance imaging (MRI) of the brain D. Computed tomography (CT) of the brain E. Ophthalmic eye drops to both eyes
C
Regarding routine testing in normal pregnancy, which one of the following pairs is an incorrect match? A. First trimester screen (free β-hCG, PAPP-A)/Assessment for Down syndrome B. Glucose/Assessment for gestational diabetes mellitus C. Treponemal antibody test/Assessment for group B Streptococcus to prevent transmission to fetus during delivery D. Second trimester "quad" screen (hCG, AFP, estriol, inhibin A)/Assessment for Down syndrome, neural tube defects, and other fetal anomalies
C
You are seeing a 31-year-old G2P1 at 41 weeks of gestation by definite last menstrual period and 16-week ultrasound. She continues to note fetal movement and her examination is normal: BP 120/68 mm Hg, urine dipstick negative for protein and glucose, fundal height 42 cm, fetus is vertex, FHR 156 bpm. Her cervix is soft, anterior, 2 to 3 cm dilated, 50% effaced, and +1 station. She was induced with her first pregnancy, and this time she wants to have a "natural labor." You decide to calculate a Bishop score of 9-10 (favorable). Which of the following is the most appropriate recommendations at this point? A. She should be induced at once; there is a high chance of fetal mortality after 41 weeks of gestation B. Since her antepartum course has been uncomplicated to date, it is safe for her to await spontaneous labor until 43 weeks of gestation C. She should undergo a nonstress test and ultrasound for amniotic fluid index D. She should plan for a cesarean section
C
You are taking obstetric calls for your group over Labor Day (Get it? Bad joke?) weekend. Labor and delivery calls you about a 27-year-old G1P0 at 38 weeks of gestation who awoke this morning complaining of wetness. However, when she went to the bathroom, she discovered significant vaginal bleeding that had soaked her bed. She denies any cramping or abdominal pain. She is on her way to the hospital—and so are you. You tell the nurses to call you with her vital signs and to initiate all of the following interventions immediately upon the patient's arrival EXCEPT: A. Obtain IV access B. Draw blood for type and screen C. Perform a digital vaginal examination D. Initiate fetal monitoring E. Draw blood for complete blood count
C
A 22-year-old woman is diagnosed with a septic abortion after an incomplete abortion, fever, and uterine tenderness. She is treated with triple intravenous (IV) antibiotics and dilation and curettage (D&C) of the uterus. After 48 hours of antibiotic therapy, she still has a fever of 102 °F (38.8 °C), blood pressure of 80/40 mm Hg, and heart rate of 105 beats per minute. A computed tomography (CT) scan of the abdomen and pelvis is performed, revealing pockets of air within the muscle of the uterus. Which of the following is the best treatment for this patient? A. Add extended anaerobic coverage to the antibiotic regimen B. Add IV heparin to the regimen C. Continue the present antibiotic therapy D. Counsel the patient regarding the need for a hysterectomy
D
A 23-year-old woman who is in the 24th week of gestation presents to the emergency department complaining of dizziness, headache, and swelling of hands and feet. Upon physical examination, she was found to have proteinuria and blood pressure of 168/98 mm Hg. This lady is likely suffering from A. anxiety. B. preterm labor. C. spontaneous abortion or miscarriage. D. preeclampsia
D
A 25-year-old G1P0 woman at 28 weeks' gestation is diagnosed with severe preeclampsia based on a blood pressure of 160/100 mm Hg and a platelet count of 98,000/mm3. The patient is treated with hydralazine for the hypertension. Which of the following is the most appropriate reason for delivery? A. Blood pressures persist in the range of 150/95 mm Hg B. Urine protein increases to 5 g over 24 hours C. The patient reaches 32 weeks' gestation D. Patient develops pulmonary edema E. Repeat platelet count is 95,000/mm3
D
A 25-year-old woman is slightly obese, slightly hirsute, and has a long history of irregular menses. A. Gonadotropin receptor insensitivity B. Pituitary dysfunction C. Ovarian insufficiency D. Estrogen excess
D
A 26-year-old G2P1 woman at 7 weeks' gestation was seen 1 week ago with crampy lower abdominal pain and vaginal spotting. Her hCG level was 1000 mIU/mL at that time. Today, the woman does not have abdominal pain or passage of tissue per vagina. Her repeat hCG level is 1100 mIU/mL. A transvaginal ultrasound examination today shows no clear pregnancy in the uterus and no adnexal masses. Which of the following can be concluded based on the information presented? A. The woman had a spontaneous abortion and needs a dilation and curettage. B. The woman has an ectopic pregnancy. C. No clear conclusion can be drawn from this information, and the hCG needs to be repeated in 48 hours. D. The woman has a nonviable pregnancy, but its location is unclear
D
A 28-year-old G0P0 woman has a chronic history of oligomenorrhea and amenorrhea. She undergoes an endometrial biopsy in light of her long history of anovulation, which returns as grade 1 adenocarcinoma of the endometrium. Magnetic resonance imaging (MRI) seems to indicate that the endometrial cancer is isolated to the uterus. The patient desires to have children if possible. Which of the following is the best therapy for this patient? A. Endometrial ablation B. Radical hysterectomy C. Cervical conization D. High-dose progestin therapy E. Oral contraceptive agent
D
A 29-year-old woman complains of syncope. She is 6 weeks' pregnant and, on examination, has diffuse significant lower abdominal tenderness. The pelvic examination is difficult to accomplish due to guarding. Her hCG level is 400 mIU/mL, and the transvaginal ultrasound shows no pregnancy in the uterus and no adnexal masses. There is moderate free fluid in the abdomen. Which of the following is the next best step? A. Follow-up hCG level in 48 hours B. Initiation of methotrexate C. Observation in the hospital D. Surgical therapy
D
A 30-year-old woman wants to go back to work 3 weeks after delivery of her daughter. She is able to do this because her mother-in-law lives close by and take care of the baby during the day. The women is planning to nurse the baby at night but not planning to pump her breasts during the day while she is at work. What is the consequence of intermittent nursing of the neonate by the mother? A. An increase in prolactin releasing hormone B. An increase in oxytocin C. Lack of birth control D. Lack of prolactin surge
D
A 31-year-old woman is diagnosed with gestational diabetes based on two abnormal values on a 3-hour, 100-g GTT. She is at 28 weeks' gestation. The patient is concerned about the risks of congenital anomalies after reading about the adverse effects of diabetes on the Internet. Which of the following is the best response to this patient? A. Your risk of fetal congenital anomalies is essentially the same as that of the general population. B. We can draw an HbA1C test today, and your risk of fetal anomalies depends on the HbA1C result. C. Tight glucose control from this point onward and during labor and delivery will determine the risk of congenital anomalies. D. The majority of patients with gestational diabetes have normal glucose levels at conception and no increased risk of fetal anomalies.
D
A 32-year-old woman enters your OB clinic after taking an over-the-counter pregnancy test that was positive. Your physical examination suggests that she is pregnant. She has type 1 diabetes. In order to verify your physical findings, you order a blood test for pregnancy that measures which hormone? A. Gonadotropin releasing hormone B. Luteinizing hormone C. Follicular stimulating hormone D. Chorionic gonadotropin
D
A 35-year-old woman takes a home pregnancy test 4 weeks after her last menstrual period and the test is positive. At this time immediately following fertilization and early after implantation into the endometrium, nutrition of the blastocyst is due to what structure? A. Placenta B. Decidua C. Thecal cells D. Corpus luteum
D
A 41-year-old G4P3013 woman presents to your clinic due to a positive pregnancy test. Her last menstrual period was about 5 weeks and 1 day ago. She reports that she does not wish to continue the pregnancy and would like information about pregnancy termination options. She has no medical or surgical history and had three prior vaginal deliveries. While reviewing her social history, she reveals that she is a busy single mother, as she takes care of her three children while working full time, and she would like the process to end the pregnancy to be as quick as possible. On her laboratory results, her hemoglobin is 13.6 g/dL and hematocrit is 38%. She is Rh negative and antibody negative. Which of the following characteristics makes her a poor candidate for a medical abortion? A. Rh-negative, antibody-negative status B. Age C. Multiparity D. Desire for time-efficient treatment E. Gestational age of 36 days
D
A 54-year-old postmenopausal individual is complaining of vaginal dryness, itching, and pain with intercourse. They have not had any other problems associated with menopause and have an intact uterus. Which of the following recommendations is the best treatment option that balances risks and benefits for the management of this patient's symptoms? A. Oral conjugated estrogen + medroxyprogesterone acetate B. Transdermal estradiol + micronized oral progesterone C. Intravaginal estrogen cream + oral progestogen D. Intravaginal estrogen cream
D
A 55-year-old woman has several coarse calcifications found on mammography that are suspicious for breast cancer. She has no family history of breast cancer, and no mass is palpable. Which of the following is the best next step in the management of this patient? A. Fine-needle aspiration B. Magnetic resonance imaging (MRI) of the lesion C. Repeat mammography in 3 months due to absence of a palpable mass D. Core tissue biopsy by stereotactic approach
D
All of the following are true about cervical cancer, except: A. Most cases are related to high-risk human papillomavirus types. B. About 75% are squamous type. C. Screening for premalignant lesions is effective because of slow progression through dysplastic precursors. D. Carcinoma occurs most frequently in women between the ages of 20 and 30 years. E. Vaccination is targeted to both protect individuals and limit prevalence of infection.
D
Axillary lymph node metastases from breast cancer: A. Are not important for predicting patient survival in women with breast cancer B. Are generally palpable if present C. Can be reliably detected by sestamibi scintigraphy D. Can be reliably detected by sentinel lymph node biopsy in women with clinically uninvolved axillary lymph nodes E. Are frequently present in residual lymph nodes when sentinel lymph node biopsy shows no evidence of disease
D
R.P. is a 21-year-old, unmarried, college student with severe endometriosis pain that has been unresponsive to 6 months treatment with depot medroxyprogesterone. Their past medical history includes asthma, migraine with aura, and anxiety and medications include citalopram 10 mg by mouth daily, fluticasone/salmeterol 100/50 one puff twice a day, albuterol HFA two puffs every 6 hours as needed, and sumatriptan 50 mg by mouth as needed. Which of the following treatment recommendations would be the best option for R.P. to switch to based on the information given? A. Place an LNG-IUS B. Start a low-dose combined oral contraceptive pill C. Start letrozole and oral medroxyprogesterone acetate D. Start leuprolide, estradiol, and norethindrone acetate
D
Risk factors for breast cancer include: A. Early childbearing B. Iodine deficiency C. BRCA1 mutation only in families of Ashkenazi Jewish descent D. A personal history of breast cancer E. None of the above
D
The differential diagnosis of a vulvar lesion includes all of the following, except: A. Bartholin abscess B. Melanoma C. Hidradenitis suppurativa D. Luteal cyst E. Epithelial inclusion cyst
D
The differential diagnosis of adnexal masses includes: A. Endometrioma B. Appendiceal mass C. Pedunculated uterine leiomyoma D. A, B, and C E. A and C only
D
What additional screening test(s) is/are obtained near 36 weeks of gestation? A. Amniocentesis B. 3-hour glucose tolerance test C. Fetal fibronectin (FFN) D. Group B streptococcus (GBS) culture or PCR E. All of the above
D
What important lactation hormone enhances contraception and inhibits ovulation? A. Estrogen B. Oxytocin C. Progesterone D. Prolactin
D
Which one of the following is not a characteristic of an ectopic pregnancy? A. A transvaginal ultrasound examination consistent with an ectopic pregnancy B. A slow increase in the concentration of hCG in the mother C. An adnexal mass D. Decreased platelets with an elevated LDH, ALT, and AST
D
Your 24yo patient who is coming in to start contraception reports that she has headaches every 1 to 2 months. She has never been evaluated for migraines, but reports that her headaches are bilateral, posterior, throbbing, and relieved with sleep and over-the-counter medication. She denies associated aura, nausea, or focal neurologic changes. How would you counsel her regarding OCPs and headaches? A. Headaches are an uncommon reason for discontinuation of OCPs B. She should not use OCPs because they are contraindicated in anyone with headaches C. She should use progestin-only pills D. She can use OCPs, as it is hard to predict whether her headaches will be affected
D
Your patient is currently in labor (success!), and now her cervical examination is 6 cm dilation, 1 cm effaced, and −1 station. The amniotic fluid is still clear, having ruptured approximately 22 hours ago. She has had an epidural placed for analgesia. The FHR baseline has increased to 165 beats per minute with minimal variability. Contractions occur every 3 minutes. Maternal temperature is now 38.6°C, and her pulse is 110 bpm. The patient denies any complaints. Given the history of prolonged rupture of membranes and fever, which of the following is the most likely diagnosis? A. Normal labor B. Epidural fever C. Nosocomial infection D. Chorioamnionitis
D
A 34-year-old G1P0 woman at 16 weeks' gestation comes in for her first prenatal visit. Her hepatitis B surface antigen is positive. Which of the following is the best next step? A. Advise to terminate pregnancy B. Start multidrug antiviral therapy C. Administer hepatitis B immune globulin D. Perform an ultrasound of the liver E. Obtain liver function tests, viral load, and further hepatitis serology
E
A 45-year-old G2P2 woman is being seen in the emergency department for profuse vaginal bleeding that has lasted for 12 hours. The patient states that she has soaked five large towels with blood and clots. Her menstrual history includes menarche at age 11, as well as irregular and unpredictable menses for her entire life. She also has diabetes but has not been consistent in taking her medication. Two years ago, she said she had a "light stroke" with no problems since. She has been told that her cholesterol level is high. On examination, her blood pressure is 60/40 mm Hg, heart rate is 130 beats per minute, and respiratory rate is 20 breaths per minute. The oxygen saturation is 98% on room air, and finger stick blood sugar is 180 mg/dL. The patient appears moderately obese and pale. Her heart, lung, and abdominal exams are normal. On pelvic examination, her uterus appears to be normal size. The speculum exam shows a large amount of bright red blood flowing from the cervix. Which of the following is the best next step in the management of this patient? A. Emergency uterine dilation and curettage B. Insulin therapy C. Intravenous estrogen D. Pregnancy test E. Transfuse with O-negative blood
E
