PAeasy - Reproductive

A 25-year-old woman and her husband have been using condoms and spermicidal foam for the 8 months since the birth of their baby. She plans to wean the baby from the breast sometime between a year and 18 months of age, but would like to begin a "less messy" method of contraception. Prior to her pregnancy she took combination oral contraceptives for several years without any difficulties. Which of the following is an appropriate recommendation for this woman?

"Progestin-only pills are recommended for women who are breast feeding."

A women presents to the labor department complaining of contraction every 3 to 4 minutes for the last 3 hours. She is a G1P0 at 40 weeks gestation. Her pregnancy is uncomplicated; her group B strep culture is negative. Physical exam vitals are normal, the baby is cephalic in a +2 station, and the bag of water is intact. The fetal heart monitor reveals fetal heart tones in the 140s with contractions every 3 minutes lasting 45 seconds. Her cervix is 4-cm dilated and 50% effaced. What is the expected rate of cervical dilation?

1.2 cm per hour This patient is in stage one active labor and is a primigravida. She should expect 1.2 cm of dilatation per hour; multigravida women can expect a faster rate of dilatation

A 25-year-old woman brings in her menstrual calendar as part of a preconceptional counseling visit. Her cycles are regular, occurring every 30 days and lasting 3-4 days. She has mild cramping on days 1 and 2 that is easily relieved by ibuprofen or acetaminophen. On what day of her cycle is she most likely ovulating?

16

A women is being evaluated at her 36-week obstetrical appointment. She is not obese, her bladder is empty, and she does not have any complications. The fetus is in a cephalic position by Leopold maneuver. You measure her fundal height. What should it measure?

34 to 38 cm Fundal height in an uncomplicated, normal weight pregnancy should be within 1 to 2 cm per week of gestation in pregnancies above 20 weeks.

You are caring for a 29-year-old G1P0 at who is pregnant with twins. She has received routine obstetrical care and her pregnancy has been uneventful to date. What is the average gestation age for twins at delivery?

36 to 37 The average length of gestation for a single fetus is 40 weeks; the average age of gestation decreases with increasing number of fetuses.

A 22-year-old female presents to her obstetrical appointment at 39 weeks gestation. Her pregnancy to date has been uncomplicated. She is concerned that her infant may be larger than average, as her fundal height measures 41. On physical exam, her fetus is in a cephalic presentation, her cervix is soft and 1-cm dilated, and the fetus is at a -3 station. Her membranes are intact, she is not contracting, and her vitals are normal. She requests to be induced. For decreased risk of complication and optimal fetal outcome, when should she expect to be induced?

41.5 weeks In the absence of complication, the recommendation from ACOG is to wait for labor to occur. Large for gestational age is not an indication for induction in the absence of diabetes. Gestations greater than 42 weeks increase risk of fetal stillbirth.

In taking the family history of your 25-year-old male patient, you discover that he has numerous relatives with breast and ovarian cancers. In the past, his mother received genetic counseling and testing for the BRCA1 and BRCA2 gene mutations and was found to be positive for a mutant allele. What is his risk for developing this genetic cancer?

50%

You are caring for a pregnant woman who is Rh-negative. The father of the child is Rh-positive and heterozygous. What percent chance will the fetus have of being Rh-positive?

50%

A G4P4 woman delivers a viable infant at 38 weeks gestation by normal spontaneous vaginal delivery. The infant has apgars of 7 and 8 (at 1 and 5 minutes respectively). What is the most crucial time for maternal and fetal physiologic changes to occur?

60 minutes after birth The hour after birth is the most critical time for physiologic changes to occur, including maternal fluid shifts, hemorrhage, retained placenta, and fetal lung cardiovascular transitions.

A 19-year-old presents to clinic requesting emergency contraception. She is a G1P0Ab1 and a non smoker who has had intercourse and the condom broke. Her LMP was 3 weeks ago. Her PMH is negative. What would be the time frame for maximum efficacy for her to use emergency contraception?

72 hours

A 29-year-old G2 P1 who is term requests induction. Her pregnancy has been uncomplicated. She has been bothered by significant, poor quality contractions, which have caused her pain and interfered with her sleep. An elective induction is considered safe when the Bishops score is greater than what number?

8 A Bishop score greater than 9 is considered a positive predictor for safe delivery in a term pregnancy.

A 53-year-old woman presents to clinic complaining of amenorrhea, irritability, and hot flashes for 6 months. She would like to try hormone replacement therapy. You are counseling her about possible risks versus benefits. Which of the following is a benefit of combined estrogen progestin therapy?

A decrease in somatic symptoms

During her active phase of labor, a provider has placed an external fetal monitor on a patient. The fetal heart rate (FHR) is noted to have a base line rate of 109, there are no late or variable decelerations, and the baseline variability is 0 beats per minute. What is this monitor tracing indicative of?

A distress FHR pattern the definition of fetal distress includes absence of baseline variability, and either bradycardia (FHR<110) or recurrent variable or late decelerations.

A 29-year-old G3P2 presents to the office for her obstetrical visit. She is currently 16 weeks gestation by ultrasound. Her pregnancy has had no complications to date. She is a non-smoker and takes her prenatal vitamin. What routine obstetric lab should be offered at this visit?

Alpha fetal protein screen AFP testing is only available between 15 and 20 weeks gestation.

A 28-year-old G1P0 at 37.5 weeks gestation complains of a thin, watery discharge for the last 5 hours. She has soaked 3 pads. She has no pain and the fetus continues to be active. An external fetal monitor reveals heart tones in the 140s, with variability and no contractions. The pH of the vaginal fluids is 8. What does this indicate?

Amniotic fluid

A 37-year-old female presents to the labor and delivery department complaining of intermittent pain and contractions. Upon arrival, she also complains of vaginal bleeding. She is a G3P2 at 39 weeks gestation; no other prenatal complications are noted. She is a non-smoker. A physical exam reveals the following: P 90, BP 130/80, T 98.7°F, abdomen gravid, positive bowel sounds, and left lower quadrant tenderness noted. A sterile speculum exam reveals the cervix to be dilated 8, fetus is cephalic, and membranes are intact. The fetal monitor reveals heart tones in the 140s with mild, decreased variability and good quality contractions noted. Delivery is felt to be imminent, and vaginal delivery has been determined to be the best course of action. What will likely decrease bleeding and shorten time to delivery?

Amniotomy If the fetus is mature and vaginal delivery (versus c-section) has been determined to be the best course of action, then amniotomy may diminished amnionic fluid volume. This might also allow for better spiral artery compression, and serve to both decrease bleeding from the implantation site and reduce entry of thromboplastin into the maternal circulation.

A 47-year-old female presents to the office complaining of excessive menstrual flow for the past two months. She complains of mid-cycle bleeding, as well as periods that last for nine days. What is the mostly likely cause of her bleeding?

Anovulatory uterine bleeding While all are causes for abnormal bleeding, anovulotory bleeding occurs in perimenopausal women due to the unopposed estrogen.

You are monitoring a 30-year-old G2P1 at 40 weeks gestation, who is in an active stage of labor and is 6-cm dilated. The fetal heart tracing has a baseline heart rate of 140, with 7 to 10 beats of variability. With the last five contractions you have noted late decelerations. What would be the next most appropriate course of action?

Assessment of dilatation The presence of recurrent late decelerations should raise the suspicion for fetal distress. Vaginal evaluation for change in dilatation or cord prolapse, and to assess the fetal response to stimulation, are the first steps in evaluating the need for intervention.

A 27-year-old female presents to the office complaining of a lump on one side of her vagina. It has been present for several weeks, and causes only slight discomfort with intercourse. She has no new sexual partners and no other vaginal or systemic symptoms. On physical exam you note a 1.5-cm area of swelling in the left posterior labia majora. It is firm, well circumscribed, and minimally tender, and no changes are noted in the skin. No vaginal discharge or other lesions are noted. What is the most likely diagnosis?

Bartholin gland duct cyst

You are caring for a 33-year-old G3P2 women. Her PMH is significant for obesity and allergies. She receives routine obstetrical care. When is she due for her glucose challenge testing to rule out gestational diabetes?

Between 24 and 28 weeks gestation

You are taking care of a 32-year-old G2P1 at 39 weeks gestation in active labor. Her pregnancy is complicated by gestation diabetes. The fetal head delivered, but the anterior shoulder did not deliver with gentle downward traction. What would be the next most appropriate action?

Call for assistance and McRoberts maneuver Shoulder dystocia is an obstetrical emergency, and help should always be summoned. The McRoberts maneuver increased the AP diameter, thus accommodating a large head; subrapubic pressure can help dislodge the anterior shoulder, but simple fundal pressure continues to impact it against the pelvic bone.

You are caring for a 29-year-old G3P2 at 39 weeks gestation, who has been laboring for 6 hours. She is a diet-controlled diabetic. Her last child was 9 pounds 8 ounces. She has been completely dilated for 2 hours, and the fetal head is at a plus 2 station, which is unchanged. What is the next most appropriate course of action?

Cesarean section The patient is a diabetic with a history of a macrosomic infant; the likelihood of macrosomia in this infant is significant. Instrument delivery is not recommended if macrosomia is suspected. By definition, she has had an arrest of descent of the fetal head and one should be highly suspicious for macrosomia, in which case a c-section is the preferred method of delivery.

A 40-year-old female is status post a dilatation and curettage for hydatidiform mole. On week 3 post surgery, her follow-up quantitative hCG level has elevated slightly. What is the most likely diagnosis?

Choriocarcinoma 5% of hydatidiform mole progress to choriocarcinoma; the longer the mole in intrauterine the higher the risk.

A 24-year-old female, with a history of type 2 diabetes, presents with the inability to conceive after 14 months of unprotected sexual intercourse with her husband. Her vital signs are unremarkable and you calculate a BMI of 31. Physical examination reveals acne vulgaris and hirsutism. Which of the following treatment options for her infertility would be the most effective considering your suspected diagnosis?

Clomiphene citrate

A 29-year-old woman comes in for evaluation of an increased vaginal discharge for the past week. She describes it as "sort of whitish gray with a disgusting odor." She has no other symptoms. She has had no new sexual partners, has taken no antibiotics, and has not used any new hygiene products. Examination reveals no vulvar erythema. She does have an adherent whitish discharge in the vaginal vault, but no vaginal erythema. Whiff test of the secretions is positive. Microscopic examination of saline and potassium hydroxide preparations is most likely to reveal which of the following?

Clue cells Bish has BV

A 24-year-old female, with a history of type 2 diabetes, presents with the inability to conceive after 14 months of unprotected sexual intercourse with her husband. Vital signs are as follows: Temperature 37˚ C, BP 115/85, P 65, RR 20. Her BMI is 31. Which physical examination finding would you expect to observe with your suspected diagnosis?

Coarse dark hair on the face, chest, and back Polycystic ovarian syndrome (PCOS) affects 5-10% of reproductive age women. It is associated with hirsutism (50% of cases) (D), obesity (80% of cases), and virilization (20%), and those affected have an increased risk of diabetes mellitus, cardiovascular disease, and metabolic syndrome. PCOS patients are often infertile. A palpable ovary may be noted on thin individuals with enlarged ovaries, not the uterus

A 23-year-old complains of chronic pelvic pain. It is worse with intercourse, several days before her period, and throughout her period. She is a GOPO, LMP two weeks ago. She is married and has had one partner for the last three years. Her symptoms have been increasing over the last year. What would the most appropriate initial management of her symptoms include?

Combined oral contraceptives Endometriosis treatment is aimed at reducing pain and preserving fertility.

A 35-year-old female presents to discuss non-permanent methods of birth control. She is a G3P2, PMH negative. She is a smoker. Which method of contraception would have the lowest risk profile for her?

Copper intrauterine device A women who is over 35 and smokes is at high risk for cardiovascular complications. All choices except the copper IUD contain hormones, which may increase the risk of complications. The copper IUD is long term but non-permanent.

A 27-year-old female is 8 weeks postpartum with her first child and has been exclusively nursing since discharge at the hospital. She has a 5-day history of engorgement in her right breast, which is red, tender, and feels warm to the touch. She states she is feverish but has not taken her temperature. She reports no known drug allergies. On physical examination you see the breast as shown below. Which of the following is the most appropriate therapy in the management of this patient?

Dicloxacillin 500 mg orally every 6 hours for 10 days; continue breastfeeding staphylococcus aureus is usually the causing agent in puerperal mastitis. Treatment includes antibiotics that are effective against penicillin-resistant staphylococci and nursing of the infant with the affected breast is safe.

A 30-year-old G 2 P 1 woman comes to the emergency department at 37 weeks gestation with a chief complaint of worsening abdominal pain for the past two hours. On examination, the uterus is tense and tender. External fetal monitoring indicates frequent uterine contractions with late decelerations. An ultrasound suggests a retroplacental hemorrhage. What is the most appropriate course of action at this time?

Emergency operative delivery

A 49-year-old woman has had irregular menses for more than two years. Most of the time she requires only 1-2 mini-pads per day to handle the flow, but recently she soaked through a dozen maxi-pads in a day. On physical examination, she appears well and her pelvic exam in unremarkable. Her serum progesterone is low and her hematocrit is 39%. A transvaginal ultrasound reveals an endometrial stripe of 11 mm. Which of the following is the most appropriate next step in her management?

Endometrial biopsy This woman's excessive bleeding and endometrial stripe > 5 mm raises the suspicion for endometrial hyperplasia or cancer. The next step is an endometrial biopsy, which can be performed without anesthesia in the outpatient setting.

A 51-year-old female presents to the office complaining of intermittent vaginal spotting for three months. She has a history of well-controlled hypertension. She is a nonsmoker. Her LMP was two years ago. Her family history is significant for colon cancer. Physical exam and pelvic exam were performed and unremarkable. What is the best diagnostic step in evaluating her vaginal bleeding?

Endometrial sampling in postmenopausal women with a family history of colon cancer, there is a 30% risk of endometrial cancer. sampling required to r/o cancer

For the past year, a 30-year-old woman and her husband have been trying unsuccessfully to become pregnant. Over-the-counter ovulation tests have indicated that she is ovulating. Neither partner smokes cigarettes, uses any mind-altering drugs, or has a history of sexually transmitted infection. She has no history of abdominal surgery or pelvic procedures, diethylstilbestrol (DES) exposure, or major illness. On examination, she is 66" tall, weighs 135#, and appears healthy. Her thyroid is nonpalpable, and pelvic examination is unremarkable. What is the most appropriate next step in evaluation of this couple's infertility?

Examination of the husband

You are providing care to a woman who is at 33 weeks gestation. Her pregnancy is complicated by gestational diabetes. She is being provided education by the dietician, and has weekly obstetrical appointments. What fasting blood sugar (FBS) readings should necessitate switching from diet control to insulin therapy?

FBS > 95 mg/dL Gestational diabetes has different risks associated with it, in particular for the fetus. Stricter glycemic controls are recommended for pregnant versus non pregnant women by the ACOG and the ADA.

A 26-year-old female presents to the clinic for evaluation of her inability to conceive for 12 months. She menstruates monthly. Her past medical history is significant for PID x 2 and mild asthma. Her GC, Chlamydia, and pap smear are negative. Her TSH is 3.0 and her UCG today is negative. What is the most likely cause for her inability to conceive?

Fallopian tube scarring

A 19-year-old G1P0 presents for her routine obstetric exam. She is at 34 weeks gestation. When completing the physical assessment you perform a Leopold maneuver. What does this maneuver assess?

Fetal lie and position

22-year-old female present complaining of a lump in her left breast. She noticed it two days ago while taking a shower. She is a non-smoker and has three to four drinks per week. PMH is negative and FMH is negative. On physical exam, vitals are normal, and a breast exam reveals a 1-cm discrete, soft, and rubbery lesion in the upper outer quadrant—it is non-tender, and the remainder of the breast exam is normal. What is the most likely diagnosis?

Fibroadenoma The most common mass in premenopausal women by far is a fibroadenoma. While any lesion needs to be followed, soft, mobile, non-tender, and small lesions in young women without family history are very characteristic of fibroadenoma.

A 26-year-old female presents to clinic complaining of increasing headaches for one year, irritability, bloating and fluid retention, and abdominal discomfort with loose stools during her menstrual cycle. The symptoms begin a day or two before her menses, and last until the middle of her cycle. She has tried acetaminophen and ibuprofen without improvement. On physical exam she is a well-developed, well-nourished female in no acute distress. Vitals are normal, CV and lungs are normal, pelvis exam is normal, pap smear is normal, and GC and Chlamydia testing are negative. What would be the most appropriate next step?

Fluoxetine on cycle day 21-7 Hx and Px are key to diagnosing premenstrual syndrome. Laboratory and radiologic procedures are not useful, particularly in light of a normal exam. With failure of NSAIDS, treatment is aimed at reducing symptoms. For mild to moderate symptoms, SSRI therapy prior to and through the menstrual cycle has become a primary therapy.

A 24-year-old G1P1 presents to the office complaining of a red, tender area of her right breast. She is four weeks postpartum and is nursing her infant with good success. She complains of no other symptoms. On physical exam, her vitals are normal. Lungs CTA, CV RRR, left breast is normal, right breast has a 3-cm area that is warm with erythema, and no mass or area of fluctuance is noted. She has a MRSA mastitis. How did she most likely contract the infection?

From her infant infants usually contract MRSA due to poor hand washing technique from the hospital staff, but it is then spread to the mother via the infant

A 25-year-old female presents for an ultrasound after having a positive home pregnancy test. She has an unremarkable past medical history and physical exam. She states she has been feeling fine without any abdominal discomfort or vaginal bleeding noted. On ultrasound you determine she is 10 weeks pregnant. You note a noncomplex unilateral mass on her left ovary measuring 2 cm in diameter. What is the most likely diagnosis?

Functional ovarian cyst

You are examining the wet prep of a young woman who presented complaining of vaginal discharge. You see 15 to 20 WBCs, 2+ bacteria, and clues cells. The KOH prep is whiff positive. What type of vaginitis does this indicate?

Gardnerella vaginitis

A 37-year-old woman, G3P2 at 30 weeks gestation, complains of lower extremity swelling and her weight is up 5 pounds this week. Her PMH is insignificant, and her other pregnancy was uncomplicated. Her BP baseline is now 142/92. On exam her BP is unchanged, her UA shows 2+ protein, and FHTs are 152. What is the cause of the protein in her urine?

Glomeruloendotheliosis The classic histological change that occurs in the renal system (in preeclampsia) is swelling and inflammation of the endothelium and of the glomeruli, which leads to endothelial leaking.

A 37-year-old female presents to the office complaining of increasing heavy vaginal bleeding with her menses. CBC reveals an iron deficient anemia. Her pelvic exam is notable for a moderately enlarged uterus. A transvaginal ultrasound reveals a 3-cm leiomyoma and a 15-cm leiomyoma. The patient wishes to preserve her fertility. Appropriate management would include which of the following?

Gonadotropin-releasing hormone analog followed by myomectomy GRH causes a reversible hypogonadism, which reduces tumor size, makes surgical intervention safer, and reduces bleeding

Pre-eclampsia triad

HTN, proteinuria, edema most common in first pregnancy and becomes evident in 3rd trimester , after 20th week of pregnancy

A 37-year-old female presents to the clinic for her obstetrical appointment. She is a G5P4 African American female. On physical exam her uterus is larger than expected for dates by 5 cm. What is her risk of having twins increased by?

Her use of clomifine Incidence of multiples is not related to age, parity, or menarche; the increase seen in the last few decades is solely related to the increased use of fertility drugs.

An 18-year-old G1P0 presents for evaluation of her amenorrhea. Her LMP was 2 months ago. Her HCG is positive, and she has been having vaginal spotting x 2 weeks. Her ultrasound reveals an intrauterine heterogeneous echogenic mass, without fetus or placenta. What is the most likely diagnosis?

Hydatidiform mole =A noncancerous tumor that develops in the uterus as a result of a nonviable pregnancy.(molar) The classic signs for a mole are a heterogenous mass without the placenta or fetus, and vaginal spotting is present all of the time

A 30-year-old woman delivers a viable 7 pound 6 ounce female infant by normal spontaneous vaginal delivery. The infant was delivered and held below the introitus. The infant was dried, stimulated, and apgars were assigned. The cord was then clamped and the infant was placed on the maternal abdomen. Which of the following is a complication that can arise from this?

Hyperbilirubinemia In a normal delivery, after the infant is delivered through the introitus it should not be held below it; excessive fluids can be passed to the infant, resulting in increased hematocrit and hemoglobin, which will hemolyze and cause hyperbilirubinemia.

A 26-year-old athlete presents complaining of scant menses x 4 months. She is a G0P0, menarche was at age 13, and her menses have been mostly regular. She is a non-smoker and non-drinker, and has been trying to achieve pregnancy x 8 months. Physical exam reveals a thin, white female in no distress. Vitals are normal, BMI is 17.5, her pelvic exam is normal, and STD cultures are negative. A pregnancy test is negative in clinic. What is the most likely cause for her amenorrhea?

Hypothalamic young healthy woman with a low BMI, no other signs of virilization, and a history of normal menarche is most likely to have induced amenorrhea, due to suppression of the hypothalamic axis from low weight and fat index.

A 20-year-old woman was just told by her new sexual partner that she needed to be checked for a sexually transmitted infection because he has developed dysuria and a profuse urethral discharge. She herself has had a subjective fever for the past two days, some nausea but no vomiting, diffuse lower abdominal pain, and a severe backache. On examination, she has a temperature of 100.5˚F, hypoactive bowel sounds, bilateral lower abdominal quadrant tenderness, a profuse mucopurulent cervical discharge and pronounced cervical motion tenderness. Serum pregnancy testing is negative. She is given an injection of ceftriaxone and a prescription for doxycycline for 14 days and an appointment for follow up the next day. Under which of the following conditions should metronidazole be added to her regimen?

If she has a probable tubo-ovarian abscess

A 24-year-old gravid 3 para 0 ab 2 presents complaining of vaginal pressure every 2 hours, but no pain. She is at 26 weeks gestation. This pregnancy is uncomplicated to date. On physical exam she is in no acute distress and her vitals are normal. She is placed on a fetal monitor and no contractions are noted; fetal heart tones are 138. A sterile speculum exam reveals her cervix to be dilated to 4 cm. What is the most likely diagnosis?

Incompetent cervix While infection is a significant cause of premature labor, it is not a cause of incompetent cervix. Incompetent cervix is most likely found in the presence of recurrent pregnancy loss and painless dilatation.

A 27-year-old woman and her male partner come to the emergency department for assistance with emergency contraception. They experienced condom failure during intercourse an hour ago and neither desires pregnancy. Her last menstrual period was approximately two weeks ago and her cycles occur every 28-30 days. Her medical history includes a deep venous thrombosis during labor and delivery 5 years ago. What is the most appropriate course of action at this time?

Insertion of a copper-containing intrauterine device

A 37-year-old woman who takes no medication and is otherwise healthy has developed a spontaneous "bloody discharge" from her left breast. Examination reveals no tenderness, masses, dimpling, or asymmetry. Gentle pressure at the margin of the areola reveals single duct involvement. This most likely represents which of the following?

Intraductal papilloma unilateral serous or serosanguinous nipple discharge from a single duct is more likely a benign intraductal papilloma

A 19 year old female presents for her first pelvic examination and is noted to have a palpable, non-tender right ovary. She is sexually active, and uses condoms for birth control and protection from STDs. Her LMP was 20 days ago. She underwent transvaginal ultrasound and was found to have a 3-cm follicular cyst. What does this right ovarian mass represent?

Intrafollicular fluids

A 19-year-old G1 P0 presents to the emergency department complaining of abdominal pain. Her LMP was 2 months ago, and she has been spotting for the last two days. Her HCG is positive, and transvaginal ultrasound reveals no intrauterine gestational sac. The patient has an ectopic pregnancy, which has likely implanted in the fallopian tube. Why is the fallopian tube the most common non-uterine implantation site?

Lack of sub-mucosal layer in the fallopian tube he lack of a submucosal layer allows for easy wall access and implantation of the fertilized ovum. The increasing rate of Chlamydia infections in the U.S. also impacts the physical anatomy of the fallopian tube, and impacts where the ovum implants.

A 30-year-old woman comes in for evaluation of infertility. She and her husband have been having unprotected intercourse for the past year. Her menstrual cramps have become increasingly painful, and she has a severe low backache for several days before and during her menses. She complains that intercourse is painful when her husband "goes deep." Physical examination reveals multiple tender nodules of various sizes in the posterior vaginal fornix. Definitive diagnosis is best accomplished using what methodology?

Laparoscopy This woman has a classic presentation for endometriosis. Definitive or final diagnosis can only be made at laparoscopy or laparotomy, allowing direct visualization of the endometrial implants.

A 27-year-old woman complains of years of menstrual irregularity and increasing facial and chest hair. PMH: significant for ovarian cyst and left cytectomy. She is a non-smoker and non-drinker. Labs include a negative uCG, elevated LH, and low FSH. She desires fertility and she has not responded to three cycles of clomiphene. What would be the next choice of medication that may return ovulation?

Metformin PCO has an underlying insulin resistance that can be treated with oral hypoglycemics and improve sensitivity to insulin.

A 24-year-old G2P2 delivered a viable female infant (8 lb 4 oz) via caesarean section, after a failed 20-hour induction for post date pregnancy. On day 2, she developed a postoperative fever of 101F (38.3C). She had slightly increasing abdominal cramping and pain, no change in loci, is voiding well, and has passed flatulence. Her WBC is 19,000. What is the mostly likely cause for her fever?

Metritis (inflammation of the uterus) The patient is passing urine and flatulence well, making choicesUTI and ileus less likely. Fever greater the 38C is the most important indicator of metritis.

A 19-year-old presents complaining of vaginal discharge and itching for 3 days. She is sexually active and uses condoms most of the time. A physical exam reveals the following: vitals are normal, abdomen is soft and non-tender, + bowel sounds, the pelvic exam is notable for moderate discharge with no masses or tenderness. Her wet mount/KOH prep reveals 20 wbcs, 2+ bacteria, no hyphae, 5 to 7 clue cells. What is the most appropriate treatment?

Metronidazole 500 mg BID x 7 days Clues cells with bacteria and white blood cells are indicative of Gardnerella vaginitis, which is best treated with metronidazole.

A 33-year-old returns to clinic for reevaluation of her dysmenorrhea. She is a G3P3 who menstruates every 27 days. She has had a tubal ligation. She is a non-smoker. She has tried Tylenol (acetaminophen) and just completed 3 months of ibuprofen 800 mg TID x 7 days, starting 2 days before her menstrual cycle. She had only mild improvement of her symptoms. What should be the next step in management of her symptoms?

Norgestimate/ethinyl estradiol Primary dysmenorrhea is associated with ovulation, so suppression of ovulation in a woman who no longer desires fertility usually improves symptoms. Narcotics are not indicated as primary treatment in the absence of pathologic disease. Combination oral contraception will suppress ovulation

A 36-year-old presents to the office for evaluation of painful breasts, which is worse before her period. She complains of them feeling fuller and lumpier before onset of her menses. She has tried acetaminophen and ibuprofen with minimal relief. Her symptoms resolve at the end of her menses. What is the most likely cause of the symptoms?

Normal cyclic hormone fluctuation

A 34-year-old woman presents for her obstetrical checkup. She is a G2P1 and her pregnancy is uncomplicated to date. During her visit, what is the most important predictor of fetal well-being?

Normal maternal vitals and fetal activity

A 33-year-old G1P0 presents for evaluation of her inability to conceive a pregnancy for six months. She menstruates monthly. Her past medical history is significant for PID x 2, for which she was hospitalized for IV antibiotics. Her Chlamydia, GC, and pap smear are normal. When should a more comprehensive evaluation for her infertility begin?

Now A comprehensive work up should begin now, due to her advancing age and history of significant PID, which may require surgical treatment.

A woman who is pregnant suffered a spontaneous abortion at 12 weeks gestation. She is now a G2P1Ab1 and is Rh negative. When should she receive her next Rhogam (Rho D immune globulin) shot?

Now Placental implantation occurred and separated with the spontaneous miscarriage. Therefore, there is a slight chance of isoimmunization, so Rhogam should be given now so that the mother does not develop antigens that can cross the placenta during the first half of the next pregnancy.

A 51-year-old female presents to her primary care provider for her annual physical. She is a healthy white female and a non-smoker. She has mild HTN, but an otherwise negative health Hx. In addition, FHx is negative and ROS is negative. Her LMP was 6 months ago. Her last mammogram was 3 years ago. When should she have her next mammogram?

Now The preponderance of data strongly supports the benefits of a screening mammography

A 30-year-old woman and her husband have been trying unsuccessfully to become pregnant for the past year. Over-the-counter ovulation tests have indicated that she is ovulating. As part of her evaluation she undergoes a hysterosalpingogram that reveals tubal scarring. Which of the following is the most likely explanation for this finding?

Past asymptomatic chlamydial infection

A 48-year-old woman presents complaining of vaginal fullness and difficulty passing stool. Upon exam she is found to have a stage 3 rectocele by the Baden Walker System. What is the most common cause for this?

Pelvic floor injury

A 21-year-old female presents to clinic complaining of mild, low abdominal ache and intermittent dysuria. She denies N/V/D, and she is sexually active and uses condoms some of the time. Her LMP was 10 days ago, and she is a G0P0. Physical exam reveals a healthy female in no acute distress. Vitals are as follows: P 70, BP 120/80, T 99.9°F. Lungs are clear, CV RRR, abd soft non-tender, + BS. Pelvic exam reveals normal external genitalia, scant discharge, moderate cervical motion tenderness, and no adnexal masses. What is her most likely diagnosis?

Pelvic inflammatory disease Suspicion for PID should be very high in a young, healthy, and sexually active woman with cervical motion tenderness.

A 54-year-old female presents to clinic complaining of vaginal fullness and leaking of urine for 10 years, which is progressively getting worse. She is a G4P4 and is postmenopausal. Nothing seems to improve her symptoms, and coughing or running makes them worse. On physical exam her vitals are as follows: Ht 5'4", Wt 135 lb, T 98°F, BP 130/72. Her abdomen is soft and non-tender with no masses, and her pelvic exam reveals the anterior wall to be at the level of the hymen. In addition, UA dip is negative. She is on no medication. What would the most appropriate initial management include?

Pessary - used for vag prolapse This is a stage 2 cystocele by the Baden Walker System, with urinary incontinence. It is best treated with conservative measures. If they fail, then surgery should be considered.

A 30-year-old woman presents to the office complaining of an inability to achieve pregnancy after over a year of trying. What is the couple's least likely cause for infertility?

Pituitary disease

A 30-year-old patient presents to labor and delivery complaining of bright red vaginal bleeding. She has no pain. The fetus is still active. She is 37 weeks pregnant. PMH is significant for in vitro fertilization. What is the most likely diagnosis?

Placenta previa bc bleeding is bright red and painless. Labor and abruption are associated with discomfort and pain.

A 37-year-old G3P2 female at 39 weeks gestation presents to the labor and delivery unit complaining of abdominal pain. Laboratory evaluation reveals anemia coagulopathy that is felt to be consumptive. What is the most likely diagnosis to have caused this?

Placental abruption

A 27-year-old G 0 P 0 woman has been trying to become pregnant for the past 10 months. Menarche occurred at age 13 and her cycles have "always been irregular" except during the 10-year period when she took oral contraceptives. Since stopping contraception two years ago, she and her partner of six years have used condoms consistently until they desired pregnancy. Neither partner has a history of sexually transmitted infection, and both have been mutually monogamous. On physical examination she is 64" tall and weighs 189 pounds. She has increased dark hair on her upper lip and chin and on her lower abdomen and says she has had this hair distribution as long as she can remember. Of the following, what is the most likely cause of her apparent infertility?

Polycystic ovarian syndrome

A 23-year-old G1P0 presents to the office complaining of headache, nausea, swelling, and generally not feeling well. She is at 33 weeks gestation. A physical exam reveals a 5-pound weight gain in 2 weeks, BP 148/90, P 84, T 98.1°F, and UA concentrated with 1+ protein. What is the most likely diagnosis?

Preeclampsia triad HTN, wt gain, proteinuria

you are providing care for a 28-year-old who presents to clinic for her 27-week obstetrical check. She has no complaints and the fetus is active. Physical exam reveals the following: P 88, BP 142/90, FHT 148, UA negative. CBC is normal. Her BP pre-partum was 110/70. What is the most likely diagnosis at this point?

Pregnancy induced hypertension

A 17-year-old female presents to the emergency department complaining of watery vaginal discharge for 6 hours. She is found to be at 35 weeks gestation. An external fetal monitor reveals fetal heart tones in the 130s, good variability, and no contractions. What is the most likely diagnosis?

Preterm and premature rupture of membranes Preterm rupture of membranes is defined as rupture before 37 weeks gestation; premature is defined as before the onset of labor. The absence of pain or contractions decreases the likelihood of labor.

A 23-year-old woman presents to clinic complaining of amenorrhea for 3 months. She also complains of increasing facial hair and weight gain. On exam, PMH: menarche age 13. Physical exam reveals a well-developed, slightly obese female with a BMI of 29. Her amenorrhea can likely be improved with which therapy?

Progesterone administration Progesterone administration slows GnRH pulses, thereby improving FSH secretion and follicular maturation.

A woman brings her 13-year-old daughter to clinic, concerned about the fact that she has not yet had her first menstrual cycle. The patient is PMH negative, Social Hx negative, FMH: mothers' age of menarche was 13. Physical exam reveals the child to be a well-developed, well-nourished female, height and weight at the 50% for age and gender. Thelarche is present and has sparse pubic hair. The remainder of her physical exam is normal for age. The most appropriate course of action is?

Reevaluation in 6 months

A 54 year-old female returns for pathology results after being diagnosed with ovarian cancer. Which of the following is the most likely cause of ovarian epithelial malignancy?

Serous tumors The most common of the ovarian epithelial malignancies are serous tumors (50%)

A 25-year-old female presents for an ultrasound after having a positive home pregnancy test. She has an unremarkable past medical history and physical exam. She states she has been feeling fine without any abdominal discomfort or vaginal bleeding noted. On ultrasound you determine she is 10 weeks pregnant. You note a noncomplex unilateral mass on her left ovary measuring 2 cm in diameter. Which additional history would support your suspected diagnosis?

She used clomiphene to conceive Pts who used assisted reproduction, such as clomiphene, present a special subgroup as their ovaries frequently have ovarian cysts. This is common during the first trimester due to ovarian hyperstimulation.

A 24-year-old delivers twins by cesarean section. The twins are monozygotic. The placenta was fused. What does this implies?

Single ovum and double chorion Identical twins indicate single ovum. If the placenta is fused or double it means there are two chorions, and that the trophoblast differentiation occurred before day 3.

27-year-old female is 8 weeks postpartum with her first child and has been exclusively nursing since discharge at the hospital. She has a 5-day history of engorgement in her right breast, which is red, tender, and feels warm to the touch. She states she is feverish but has not taken her temperature. On physical examination you see the breast as shown below. What is the usual causative agent of your suspected diagnosis?

Staph aureus causing agent in puerperal mastitis

At her routine annual pelvic exam, a 39-year-old female presents to the clinic complaining of pelvic pressure and bloating for several months. She is a G3P2 who delivered vaginally. She is a nonsmoker. Her maternal aunt had a history of ovarian cancer. Her pelvic exam reveals an 8-cm ovarian mass in the right adnexal area. What is the most appropriate evaluation of the ovarian mass?

Surgical evaluation The patient is high risk, as she is premenopausal, has a family history of cancer, and the mass is large. Therefore, surgical evaluation should be undertaken. CA 125 can be negative in early disease, and pelvic US and CT are not sensitive enough. Repeat examination should be reserved for low risk women with smaller ovarian masses.

A 17-year-old female presents to your office with intermittent menstrual pain. She is sexually active with a single male partner, consistently utilizing condoms. She reports that she has had this pain before, most commonly two weeks before her period, and that it has been increasing in severity over the past few months. You perform a pelvic examination and she has no lesions, discharge, or discomfort on bimanual and speculum exam. She is urinary chorionic gonadotropin (UCG) negative. Of the following, what is the most appropriate treatment for this adolescent?

Tell her she has mittelschmerz and prescribe an anti-inflammatory p.r.n. Midcycle pain (mittelschmerz) is common in women with regular menstrual periods who are not taking birth control pills.

A patient presents to the office at 5 weeks gestation. She has been spotting for several days, and the flow is increasing slightly. She has mild, crampy pain; no fetal heart tones are auscultated. Ultrasound reveals an intrauterine gestational sac with a fetal pole. What is the most likely diagnosis?

Threatened abortion While she is at risk for a spontaneous abortion, one cannot determine fetal viability with one exam. Serial exams are necessary. Fetal heart tones are not always present at 5 weeks.

29-year-old woman comes to the emergency department with abrupt onset of left lower quadrant pain approximately 1.5 hours ago after she and her roommate moved multiple heavy pieces of furniture into their new apartment. The pain is now excruciating and she rates it "100 out of 10." She vomits on admission to the department. She is not currently sexually active and has no other significant past medical history. On exam she is found to have fullness and extreme tenderness in the left adnexa. Of the following, what is the most likely diagnosis?

Torsion of the left ovary Ovarian torsion is often extremely painful and is often accompanied by vomiting, with sudden onset and may be associated with episodes of heavy exertion.

An 18-year-old woman comes in for evaluation of a bad smelling vaginal discharge. She says that it is so heavy that she must wear a pad to absorb it and that it is "yellowy green and bubbly." She also has a great deal of itching of vulva. Evaluation confirms the presence of a discharge and a vaginal pH of 5.5. Her vagina and cervix are diffusely erythematous with scattered petechiae. What is the most likely diagnosis?

Trichomoniasis

A 30-year-old female G2 P2, who delivered via normal spontaneous vaginal delivery, presents complaining of increasing vaginal pressure, low back pain, and stress incontinence. What is the mostly likely cause of her condition?

Widening of the levator gap Damage to the levator and increased abdominal pressure are known risk factors, but the widening of the gap with the associated risk factors is what allows the defect to occur. Fascia remodeling can occur instead of a prolapse defect.

A 60-year-old postmenopausal woman who has had negative annual Papanicolaou smears of the cervix for many decades reports that her husband has been in a nursing home for almost a year and that she is no longer sexually active. He was her only sexual partner. She has no personal or family history of cancer and has never taken or been exposed to any kind of hormone. She asks if she really needs to continue having testing every year. What is the correct advice for her?

You can safely extend the time between Pap smears to three years.

A progestin-only contraceptive, or "minipill," would be most appropriate for which of the following patients?

a 37-year-old woman who smokes 2 packs per day and has a history of hypertension for women older than 35 years of age who are smokers or are obese, or who have a history of hypertension or vascular disease, progesterone-only contraceptives are recommended. Ethinyl estradiol (EE), the most common estrogen found in combined hormonal contraceptives, has been associated with an increased risk of myocardial infarction in women older than 35 years of age who are smokers. Additionally, EE has also been shown to cause increases in blood pressure in both normotensive and mildly hypertensive women. Progestin-only contraceptives, however, tend to be less effective than the combined hormonal contraceptives.

A 27-year-old G3P2 at 39 weeks gestation has been in labor for 6 hours. Her membranes ruptured 3 hours ago and revealed a large amount of clear fluid. She has previously delivered a 7 pound 2 ounce infant. She is having good quality contractions, and has been completely dilated and pushing for 55 minutes. The fetal head is +4, FHT 128. What would be the most appropriate management at this time?

continue pushing

Your 24-year-old female patient has a longstanding history of hypercoaguability disorders and is on lifelong anticoagulation due to prior pulmonary emboli. She advises you that she is attempting to get pregnant. Which of the following medications should be utilized during her pregnancy?

enoxaparen

You are treating a 14-year-old female for gonorrhea. She has a past history of Chlamydia. Her LMP was 3 weeks ago. She is allergic to penicillin. Her only medication is oral combination birth control pills. Why should Levofloxin be avoided in this patient?

her age Fluoroquinolones are contraindicated in pediatric patients.

A 12-year-old boy is being seen for concerns of development of breast tissue. Upon physical exam, he is noted to have a firm, slightly tender mass under the left areola. What is the most appropriate action at this time?

reassurance and observation Type 1 idiopathic gynecomastia in adolescent men presents with a firm mass under the areola ("breast bud") typically during sexual maturation stages (SMR), stages II to III. This is a result of normal estrogen and androgen activity at the breast tissue level. Appropriate action is observation and to reassure the patient that the condition will likely resolve in 1 to 2 years

An 11-year-old boy is being seen in the clinic for well-child care. His father inquires whether his son is starting to show physical signs of puberty. Which of the following is the first sign of puberty in males?

scrotal and testicular enlargement

A 26-year-old woman who is nursing presents to clinic complaining of 2 to 3 days of increasing pain and redness in her left breast. She continues to feed her infant and has good milk supply. She is 4 weeks postpartum. She complains of some general fatigue, but no headaches, body aches, or fever. On physical exam, results are as follows: P 80, T 99.1°F, and BP 120/70, CV RRR, and lungs CTA. Her left breast has a 5-cm area of induration, in the upper outer quadrant a 2-cm mass is noted, which is tender to the touch. In addition, milk expressed is non-purulent. What is the most likely cause of the infection?

staph aureus

A 30-year-old G1P0 woman who is 15 weeks pregnant undergoes "triple screening." The maternal alphafetoprotein (AFP), human chorionic gonadotropin (hCG), and unconjugated estriol (uE3) levels are all lower than normal. This suggests which of the following possible problems with the fetus?

trisomy 18

A 19-year-old female patient presents to her family practice office for her annual Pap test and her first dose of the quadravalent human papillomavirus (HPV) vaccine. As her physician assistant, when would you schedule her to come in for her second dose of the HPV vaccine?

two months the vaccines are administered in a three-dose schedule. The second dose is administered one to two months after the first dose, and the third dose is administered six months after the first dose.

You are providing care for a 21-year-old G1P1 who delivered a 3990 gram infant by normal spontaneous vaginal delivery. After delivery, she continues to bleed vaginally, more than is expected for routine delivery. What is the most likely cause of her hemorrhage?

uterine atony Uterine atony continues to be the most common cause of postpartum hemorrhage,