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Question 1 of 40
1. Question
A 27-year-old woman, gravida 0 para 0, comes to the office with her husband for infertility evaluation. The patient discontinued her combination oral contraceptive pills 14 months ago, and the couple has been trying to conceive since then, with timed intercourse on cycle days 9 through 16. She was placed on oral contraceptive pills at age 19 for severe primary dysmenorrhea. The patient’s menstrual periods occur every 27 days; she has 2 days of breast tenderness and light bleeding with painful cramping moderately controlled with ibuprofen and heating pads. The patient has no chronic medical conditions and has had no surgeries. Her husband is age 34 and has no children from previous relationships. He has no chronic medical conditions or previous surgeries and reports normal pubertal development. The patient’s blood pressure is 120/70 mm Hg and pulse is 76/min. Height is 157.5 cm (5 ft 2 in). BMI is 24 kg/m2. Pelvic examination reveals a well-rugated vagina; a small, anteverted uterus; and no adnexal masses. Physical examination of the husband shows normal secondary sexual characteristics and bilaterally descended testes. Which of the following is the most appropriate response to this couple’s inability to conceive?
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Question 2 of 40
2. Question
A 24-year-old woman comes to the office for 3 months of worsening vulvar pain. The patient reports a burning sensation and pain that makes her skin feel “like it is being rubbed raw with sandpaper.” The pain prevents her from having intercourse, which is straining her relationship with her partner. An over-the-counter antifungal preparation did not improve symptoms. The patient has had no dysuria, hematuria, or vaginal discharge. She has no other chronic medical conditions and has had no surgeries. The patient has never had a sexually transmitted infection. She is using depot medroxyprogesterone acetate for contraception. The patient has no known allergies. Blood pressure is 100/60 mm Hg and pulse is 80/min. BMI is 20 kg/m2. On pelvic examination, the external genitalia show no erythema, ulcers, or lesions; light contact of the vulva and labia with a cotton swab causes sharp pain. Separation of the labia majora for speculum examination causes discomfort; however, insertion of the speculum does not produce vaginal pain. Speculum examination demonstrates a well-rugated vagina and a normal cervix with no abnormal discharge. Bimanual examination cannot be performed because of patient discomfort. Which of the following is the best next step in management of this patient?
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Question 3 of 40
3. Question
A 64-year-old woman comes to the office for evaluation of dysuria and difficulty voiding. The patient began having difficulty voiding a year ago, but it has progressively worsened and now causes a sensation of incomplete emptying. She awakens several times at night to void but has no uncontrolled leakage of urine. The patient also has increasing vulvar pruritus, which she attributes to irritation from wiping with toilet paper so frequently. She has no chronic medical conditions and has had no surgeries. The patient has not been sexually active for the last 5 years; her husband has multiple medical conditions that preclude intercourse. Her last Pap test was 3 years ago and she has no history of abnormal testing. She has no known medication allergies. The patient has a 20-pack-year smoking history but quit a few years ago; she does not use alcohol or illicit drugs. Vitals signs are normal. BMI is 23 kg/m2. The abdomen is soft; there is no suprapubic or costovertebral angle tenderness. Pelvic examination reveals thin, hypopigmented lesions that extend from the clitoris to the labia majora and perineum. The labia minora appear fused over the urethra. Diffuse erosions and excoriations are present on the vulva. Speculum examination reveals an atrophic vagina with no lesions. Urinalysis is within normal limits. Which of the following is the most appropriate treatment for this patient?
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Question 4 of 40
4. Question
A 33-year-old woman comes to the office for a contraception prescription. The patient previously used oral contraceptive pills for menstrual regulation and acne treatment, but she frequently forgot to take them, resulting in an unintended pregnancy 2 years ago. During her pregnancy, she gained 36.3 kg (80 lb) and has been unable to return to her prepregnancy weight. Her postpartum course was complicated by severe postpartum depression requiring a brief hospitalization, and she does not want to become pregnant again. The patient has not been sexually active since the delivery but recently started a new relationship. She has no other chronic medical conditions and no previous surgeries. The patient has had normal routine Pap testing. Her menses occur every 45-90 days with 5-6 days of heavy bleeding and passage of large clots. The patient’s mother has type 2 diabetes mellitus and her paternal grandmother had ovarian cancer. She does not use tobacco, alcohol, or illicit drugs. BMI is 33 kg/m2. Physical examination is normal. Serum chemistries, prolactin, and TSH levels are normal. Urine pregnancy test is negative. Pelvic ultrasound reveals a small anteverted uterus and multifollicular ovaries bilaterally. Which of the following is the best contraceptive option for this patient?
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Question 5 of 40
5. Question
A 44-year-old woman, gravida 2 para 2, is being evaluated after having several episodes of painless postcoital bleeding. She has not received any preventative health care in many years. Her menstrual periods have been regular, and she uses barrier contraceptives. Speculum examination reveals an ulcerative lesion at the external cervical os. Cervical biopsy shows malignant squamous cells invading the underlying stroma. Further analysis of the malignant cells reveals that a double-stranded DNA virus, which encodes several proteins including E6 and E7, has integrated into the host genome. Which of the following is the most likely mechanism by which these viral proteins are involved in this patient’s condition?
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Question 6 of 40
6. Question
A 28-year-old nulligravid woman comes to the office after noticing a lump in her left breast while showering last week. The size of the mass has not changed, and the patient has no associated nipple discharge or skin discoloration. She has no chronic medical conditions or previous surgeries. The patient’s last menstrual period was 5 days ago. Her maternal aunt was diagnosed with breast cancer at age 56 and is doing well following treatment. The patient uses a progestin-containing subdermal implant for contraception. She smokes half a pack of cigarettes a day, drinks alcohol socially, but does not use recreational drugs. Blood pressure is 110/70 mm Hg and pulse is 70/min. BMI is 25 kg/m2. Physical examination shows a 1.5-cm, round, mobile, tender mass in the lateral superior quadrant of the left breast, 4 cm from the nipple. There is no fluctuance or erythema. No nipple discharge is expressed. Supraclavicular and axillary lymph nodes are not palpable. Which of the following is the best next step in management of this patient?
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Question 7 of 40
7. Question
A 46-year-old woman, gravida 2 para 2, comes to the office due to increasingly heavy menses. The patient’s menstrual periods previously occurred every 30 days and consisted of 4-5 days of moderate bleeding with mild cramping. However, over the past 6 months, her menses have consisted of 5-6 days of heavy bleeding with the passage of clots and severe abdominal cramping. The cramping has been unresponsive to consistent ibuprofen administration. The patient reports increasing fatigue and often sleeps 9-10 hours a night. She had 2 vaginal deliveries and a tubal ligation after the birth of her second child. The patient has no known chronic medical conditions. In addition to ibuprofen, she takes a daily multivitamin. The patient is an accountant and is unable to work during her menstrual cycle due to the pain. She drinks a glass of wine with dinner most days of the week but does not use tobacco or illicit drugs. Temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, and pulse is 105/min. BMI is 22 kg/m2. The thyroid is nontender with no obvious enlargement or masses. Pelvic examination reveals a uniformly enlarged, mobile uterus. No rectovaginal or adnexal tenderness is present. On speculum examination, the vagina appears well rugated and the cervix has no visible lesions. Which of the following is the most likely diagnosis in this patient?
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Question 8 of 40
8. Question
A 48-year-old woman comes to the office due to a 2-month history of right breast nipple discharge. The patient has schizophrenia, which was diagnosed in her 20s and is well controlled with antipsychotic therapy. Family history is significant for a paternal aunt who died from metastatic breast cancer at age 50. BMI is 28 kg/m2. Vital signs are normal. On physical examination, scant reddish-brown fluid is expressed from the right breast. There are no breast masses and no supraclavicular or axillary lymphadenopathy. Mammography reveals normal findings. Which of the following is the most likely diagnosis?
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Question 9 of 40
9. Question
A 30-year-old nulligravid woman and her 31-year-old husband come to the office for an infertility evaluation. They have been unable to conceive despite 2 years of unprotected intercourse. The patient has had irregular periods since menarche, ranging between 30 and 70 days each cycle. Her BMI is 34 kg/m2. Examination shows a small, anteverted uterus and bilateral enlarged ovaries. A urine pregnancy test is negative. The patient is prescribed letrozole for ovulation induction therapy. This medication is most likely to help this patient through which of the following mechanisms?
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Question 10 of 40
10. Question
A 16-year-old girl comes to the office with her mother for a contraception consultation. The patient recently became sexually active with her boyfriend of 6 months, and they use condoms for contraception. She has regular monthly menses, with 4 days of menstrual bleeding. On the first day of her menstrual period, the patient often has heavier bleeding and mild cramping relieved by nonsteroidal anti-inflammatory drugs. Her last menstrual period was 2 weeks ago. The patient has no chronic medical conditions or previous surgeries. Family history is significant for osteoporosis in her maternal grandmother and an aunt but is otherwise noncontributory. The patient has no known drug allergies. Blood pressure is 118/68 mm Hg and pulse is 72/min. BMI is 23 kg/m2. Physical examination is unremarkable. Urine pregnancy test result is negative. Before she decides which type of contraception she would like to use, the patient asks about the adverse effects of different methods. Which of the following is the most appropriate response?
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Question 11 of 40
11. Question
A 68-year-old woman comes to the office due to vaginal spotting. The patient first noticed dark brown blood stains on her underwear several months ago. She now wears a perineal pad that is partially stained by the end of the day. Occasionally she notices bright red blood on the pad as well. The patient has had no passage of clots or heavy bleeding. For the past year she has been sexually active with a new partner and recently noticed some postcoital bleeding. The patient has no dyspareunia, abnormal vaginal discharge, dysuria, or hematuria. She has constipation that is responsive to a high-fiber diet and stool softeners. In addition, the patient has type 2 diabetes mellitus that is managed with an oral agent. She had a cervical conization 20 years ago for cervical intraepithelial neoplasia; all subsequent Pap tests have been normal, including her most recent test 4 years ago. The patient is a former smoker but does not use alcohol or illicit drugs. Vital signs are normal. BMI is 30 kg/m2. Speculum examination shows no active vaginal bleeding. There is an erosion near the posterior fornix. The cervix is erythematous but there are no nodules or lesions. The uterus is small, mobile, and nontender. There are no adnexal masses or tenderness. On Valsalva, a mass is noted to protrude past the hymenal ring. Anal sphincter tone is normal on rectal examination. Which of the following is the most likely diagnosis for this patient?
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Question 12 of 40
12. Question
A 34-year-old woman comes to the office for follow-up after 2 abnormal Pap test results. The patient has had 4 lifetime sex partners, uses oral contraceptive pills, and has never been pregnant. She has no chronic medical conditions and does not use tobacco, alcohol, or recreational drugs. Physical examination is normal. A cervical biopsy reveals high-grade cervical intraepithelial neoplasia. Which of the following microscopic findings is most likely to be present in the tissue sample?
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Question 13 of 40
13. Question
A 20-year-old woman comes to the office for contraception management. The patient was recently diagnosed with factor V Leiden deficiency after developing deep vein thrombosis in the left lower extremity, for which she takes therapeutic anticoagulation. She is sexually active with 1 partner and uses condoms with spermicide for contraception. The patient has no other chronic medical conditions or previous surgeries. Menses occur every 30 days and consist of 7 days of heavy vaginal bleeding and 2 days of moderate cramping that is relieved by nonsteroidal anti-inflammatory drugs. The patient does not use tobacco, alcohol, or recreational drugs. Her maternal grandmother was diagnosed with metastatic ovarian cancer at age 65; family history is otherwise notable for an aunt with a factor V Leiden mutation. Blood pressure is 110/70 mm Hg and pulse is 70/min. BMI is 23 kg/m2. Pelvic examination shows a normal-sized, nontender uterus and no adnexal masses or tenderness. Urine pregnancy test is negative. Hemoglobin level is 10 g/dL. Which of the following is the best contraception option for this patient?
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Question 14 of 40
14. Question
A 22-year-old woman comes to the office for an annual physical examination. She has no concerns at the visit. The patient has regular, monthly menses, with 3-4 days of light bleeding and no palpable breast masses, abnormal vaginal discharge, dysuria, or changes in bowel function. She has no chronic medical conditions or previous surgeries. The patient engages in sexual activities with women only and has had 3 lifetime partners. Sexually transmitted infection testing a year ago was negative. She has not received a human papillomavirus vaccination. The patient does not use tobacco, alcohol, or recreational drugs. She is finishing her last year of college and plans to attend graduate school. Vitals signs are stable. BMI is 26 kg/m2. Physical examination is unremarkable. She asks for counseling for herself and her partner regarding the health risks of their sexual orientation. Which of the following is the most appropriate statement regarding general health-related issues for this patient?
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Question 15 of 40
15. Question
A 37-year-old woman comes to the office for evaluation of a left breast mass. The patient has had left breast discomfort before menses for the past year, but over the past 3 months has had continuous pain. She noticed the mass last week and reports no associated trauma or skin changes. At age 29, the patient underwent an excisional biopsy for a benign fibroadenoma in the right breast. She has type 2 diabetes mellitus that is well controlled with oral medications. The patient also has polycystic ovary syndrome and takes a combined estrogen progestin oral contraceptive for menstrual regulation. There is no family history of breast or ovarian cancer. Blood pressure is 128/70 mm Hg and pulse is 73/min. BMI is 31 kg/m2. A 2-cm, smooth, tender, mobile mass is palpated in the upper outer quadrant of the left breast, 10 cm from the nipple. Both breasts are diffusely nodular, and a small biopsy scar is noted on the right breast. There is no nipple discharge or lymphadenopathy. Mammogram shows no calcifications. Ultrasound of the breast reveals a 2-cm, cystic mass with smooth borders, thin walls, and no internal septations. Fine-needle aspiration shows a thin, green fluid; after the procedure, the mass resolves completely and the patient’s pain is gone. Which of the following is the best next step in management of this patient?
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Question 16 of 40
16. Question
An 18-year-old woman comes to the office because she has not had a menstrual period for the past 3 months. She reached menarche at age 12, and her menstrual cycles had been every 28 days with 3-4 days of moderate bleeding. The patient has had no changes in appetite, vision, or voice and has had no headaches. She has no chronic medical conditions or previous surgeries. The patient is a gymnast and has increased her training to 4 hours a day to prepare for a national competition. She has never been sexually active. The patient takes ibuprofen occasionally after practices and has no known medication allergies. Temperature is 37.2 C (99 F), blood pressure is 100/60 mm Hg, pulse is 60/min, and respirations are 12/min. BMI is 18 kg/m2. Physical examination shows well-defined musculature. Fine, pale hair is present above the upper lip and on the forearms. There is no nipple discharge. The abdomen is soft and nontender and has no palpable masses. Pelvic examination indicates a sexual maturity rating at stage 5. Bimanual examination reveals a small, anteverted, mobile uterus and small ovaries. Urine pregnancy test result is negative. Which of the following is the most likely diagnosis in this patient?
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Question 17 of 40
17. Question
A 42-year-old nulliparous woman comes to the office for follow-up. The patient was diagnosed with stage I breast cancer that was estrogen receptor positive, HER2 negative, lymph node negative, and without metastases. She underwent surgery and recently completed adjuvant therapy. She has had no weight loss, loss of appetite, weakness, or abdominal pain. The patient also has a history of hypertension controlled with a single medication. She uses a copper-containing intrauterine device for contraception and has regular menstrual periods that last 5 days with moderate bleeding on the first day. Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, and pulse is 76/min. BMI is 28 kg/m2. Breast examination is consistent with postsurgical changes with no abnormalities palpated. Because of the estrogen receptor–positive tumor, she will be started on tamoxifen as part of her treatment. Which of the following is the best strategy for evaluation of the adverse effects of tamoxifen in this patient?
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Question 18 of 40
18. Question
A 15-year-old girl is brought to the office for evaluation of lower abdominal pain associated with her menses that has occurred over the past few months. She describes the pain as “dull” and “crampy” and radiating to her back and lower thighs. The pain is associated with nausea and bloating, and the patient vomited twice during her last menstrual cycle. She has tried using a heating pad with minimal relief of symptoms. The patient “dreads” her periods and has missed several days of school due to the pain and vomiting. She has had no dysuria, diarrhea, abnormal vaginal discharge, or abdominal pain between periods. Her menses started at age 14, have occurred every month, and last 5 days. When interviewed alone, she reports that she had a boyfriend last year but is not currently in a relationship and has never had sexual intercourse. The patient has no chronic medical conditions and takes no daily medications. Her immunizations, including the human papillomavirus vaccine, are up to date. She does not use tobacco, alcohol, or illicit drugs. The patient’s aunt was diagnosed with endometrial cancer at age 40 and has been in remission for several years. Temperature is 37 C (98.6 F), blood pressure is 110/60 mm Hg, and pulse is 68/min. BMI is 25 kg/m2. Cardiopulmonary examination is normal. The abdomen is soft and nondistended. Pelvic examination reveals normal external female genitalia and a small, nontender uterus without masses. On speculum examination, a small amount of clear discharge is seen throughout the vaginal vault. The cervix is nulliparous and has no lesions or areas of friability. Which of the following is the best next step in management of this patient?
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Question 19 of 40
19. Question
A 38-year-old woman, gravida 3 para 3, comes to the office for evaluation of vaginal discharge. She underwent a total laparoscopic hysterectomy 2 weeks ago for symptomatic uterine fibroids. The patient had an uncomplicated postoperative course. She was able to ambulate, void, and tolerate a regular diet within 12 hours of surgery and went home on postoperative day 1. However, over the past week, the patient has had persistent malodorous vaginal discharge, requiring her to change pads multiple times a day. She has also been voiding frequently in small volumes and is having increasing vulvar pruritus. She has had no fever, chills, hematuria, or dysuria. The patient has type 2 diabetes mellitus controlled with oral medications. Her other surgeries include 2 cesarean deliveries and laparoscopic cholecystectomy. The patient does not use alcohol or illicit drugs, but she smokes 1 or 2 cigarettes a day. Temperature is 37.1 C (98.8 F), blood pressure is 130/86 mm Hg, and pulse is 80/min. BMI is 32 kg/m2. Abdominal incision sites are clean, dry, and intact. External genitalia are diffusely erythematous with superficial excoriations. Sterile speculum examination reveals a pool of clear, thin fluid in the vaginal vault. Nitrazine paper indicates a pH of 5. The vagina has a small, red area of granulation tissue over the anterior aspect; the cuff at the vaginal apex appears intact. On bimanual examination, there are no palpable masses in the vaginal vault. Which of the following is the best next step in management of this patient?
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Question 20 of 40
20. Question
A 32-year-old woman calls the office due to continued vaginal discharge and vulvar pruritus. She first noticed the presence of white, malodorous vaginal discharge a week ago. The patient began using an over-the-counter antifungal cream at that time, but her symptoms have not improved. A few times last year she had similar symptoms that resolved with the same medication. The patient was diagnosed with type 1 diabetes mellitus 20 years ago. She has no drug allergies and does not use tobacco, alcohol, or recreational drugs. The patient is sexually active and uses a levonorgestrel-releasing intrauterine device for contraception. She is concerned about the ongoing symptoms and asks for a more effective treatment. Which of the following is the most appropriate next step?
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Question 21 of 40
21. Question
A 32-year-old woman comes to the office due to leakage of urine. The leakage started a year ago and occurred occasionally while the patient was exercising but recently has worsened significantly. She states, “I leak urine every time I work out, particularly when I lift weights. I have been training for a triathlon and wanted to increase my strength, but now if I lift more than 15 kg (33 lb), I soak through my underwear.” For the past month she has skipped workouts due to embarrassment from the leakage. The patient reports frequent urination and awakens 1 or 2 times at night to urinate. She has no dysuria or hematuria. The patient has no chronic medical conditions. She has had 2 cesarean deliveries but no other surgeries. The patient takes oral contraceptives and a daily multivitamin. She drinks 4 L (1.06 gal) of water daily but can double her intake on workout days. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 110/70 mm Hg and pulse is 58/min. BMI is 26 kg/m2. Pelvic examination reveals a normal-sized, anteverted uterus and no adnexal masses. Speculum examination shows a well-rugated vagina and no evidence of pelvic organ prolapse. Leakage of urine is observed when the patient is asked to cough. Serum electrolytes are normal. A urinalysis has a specific gravity of 1.001 but is otherwise within normal limits. Which of the following is the most likely cause of this patient’s symptoms?
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Question 22 of 40
22. Question
A 23-year-old nulligravid woman comes to the office for evaluation of dyspareunia. The patient reports a year-long history of increasing dyspareunia and has not been sexually active for the last 3 months due to pain on penetration. The pain is deep in the pelvis and becomes intolerable, causing her to become tense during intercourse. The pain is not relieved with water-based lubricants. The patient became sexually active at age 19 and has had 4 lifetime partners. She had gonococcal cervicitis at age 20. She has no chronic medical conditions and has never had surgery. Menarche was at age 14 and menstrual periods are regular. The patient has painful cramping with menses that requires nonsteroidal anti-inflammatory drugs for the first 3 days of her menstrual period as well as the day prior. She does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98 F), blood pressure is 110/80 mm Hg, and pulse is 76/min. BMI is 22 kg/m2. Pelvic examination reveals normal external genitalia with no tenderness to palpation. The cervix has no lesions and no discharge. There is mild tenderness on bimanual examination of the uterus; no adnexal masses are palpated. Transvaginal ultrasound reveals a small, anteverted uterus with no adnexal masses. Which of the following is the best next step in management of this patient?
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Question 23 of 40
23. Question
An 18-year-old woman comes to the emergency department with heavy vaginal bleeding for the past 3 days. The patient has soaked 6 thick sanitary pads today and has had several large blood clots. She has bled through her clothing for the past 2 nights. The patient has no syncope, palpitations, or dyspnea on exertion. There is no history of recurrent epistaxis, easy bleeding, or bruising. Menarche was at age 14; her menstrual periods have been irregular since the onset of menses. She has never been sexually active. The patient has no chronic medical conditions and has had no surgeries. Family history is noncontributory. She has no known drug allergies. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 37 C (98.6 F), blood pressure is 120/70 mm Hg, and pulse is 95/min. BMI is 28 kg/m2. Mucous membranes are moist and capillary refill is normal. Cardiac examination shows a normal rate and regular rhythm. Pelvic examination reveals bleeding from the cervix after several large clots are evacuated from the vaginal vault. On bimanual examination, the uterus is small and mobile; there are no adnexal masses.
Complete blood count
Hemoglobin
11 g/dL
Platelets
180,000/mm3
Coagulation studies
INR
0.8
Activated PTT
35 sec
Urine pregnancy test is negative. Pelvic ultrasound shows a small uterus with a thickened endometrium and normal ovaries bilaterally. Which of the following is the most appropriate next step in management of this patient?
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Question 24 of 40
24. Question
A 15-year-old girl is brought to the office because she has never had a menstrual period. The patient is very concerned and feels isolated due to her perceived delay. Both her mother and younger sister reached menarche at age 13. The patient has never been sexually active. Vital signs are normal. Height is 160 cm (5 ft 3 in) and weight is 57 kg (125.6 lb). BMI is 22.2 kg/m2. On physical examination, breast and pubic hair development are sexual maturity rating (Tanner stage) IV. The abdomen is soft, non-tender, and without palpable masses. Pelvic examination shows normal female external genitalia and a well-rugated vagina; no cervix is visualized. A pelvic ultrasound shows a midline hypoechoic mass and ovaries with a few small cysts. Which of the following is the most likely diagnosis in this patient?
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Question 25 of 40
25. Question
A 34-year-old woman comes to the office for treatment of infertility. The patient has been trying to become pregnant with her current partner for the past year but has not yet conceived. Since menarche, she has had irregular menses, occurring every 3-6 months, with 7-14 days of bleeding. The patient’s last menstrual period was 2 months ago. Over the last 6 months, she has tried to lose weight with exercise and diet but has been unsuccessful. The patient has no chronic medical conditions or prior surgeries. She takes a daily prenatal vitamin and has no medication allergies. BMI is 33 kg/m2. On skin examination, there is moderate acne on the chest and back and terminal hairs on the upper lip. Pelvic examination shows a nulliparous cervix, a normal uterus, and bilateral enlarged ovaries. The remainder of the physical examination is unremarkable. Hysterosalpingography reveals a normal uterine cavity with bilateral tubal patency, and her partner’s semen analysis is normal. A urine pregnancy test is negative. Which of the following is the best treatment option for this patient’s infertility?
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Question 26 of 40
26. Question
A 42-year-old woman, gravida 4 para 4, comes to the office due to heavy and painful menstrual bleeding over the past 3 months. The patient’s last menstrual period was 3 weeks ago. Menarche was at age 10, and menstrual periods last for 3-5 days and occur every 30 days. She is sexually active with her husband and does not have pain with intercourse. The patient had a bilateral tubal ligation 3 years ago after the birth of her last child. She takes no medications and has no allergies. BMI is 24 kg/m2. Vital signs are normal. On bimanual examination, the uterus is uniformly enlarged and tender. Urine β-hCG is negative. Which of the following is the most likely cause of this patient’s symptoms?
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Question 27 of 40
27. Question
A 69-year-old woman, gravida 5 para 5, comes to the office for leakage of urine. The patient reports that her urine “leaks all the time” and that she is “afraid to leave the house because I constantly smell like urine.” She is also “exhausted from waking up every hour to go to the bathroom.” Since menopause at age 53, the patient has had occasional leakage of urine after sneezing, but her symptoms have worsened over the last few months. She has type 2 diabetes mellitus and is on an insulin regimen. The patient recently moved to be closer to her grandchildren; since moving, she has been diagnosed with allergic rhinitis and started on a daily antihistamine. She has had no previous surgery. The patient’s pregnancies all resulted in spontaneous vaginal deliveries; the largest infant was 4.6 kg (10.2 lb). She does not use tobacco, alcohol, or illicit drugs. The patient does aqua-aerobic exercises at the senior center 5 times a week. Blood pressure is 120/80 mm Hg and pulse is 70/min. BMI is 25 kg/m2. Abdominal examination shows no tenderness or masses. Speculum examination shows a pale vagina but no evidence of pelvic organ prolapse. Bimanual examination shows a small, mobile, nontender uterus and no adnexal masses. Urine dribbling is noted on examination, but no leakage occurs when the patient is asked to cough. There is decreased sensation to pinprick testing over the perineum. Which of the following is the most likely diagnosis in this patient?
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Question 28 of 40
28. Question
A 34-year-old primigravid woman comes to the office 2 days after a positive home pregnancy test. She reports mild nausea and breast tenderness but no vomiting, abdominal pain, or vaginal bleeding. The patient’s menses are irregular, and she is unsure of the date of her last menstrual period. She has type 1 diabetes mellitus, which is managed with an insulin pump and is complicated by nephropathy. The patient has no previous surgeries. She is sexually active with 1 partner and has had 9 lifetime partners. The patient has a history of Chlamydia trachomatis as a teenager, but sexually transmitted infection screening has since been negative. Temperature is 36.7 C (98.1 F), blood pressure is 100/66 mm Hg, and pulse is 108/min. BMI is 22 kg/m2. The abdomen is soft and without palpable masses; there is discomfort to deep palpation in the left lower quadrant, but no rebound or guarding. Speculum examination shows no abnormal cervical discharge or bleeding. Pelvic examination reveals a small, anteverted uterus with no cervical motion tenderness. Laboratory results are as follows:
Complete blood count
Hemoglobin
10.8 g/dL
Platelets
300,000/mm3
Leukocytes
7,500/mm3
Serum chemistry
Creatinine
2.5 mg/dL
Glucose
180 mg/dL
Liver function studies
Aspartate aminotransferase (SGOT)
37 U/L
Alanine aminotransferase (SGPT)
24 U/L
Endocrine
Quantitative β-hCG
5,112 IU/L
Transvaginal ultrasound reveals a thin endometrial stripe, a large amount of free fluid in the posterior cul-de-sac, and a left adnexal mass containing a fetal pole with a heart rate of 160/min. Which of the following is the best next step in management of this patient?
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Question 29 of 40
29. Question
A 33-year-old nulligravid woman comes to the office due to intermittent episodes of abdominal bloating for the past 3 months. The patient has also had increased moodiness, constipation, and fatigue. She was previously taking continuous combination oral contraceptive pills but had a progestin-releasing intrauterine device (IUD) placed 6 months ago. Since the placement, the patient has had irregular menstrual bleeding with weeks of intermittent, light spotting followed by weeks of no bleeding. She has no heavy vaginal bleeding, passage of clots, or pelvic pain. The patient has no chronic medical conditions and has had no prior surgeries. Vital signs are normal. BMI is 34 kg/m2. The abdomen is soft, nontender, nondistended, and has no palpable masses. On pelvic examination, the IUD strings are seen at the cervical os, and there are no cervical lesions. The uterus is nontender and there are no palpable adnexal masses. The remainder of the physical examination is unremarkable. A urine pregnancy test is negative. Serum TSH and pelvic ultrasound are normal. Which of the following is the best next step in management of this patient?
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Question 30 of 40
30. Question
A 17-year-old girl comes to the office for increasing malodorous vaginal discharge over the past week. The patient has had no fevers, chills, nausea, dysuria, hematuria, vulvar pruritus, or postcoital bleeding. Her last menstrual period was 2 weeks ago. The patient’s menses have become irregular since a progestin-containing intrauterine device was placed 8 months ago. She has no chronic medical conditions or previous surgeries. The patient is sexually active with a male partner and has had 2 lifetime partners. She does not use tobacco, alcohol, or illicit drugs. The patient has no known drug allergies. She is currently a senior in high school and will be going to a local university in the fall. Temperature is 37.2 C (99 F), blood pressure is 110/70 mm Hg, and pulse is 76/min. BMI is 20 kg/m2. Pelvic examination shows normal external genitalia with no lesions, erythema, or inguinal lymphadenopathy. Bimanual examination reveals no cervical motion tenderness, a mobile uterus, and no adnexal masses. On speculum examination, there is purulent discharge from the cervical os, and the ectocervix bleeds easily when touched with a cotton swab. The intrauterine device strings are visible in the cervix. A urine pregnancy test is negative. Which of the following is the best next step in management of this patient?
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Question 31 of 40
31. Question
A 31-year-old woman, gravida 5 para 3, comes to the office to discuss contraception methods. The patient has 3 children delivered vaginally at term and 2 elective first-trimester pregnancy terminations. Her last delivery was a year ago and she does not currently use contraception. She has just finished breastfeeding. The patient is worried about unintended pregnancy and says that she has completed childbearing. She has no history of thromboembolism, migraines, or liver disease. Her regular monthly menses typically have 4-5 days of moderate bleeding. The last menstrual period was a week ago. Her last Pap test was a year ago, and all testing has been normal. The patient had acute cervicitis at age 19 with negative sexually transmitted infection screening since then. Her maternal aunt was diagnosed with breast cancer at age 54 and died from complications of pulmonary embolism. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 128/70 mm Hg and pulse is 70/min. BMI is 27 kg/m2. Physical examination is normal. Which of the following is the best contraception option for this patient?
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Question 32 of 40
32. Question
A 16-year-old girl is brought to the office by her mother to discuss contraception. The patient recently became sexually active with her boyfriend of a year and uses condoms most of the time. She reports no vaginal spotting or abnormal vaginal discharge. The patient has no chronic medical conditions and takes no medications. She does not use tobacco, alcohol, or illicit drugs. The patient started menstruating at age 12; menses occur every 29 days and consist of 2-3 days of light bleeding and no cramping. Family history is noncontributory. Blood pressure is 120/80 mm Hg and pulse is 68/min. BMI is 23 kg/m2. The rest of the physical examination is unremarkable. Sexually transmitted infection screening is performed. Urine pregnancy test is negative. The patient and her mother request the most reliable form of contraception. In addition to condom use, which of the following is the best contraception option for this patient?
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Question 33 of 40
33. Question
A 27-year-old woman, gravida 3 para 3, comes to the office for an annual examination. She has no intermenstrual or postcoital bleeding or abnormal vaginal discharge. Her last menstrual period was 2 weeks ago. The patient has no chronic medical conditions and takes a multivitamin daily. She has had 3 uncomplicated vaginal deliveries and no surgeries. The patient has had 2 sexual partners in the past 3 years and uses oral contraceptive pills. Her last Pap test 3 years ago demonstrated atypical squamous cells of undetermined significance (ASCUS), and reflex human papillomavirus (HPV) testing at that time was negative. The patient has no history of sexually transmitted infections. Vital signs are normal. BMI is 22 kg/m2. The cervix appears parous and without visible lesions. The uterus is small, anteverted, and mobile, with notable descent of the cervix to the introitus during the Valsalva maneuver; the adnexa are not enlarged. Pap testing indicates a high-grade squamous intraepithelial lesion (HSIL). Which of the following is the best next step in management of this patient?
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Question 34 of 40
34. Question
An 11-year-old girl is brought to the office for vulvar pruritus that has increased over the past 3 months and now causes her to awaken from sleep. She tried applying her sister’s diaper cream but had no relief of symptoms. The patient has also developed perianal pruritus and constipation. She has had no vaginal or rectal bleeding and no abnormal vaginal discharge. The patient has allergic rhinitis managed with a glucocorticoid nasal spray. She has had no surgeries. Vaccinations are up to date. The patient has not reached menarche. She has no known drug allergies. Weight and height are at the 50th and 45th percentile, respectively. Blood pressure is 98/62 mm Hg and pulse is 84/min. Physical examination reveals Tanner stage 2 breast and pubic hair development. Thin white lesions cover the vulva and extend over the perineum and around the anus. The labia majora and minora are edematous and have areas of thickened skin. Multiple excoriations appear throughout the vulva. There is no evidence of trauma. Which of the following is the most likely diagnosis in this patient?
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Question 35 of 40
35. Question
A 37-year-old woman, gravida 4 para 3, comes to the emergency department due to contractions and vaginal bleeding. She has no leakage of fluid and has had normal fetal movement. The patient did not receive prenatal care, and her last menstrual period was 10 months ago. Her 3 prior pregnancies ended in uncomplicated, term vaginal deliveries. The patient has no chronic medical conditions and takes no medications. Blood pressure is 130/82 mm Hg and pulse is 78/min. The fetal heart rate shows moderate variability, no accelerations, and occasional late decelerations. The tocodynamometer shows contractions every 3 minutes. The cervix is dilated 8 cm and 100% effaced, and the fetal head is at +1 station. The patient is admitted and precipitously delivers a small-for-gestational-age (2.8-kg [6.2-lb]) male infant. Apgar scores are 8 and 9 at 1 and 5 minutes, respectively. The infant has green, wrinkled, peeling skin; thin fingers; and long fingernails. Loose skin and prominent skin creases are noted over the thighs and buttocks. The placental membranes are stained green. The remainder of the examination is unremarkable. Which of the following is the most likely cause of this infant’s examination findings?
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Question 36 of 40
36. Question
A 32-year-old woman, gravida 2 para 1, has a spontaneous vaginal delivery. Immediately after delivery of the placenta, the patient has a large amount of vaginal bleeding with passage of fist-sized clots, findings consistent with postpartum hemorrhage. A dose of tranexamic acid is administered. Which of the following is the most likely mechanism of action of this drug?
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Question 37 of 40
37. Question
A 29-year-old woman, gravida 1 para 1, had an uncomplicated vaginal delivery 8 hours ago. The patient underwent induction of labor at 39 weeks gestation for insulin-controlled gestational diabetes mellitus. An insulin drip was intermittently required for glycemic control during labor and was stopped at delivery. The patient was diagnosed with gestational diabetes mellitus at 26 weeks gestation and prescribed an insulin regimen at 29 weeks gestation when glycemic control with dietary modification failed. The pregnancy has been otherwise uncomplicated. The patient has no other medical conditions or previous surgeries. Temperature is 36.7 C (98.1 F), blood pressure is 110/80 mm Hg, and pulse is 88/min. Prepregnancy BMI was 23 kg/m2. Physical examination reveals a nontender uterine fundus 1 cm above the umbilicus. Bilateral lower extremities have trace edema but no calf tenderness. The blood glucose level at delivery was 118 mg/dL. Fasting blood glucose level is 90 mg/dL. Which of the following is the best next step in management of this patient?
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Question 38 of 40
38. Question
A 26-year-old woman comes to the office for a health maintenance visit. The patient feels well except for increasing fatigue over the past 3 months. She has a history of hypothyroidism and has been treated with a stable dose of levothyroxine for the past several years. The patient has no other medical conditions and has had no surgeries. She does not use tobacco, alcohol, or illicit drugs, and consumes a balanced diet. The patient is sexually active with her boyfriend and recently began taking a combination oral contraceptive for birth control. Vital signs are normal. The thyroid is normal to palpation. Cardiopulmonary and abdominal examinations show no abnormality. Thyroid function studies reveal significant changes compared to testing performed 6 months ago, and the changes are attributed to the oral contraceptive. This medication most likely altered which of the following aspects of thyroid function in this patient?
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Question 39 of 40
39. Question
The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once you click Proceed to Next Item, you will not be able to add or change an answer.
A 23-year-old woman, gravida 2 para 0 aborta 1, at 10 weeks gestation comes to the office due to nausea, frequent vomiting, hand tremors, and nervousness. She has also had increasing restless movements of her legs and decreased quality of sleep. The patient has lost 1 kg (2.2 lb) since her symptoms started 4 weeks ago. She has no chronic medical conditions. Her only surgery was a suction curettage for a missed abortion 3 years ago. The patient takes a daily prenatal vitamin and does not use alcohol, tobacco, or recreational drugs. Her maternal aunt had Graves disease, and her mother has primary hypothyroidism. Temperature is 37.1 C (98.8 F), blood pressure is 112/72 mm Hg, and pulse is 98/min. BMI is 22 kg/m2. Physical examination shows mild hand tremors; neurologic examination is otherwise normal. There is no thyromegaly. Transvaginal ultrasound demonstrates a 10-week-sized fetus with normal cardiac activity. The patient is worried about the possibility of hyperthyroidism, given her symptoms and family history.
Item 1 of 2
Which of the following is the most appropriate initial screening test for this patient?CorrectIncorrect -
Question 40 of 40
40. Question
Item 2 of 2
The patient’s serum TSH is 0.08 µU/mL, which is below the laboratory’s reference range for the first trimester. Additional studies are ordered, and the patient returns in a week for follow-up. She still feels anxious and has frequent vomiting, but her other symptoms have improved. On repeat examination, vital signs are normal. The patient has warm, slightly sweaty palms, but the remainder of the examination is normal. Follow-up laboratory results are as follows:Serum TSH
0.1 µU/mL
(1st-trimester reference range: 0.1-2.5)
T4, total
13 μg/dL
(1st-trimester reference range: 6-14)
T3, total
240 ng/dL
(1st-trimester reference range: 85-225)
Which of the following is the most likely diagnosis in this patient?
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