3 set

Question 1

Which type of sexual precocity can arise from cranial tumors or hypothyroidism?
A. True sexual precocity
B. Incomplete sexual precocity
C. Isosexual precocious pseudopuberty
D. Heterosexual precocious pseudopuberty
E. Precocity caused by gonadotropin-producing tumors

Answer 1

A. True sexual precocity

Question 2

A 51-year-old woman is diagnosed with invasive cervical carcinoma by cone biopsy. Pelvic examination and rectal-vaginal examination reveal the parametrium to be free of disease, but the upper portion of the vagina is involved with tumor. Intravenous pyelography (IVP) and sigmoidoscopy are negative, but a computed tomography (CT) scan of the abdomen and pelvis shows grossly enlarged pelvic and periaortic nodes. This patient is classified at which of the following stages?
A. lla
B. Ilb
C. Illa
D. Illb
E. IV

Answer 2

A. lla

Question 3

A 39-year-old patient is contemplating discontinuing birth control pills in order to conceive. She is concerned about her fertility at this age, and inquires about when she can anticipate resumption of normal menses. You counsel her that by 3 months after discontinuation of birth control pills, what proportion of patients will resume normal menses?
A. 99%
B. 95%
C. 80%
D. 50%
E. 5%

Answer 3

C. 80%

Question 4

A postmenopausal woman presents with pruritic white lesions on the vulva. Punch biopsy of a representative area is obtained. Which of the following histologic findings is consistent with the diagnosis of lichen sclerosus?
A. Blunting or loss of rete pegs
B. Presence of thickened keratin layer
C. Acute inflammatory infiltration
D. Increase in the number of cellular layers in the epidermis
E. Presence of mitotic figures

Answer 4

A. Blunting or loss of rete pegs

Question 5

A 48-year-old woman presents to your office with the complaint of vaginal dryness during intercourse. She denies any medical problems or prior surgeries and does not take any medications. She still has regular menstrual cycles every 28 days. She denies any sexually transmitted diseases. She describes her sexual relationship with her husband as satisfying. Her physical examination is normal. Components of the natural lubrication produced by the female during sexual arousal and intercourse include which of the following?
A. Fluid from Skene glands
B. Mucus produced by endocervical glands
C. Viscous fluid from Bartholin glands
D. Transudate-like material from the vaginal walls
E. Uterotubal fluid

Answer 5

D. Transudate-like material from the vaginal walls

Question 6

A patient misses 1 oral contraceptive pill. What is the most appropriate response?
A. Stop pills and resume after 7 days.
B. Continue pills as usual.
C. Continue pills and use an additional form of contraception.
D. Take an additional pill.
E. Stop pills and seek a medical examination.

Answer 6

D. Take an additional pill.

Question 7

A 28-year-old nulligravid patient complains of bleeding between her periods and increasingly heavy menses. Over the past 9 months, she has had two dilation and curettages (D&Cs), which have failed to resolve her symptoms, and oral contraceptives and antiprostaglandins have not decreased the abnormal bleeding. Which of the following options is most appropriate at this time?
A. Perform a hysterectomy.
B. Perform hysteroscopy.
C. Perform endometrial ablation.
D. Treat with a GnRH agonist.
E. Start the patient on a high-dose progestational agent.

Answer 7

B. Perform hysteroscopy.

Question 8

What is the most appropriate rate of use effectiveness (percentage of pregnancies per year of actual patient use) for oral contraceptives?
A. 80%
B. 40%
C. 15% to 25%
D. 5% to 15%
E. 3% to 10%

Answer 8

D. 5% to 15%

Question 9

A 32-year-old woman presents to the emergency room complaining of severe lower abdominal pain. She says she was diagnosed with pelvic inflammatory disease by her gynecologist last month, but did not take the medicine that she was prescribed because it made her throw up. She has had fevers on and off for the past 2 weeks. In the emergency room, the patient has a temperature of 38.3°C (101°F). Her abdomen is diffusely tender, but more so in the lower quadrants. She has diminished bowel sounds. On bimanual pelvic examination, bilateral adnexal masses are palpated. The patient is sent to the ultrasound department, and a transvaginal pelvic ultrasound demonstrates bilateral tubo-ovarian abscesses. Which of the following is the most appropriate next step in the management of this patient?
A. Admit the patient for emergent laparoscopic drainage of the abscesses.
B. Call interventional radiology to perform CT-guided percutaneous drainage of the abscesses.
C. Send the patient home and arrange for intravenous antibiotics to be administered by a home health agency.
D. Admit the patient for intravenous antibiotic therapy.
E. Admit the patient for exploratory laparotomy, TAH/BSO.

Answer 9

D. Admit the patient for intravenous antibiotic therapy.

Question 10

One day after a casual sexual encounter with a bisexual man recently diagnosed as antibody-positive for human immunodeficiency virus (HIV), a patient is concerned about whether she may have become infected. A negative antibody titer is obtained. To test for seroconversion, when is the earliest you should reschedule repeat antibody testing after the sexual encounter?
A. 1 to 2 weeks
B. 3 to 4 weeks
C. 4 to 10 weeks
D. 12 to 15 weeks
E. 26 to 52 weeks

Answer 10

C. 4 to 10 weeks

Question 11

You suspect that your infertility patient has an inadequate luteal phase. She should undergo an endometrial biopsy on which day of her menstrual cycle?
A. Day 3
B. Day 8
C. Day 14
D. Day 21
E. Day 26

Answer 11

E. Day 26

Question 12

Your patient is a 23-year-old woman with primary infertility. She is 5 ft 4 in tall and weighs 210 lb. She has had periods every 2 to 3 months since starting her period at age 12. She has a problem with acne and hair growth on her chin. Her mother had the same problem at her age and now has adult-onset diabetes. On physical examination of the patient, you notice a few coarse, dark hairs on her chin and around her nipples.
She has a normal-appearing clitoris. Her ovaries and uterus are normal to palpation. Which of the following blood tests has no role in the evaluation of this patient?
A. Total testosterone
B. 17 a-hydroxyprogesterone
C. DHEAS
D. Estrone
E. TSH

Answer 12

D. Estrone

Question 13

A postmenopausal woman is undergoing evaluation for fecal incontinence. She has no other diagnosed medical problems. She lives by herself and is self-sufficient, oriented, and an excellent historian. Physical examination is completely normal. Which of the following is the most likely cause of this patient’s condition?
A. Rectal prolapse
B. Diabetes
C. Obstetric trauma
D. Senility
E. Excessive caffeine intake

Answer 13

C. Obstetric trauma

Question 14

Which type of sexual precocity is characterized by the presence of premature adrenarche, pubarche, or thelarche?
A. True sexual precocity
B. Incomplete sexual precocity
C. Isosexual precocious pseudopuberty
D. Heterosexual precocious pseudopuberty
E. Precocity caused by gonadotropin-producing tumors

Answer 14

B. Incomplete sexual precocity

Question 15

In the evaluation of a 26-year-old patient with 4 months of secondary amenorrhea, you order serum prolactin and B-hCG assays. The B-hCG test is positive, and the prolactin level is 100 ng/mL (normal is <25 ng/mL in nonpregnant women in this assay). This patient requires which of the following?
A. Routine obstetric care
B. Computed tomography (CT) scan of her sella turcica to rule out pituitary adenoma
C. Repeat measurements of serum prolactin to ensure that values do not increase more than 300 ng/mL
D. Bromocriptine to suppress prolactin
E. Evaluation for possible hypothyroidism

Answer 15

A. Routine obstetric care

Question 16

What is the most appropriate rate of use effectiveness (percentage of pregnancies per year of actual patient use) for a condom alone?
A. 80%
B. 40%
C. 15% to 25%
D. 5% to 15%
E. 3% to 10%

Answer 16

C. 15% to 25%

Question 17

You ask a patient to call your office during her next menstrual cycle to schedule a hysterosalpingogram as part of her infertility evaluation. Which day of the menstrual cycle is best for performing the hysterosalpingogram?
A. Day 3
B. Day 8
C. Day 14
D. Day 21
E. Day 26

Answer 17

B. Day 8

Question 18

What is the most appropriate rate of use effectiveness (percentage of pregnancies per year of actual patient use) for a diaphragm?
A. 80%
B. 40%
C. 15% to 25%
D. 5% to 15%
E. 3% to 10%

Answer 18

C. 15% to 25%

Question 19

An infertile couple presents to you for evaluation. A semen analysis from the husband is ordered. The sample of 2.5 cc contains 25 million sperm per mL; 65% of the sperm show normal morphology; 20% of the sperm show progressive forward mobility. You should tell the couple which of the following?
A. The sample is normal, but of no clinical value because of the low sample volume.
B. The sample is normal and should not be a factor in the couple’s infertility.
C. The sample is abnormal because the percentage of sperm with normal morpho-logy is too low.
D. The sample is abnormal because of an inadequate number of sperm per milliliter.
E. The sample is abnormal owing to a low percentage of forwardly mobile sperm.

Answer 19

E. The sample is abnormal owing to a low percentage of forwardly mobile sperm.

Question 20

A couple presents to your office to discuss sterilization. They are very happy with their four children and do not want any more. You discuss with them the pros and cons of both female and male sterilization. The 34-year-old male undergoes a vasectomy. Which of the following is the most frequent immediate complication of this procedure?
A. Infection
B. Impotence
C. Hematoma
D. Spontaneous reanastomosis
E. Sperm granulomas

Answer 20

C. Hematoma

Question 21

A couple presents for evaluation of primary infertility. The evaluation of the woman is completely normal. The husband is found to have a left varicocele. If the husband’s varicocele is the cause of the couple’s infertility, what would you expect to see when evaluating the husband’s semen analysis?
A. Decreased sperm count with an increase in the number of abnormal forms
B. Decreased sperm count with an increase in motility
C. Increased sperm count with an increase in the number of abnormal forms
D. Increased sperm count with absent motility
E. Azoospermia

Answer 21

A. Decreased sperm count with an increase in the number of abnormal forms

Question 22

An intravenous pyelogram (IVP) shows hydronephrosis in the workup of a patient with cervical cancer otherwise confined to a cervix of normal size. This indicates which one of the following stages?
A. Microinvasive stage
B. I
C. II
D. III

Answer 22

D. III

Question 23

During the evaluation of infertility in a 25-year-old female, a hysterosalpingogram showed evidence of Asherman syndrome. Which one of the following symptoms would you expect this patient to have?
A. Hypomenorrhea
B. Oligomenorrhea
C. Menorrhagia
D. Metrorrhagia
E. Dysmenorrhea

Answer 23

A. Hypomenorrhea

Question 24

A 17-year-old woman is referred by her primary care physician for the evaluation of primary amenorrhea. On physical examination, the patient has evidence of virilization. She also has a pelvic mass. During the workup of the patient, she is found to have sex chromosome mosaicism (45,X/46,XY). What is the ovarian tumor that is most likely to be associated with this clinical picture?
A. Granulosa tumor
B. Sertoli-Leydig cell tumor
C. Immature teratoma
D. Gonadoblastoma
E. Krukenberg tumor

Answer 24

D. Gonadoblastoma

Question 25

A 24-year-old woman presents with new-onset right lower quadrant pain, and you palpate an enlarged, tender right adnexa. Which of the following sonographic characteristics of the cyst in this patient suggests the need for surgical exploration now instead of observation for one menstrual cycle?
A. Lack of ascites
B. Unilocularity
C. Papillary vegetation
D. Diameter of 5 cm
E. Demonstration of arterial and venous flow by Doppler imaging

Answer 25

C. Papillary vegetation

Question 26

A 25-year-old woman presents to your office for evaluation of primary infertility. She has regular periods every 28 days. She has done testing at home with an ovulation kit, which suggests she is ovulating. A hysterosalpingogram demonstrates patency of both fallopian tubes. A progesterone level drawn in the mid-luteal phase is lower than expected. A luteal phase defect is suspected to be the cause of this patient’s infertility. Which of the following studies performed in the second half of the menstrual cycle is helpful in making this diagnosis?
A. Serum estradiol levels
B. Urinary pregnanetriol levels
C. Endometrial biopsy
D. Serum follicle-stimulating hormone (FSH) levels
E. Serum luteinizing hormone (LH) levels

Answer 26

C. Endometrial biopsy

Question 27

A patient is seen on the first postoperative day after a difficult abdominal hysterectomy complicated by hemorrhage from the left uterine artery pedicle. Multiple sutures were placed into this area to control bleeding. Her estimated blood loss was 500 mL. The patient now has fever, left back pain, left costovertebral angle tenderness, and hematuria. Her vital signs are temperature 38.2°C (100.8°F), blood pressure 110/80 mm Hg, respiratory rate 18 breaths per minute, and pulse 102 beats per minute. Her postoperative hemoglobin dropped from 11.2 to 9.8, her white blood cell count is 9.5, and her creatinine rose from 0.6 mg/dL to 1.8 mg/dL. What is next best step in the management of this patient?
A. Order chest x-ray.
B. Order intravenous pyelogram.
C. Order renal ultrasound.
D. Start intravenous antibiotics.
E. Transfuse two units of packed red blood cells.

Answer 27

C. Order renal ultrasound.

Question 28

A patient is receiving external beam radiation for treatment of metastatic endometrial cancer. The treatment field includes the entire pelvis. Which of the following tissues within this radiation field is the most radiosensitive?
A. Vagina
B. Ovary
C. Rectovaginal septum
D. Bladder
E. Rectum

Answer 28

Ovary

Question 29

What is the most common side effect of taxol?
A. Hemorrhagic cystitis
B. Renal failure
C. Tympanic membrane fibrosis
D. Necrotizing enterocolitis
E. Pulmonary fibrosis
F. Pancreatic failure
G. Ocular degeneration
H. Cardiac toxicity
I. Peripheral neuropathy
J. Bone marrow depression

Answer 29

J. Bone marrow depression

Question 30

A 50-year-old woman is diagnosed with cervical cancer. Which lymph node group would be the first involved in metastatic spread of this disease beyond the cervix and uterus?
A. Common iliac nodes
B. Parametrial nodes
C. External iliac nodes
D. Paracervical or ureteral nodes
E. Para-aortic nodes

Answer 30

D. Paracervical or ureteral nodes

Question 31

A 44-year-old woman complains of urinary incontinence. She loses urine when she laughs, coughs, and plays tennis. Urodynamic studies are performed in the office with a multiple-channel machine. If this patient has genuine stress urinary incontinence, which of the following do you expect to see on the cystometric study?
A. An abnormally short urethra
B. Multiple uninhibited detrusor contractions
C. Total bladder capacity of 1000 cc
D. Normal urethral pressure profile
E. First urge to void at 50 cc

Answer 31

C. Total bladder capacity of 1000 cc

Question 32

What is the most common side effect of cisplatin?
A. Hemorrhagic cystitis
B. Renal failure
C. Tympanic membrane fibrosis
D. Necrotizing enterocolitis
E. Pulmonary fibrosis
F. Pancreatic failure
G. Ocular degeneration
H. Cardiac toxicity
I. Peripheral neuropathy
J. Bone marrow depression

Answer 32

B. Renal failure

Question 33

A 50-year-old G4P4 presents for her well-woman examination. She had one cesarean delivery followed by three vaginal deliveries. Her menses stopped 1 year ago and she occasionally still has a hot flash. She tells you that about 10 years ago she was treated with a laser conization for carcinoma in situ of her cervix. Since that time, all of her Pap tests have been normal. What recommendation should you make regarding how frequently she should undergo Pap smear testing?
A. Every 3 months
B. Every 6 months
C. Every year
D. Every 2 years
E. Every 3 years

Answer 33

C. Every year

Question 34

A 20-year-old female with Müllerian agenesis is undergoing laparoscopic appendectomy by a general surgeon. You are consulted intraoperatively because the surgeon sees several lesions in the pelvis suspicious for endometriosis. You should tell the surgeon which of the following?
A. Endometriosis cannot occur in patients with Müllerian agenesis since they do not have a uterus.
B. Endometriosis is common in women with Müllerian agenesis since they have menstrual outflow obstruction.
C. Endometriosis probably occurs in patients with Müllerian agenesis as a result of retrograde menstruation.
D. Endometriosis may arise in patients with Müllerian agenesis as a result of coelomic metaplasia.
E. Endometriosis cannot occur in patients with Müllerian agenesis because they have a 46,XY karyotype.

Answer 34

D. Endometriosis may arise in patients with Müllerian agenesis as a result of coelomic metaplasia.

Question 35

A 20-year-old woman presents to your office for a well-woman examination. She has been sexually active with one male partner for the past year. She has not achieved orgasm with her partner. On further questioning, she has never achieved orgasm with other partners or with masturbation or the use of a vibrator. Which of the following statements is true regarding her condition?
A. It is unrelated to partner behavior.
B. The influence of orthodox religious beliefs is still of major etiologic significance.
C. It is unrelated to partner’s sexual performance.
D. It is not associated with a history of rape.
E. It always has an underlying physical etiology.

Answer 35

B. The influence of orthodox religious beliefs is still of major etiologic significance.

Question 36

A 25-year-old G1P0 presents to your office for a routine return OB visit at 30 weeks. On listening to the fetal heart tones, you notice that thecpatient has a number of bruises on the abdomen. You ask the patient what happened, and she tells you the bruises resulted from a fall she suffered several days earlier, when she slipped on the stairs. The patient returns to your office 3 weeks later for another routine visit, and you note that she has a broken arm in a cast. She states that she fell again. You question her about physical abuse and the patient begins crying and reveals a long-standing history of abuse by her husband. Which of the following is the most likely reason for upper extremity injury in this patient?
A. Injury from being restrained
B. Defensive injury
C. Fall from being pushed
D. Injury related to striking back at her husband
E. Self-inflicted wounds

Answer 36

B. Defensive injury

Question 37

A 49-year-old G4P4 presents to your office complaining of a 2-month history of leakage of urine every time she exercises. She has had to limit her physical activities because of the loss of urine. She has had burning with urination and some blood in her urine for the past few days. Which of the following is the best next step in the evaluation and management of this patient?
A. Physical examination
B. Placement of a pessary
C. Urinalysis with urine culture
D. Cystoscopy
E. Office cystometrics

Answer 37

A. Physical examination

Question 38

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

Answer 38

E. Urethral diverticulum

Question 39

A 40-year-old G3P2012 presents for her well-woman examination. She has had two vaginal deliveries and her largest baby weighed 4000 g. She had a postpartum bilateral tubal ligation. Her menstrual cycles are regular every 28 days and last 5 days. She states that with cough she may occasionally lose some urine; otherwise she has no complaints. She denies any medical problems. On examination she weighs 56 kg and her blood pressure is 132/81 mm Hg. What type of speculum would be most appropriate to use when performing this patient’s Pap test?
A. Graves speculum
B. Pederson speculum
C. Vaginoscope
D. Hysteroscope
E. Pediatric speculum

Answer 39

A. Graves speculum

Question 40

A 23-year-old woman presents to your office with the complaint of a red splotchy rash on her chest that occurs during intercourse. It is nonpuritic and painless. She states that it usually resolves within a few minutes to a few hours after intercourse. Which of the following is the most likely cause of the rash?
A. Allergic reaction to her partner’s pheromones
B. Decreased systolic blood pressure during the plateau phase
C. Increased estrogen during the excitement phase
D. Vasocongestion during the excitement phase
E. Vasocongestion during the orgasmic phase

Answer 40

D. Vasocongestion during the excitement phase

Question 41

A 19-year-old woman presents for voluntary termination of pregnancy 6 weeks after her expected (missed) menses. She previously had regular menses every 28 days. Pregnancy is confirmed by B-human chorionic gonadotropin (B-hCG), and ultrasound confirms expected gestational age. Which of the following techniques for termination of pregnancy would be safe and effective in this patient at this time?
A. Dilation and evacuation (D&E)
B. Hypertonic saline infusion
C. Suction dilation and curettage (D&C)
D. 15-methyl a-prostaglandin injection
E. Hysterotomy

Answer 41

C. Suction dilation and curettage (D&C)

Question 42

A 36-year-old woman presents to the emergency room complaining of pelvic pain, fever, and vaginal discharge. She has had nausea and vomiting and cannot tolerate liquids at the time of her initial evaluation. The emergency room physician diagnoses her with pelvic inflammatory disease and asks you to admit her for treatment. Which of the following is the most appropriate initial antibiotic treatment regimen for this patient?
A. Doxycycline 100 mg PO twice daily for 14 days
B. Clindamycin 450 mg IV every 8 hours plus gentamicin 1 mg/kg load followed by 1 mg/kg every 12 hours
C. Cefoxitin 2 g IV every 6 hours with doxycycline 100 mg IV twice daily
D. Ceftriaxone 250 mg IM plus doxycycline 100 mg PO twice daily for 14 days
E. Ofloxacin 400 mg PO twice daily for 14 days plus Flagyl 500 mg PO twice daily for 14 days

Answer 42

C. Cefoxitin 2 g IV every 6 hours with doxycycline 100 mg IV twice daily

Question 43

What method of contraception is medically contraindicated for a woman with multiple sexual partners?
A. Oral contraceptives
B. IUD
C. Condoms
D. Laparoscopic tubal ligation
E. Diaphragm

Answer 43

B. IUD

Question 44

After diagnosing a 24-year-old GO with vulvar vestibulitis, you recommended that she wear loose clothing and cotton underwear and to stop using tampons. After 1 month she returns, reporting that her symptoms of intense burning and pain with intercourse have not improved. Which of the following treatment options is the best next step in treating this patient’s problem?
A. Podophyllin
B. Surgical excision of the vestibular glands
C. Topical Xylocaine
D. Topical trichloroacetic acid
E. Valtrex therapy

Answer 44

C. Topical Xylocaine

Question 45

A 20-year-old woman presents to your office for her well-woman examination. She has recently become sexually active and desires an effective contraceptive method. She has no medical problems, but family history is significant for breast cancer in a maternal aunt at the age of 42. She is worried about getting cancer from taking birth control pills. You discuss with her the risks and benefits of contraceptive pills. You tell her that which of the following neoplasms has been associated with the use of oral contraceptives?
A. Breast cancer
B. Ovarian cancer
C. Endometrial cancer
D. Hepatic cancer
E. Hepatic adenoma

Answer 45

E. Hepatic adenoma

Question 46

A 20-year-old GO and her partner, a 20-year-old man, present for counseling for sexual dysfunction. Prior to their relationship, neither had been sexually active. Both deny any medical problems. In medical experience, which type of male or female sexual dysfunction has the lowest cure rate?
A. Premature ejaculation
B. Vaginismus
C. Primary impotence
D. Secondary impotence
E. Female orgasmic dysfunction

Answer 46

C. Primary impotence

Question 47

A 32-year-old woman presents to your office to discuss contraception. She has recently stopped breast-feeding her 8-month-old son and wants to stop her progestin-only pill because her cycles are irregular on it. You recommend a combination pill to help regulate her cycle. You also mention that with estrogen added, the contraceptive efficacy is also higher. In combination birth control pills, which of the following is the primary contraceptive effect of the estrogenic component?
A. Conversion of ethinyl estradiol to mestranol
B. Atrophy of the endometrium
C. Suppression of cervical mucus secretion
D. Suppression of luteinizing hormone (LH) secretion
E. Suppression of follicle-stimulating hormone (FSH) secretion

Answer 47

E. Suppression of follicle-stimulating hormone (FSH) secretion

Question 48

You are called to the emergency department to evaluate an 18-year-old woman for a vulvar laceration. She is accompanied by her mother and father. The father explains that the injury was caused by a fall onto the support bar on her bicycle. You interview the woman alone and find out that her father has been sexually assaulting her. Which of the following statements best describes injuries related to sexual assault?
A. Most injuries are considered major and require surgical correction.
B. Most injuries require hospitalization.
C. More than 50% of victims will have an injury.
D. Most injuries occur after the assault has taken place.
E. Vaginal and vulvar lacerations are common in virginal victims.

Answer 48

E. Vaginal and vulvar lacerations are common in virginal victims.

Question 49

What method of contraception is medically contraindicated for a woman with severely reduced functional capacity as a result of chronic obstructive lung disease?
A. Oral contraceptives
B. IUD
C. Condoms
D. Laparoscopic tubal ligation
E. Diaphragm

Answer 49

D. Laparoscopic tubal ligation

Question 50

A 56-year-old woman presents to your office for her routine well-woman examination. She had a hysterectomy at age 44 for symptomatic uterine fibroids. She entered menopause at age 54 based on menopausal symptoms and an elevated FSH level. She started taking estrogen replacement therapy at that time for relief of her symptoms. She is fasting and would like to have her lipid panel checked while she is in the office today. You counsel the patient on the effects of estrogen therapy on her lipid panel. She should expect which of the following?
A. An increase in her LDL
B. An increase in her HDL
C. An increase in her total cholesterol
D. A decrease in her triglycerides
E. A decrease in her HDL

Answer 50

B. An increase in her HDL

Question 51

You have just diagnosed a 21-year-old infertile woman with polycystic ovarian syndrome. The remainder of the infertility evaluation, including the patient’s hysterosalpingogram and her husband’s semen analysis, were normal. Her periods are very unpredictable, usually coming every 3 to 6 months. She would like your advice on the best way to conceive now that you have made a diagnosis. Which of the following treatment options is the most appropriate first step in treating this patient?
A. Dexamethasone
B. Gonadotropins
C. Artificial insemination
D. Metformin
E. In vitro fertilization

Answer 51

D. Metformin

Question 52

A patient is diagnosed with carcinoma of the breast. Which of the following is the most important prognostic factor in the treatment of this disease?
A. Age at diagnosis
B. Size of tumor
C. Axillary node metastases
D. Estrogen receptors on the tumor
E. Progesterone receptors on the tumor

Answer 52

C. Axillary node metastases

Question 53

Which type of sexual precocity is frequently caused by ovarian tumors?
A. True sexual precocity
B. Incomplete sexual precocity
C. Isosexual precocious pseudopuberty
D. Heterosexual precocious pseudopuberty
E. Precocity caused by gonadotropin-producing tumors

Answer 53

C. Isosexual precocious pseudopuberty

Question 54

A 58-year-old Caucasian woman comes in to your office for advice regarding her risk factors for developing osteoporosis. She is 5 ft 1 in tall and weighs 195 lb. She stopped having periods at age 49. She is healthy but smokes one pack of cigarettes per day. She does not take any medications. She has never taken hormone replacement for menopause. Her mother died at age 71 after she suffered a spontaneous hip fracture. Which of the following will have the least effect on this patient’s risk for developing osteoporosis?
A. Her family history
B. Her race
C. Her history of smoking cigarettes
D. Her menopause status
E. Her obesity

Answer 54

E. Her obesity

Question 55

Your patient is 43 years old and is concerned that she may be too close to menopause to get pregnant. You recommend that her gonadotropin levels be tested. Which is the best day of the menstrual cycle to check gonadotropin levels in this situation?
A. Day 3
B. Day 8
C. Day 14
D. Day 21
E. Day 26
A. ov

Answer 55

A. Day 3

Question 56

A patient presents to your office approximately 2 weeks after having a total vaginal hysterectomy with anterior colporrhaphy and Burch procedure for uterine prolapse and stress urinary incontinence. She complains of a constant loss of urine throughout the day. She denies any urgency or dysuria. Which of the following is the most likely explanation for this complaint?
A. Failure of the procedure
B. Urinary tract infection
C. Vesicovaginal fistula
D. Detrusor instability
E. Diabetic neuropathy

Answer 56

C. Vesicovaginal fistula

Question 57

After your evaluation and treatment of a rape victim has been completed, you discharge the patient to home. When is the best time to schedule a follow-up appointment for the patient?
A. 24 to 48 hours
B. 1 week
C. 6 weeks
D. 12 weeks
E. There is no need for the patient to have any additional follow-up as long as she feels well.

Answer 57

A. 24 to 48 hours

Question 58

What is the most common side effect of cyclophosphamide?
A. Hemorrhagic cystitis
B. Renal failure
C. Tympanic membrane fibrosis
D. Necrotizing enterocolitis
E. Pulmonary fibrosis
F. Pancreatic failure
G. Ocular degeneration
H. Cardiac toxicity
I. Peripheral neuropathy
J. Bone marrow depression

Answer 58

A. Hemorrhagic cystitis

Question 59

A 20-year-old G2P0020 with an LMP 5 days ago presents to the emergency room complaining of a 24-hour history of increasing pelvic pain. This morning she experienced chills and a fever, although she did not take her temperature. She reports no changes in her urine or bowel habits. She has had no nausea or vomiting. She is hungry. She denies any medical problems. Her only surgery was a laparoscopy performed last year for an ectopic pregnancy. She reports regular menses and denies dysmenorrhea. She is currently sexually active. She has a new sexual partner and had sexual intercourse with him just prior to her last menstrual period. She denies a history of any abnormal Pap smears or sexually transmitted diseases. Urine pregnancy test is negative. Urinalysis is completely normal. WBC is 18,000. Temperature is 38.8°C (102°F). On physical examination, her abdomen is diffusely tender in the lower quadrants with rebound and voluntary guarding. Bowel sounds are present but diminished. Which of the following is the most likely diagnosis?
A. Ovarian torsion
B. Endometriosis
C. Pelvic inflammatory disease
D. Kidney stone
E. Ruptured ovarian cyst

Answer 59

C. Pelvic inflammatory disease

Question 60

What method of contraception is medically contraindicated for a woman with moderate cystocele?
A. Oral contraceptives
B. IUD
C. Condoms
D. Laparoscopic tubal ligation
E. Diaphragm

Answer 60

E. Diaphragm

Question 61

A 22-year-old woman has been seeing you for treatment of recurrent urinary tract infections over the past 6 months. She married 6 months ago and became sexually active at that time. She seems to become symptomatic shortly after having sexual intercourse. Which of the following is the most appropriate recommendation for this patient to help her with her problem?
A. Refer her to a urologist.
B. Schedule an IVP.
C. Prescribe prophylactic urinary antispasmodic.
D. Prescribe suppression with an antibiotic.
E. Recommend use of condoms to prevent recurrence of the UTls.

Answer 61

D. Prescribe suppression with an antibiotic.

Question 62

A 55-year-old postmenopausal female presents to her gynecologist for a routine examination. She denies any use of hormone replacement therapy and does not report any menopausal symptoms. She denies the occurrence of any abnormal vaginal bleeding. She has no history of any abnormal Pap smears and has been married for 30 years to the same partner. She is currently sexually active with her husband on a regular basis. Two weeks after her examination, her Pap smear comes back as atypical glandular cells of undetermined significance (AGUS). Which of the following is the most appropriate next step in the management of this patient?
A. Repeat the Pap in 4 to 6 months
B. HPV testing
C. Hysterectomy
D. Cone biopsy
E. Colposcopy, endometrial biopsy, endocervical curettage

Answer 62

E. Colposcopy, endometrial biopsy, endocervical curettage

Question 63

A 22-year-old woman presents for her first Pap smear. She has been sexually active with only one boyfriend since age 19. Her physical examination is completely normal. However, 2 weeks later her Pap smear results return showing HGSIL. There were no endocervical cells seen on the smear. Which of the following is the most appropriate next step in the management of this patient?
A. Perform a cone biopsy of the cervix
B. Repeat the Pap smear to obtain endocervical cells
C. Order HPV typing on the initial Pap smear
D. Perform random cervical biopsies
E. Perform colposcopy and directed cervical biopsies

Answer 63

E. Perform colposcopy and directed cervical biopsies

Question 64

A 51-year-old woman G3P3 presents to your office with a 6-month history of amenorrhea. She complains of debilitating hot flushes that awaken her at night; she wakes up the next day feeling exhausted and irritable. She tells you she has tried herbal supplements for her hot flushes, but nothing has worked. She is interested in beginning hormone replacement therapy (HRT), but is hesitant to do so because of its possible risks and side effects. The patient is very healthy. She denies any medical problems and is not taking any medication except calcium supplements. She has a family history of osteoporosis. Her height is 5 ft 5 in and her weight is 115 lb. In counseling the patient regarding the risks and benefits of hormone replacement therapy, you should tell her that HRT (estrogen and progesterone) has been associated with which of the following?
A. An increased risk of colon cancer
B. An increased risk of uterine cancer
C. An increased risk of thromboembolic events
D. An increased risk of developing Alzheimer disease
E. An increased risk of malignant melanoma

Answer 64

C. An increased risk of thromboembolic events

Question 65

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

Answer 65

B. Hydrosalpinx

Question 66

A 48-year-old woman consults with you regarding menopausal symptoms. Her periods have become less regular over the past 6 months. Her last period was 1 month ago. She started having hot flushes last year. They have been getting progressively more frequent. She has several hot flushes during the day, and she wakes up twice at night with them as well. She has done quite a lot of reading about perimenopause, menopause, and hormone replacement therapy. She is concerned about the risks of taking female hormones. She wants to know what she should expect in regard to her hot flushes if she does not take hormone replacement. You should tell her which of the following?
A. Hot flushes usually resolve spontaneously within 1 year of the last menstrual period.
B. Hot flushes are normal and rarely interfere with a woman’s well-being.
C. Hot flushes usually resolve within 1 week after the initiation of HRT.
D. Hot flushes can begin several years before actual menopause.
E. Hot flushes are the final manifestation of ovarian failure and menopause.

Answer 66

D. Hot flushes can begin several years before actual menopause.

Question 67

A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy of the cervix shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. How should you classify or stage this patient’s disease?
A. Carcinoma of low malignant potential
B. Microinvasive cancer, stage la1
C. Atypical squamous cells of undetermined significance
D. Carcinoma in situ
E. Invasive cancer, stage lla

Answer 67

B. Microinvasive cancer, stage la1

Question 68

A 65-year-old woman presents to your office for evaluation of genital prolapse. She has a history of chronic hypertension, well controlled with a calcium channel blocker. She has had three full-term spontaneous vaginal deliveries. The last baby weighed 9 lb and required forceps to deliver the head. She says she had a large tear in the vagina involving the rectum during the last delivery. She has a history of chronic constipation and often uses a laxative to help her have a bowel movement. She has smoked for more than 30 years and has a smoker’s cough. She entered menopause at age 52 but has never taken hormone replacement therapy. Which of the following factors is least important in the subsequent development of genital prolapse in this patient?
A. Chronic cough
B. Chronic constipation
C. Chronic hypertension
D. Childbirth trauma
E. Menopause

Answer 68

C. Chronic hypertension

Question 69

A 17-year-old girl is seen by her primary care physician for the evaluation of left lower quadrant pain. The physician felt a pelvic mass on physical examination and ordered a pelvic ultrasound. You are consulted because an ovarian neoplasm is identified by the ultrasound. Which of the following is the most common ovarian tumor in this type of patient?
A. Germ cell
B. Papillary serous epithelial
C. Fibrosarcoma
D. Brenner tumor
E. Sarcoma botryoides

Answer 69

A. Germ cell

Question 70

A 57-year-old menopausal patient presents to your office for evaluation of postmenopausal bleeding. She is morbidly obese and has chronic hypertension and adult onset diabetes. An endometrial sampling done in the office shows complex endometrial hyperplasia with atypia, and a pelvic ultrasound done at the hospital demonstrates multiple, large uterine fibroids. Which of the following is the best treatment option for this patient?
A. Myomectomy
B. Total abdominal hysterectomy
C. Oral contraceptives
D. Uterine artery embolization
E. Oral progesterone

Answer 70

B. Total abdominal hysterectomy

Question 71

A 45-year-old G3P3 presents for her yearly examination. She last saw a doctor 7 years ago after she had her last child. She had three vaginal deliveries, the last of which was complicated by gestational diabetes and preeclampsia. She has not been sexually active in the past year. She once had an abnormal Pap smear for which she underwent cryotherapy. She denies any medical problems. Her family history is significant for coronary artery disease in her dad and a maternal aunt who developed ovarian cancer at the age of 67. Which of the following is best screening approach for this patient?
A. Pap smear
B. Pap smear and mammography
C. Pap smear, mammography, and cholesterol profile
D. Pap smear, mammography, cholesterol profile, and fasting blood sugar
E. Pap smear, mammography, cholesterol profile, fasting blood sugar, and serum CA-125

Answer 71

D. Pap smear, mammography, cholesterol profile, and fasting blood sugar

Question 72

A 62-year-old woman presents for annual examination. Her last spontaneous menstrual period was 9 years ago, and she has been reluctant to use postmenopausal hormone replacement because of a strong family history of breast cancer. She now complains of diminished interest in sexual activity. Which of the following is the most likely cause of her complaint?
A. Decreased vaginal length
B. Decreased ovarian function
C. Alienation from her partner
D. Untreatable sexual dysfunction
E. Physiologic anorgasmia

Answer 72

B. Decreased ovarian function

Question 73

A 43-year-old G2P2 comes to your office complaining of an intermittent right nipple discharge that is bloody. She reports that the discharge is spontaneous and not associated with any nipple pruritus, burning, or discomfort. On physical examination, you do not detect any dominant breast masses or adenopathy. There are no skin changes noted. Which of the following conditions is the most likely cause of this patient’s problem?
A. Breast cancer
B. Duct ectasia
C. Intraductal papilloma
D. Fibrocystic breast disease
E. Pituitary adenoma

Answer 73

C. Intraductal papilloma

Question 74

A 7-year-old girl is brought in to see you by her mother because the girl has developed breasts and has a few pubic hairs starting to show up. Which of the following is the best treatment for the girl’s condition?
A. Exogenous gonadotropins
B. Ethinyl estradiol
C. GnRH agonists
D. Clomiphene citrate
E. No treatment; reassure the mother that pubertal symptoms at age 7 are normal

Answer 74

C. GnRH agonists

Question 75

A 32-year-old woman presents to your office for her well-woman examination. She is also worried because she has not been able to achieve orgasm with her new partner, with whom she has had a relationship for the past 3 months. She had three prior sexual partners and achieved orgasm with them. She is taking a combined oral contraceptive pill for birth control and an antihypertensive medication for chronic hypertension. She has also been on fluoxetine for depression for the past 2 years. She smokes one pack per day and drinks one drink per week. She had a cervical cone biopsy for severe cervical dysplasia 6 months ago. Which of the following is the most likely cause of her sexual dysfunction?
A. Clonidine
B. Contraceptive pill
C. Disruption of cervical nerve pathways
D. Fluoxetine
E. Nicotine

Answer 75

A. Clonidine

Question 76

You are consulted in the hospital to provide a gynecological examination on a patient who has injuries as the result of an assault by her husband. What percentage of family relationships are violent?
A. 10%
B. 30%
C. 50%
D. 75%
E. 95%

Answer 76

C. 50%

Question 77

A 65-year-old woman complains of leakage of urine. Which of the following is the most common cause of this condition in such patients?
A. Anatomic stress urinary incontinence
B. Urethral diverticulum
C. Overflow incontinence
D. Unstable bladder
E. Fistula

Answer 77

D. Unstable bladder

Question 78

A 78-year-old woman with chronic obstructive pulmonary disease, chronic hypertension, and history of myocardial infarction requiring angioplasty presents to your office for evaluation of something hanging out of her vagina. She had a hysterectomy for benign indications at age 48. For the past few months, she has been experiencing the sensation of pelvic pressure. Last month she felt a bulge at the vaginal opening.
Two weeks ago something fell out of the vagina. On pelvic examination, the patient has total eversion of the vagina. There is a superficial ulceration at the vaginal apex. Which of the following is the best next step in the management of this patient?
A. Biopsy of the vaginal ulceration
B. Schedule abdominal sacral colpopexy
C. Place a pessary
D. Prescribe oral estrogen
E. Prescribe topical vaginal estrogen cream

Answer 78

E. Prescribe topical vaginal estrogen cream

Question 79

A 55-year-old G3P3 with a history of fibroids presents to you complaining of irregular vaginal bleeding. Until last month, she had not had a period in over 9 months. She thought she was in menopause, but because she started bleeding again last month she is not sure. Over the past month she has had irregular, spotty vaginal bleeding. The last time she bled was 1 week ago. She also complains of frequent hot flushes and emotional lability. She does not have any medical problems and is not taking any medications. She is a nonsmoker and denies any alcohol or drug use. Her gynecologic history is significant for cryotherapy of the cervix 10 years ago for moderate dysplasia. She has had three cesarean sections and a tubal ligation. On physical examination, her uterus is 12 weeks in size and irregularly shaped. Her ovaries are not palpable. A urine pregnancy test is negative. Which of the following is the most reasonable next step in the evaluation of this patient?
A. Schedule her for a hysterectomy.
B. Insert a progesterone-containing intrauterine device (IUD).
C. Arrange for outpatient endometrial ablation.
D. Perform an office endometrial biopsy.
E. Arrange for outpatient conization of the cervix.

Answer 79

D. Perform an office endometrial biopsy.

Question 80

A 34-year-old G1P1 with a history of pulmonary embolism presents to your office to discuss contraception. Her cycles are regular. She has a history of pelvic inflammatory disease last year, for which she was hospitalized. She has currently been sexually active with the same partner for the past year. She wants to use condoms and a spermicide. You counsel her on the risks and benefits. Which of the following statements is true regarding spermicides found in vaginal foams, creams, and suppositories?
A. The active agent in these spermicides is nonoxynol-9.
B. The active agent in these spermicides is levonorgestrel.
C. Effectiveness is higher in younger users.
D. Effectiveness is higher than that of the diaphragm.
E. These agents are associated with an increased incidence of congenital mal- formations.

Answer 80

A. The active agent in these spermicides is nonoxynol-9.

Question 81

A mother brings her 12-year-old daughter in to your office for consultation. She is concerned because most of the other girls in her daughter’s class have already started their period. She thinks her daughter hasn’t shown any evidence of going into puberty yet. Knowing the usual first sign of the onset of puberty, you should ask the mother which of the following questions?
A. Has her daughter had any acne?
B. Has her daughter started to develop breasts?
C. Does her daughter have any axillary or pubic hair?
D. Has her daughter started her growth spurt?
E. Has her daughter had any vaginal spotting?

Answer 81

B. Has her daughter started to develop breasts?

Question 82

Five patients present for contraceptive counseling, each requesting that an IUD be inserted. Which of the following is a recognized contraindication to the insertion of an IUD?
A. Pelvic inflammatory disease
B. Previous pregnancy with an IUD
C. Dysfunctional uterine bleeding
D. Cervical conization
E. Chorioamnionitis in previous pregnancy

Answer 82

A. Pelvic inflammatory disease

Question 83

A 70-year-old woman presents for evaluation of a pruritic lesion on the vulva. Examination shows a white, friable lesion on the right labia majora that is 3 cm in diameter. No other suspicious areas are noted. Biopsy of the lesion confirms squamous cell carcinoma. In this patient, lymphatic drainage characteristically would be first to which of the following nodes?
A. External iliac lymph nodes
B. Superficial inguinal lymph nodes
C. Deep femoral lymph nodes
D. Periaortic nodes
E. Internal iliac nodes

Answer 83

B. Superficial inguinal lymph nodes

Question 84

You are evaluating a 19-year-old woman for a sexual assault. She denies any medical problems or allergies to medications. Her pregnancy test is negative. Which of the following antibiotic prophylaxes do you recommend for sexually transmitted infections?
A. No antibiotic prophylaxis is indicated
B. Flagyl 500 mg PO twice daily for 7 days
C. Rocephin 250 mg IM
D. Doxycycline 100 mg PO twice daily for 7 days plus Rocephin 250 mg IM
E. E Erythromycin 500 mg PO twice daily for 7 days

Answer 84

D. Doxycycline 100 mg PO twice daily for 7 days plus Rocephin 250 mg IM

Question 85

A 32-year-old woman presents to your office with dysuria, urinary frequency, and urinary urgency for 24 hours. She is healthy but is allergic to sulfa drugs. Urinalysis shows large blood, leukocytes, and nitrites in her urine. Which of the following medications is the best to treat this patient’s condition?
A. Dicloxacillin
B. Bactrim
C. Nitrofurantoin
D. Azithromycin
E. Flagyl

Answer 85

C. Nitrofurantoin

Question 86

Which type of sexual precocity results from premature activation of the hypothalamic-pituitary system?
A. True sexual precocity
B. Incomplete sexual precocity
C. Isosexual precocious pseudopuberty
D. Heterosexual precocious pseudopuberty
E. Precocity caused by gonadotropin-producing tumors

Answer 86

A. True sexual precocity

Question 87

While evaluating a 30-year-old woman for infertility, you diagnose a bicornuate uterus. You explain that additional testing is necessary because of the woman’s increased risk of congenital anomalies in which organ system?
A. Skeletal
B. Hematopoietic
C. Urinary
D. Central nervous
E. Tracheoesophageal

Answer 87

C. Urinary

Question 88

An intrauterine pregnancy of approximately 10 weeks gestation is confirmed in a 30-year-old G5P4 woman with an IUD in place. The patient expresses a strong desire for the pregnancy to be continued. On examination, the string of the IUD is noted to be protruding from the cervical os. Which of the following is the most appropriate course of action?
A. Leave the IUD in place without any other treatment.
B. Leave the IUD in place and continue prophylactic antibiotics throughout pregnancy.
C. Remove the IUD immediately.
D. Terminate the pregnancy because of the high risk of infection.
E. Perform a laparoscopy to rule out a heterotopic ectopic pregnancy.

Answer 88

C. Remove the IUD immediately.

Question 89

You are treating a 31-year-old woman with danazol for endometriosis. You should warn the patient of potential side effects of prolonged treatment with the medication. When used in the treatment of endometriosis, which of the following changes should the patient expect?
A. Occasional pelvic pain, since danazol commonly causes ovarian enlargement
B. Lighter or absent menstruation, since danazol causes endometrial atrophy
C. Heavier or prolonged periods, since danazol causes endometrial hyperplasia
D. More frequent Pap smear screening, since danazol exposure is a risk factor for cervical dysplasia
E. Postcoital bleeding caused by the inflammatory effect of danazol on the endocervical and endometrial glands

Answer 89

B. Lighter or absent menstruation, since danazol causes endometrial atrophy

Question 90

What is the most appropriate rate of use effectiveness (percentage of pregnancies per year of actual patient use) for an IUD?
A. 80%
B. 40%
C. 15% to 25%
D. 5% to 15%
E. 3% to 10%

Answer 90

E. 3% to 10%

Question 91

A family medicine physician refers a 19-year-old woman to you for abnormal findings during her well-woman examination. She emigrated to the United States with her family 6 years ago from West Africa. She is not sexually active at this time but has had one partner 2 years ago. She denies any sexually transmitted diseases. She is on nitrofurantoin for recurrent urinary tract infections; otherwise she is healthy. She denies any surgeries, but she remembers undergoing a special ceremony as young child in Africa. Lung, cardiac, breast, and abdominal examination is within normal limits. On pelvic examination you note extensive scarring on the vulva, and the labia minora have been removed. The prepuce of the clitoris is missing and the clitoris is scarred over. Which of the following is most likely a result of the procedure the patient had in Africa?
A. Amenorrhea
B. Decreased vaginal infections
C. Easier vaginal deliveries
D. Enhanced sexual function
E. Psychosomatic symptoms

Answer 91

E. Psychosomatic symptoms

Question 92

A 29-year-old GO comes to your OB/GYN office complaining of PMS. On taking a more detailed history, you learn that the patient suffers from emotional lability and depression for about 10 days prior to her menses. She reports that once she begins to bleed she feels back to normal. The patient also reports a long history of premenstrual fatigue, breast tenderness, and bloating. Her previous health-care provider placed her on oral contraceptives to treat her PMS 6 months ago. She reports that the pills have alleviated all her PMS symptoms except for the depression and emotional symptoms. Which of the following is the best next step in the treatment of this patient’s problem?
A. Spironolactone
B. Evening primrose oil
C. Fluoxetine
D. Progesterone supplements
E. Vitamin B6

Answer 92

C. Fluoxetine

Question 93

You have just performed diagnostic laparoscopy on a patient with chronic pelvic pain and dyspareunia. The patient had multiple implants of endometriosis on the uterosacral ligaments and ovaries and several on the rectosigmoid colon. At the time of the procedure, you ablated all of the visible lesions on the peritoneal surfaces with the CO 2 laser. But because of the extent of the patient’s disease, you recommend postoperative medical treatment. Which of the following medications is the best option for the treatment of this patient’s endometriosis?
A. Continuous unopposed oral estrogen
B. Dexamethasone
C. Danazol
D. Gonadotropins
E. Parlodel

Answer 93

C. Danazol

Question 94

A 29-year-old G0 comes to your office complaining of a vaginal discharge for the past 2 weeks. The patient describes the discharge as thin in consistency and of a grayish white color. She has also noticed a slight fishy vaginal odor that seems to have started with the appearance of the discharge. She denies any vaginal or vulvar pruritus or burning. She admits to being sexually active in the past, but has not had intercourse during the past year. She denies a history of any sexually transmitted diseases. She is currently on no medications with the exception of her birth control pills. Last month she took a course of amoxicillin for treatment of a sinusitis. On physical examination, the vulva appears normal. There is a discharge present at the introitus. A copious, thin, whitish discharge is in the vaginal vault and adherent to the vaginal walls. The vaginal pH is 5.5. The cervix is not inflamed and there is no cervical discharge. Wet smear of the discharge indicates the presence of clue cells. The patient’s likely diagnosis is bacterial vaginosis. Which of the following is the best treatment?
A. Reassurance
B. Oral Diflucan
C. Doxycycline 100 mg PO twice daily for 1 week
D. Ampicillin 500 mg PO twice daily for 1 week
E. Metronidazole 500 mg PO twice daily for 1 week

Answer 94

E. Metronidazole 500 mg PO twice daily for 1 week

Question 95

At the time of annual examination, a patient expresses concern regarding possible exposure to sexually transmitted diseases. During your pelvic examination, a single, indurated, nontender ulcer is noted on the vulva. Venereal Disease Research Laboratory (VDRL) and fluorescent treponemal antibody (FTA) tests are positive. Without treatment, the next stage of this disease is clinically characterized by which of the following?
A. Optic nerve atrophy and generalized paresis
B. Tabes dorsalis
C. Gummas
D. Macular rash over the hands and feet
E. Aortic aneurysm

Answer 95

D. Macular rash over the hands and feet

Question 96

A mother brings her 14-year-old daughter in to the office for consultation. The mother says her daughter should have started her period by now. She is also concerned that she is shorter than her friends. On physical examination, the girl is 4 ft 10 in tall. She shows evidence of breast development at Tanner stage 2. She has no axillary or pubic hair. You reassure the mother that her daughter seems to be developing normally.
Educating the mother and daughter, your best advice is to tell them which of the following?
A. The daughter will start her period when her breasts reach Tanner stage 5.
B. The daughter will start her period, then have her growth spurt.
C. The daughter’s period should start within 1 to 2 years since she has just started developing breast buds.
D. The daughter will have her growth spurt, then pubic hair will develop, heralding the onset of menstruation.
E. The daughter’s period should start by age 18, but if she has not had her period by then, she should come back in for further evaluation.

Answer 96

C. The daughter’s period should start within 1 to 2 years since she has just started developing breast buds.

Question 97

A 21-year-old woman returns to your office for evaluation of an abnormal Pap smear. The Pap smear showed a squamous abnormality suggestive of a high-grade squamous intraepithelial lesion (HGSIL). Colposcopy confirms the presence of a cervical lesion consistent with severe cervical dysplasia (CIN III). Which of the following human papilloma virus (HPV) types is most often associated with this type of lesion?
A. HPV type 6
B. HPV type 11
C. HPV type 16
D. HPV type 42
E. HPV type 44

Answer 97

C. HPV type 16

Question 98

A patient experiences light bleeding at midcycle during her first month on the oral contraceptive pill. What is the most appropriate response?
A. Stop pills and resume after 7 days.
B. Continue pills as usual.
C. Continue pills and use an additional form of contraception.
D. Take an additional pill.
E. Stop pills and seek a medical examination.

Answer 98

B. Continue pills as usual.

Question 99

A 24-year-old G0 presents to your office complaining of vulvar discomfort. More specifically, she has been experiencing intense burning and pain with intercourse. The discomfort occurs at the vaginal introitus primarily with penile insertion into the vagina. The patient also experiences the same pain with tampon insertion and when the speculum is inserted during a gynecologic examination. The problem has become so severe that she can no longer have sex, which is causing problems in her marriage. She is otherwise healthy and denies any medical problems. She is experiencing regular menses and denies any dysmenorrhea. On physical examination, the region of the vulva around the vaginal vestibule has several punctate, erythematous areas of epithelium measuring 3 to 8 mm in diameter. Most of the lesions are located on the skin between the two Bartholin glands. Each inflamed lesion is tender to touch with a cotton swab. Which of the following is the most likely diagnosis?
A. Vulvar vestibulitis
B. Atrophic vaginitis
C. Contact dermatitis
D. Lichen sclerosus
E. Vulvar intraepithelial neoplasia

Answer 99

A. Vulvar vestibulitis

Question 100

A 22-year-old G3P0030 obese female comes to your office for a routine gynecologic examination. She is single, but is currently sexually active. She has a history of five sexual partners in the past, and became sexually active at age 15. She has had three first-trimester voluntary pregnancy terminations. She uses Depo-Provera for birth control, and reports occasionally using condoms as well. She has a history of genital warts, but denies any prior history of abnormal Pap smears. The patient denies use of any illicit drugs, but admits to smoking about one pack of cigarettes a day. Her physical examination is normal. However, 3 weeks later you receive the results of her Pap smear, which shows a high-grade squamous intraepithelial lesion (HGSIL). Which of the following factors in this patient’s history does not increase her risk for cervical dysplasia?
A. Young age at initiation of sexual activity
B. Multiple sexual partners
C. History of genital warts
D. Use of Depo-Provera
E. Smoking

Answer 100

D. Use of Depo-Provera

Question 101

Your patient delivers a 7-Ib 0-oz male infant at term. On physical examination, the baby has normal-appearing male external genitalia. However, the scrotum is empty. No testes are palpable in the inguinal canals. At 6 months of age the boy’s testes still have not descended. A pelvic ultrasound shows the testes in the pelvis, and there appears to be a uterus present as well. The presence of a uterus in an otherwise phenotypically normal male is owing to which of the following?
A. Lack of Müllerian-inhibiting factor
B. Lack of testosterone
C. Increased levels of estrogens
D. 46,XX karyotype
E. Presence of ovarian tissue early in embryonic development

Answer 101

A. Lack of Müllerian-inhibiting factor

Question 102

A 51-year-old menopausal woman is undergoing exploratory laparotomy for bilateral adnexal masses. A frozen section is performed on the excised ovaries and shows significant numbers of signet cells. What is the ovarian tumor that is most likely to be associated with this clinical picture?
A. Granulosa tumor
B. Sertoli-Leydig cell tumor
C. Immature teratoma
D. Gonadoblastoma
E. Krukenberg tumor

Answer 102

E. Krukenberg tumor

Question 103

You are called to the pediatric emergency department to evaluate a 7-year-old girl for sexual assault. As a health care provider taking care of this girl, which of the following are you required to do?
A. Administer antibiotics only if testing for infection is positive.
B. Demand that the child be placed in foster care pending further investigation.
C. Hospitalize the child until the offender has been apprehended.
D. Inform the parents that they must notify the police.
E. Notify child welfare authorities.

Answer 103

E. Notify child welfare authorities.

Question 104

A 48-year-old G2P2 presents for her well-woman examination. She had two uneventful vaginal deliveries. She had a vaginal hysterectomy for fibroids and menorrhagia. She denies any medical problems, but has not seen a doctor in 6 years. Her family history is significant for stroke, diabetes, and high blood pressure. On examination she is a pleasant female, stands 5 ft 3 in tall, and weighs 85 kg. Her blood pressure is 150/92 mm Hg, pulse 70 beats per minute, respiratory rate 14 breaths per minute, and temperature 37°C (98.4°F). Her breast, lung, cardiac, abdomen, and pelvic examinations are normal. The next appropriate step in the management of this patient’s blood pressure is which of the following?
A. Beta-blocker
B. Calcium channel blocker
C. Diuretic
D. Diet, exercise, weight loss, and repeat blood pressure in 2 months

Answer 104

D. Diet, exercise, weight loss, and repeat blood pressure in 2 months

Question 105

An 81-year-old woman presents to your office complaining that her uterus fell out 2 months ago. She has multiple medical problems, including chronic hypertension, congestive heart failure, and osteoporosis. She is limited to sitting in a wheelchair because of her health problems. Her fallen uterus causes significant pain. On physical examination, the patient is frail and requires assistance with getting on the examination table. She has complete procidentia of the uterus. Which of the following is the most appropriate next step in the management of this patient?
A. Reassurance
B. Placement of a pessary
C. Vaginal hysterectomy
D. Le Fort procedure
E. Anterior colporrhaphy

Answer 105

B. Placement of a pessary

Question 106

A 26-year-old G2P1 presents to the gynecologist complaining of increasing hair growth on her face, chest, and abdomen, but the hair on her head is receding in the temporal regions. She also has had problems with acne. On physical examination the patient has significant amounts of coarse, dark hair on her face, chest, and abdomen. On pelvic examination she has an enlarged clitoris. She has a 7-cm left adnexal mass.
What is the ovarian tumor that is most likely to be associated with this clinical picture?
A. Granulosa tumor
B. Sertoli-Leydig cell tumor
C. Immature teratoma
D. Gonadoblastoma
E. Krukenberg tumor

Answer 106

B. Sertoli-Leydig cell tumor

Question 107

A rape victim returns to your office 2 months after the attack for a follow-up visit. She informs you that her sleep has improved and she can now be by herself without feeling anxious or panicked. She has also developed new friendships through her church. She states that she is changing jobs and moving to a new town. She feels that with this change she will be in control of her life. The best recommendation you can make for the recovery of this patient is which of the following?
A. Continue counseling.
B. Face her attacker to bring closure to this event.
C. Get her to accept responsibility for the attack.
D. Stop counseling since her recovery is now complete.
E. Take anxiolytic medication.

Answer 107

A. Continue counseling.

Question 108

A 67-year-old woman is found to have bilateral adnexal masses while undergoing evaluation of her recently diagnosed colon cancer. What is the ovarian tumor that is most likely to be associated with this clinical picture?
A. Granulosa tumor
B. Sertoli-Leydig cell tumor
C. Immature teratoma
D. Gonadoblastoma
E. Krukenberg tumor

Answer 108

E. Krukenberg tumor

Question 109

A 27-year-old woman presents to your office complaining of mood swings, depression, irritability, and breast pain each month in the week prior to her menstrual period. She often calls in sick at work because she cannot function when she has the symptoms. Which of the following medications is the best option for treating the patient’s problem?
A. Progesterone
B. A short-acting benzodiazepine
C. A conjugated equine estrogen
D. A nonsteroidal anti-inflammatory drug (NSAID)
E. Selective serotonin reuptake inhibitors (SSRIs)

Answer 109

E. Selective serotonin reuptake inhibitors (SSRIs)

Question 110

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

Answer 110

B. Stress incontinence

Question 111

A 39-year-old G3P3 presents for her postpartum examination and desires a long-term contraceptive method, but is unsure if she wants sterilization. She has been happily married for 15 years and denies any sexually transmitted diseases. Her past medical history is significant for mild hypertension, for which she takes a low-dose diuretic. She is considering an intrauterine device and wants to know how it works. Which of the following is the best explanation for the mechanism of the action of the intrauterine device (IUD)?
A. Hyperperistalsis of the fallopian tubes accelerates oocyte transport and prevents fertilization.
B. A subacute or chronic bacterial endometritis interferes with implantation.
C. Premature endometrial sloughing associated with menorrhagia causes early abortion.
D. A sterile inflammatory response of the endometrium prevents implantation.
E. Cervical mucus is rendered impenetrable to migrating sperm.

Answer 111

D. A sterile inflammatory response of the endometrium prevents implantation.

Question 112

An 18-year-old consults you for evaluation of disabling pain with her menstrual periods. The pain has been present since menarche and is accompanied by nausea and headache. History is otherwise unremarkable, and pelvic examination is normal. You diagnose primary dysmenorrhea and recommend initial treatment with which of the following?
A. Ergot derivatives
B. Antiprostaglandins
C. Gonadotropin-releasing hormone (GnRH) analogues
D. Danazol
E. Codeine

Answer 112

B. Antiprostaglandins

Question 113

You are evaluating a rape victim in the emergency department. As a physician, your legal requirement includes which of the following?
A. Identification of the attacker
B. Detailed notation of injuries
C. Delivery of evidence to a law enforcement facility
D. Treating patient even if she refuses
E. Writing the diagnosis of rape in the patient’s chart

Answer 113

B. Detailed notation of injuries

Question 114

A 22-year-old woman consults you for treatment of hirsutism. She is obese and has facial acne and hirsutism on her face and periareolar regions and a male escutcheon. Serum LH level is 35 mlU/mL and FSH is 9 mlU/mL. Androstenedione and testosterone levels are mildly elevated, but serum DHAS is normal. The patient does not wish to conceive at this time. Which of the following single agents is the most appropriate treatment of her condition?
A. Oral contraceptives
B. Corticosteroids
C. GnRH.
D. Parlodel
E. Wedge resection

Answer 114

A. Oral contraceptives

Question 115

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

Answer 115

B. Polycystic ovarian syndrome

Question 116

You have recommended a postcoital test for your patient as part of her evaluation for infertility. She and her spouse should have sexual
intercourse on which day of her menstrual cycle as part of postcoital testing?
A. Day 3
B. Day 8
C. Day 14
D. Day 21
E. Day 26

Answer 116

C. Day 14