1. A 23-year-old woman has been amenorrheic for 7 months. Menarche was at the age of 13 years. Menses previously occurred at regular intervals. She uses a diaphragm for contraception. She states that she has had a moderate amount of job-relates stress. Pelvic examination shows normal findings. A pregnancy test is negative. Which of the following is the most appropriate next step in management?

2. A 15-year-old girl, gravida 3, para 1, aborta 2, requests contraceptive counseling. She has had two elective abortions over the past 8 months while she was using oral contraceptives; she currently has two sexual partners. In addition to use of condoms, which of the following additional methods of contraception is most effective for this patient?

3. A 22-year-old woman, gravida 1, para 1, comes to the emergency department because of a high fever for 12 hours. Four days ago, she had a cesarean delivery with epidural anesthesia after rupture of membranes at 38 weeks’ gestation and a protracted second stage of labor. Her temperature is 39.5C (103.1F). Abdominal examination shows suprapubic tenderness and a well-healing surgical incision with no erthema or induration. The lungs are clear to auscultation. Hematocrit is 37%, and leukocyte count is 17,000/mm3. Urinalysis shows:
WBC 5-7/hpf
RBC 1/hpf
Bacteria none
Leukocyte esterase negative

Which of the following is the most likely cause of this patient’s fever?

4. A 34-year-old woman, gravida 3, para 2, at 8 weeks’ gestation is exposed to a child with rubella. She has no history of rubella. Two days later, a rubella antibody titer shows less than 1:10 dilution. Which of the following is the most appropriate next step?

5. Four weeks after a total vaginal hysterectomy for cervical dysplasia, a 57-year-old woman comes for a follow-up visit. A pathology report confirms the presence of cervical intraepithelial neoplasia (CIN 3) with all surgical margins clear of disease. Which of the following is the most appropriate recommendation for future screening for recurrent squamous cell intraepithelial neoplasia in this patient?

6. A 32-year-old woman, gravida 2, para 1, at 10 weeks’ gestation comes for her first prenatal visit. She delivered her last child 9 months ago; the pregnancy was complicated by deep venous thrombosis (DVT) of the left lower extremity documented by venous Doppler ultrasonography. Her mother and sister also have DVT during pregnancy, and her maternal grandfather and uncle died of cerebral infarction in their 40s. Examination shows a uterus consistent in size with a 10-week gestation. Which of the following is the most appropriate screening test for this patient?

7. A 42-year-old woman comes to the emergency department because of heavy menstrual bleeding with cramping for the past 6 hours. Her last menstrual period began 4 weeks ago. Menses for the past 6 months have been regular but increasingly painful. There is a smooth, firm, 4-cm mass dilating the cervical os. Which of the following is the most likely diagnosis?

8. An asymptomatic 52-year-old African American woman comes to the physician for an annual health maintenance examination. Menarche was at the age of 10 years, and she has a long history of irregular menses. Her last menstrual period occurred 12 days ago, and her prior menses occurred 8 weeks ago. She has had a family history of a maternal aunt who developed breast cancer at the age of 80 years. Physical examination of the patient shows no abnormalities except for fibrocystic changes of the breast. Mammography is recommended for this patient primarily for which of the following reasons? 

9. A 37-year-old woman delivers a 2350 g (5 lb 3 oz) newborn at 39 weeks’ gestation. Her pregnancy was complicated by bronchitis at 30 weeks’ gestation; she also smoked 10 cigarettes daily and did not maintain a nutritionally balanced diet. Which of the following is the most likely explanation for the newborn’s small size at birth?

10. One week after cesarean delivery of a healthy newborn at term, a 22-year-old woman, gravida 1, para 1, is brought to the emergency department 3 hours after the acute onset of shortness of breath. The pregnancy was complicated by varicella pneumonia that required 14 days of hospitalization prior to delivery. Her temperature is 38 C (100.4 F), blood pressure is 145/70 mm Hg, pulse is 115/min, and respirations are 28/min. Breath sounds are decreased at the lung bases. Arterial blood gas analyses on room air shows:

pH 7.46
PCO2 26 mm Hg
PO2 77 mm Hg

An x-ray film of the chest shows basilar atelectasis. Which of the following is the most likely diagnosis?

11. A 15-year-old girl has had irregular, profuse, painless vaginal bleeding for 6 months. Menarche occurred at age 11 years, and cycles were regular with mild cramping until the recent episodes. She has gained 7.2 kg (16 lb) above her ideal weight over the past year. Which of the following is the most likely explanation?

12. A 37-year-old woman comes to the physician because she has been amenorrheic for 6 weeks. She also has had breast fullness and tenderness. Menses had occurred at regular 28-day intervals. She has a 5-year history of hypertension treated with lisinopril. She stopped taking her medication 6 months ago because she was feeling well. Her temperature is 37.1 C (98.8 F), blood pressure is 180/110mm Hg, pulse is 84/min, and respirations are 16/min. Physical and pelvic examinations show no abnormalities except for a cyanotic cervix. Urine β-hCG testing is positive. Which of the following is the most appropriate pharmacotherapy for this patient’s hypertension?

13. A 21-year-old woman, gravida 2, para 1, at 28 weeks’ gestation comes to the physician for her first prenatal visit. Her first pregnancy and delivery were uncomplicated. Examination shows a uterus consistent in size with a 28-week gestation. She is Rh- negative. Her anti-D antibody titer is 1:512. Which of the following is the most appropriate next step in management?

14. A 36-year-old primigravid woman at 32 weeks’ gestation comes to the emergency department 1 hour after the sudden onset of a severe headache. Pregnancy had been uncomplicated. She is mildly lethargic but able to respond to commands. Her temperature is 37C (98.6F), blood pressure is 194/104 mm Hg, pulse is 104/min and regular, and respirations are 18/min and unlabored. She has nuchal rigidity and photophobia. Which of the following is the most likely underlying cause of her symptoms?

15. A 27-year-old nulligravid woman comes to the physician because she has been unable to conceive for 18 months. Her husband has a child from a previous marriage. She has no history of sexually transmitted diseases. Her only previous contraceptive method was a diaphragm. Her menses have always been irregular with occasional missed periods. She weighs 100 kg (220 Ib) and is 160cm (63 in) tall. Examination shows no signs of hirsutism, breast masses, galactorrhea, or adnexal masses. Pubic hair, uterus, and cervix appear normal; the vagina is moist and well rugated. Which of the following is the most likely cause of the infertility?

16. A 37-year-old primigravid woman at 41 weeks gestation comes to the physician for a routine prenatal visit. Fetal biophysical profile shows:
Fetal breathing present
Tone present
Fetal movements 2/30 min
Amniotic fluid Single deepest pocked of 1.5 cm

Pelvic examination shows a long, closed cervix. Which of the following is the most appropriate next step in management?

17. A 24-year-old woman, gravida 2, para 1, at 30 weeks’ gestation is hospitalized and treated for pyelonephritis with intravenous antibiotics. This is her second hospitalization for pyelonephritis during this pregnancy. After the acute infection resolves, which of the following is the most appropriate next step in management?

18. For the past 6 months, a 42-year-old woman, gravida 2, para 2, has had 3-4 daily episodes of hot flashes followed by intense perspiration; she has 2-3 similar episodes each night. Menses occur at irregular intervals of 6-8weeks. Her last menstrual period began 6 weeks ago. Which of the following is the most appropriate next step in diagnosis?

19. A 57-year-old woman is brought to the emergency department 2 hours after the onset of urgent, frequent urination with hematuria. She is taking cyclophosphamide for Wegeners granulomatosis and lithium carbonate for bipolar disorder. Examination shows normal findings. Which of the following is the most likely diagnosis?

20. A 28-year-old nulligravid woman has had increasingly severe dysmenorrhea over the past 2 years and dyspareunia and pain with defecation for 6 months. She has been unable to conceive for 2 years. Pelvic examination shows a fixed, tender, retroverted uterus, nodularity of the uterosacral ligaments, and tender adnexa bilaterally; there is a 5-cm, tender. cystic, right adnexal mass. A pregnancy test is negative. What is the most likely diagnosis?

21. A 27-year-old woman, gravida 3, par 3, had the sudden onset of severe, sharp pain in the right lower quadrant of the abdomen, pain in the right shoulder, light-headedness, nausea, and rectal pressure 6 hours ago. She uses a diaphragm for contraception, and her last menstrual period was 24 days ago. Her blood pressure is 120/70mm Hg, and pulse is 80/mm with no orthostatic changes. There is moderate tenderness of the right lower quadrant of the abdomen without guarding or rebound tenderness; bowel sounds are active. Culdocentesis shows 15 mL of nonclotting, serosanguineous fluid with a hematocrit of 5%. A pregnancy test is negative. What is the most likely diagnosis?

22. A 32-year-old primigravid woman comes to the physician for her first prenatal visit. Her last menstrual period was 10 weeks ago. She has a 2½-year history of infertility. Laparoscopy showed normal findings 1 year ago. She conceived after receiving ovulation induction therapy. Her blood pressure is 120/80mm Hg. The uterus is consistent in size with a 14-week gestation. Fetal heart tones are heard. Her hematocrit is 37%. What is the most likely cause?

23. A 27-year-old woman, gravida 2, para 1, has had mild vaginal bleeding for 6 days and right-sided pelvic pain for 3 days. Her last menstrual period was 6 weeks ago. Her quantitative serum beta-hCG level is 6000 inIU/mL. Ultrasonography shows no gestational sac in the uterine cavity. What is the most likely cause?

24. A 32-year-old woman, gravida 2, para 2, has been amenorrheic since the birth of her last child 22 months ago. At that time, she underwent dilatation and curettage for postpartum hemorrhage. She breast-led her last child for 12 months. Her husband had a vasectomy 18 months ago. She has had no hot flashes, nausea, vomiting, vaginal dryness. or galactorrhea. What is the most likely cause?

25. An 18-year-old woman has been amenorrheic for 12 weeks. Her menses are irregular and occur every 6-12 weeks. She is not sexually active. She weighs 100 kg (220 Ib) and is 163 cm (64 in) tall. She has no hirsutism. What is the most likely cause?