Exam 5: Obstetrics & Gynecology

A 23-year-old woman, gravida 1 para 1, is evaluated on the postpartum floor for fever.  The patient awoke this morning with fever, chills, and increasing abdominal pain.  She is passing flatus and has no nausea.  Two days ago, the patient was in active labor, developed prolonged fetal bradycardia, and was rushed to the operating room for an emergency cesarean delivery under general anesthesia.  The fetus was delivered with Apgar scores of 6 and 8 at 1 and 5 minutes, respectively.  The patient was unable to void on the first postoperative day, so the Foley catheter was replaced and is continuing to drain.  The patient developed a fever this morning, and now her temperature is 38.4 C (101.1 F).  Bilateral breasts are engorged, tender, and have no erythema.  The uterine fundus is nontender and palpable at the umbilicus.  The skin overlying the incision is intact and has induration and erythema extending to the mons pubis.  There are no palpable abdominal masses, rebound, or guarding.  A Foley catheter is draining blood-tinged urine.  Urinalysis shows trace blood, negative leukocyte esterase, and negative nitrites.  Which of the following is the most likely underlying cause of this patient's presentation?

A 30 year-old-woman, gravida 1 para 0, at 29 weeks gestation comes to the office for a routine prenatal visit.  She reports increasing fatigue, shortness of breath with exertion, and bilateral leg swelling over the past few weeks.  The patient has had no vaginal bleeding, contractions, or leakage of fluid.  Fetal movement is normal.  Her initial prenatal visit was at 10 weeks gestation, and results of a complete blood count at that time were as follows: Today, blood pressure is 124/84 mm Hg, pulse is 77/min, and respirations are 22/min.  Cardiac examination is normal, and the lungs are clear to auscultation bilaterally.  Fundal height is 29 cm and fetal heart rate is 160/min.  Bilateral lower extremities have 2+ pitting edema up to the knees.  Results of a complete blood count today are as follows: Third-trimester HIV and syphilis tests are negative.  Which of the following is the most appropriate management of this patient?

A 39-year-old woman, gravida 1 para 0, at 36 weeks gestation is undergoing cesarean delivery for a failed induction of labor for preeclampsia with severe features.  The patient has been undergoing an induction of labor under epidural analgesia for the past 24 hours.  Despite an increasing oxytocin infusion, she has had minimal cervical dilation, and now, the amniotic fluid has turned meconium stained.  In the operating room, a dose of prophylactic antibiotics is administered, and an adequate sensory block is confirmed.  Prior to the skin incision, the patient develops acute dyspnea.  On repeat vital signs, temperature is 36.7 C (98.1 F), blood pressure is 80/50 mm Hg, pulse is 120/min, and respirations are 16/min.  Fetal heart rate monitoring shows recurrent, deep variable decelerations, and tocodynamometry shows increased uterine contractions every 2 minutes.  The patient appears flushed and in acute distress.  Heart sounds are regular and tachycardic.  The lungs have scattered wheezes bilaterally.  The abdomen is soft, gravid, and nontender.  Which of the following is the most likely cause of this patient's clinical presentation?

A 32-year-old woman comes to the emergency department due to left lower quadrant abdominal pain.  The pain started suddenly this morning along with nausea, but she has had no vomiting or diarrhea.  The patient has a history of heavy menstrual bleeding due to uterine fibroids, which was previously controlled with combined oral contraceptives.  She recently stopped the pills to try for pregnancy, and her last menstrual period was 2 weeks ago.  BMI is 30 kg/m².  Temperature is 37.2 C (99 F), blood pressure is 122/84 mm Hg, and pulse is 82/min.  The abdomen is soft and diffusely tender to deep palpation in the left lower quadrant, but there is no rebound or guarding.  The uterus is enlarged, irregular in contour, and nontender.  Urine pregnancy testing is negative.  Ultrasound reveals multiple subserosal and intramural uterine fibroids, a homogenous endometrial stripe, moderate free fluid in the pelvis, and a left ovary with a 4-cm cyst with thin walls.  Which of the following is the best next step in the immediate management of this patient?

A 23-year-old woman, gravida 1 para 1, is evaluated on the postpartum floor due to increased perineal pain.  The patient underwent a spontaneous vaginal delivery 8 hours ago after pushing for 3 hours.  She had a second-degree perineal laceration repaired immediately after delivery.  For the past 30 minutes, the patient has had increasing perineal pain, particularly with voiding.  Temperature is 37.4 C (99.3 F), blood pressure is 132/86 mm Hg, and pulse is 90/min.  On abdominal examination, there is no rebound or guarding and the uterus is firm and palpable below the umbilicus.  The patient's pad contains a small amount of dark red blood, and no clots are expressed with uterine massage.  The perineum and labia majora are edematous.  The laceration repair appears intact with no purulent drainage but is tender to palpation.  Which of the following is the best next step in management of this patient?

An 18-year-old woman comes to the emergency department due to heavy vaginal bleeding.  The patient previously had regular monthly menses; however, for the past month, she has had daily vaginal bleeding with passage of clots.  Today, the patient developed dizziness and shortness of breath.  She has no chronic medical conditions and has had no surgeries.  The patient's grandmother was recently diagnosed with endometrial cancer.  Blood pressure is 100/60 mm Hg, pulse is 110/min, and respirations are 16/min.  BMI is 44 kg/m².  She appears pale.  There is continuous, heavy vaginal bleeding on pelvic examination.  Pregnancy test is negative.  Hemoglobin is 8 g/dL.  The patient undergoes emergency dilation and curettage, and her vaginal bleeding resolves.  She has an uncomplicated postoperative course.  The pathology report shows endometrial hyperplasia without atypia.  Which of the following is the best next step in management of this patient?

A 26-year-old woman comes to the office due to concerns about worsening symptoms of polycystic ovary syndrome (PCOS).  The patient was diagnosed with PCOS 6 years ago after evaluation of abnormal uterine bleeding and lip and chin hair.  She was prescribed daily combined estrogen/progestin oral contraceptives, which regulated her menses.  However, for the last 2 months, she has had irregular menstrual bleeding despite taking her pills as directed.  The patient has had no changes in hair growth, weight gain, or galactorrhea but has noticed some deepening in her voice.  She has no other chronic medical conditions and takes no other daily medications.  Blood pressure is 132/84 mm Hg, and pulse is 78/min.  BMI is 33 kg/m².  Velvety, pigmented plaques are on the back of the neck and the axilla.  A few coarse hairs are noted on the upper lip and chin.  Multiple small comedones are on the forehead but not on the chest or upper back.  The abdomen is soft and nontender with no palpable masses or terminal hair.  An ultrasound is ordered due to suspicion of an ovarian tumor.  Which of the following findings is most concerning for an ovarian tumor in this patient?

A 29-year-old woman, gravida 2 para 0, comes to the physician for a routine prenatal visit.  She previously had regular menses every 28 days and is at 18 weeks gestation based on her last menstrual period and physical examination.  The patient had a first-trimester miscarriage during her prior pregnancy.  She takes prenatal vitamins but otherwise has no medical problems and takes no medications.  Her pre-pregnancy weight was 54 kg (119 lb) and she has gained 1 kg (2.2 lb) during this pregnancy.  Vital signs and physical examination are normal.  The uterus is soft and palpable just below the umbilicus.  The maternal serum α-fetoprotein protein level obtained last week is significantly elevated.  Which of the following is the most likely abnormality associated with this finding?

A 53-year-old woman comes to the emergency department due to heavy vaginal bleeding.  The bleeding started yesterday as dark brown vaginal spotting and has increased to now soaking a thick menstrual pad every 2 hours.  Menarche was at age 14.  Menopause was at age 45 and the patient has had no prior episodes of vaginal bleeding since then.  She smoked half a pack of cigarettes daily for 20 years; she does not use alcohol or illicit drugs.  The patient's mother died of breast cancer at age 77.  Blood pressure is 110/70 mm Hg and pulse is 94/min.  BMI is 37 kg/m².  The abdomen is obese, soft, and nontender, with no rebound or guarding.  Pelvic examination shows dark red blood in the posterior vaginal vault and a 3-cm friable mass on the ectocervix and extending laterally.  The lesion is actively bleeding.  Hemoglobin is 10.2 g/dL.  Pelvic ultrasonography reveals a thin endometrial stripe and no adnexal masses.  Which of the following is a risk factor for this patient's condition?

A 22-year-old woman comes to the clinic for a routine examination.  The patient is well and has no concerns.  She is a gymnast, and her main activity is the balance beam.  Three months ago, she sustained a vulvar contusion during a competition but otherwise she has been healthy.  The patient is sexually active with 2 male partners and uses an intrauterine device for contraception.  She does not use tobacco, alcohol, or illicit drugs.  Examination shows a mobile, soft, nontender, flesh-colored, 2-cm cystic mass at the 4 o'clock position at the base of the left labium majus.  Which of the following is the most likely diagnosis for this patient?

Six days after a cesarean delivery, a 25-year-old woman comes to the emergency department with nausea, vomiting, and abdominal pain.  The patient developed a sharp, right-sided abdominal pain 12 hours ago that has been increasing in severity, and she now has persistent nausea and vomiting.  She has had no sick contacts, hematemesis, dysuria, or hematuria.  Her last bowel movement was yesterday, with no blood in the stool.  The patient has no chronic medical conditions and has had no surgeries other than the recent cesarean delivery.  Temperature is 38.3 C (101 F), blood pressure is 110/70 mm Hg, pulse is 98/min, and respirations are 18/min.  The surgical incision has minimal serosanguineous discharge with no associated fluctuance or mass.  Abdominal examination shows tenderness over the right lower quadrant.  There is guarding and rebound tenderness.  Bowel sounds are decreased.  Speculum examination shows no purulent discharge.  The uterus is 14-week sized and nontender.  Hemoglobin is 9.6 g/dL and leukocyte count is 21,000/mm³.  Which of the following is the most likely diagnosis in this patient?

A 37-year-old woman comes to the office for evaluation of infertility.  She and her 39-year-old husband have not been able to conceive after 18 months of unprotected and frequent intercourse.  Menstrual cycles occur every 28 days, last 5 days, and have heavy bleeding and cramping on the first day.  The patient had a miscarriage at age 27 that required a dilation and curettage.  The couple had another spontaneous pregnancy 6 years later that resulted in an uncomplicated term vaginal delivery.  The patient feels well and has no medical conditions.  She has never had a sexually transmitted infection.  She does not use tobacco, alcohol, or illicit drugs.  The patient is an aerobics instructor and teaches two 60-minute classes daily.  Blood pressure is 120/80 mm Hg and pulse is 84/min.  BMI is 23 kg/m².  She has no thyromegaly.  Breast examination shows no palpable masses, axillary lymphadenopathy, or expressed nipple discharge.  Pelvic examination reveals normal external genitalia, a well-rugated vagina, a mobile uterus, and normal ovaries.  Which of the following is the most likely underlying cause of this couple's failure to conceive?

A 31-year-old woman, gravida 1 para 1, is seen in the hospital on postoperative day 2 due to lower abdominal pain, chills, and pain with sitting.  The patient initially planned to have a home delivery but came to the hospital when she had no contractions a day after spontaneous rupture of membranes.  After a 26-hour induction of labor, she had a primary cesarean delivery for arrest of descent.  The patient has asthma controlled with a rescue inhaler.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 38.3 C (100.9 F), blood pressure is 100/60 mm Hg, and pulse is 96/min.  Cardiopulmonary examination is normal.  The breasts are full but have no erythema or fluctuant masses.  The uterine fundus is firm and tender to palpation.  There is scant serosanguineous drainage from the lower aspect of the incision.  Pelvic examination shows a small amount of blood on the perineal pad with mildly malodorous discharge.  Bilateral lower extremities are symmetric with minimal pedal edema.  Which of the following is the best regimen for treating this patient's condition?

Three days after an uncomplicated cesarean delivery, a 23-year-old woman, gravida 1 para 1, is evaluated on the postpartum floor due to bilateral breast pain and fatigue.  The patient has been attempting to breastfeed but has had difficulty getting the infant to latch, requiring her to supplement with formula.  The patient's pregnancy was complicated by insulin-controlled gestational diabetes mellitus.  She had a progestin-containing subcutaneous implant placed a day ago for contraception.  Temperature is 37.4 C (99.4 F), blood pressure is 130/70 mm Hg, and pulse is 100/min.  Bilateral breasts are full, erythematous, and diffusely tender.  There is no axillary lymphadenopathy.  The uterine fundus is firm, nontender, and palpable 3 cm below the umbilicus.  Which of the following is the most likely diagnosis in this patient?

A 7-year-old girl is brought to the office due to breast development that has occurred over the past 6 months.  Her parents are concerned that she appears older than her classmates.  An episode of vaginal spotting 2 months ago resolved after 3 days.  She has had no headaches or visual changes.  The patient has no chronic medical conditions and has had no surgeries.  She takes no daily medications and has no allergies.  Height and weight are at the 98th and 70th percentiles, respectively.  Physical examination shows Tanner stage 3 breast development.  The abdomen is soft and moderately distended and a palpable fullness is present in the pelvic region.  Bone age is advanced at age 10.  Pelvic ultrasound reveals a large right-sided adnexal mass.  Which of the following is the most likely diagnosis in this patient?

A 37-year-old woman, gravida 2 para 0 aborta 1, at 8 weeks gestation comes to the emergency department due to 2 days of light vaginal spotting and mild abdominal cramping.  She has not passed large clots or had heavy bleeding.  The patient has infertility issues and this pregnancy resulted from an ovulation induction.  Her only prior pregnancy was an ectopic pregnancy 10 years ago that was treated with methotrexate.  She has no other medical conditions.  The patient takes a daily prenatal vitamin and does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 116/64 mm Hg and pulse is 76/min.  BMI is 26 kg/m².  Speculum examination shows a closed cervix and scant blood in the vagina.  Bimanual examination reveals a 10-week-sized nontender uterus and no adnexal masses or tenderness.  Two 8-week intrauterine gestations with normal heartbeats are seen on ultrasound.  There is a single placenta and no dividing intertwin membrane.  Which of the following is the most likely diagnosis in this patient?

A 5-year-old girl is brought to the emergency department for evaluation of vaginal discharge.  She has had malodorous vaginal discharge and a small amount of vaginal bleeding for about a week.  Her mother called the patient's primary care provider and was told to stop letting the child take bubble baths; however, the symptoms have not improved.  Aside from the discharge, the girl is acting normally.  The patient was toilet trained at age 2 and has had no episodes of incontinence.  She started kindergarten a month ago.  The mother says that she has no fever, abdominal pain, or dysuria.  On examination, the labia appear normal.  Purulent, malodorous vaginal discharge is noted.  Visual inspection with the child in knee-chest position shows a whitish foreign body inside the vaginal introitus.  Which of the following is the best next step in management of this patient?

A 42-year-old, nulliparous woman comes to the office due to abnormal uterine bleeding.  The patient previously had regular monthly menses but, for the last 8 months, has had irregular episodes of bleeding and spotting that last 1-5 days.  She initially attributed this irregular bleeding to stress but is now having abdominal bloating and daily breast tenderness.  The patient has no chronic medical conditions and her Pap test 2 years ago was normal.  She does not use tobacco, alcohol, or illicit drugs.  The patient recently married and is hoping to conceive within the next several months.  Vital signs are normal.  BMI is 30 kg/m².  Breast examination shows bilateral diffuse tenderness and no masses.  There is fullness in the left lower quadrant of the abdomen with no rebound or guarding.  Pelvic examination shows a large, nontender left adnexal mass.  A urine pregnancy test is negative.  Pelvic ultrasound reveals a 10-cm, complex left ovarian mass and an irregular endometrial stripe.  Which of the following is the best next step in management of this patient?

A 34-year-old woman, gravida 2 para 2, is evaluated on the postpartum floor for nausea and lightheadedness.  The patient developed these symptoms when she tried to ambulate to the bathroom, forcing her to immediately lie down.  Earlier today, she underwent a repeat cesarean delivery at 39 weeks gestation; she is taking scheduled NSAIDs for incisional pain.  The patient is fatigued and feels like she can barely keep her eyes open.  She has no chronic medical conditions and takes no daily medications.  Blood pressure is 80/50 mm Hg, pulse is 124/min, and respirations are 18/min.  The patient appears pale and has cold skin.  The uterine fundus is firm at the umbilicus, and the abdomen is tender but has no increased bleeding from the incision site.  On pelvic examination, there is minimal lochia and no clots.  Which of the following is the best next step in management of this patient?

A 29-year-old woman, gravida 1 para 0, at 30 weeks gestation comes to the office for a routine prenatal visit.  For the past week, the patient has had increasing pruritus that has been most severe on her palms.  She has tried using oatmeal baths and lotion, but the pruritus has continued.  The patient also has nausea and difficulty sleeping due to pruritus and increasing back pain.  She now takes diphenhydramine and acetaminophen nightly to help her sleep.  The patient has chronic hypertension that has been well controlled during this pregnancy.  Blood pressure is 138/86 mm Hg and pulse is 76/min.  Fundal height is 30 cm.  Fetal heart rate is 150/min.  There are multiple excoriations on the abdomen and thighs.  The remainder of the examination is normal.  Laboratory results are as follows: Which of the following is the best next step in management of this patient?