Exam 5: Obstetrics & Gynecology

A 29-year-old woman with type 1 diabetes mellitus comes to the office due to increasing fatigue and irritability.  The symptoms started 2 weeks after the patient developed an upper respiratory infection.  The cough and rhinorrhea have improved, but she continues to have fatigue and has lost 7 kg (15.43 lb) over the past month.  The patient had an uncomplicated delivery 2 months ago and is exclusively formula-feeding her infant.  Blood pressure is 148/72 mm Hg, pulse is 98/min, and respirations are 16/min.  BMI is 26 kg/m².  The thyroid is symmetrically enlarged and nontender.  Cardiopulmonary examination is unremarkable.  The abdomen is soft and nontender.  A hand tremor is present.  TSH level is low, and free T3 and T4 levels are high.  There is low uptake on a radioactive iodine uptake scan.  Which of the following is the most likely cause of this patient's symptoms?

A stillborn male fetus is brought to autopsy for evaluation.  The fetus was delivered at approximately 36 weeks gestation to a 26-year-old woman, gravida 5 para 1 aborta 3, who received no prenatal care.  The mother came to the hospital in active labor; an ultrasound on admission revealed no fetal cardiac activity.  She had an uncomplicated vaginal delivery of the stillborn fetus, weight 2.2 kg (4.9 lb).  The mother had a prior healthy female infant via normal vaginal delivery at 39 weeks gestation and 3 subsequent elective terminations of pregnancy.  She does not use tobacco, alcohol, or illicit drugs.  The fetus has short, bent extremities.  X-ray reveals multiple limb fractures and a hypoplastic thoracic cavity.  Which of the following is the most likely cause of these fetal abnormalities?

A 36-year-old woman, gravida 1 para 0, at 30 weeks gestation comes to the office for a prenatal visit.  The patient is a landscape designer and has noticed skin changes over the past few weeks because she has spent more time in the sun.  She has progressive darkening of the face, particularly over the nasal bridge and cheeks, and increasing freckles on the upper and lower extremities.  The patient also has increased hair on the upper lip and itching over the stretch marks on the abdomen and chest.  On examination, there is hyperpigmentation over the cheeks and nasal bridge that spares the nasolabial folds.  The upper lip has multiple dark terminal hairs.  The abdomen is gravid and nontender with multiple erythematous papules within the striae on the abdomen and chest.  The chest also has multiple blanching, 1- to 2-cm spider angiomas.  There is a black-tan nevus with irregular borders on the lower extremity and multiple freckles on bilateral extremities.  The remainder of the examination is unremarkable.  Which of the following findings is most concerning in this patient?

A newborn male infant is evaluated in the neonatal intensive care unit for growth restriction.  The infant was born to a 29-year-old woman, gravida 3 para 0 aborta 2, who did not receive prenatal care.  The mother presented in labor at approximately 38 weeks gestation and had a forceps-assisted vaginal delivery due to fetal heart rate abnormalities.  Apgars were 6 and 8 at 1 and 5 minutes, respectively.  Weight is 2.5 kg (5.5 lb).  Physical examination shows microcephaly, a wide anterior fontanelle, cleft palate, and hypoplasia of the distal phalanges.  Further evaluation of the mother would most likely reveal a history of which of the following?

A 52-year-old woman comes to the office due to vulvar pruritus for the past week.  The patient also reports frequent urination, dysuria, and nocturia.  She has had similar symptoms 4 times in the past 3 months.  Each time previously, over-the-counter suppositories have provided symptom relief.  However, symptoms recur within the next 1-2 weeks.  The patient had irregular, heavy periods that improved after insertion of a progestin-containing intrauterine device.  She has no other medical conditions or previous surgeries.  Routine screening including a colonoscopy, mammogram, and Pap test was normal 2 years ago.  She is sexually active and in a long-term, monogamous relationship.  The patient does not use tobacco and drinks alcohol socially.  Blood pressure is 130/80 mm Hg and pulse is 84/min.  BMI is 25 kg/m².  Pelvic examination reveals vulvar erythema and multiple excoriations.  There is thick, white discharge throughout the vaginal vault.  No cervical or vaginal lesions are noted.  Microscopy reveals pseudohyphae and no motile organisms.  Which of the following additional testing should be performed in this patient?

A 58-year-old woman, gravida 2 para 2, comes to the office for evaluation of increased urinary frequency and painful urination.  The patient developed these symptoms 2 days ago, and they did not improve despite increasing fluid intake and voiding regularly.  She has had 2 other episodes of acute simple cystitis in the past 8 months, which resolved with antibiotics.  The patient underwent menopause at age 53 and has had no episodes of postmenopausal bleeding.  BMI is 28 kg/m².  Vital signs are normal.  Physical examination shows mild suprapubic tenderness and no costovertebral tenderness.  Pelvic examination shows thin vulvar tissue but no excoriations or lesions.  Urinalysis is positive for leukocyte esterase and nitrites.  The patient is prescribed a course of antibiotics and is asymptomatic a week later.  Which of the following is the best next step in management of this patient's symptoms?

A 22-year-old woman comes to the office for an initial prenatal visit.  The patient is 19 weeks gestation by her last menstrual period.  She emigrated from India 3 weeks ago and, as found on her medical screening, had a positive interferon gamma release assay.  The patient otherwise has no medical conditions and no fever, cough, or weight loss.  Temperature is 36.7 C (98.1 F), blood pressure is 100/70 mm Hg, and pulse is 70/min.  BMI is 23 kg/m².  There is no lymphadenopathy.  The lungs are clear to auscultation.  The uterus is palpated just below the umbilicus.  Transabdominal ultrasound shows a singleton intrauterine pregnancy at 19 weeks gestation and a normal fetal heart rate.  Routine prenatal laboratory results, including HIV screening, are normal.  Which of the following is the best next step in management of this patient?

A 49-year-old woman comes to the office for evaluation of decreased interest in sexual intercourse for the past 6 months.  The patient has been married for 24 years and states that this is becoming a problem in her marriage.  She has had a decreased libido for the past 6 months, and more recently, is also having pain with intercourse.  The last few attempts at intercourse were so painful that the patient is now avoiding all sexual intimacy.  Her only surgery was a laparoscopic hysterectomy at age 29 for severe endometriosis.  She takes no daily medications and drinks a glass of wine most nights.  Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, and pulse is 78/min.  BMI is 23 kg/m².  On pelvic examination, the vulva has scant pubic hair, and the vulvovaginal mucosa is pale, with clear vaginal discharge.  The cervix and uterus are surgically absent, and the ovaries are small and nontender bilaterally.  The remainder of the examination is unremarkable.  Which of the following is most likely to establish the diagnosis in this patient?

A 34-year-old woman, gravida 1 para 1, comes to the office for postpartum follow-up.  She had a vaginal delivery 6 weeks ago that was complicated by severe postpartum bleeding requiring aggressive volume resuscitation and transfusion of 5 units of packed red blood cells.  Since the delivery, the patient has been very fatigued with poor appetite.  She is "very concerned" about having little energy to bond with her child; her family has been helping with the baby.  The patient has been formula feeding her infant due to lack of milk production.  Her prepregnancy weight was 63.5 kg (140 lb), weight at delivery was 82.5 kg (182 lb), and current weight is 56.2 kg (124 lb).  Blood pressure is 90/69 mm Hg and pulse is 88/min.  Examination shows a well-healed perineal laceration scar.  Which of the following is the most likely cause of this patient's current symptoms?

A 26-year-old woman comes to the office to discuss a different form of contraception.  The patient recently started combination oral contraceptive pills but frequently forgot to take them every day and discontinued them 3 months ago.  She has regular monthly menses with 5 days of moderate bleeding and 2 days of mild cramping.  The patient typically has bloating and breast soreness 2-3 days prior to the onset of menses that resolve on the first day of her period.  She has had 2 urinary tract infections in the past year and takes no daily medications.  The patient is sexually active with a male partner and has no history of sexually transmitted infections.  She would like to have children but not for several years.  Vital signs are normal.  BMI is 22 kg/m².  On pelvic examination, the uterus has an irregular contour.  Pelvic ultrasound reveals a divergent endometrial cavity with an indented fundus and normal ovaries bilaterally.  Urine pregnancy testing is negative.  Which of the following is the best contraceptive option for this patient?

A 27-year-old woman, gravida 2 para 1, at 10 weeks gestation comes to the office for an initial prenatal visit.  The patient has had no cramping or vaginal bleeding.  She was not expecting this pregnancy because she had an uncomplicated term vaginal delivery 6 months ago and breastfed for the first 4 months postpartum.  She is taking a daily prenatal vitamin and has no chronic medical conditions.  Blood pressure is 126/80 mm Hg and pulse is 76/min.  BMI is 24 kg/m².  The abdomen is soft, nontender, and nondistended.  Pelvic ultrasound reveals a singleton intrauterine pregnancy at 10 weeks gestation with a fetal heart rate of 165/min.  Hemoglobin is 10.4 g/dL.  This patient is at increased risk for which of the following pregnancy-related complications?

A 16-year-old girl is brought to the office by her mother for evaluation of painful menstrual periods.  Since menarche, the patient has had increasingly painful menses that now cause her to miss track practice a few days each month.  Menstrual periods occur every 25-27 days with 5 days of moderate bleeding.  For the first 4 days of her menses, the patient has cramping pain in the right lower quadrant that radiates to the right flank.  The pain improves with ibuprofen and a heating pad.  She has fatigue and nausea that start the day prior to menses and resolve when the pain stops.  The patient has no chronic medical conditions and has had no surgeries.  She is not sexually active.  Her last menstrual period was 3 weeks ago.  Blood pressure is 114/70 mm Hg and pulse is 68/min.  BMI is 19 kg/m².  Pelvic examination is deferred but physical examination is unremarkable.  Which of the following findings is most concerning for a secondary cause of dysmenorrhea in this patient?

A 27-year-old woman, gravida 1 para 0, comes to the office for an initial prenatal visit.  The patient is uncertain when her last menstrual period occurred, but she has had daily nausea and vomiting for the last 2 months.  She has had no vaginal bleeding or pelvic pain.  The patient has no chronic medical conditions and has had no surgeries.  She takes a daily prenatal vitamin.  Vital signs are normal.  Abdominal examination reveals a gravid uterus that is nontender, and the fundus is just below the umbilicus.  Ultrasound shows 2 intrauterine fetal poles measuring 14 weeks gestation with heart rates of 150/min and 155/min.  Cervical length is 4.5 cm.  Which of the following is the best next step in management of this patient?

A 17-year-old girl comes to the office for evaluation of heavy menstrual bleeding.  She typically has 4 days of heavy bleeding, often requiring 5 or 6 pads a day.  The patient awakens multiple times a night to change her pad and often soaks through her clothing and bed sheets.  She has mild cramping on the first 2 days of her menses that is controlled by ibuprofen but has no intermenstrual bleeding or chronic pelvic pain.  Menarche was at age 12; menses were irregular the first couple years but are now regular and occur every 26 days.  The patient has no chronic medical conditions and has had no surgery.  She has a male partner and uses condoms for contraception.  Vital signs are normal.  BMI is 23 kg/m².  On bimanual examination, the uterus is small and mobile; no adnexal mass or tenderness is present.  Laboratory results are as follows: Urine pregnancy test is negative.  Which of the following is the most likely cause of this patient's heavy menstrual bleeding?

A 30-year-old woman, gravida 2 para 1, at 28 weeks gestation is evaluated in the emergency department for abdominal pain.  The patient's pain is severe and began abruptly this morning in the midepigastrium, but now radiates to the entire abdomen.  She has had nausea, but no vomiting, vision changes, headache, vaginal bleeding, or leakage of fluid.  The patient has had no prenatal care during this pregnancy and her prior pregnancy ended in a cesarean delivery for failed induction of labor.  She has a history of tobacco use, polysubstance drug use, and peptic ulcer disease.  Temperature is 37 C (98.7 F), blood pressure is 150/94 mm Hg, and pulse is 118/min.  The patient is in distress and is sweating profusely.  The abdomen is soft and gravid.  The uterine contour is smooth, rigid, and diffusely tender.  Tocometry shows contractions every 1-2 minutes.  Which of the following is the most likely cause of this patient's clinical presentation?

A 33-year-old woman, gravida 2 para 1, at 29 weeks gestation comes to the emergency department due to right-sided abdominal pain.  The pain developed yesterday morning, initially resolved with acetaminophen, but has become increasingly severe over the past few hours.  The patient now has continuous nausea and has vomited twice.  She has not had a bowel movement in 2 days.  She has had uterine contractions, but no vaginal bleeding or leakage of fluid.  The patient has no chronic medical conditions, and her only surgery was a cesarean delivery for failure to progress.  Temperature is 37.2 C (99 F), blood pressure is 130/80 mm Hg, and pulse is 118/min.  BMI is 30 kg/m².  Fetal heart rate monitoring shows a baseline of 160/min and no decelerations.  Tocodynamometry shows regular uterine contractions every 1-2 minutes.  The abdomen is tender to palpation, but has no rebound or guarding.  The uterus has fundal tenderness and an associated firm, tender mass.  On pelvic examination, the cervix is closed.  Leukocyte count is 19,000/mm³.  Urinalysis is normal.  Which of the following is the most likely diagnosis in this patient?

A 16-year-old girl comes to the emergency department due to left lower quadrant abdominal pain that suddenly started overnight.  The pain does not radiate and is 5/10 in severity.  The patient does not report fever, vomiting, dysuria, diarrhea, or vaginal bleeding.  She is sexually active with her boyfriend and is using condoms with spermicide for contraception.  Her last menstrual period was 2 weeks ago.  Menses occurs every 28 days with 5 days of moderate bleeding and some associated cramping on the first 2 days.  Temperature is 37.2 C (99 F), blood pressure is 110/66 mm Hg, and pulse is 80/min.  BMI is 22 kg/m².  Abdominal examination shows mild left lower quadrant tenderness with no rebound.  Pelvic examination shows a small, anteverted uterus with tenderness over a slightly enlarged left adnexa; the right adnexa is normal.  Urine pregnancy test is negative.  Pelvic ultrasound shows the left ovary with a 3-cm cyst with several subcentimeter cysts in the periphery.  There is normal Doppler blood flow with a small amount of free fluid in the posterior cul-de-sac.  Which of the following is the most likely diagnosis for this patient?

A 32-year-old nulliparous woman comes to the office for evaluation of heavy menstrual bleeding.  The patient has had progressively heavier menstrual periods for the past few years; she now has a menstrual period every month that consists of 6 days of heavy bleeding and often bleeds through her clothes.  The patient is sexually active and uses condoms for contraception.  She is planning on becoming pregnant in the next year and has started taking a daily prenatal vitamin.  The patient has occasional migraines with aura that cause her to miss work a few days a year; she otherwise is healthy and has had no surgeries.  She does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 110/74 mm Hg, pulse is 78/min, and BMI is 29 kg/m².  Pelvic examination shows an enlarged, 10-week-sized uterus.  Urine pregnancy test is negative.  Transvaginal ultrasound reveals an anteverted uterus with multiple submucosal fibroids.  The endometrium is thickened and has multiple areas impinged by the fibroids.  Which of the following is the best next step in management of this patient's heavy menstrual bleeding?

A 36-year-old woman, gravida 3 para 2, at 29 weeks gestation comes to labor and delivery due to clear vaginal discharge.  The patient has had increasing nonmalodorous discharge for the past 2 days with no associated vaginal bleeding or contractions.  She has no vulvovaginal pruritus, dysuria, or hematuria.  The patient has been treated multiple times during this pregnancy for symptomatic bacterial vaginosis but has had no other complications.  She has no chronic medical conditions.  Her prior pregnancies ended in term vaginal deliveries.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, and pulse is 68/min.  Fetal heart rate is 130/min.  The uterus is nontender and has no palpable contractions.  A speculum examination shows clear fluid in the posterior fornix that increases with Valsalva.  Microscopy shows ferning and squamous epithelial cells with no stippling.  Ultrasound shows a cephalic fetus, an anterior placenta, and minimal amniotic fluid with an amniotic fluid index of 3 cm.  This patient is at increased risk for which of the following complications?

A 16-year-old girl comes to the office for emergency contraception.  She had unprotected sexual intercourse last night and is worried that she may become pregnant.  Her last menstrual period was 1 week ago, and she has had regular menses since menarche.  Physical examination is normal and urine pregnancy test is negative.  After various emergency contraceptive options are discussed, the patient asks for a pill option and that her parents not be notified about this visit.  In most states, which of the following is the most appropriate management of this patient?