Obstetrics & Gynecology

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 OBSTETRICS AND GYNECOLOGY
General Principles 1%−5%
Gynecology 45%−49%
Promoting Health and Health Maintenance 5%−10%
Understanding Mechanisms of Disease 15%−20%
Establishing a Diagnosis 15%−20%
Applying Principles of Management 5%−10%
Obstetrics 45%−49%
Promoting Health and Health Maintenance 5%−10%
Understanding Mechanisms of Disease 10%−15%
Establishing a Diagnosis 15%−20%
Applying Principles of Management 10%−15%

1. A 57-year-old woman comes to the physician 1 week after 3. A 22-year-old woman comes to the physician because of a 2-
noticing a mass in her left breast during breast self- day history of pain with urination, intense vaginal itching, and
examination. Menopause occurred 6 months ago. She was a thick discharge. She has no history of serious illness. She is
receiving estrogen therapy but discontinued it 6 weeks ago; sexually active and uses an oral contraceptive. Her
she has had no menopausal symptoms. There is no family temperature is 37°C (98.6°F). Abdominal examination shows
history of breast cancer. Examination shows a 2-cm, no abnormalities. Genitourinary examination shows erythema
palpable, nontender, mobile mass in the upper outer of the vulva and vagina with an odorless curd-like discharge.
quadrant of the left breast; no nipple discharge can be The cervix appears normal. Bimanual examination shows no
expressed. Examination of the right breast shows no abnormalities. The pH of the vaginal discharge is 4. Wet
abnormalities. Which of the following is the most mount preparations of the discharge with saline and with
appropriate next step in management? KOH are obtained. The saline slide shows mature squamous
epithelial cells, and the KOH slide shows multiple budding
(A) Reexamination in 3 months yeasts with pseudohyphae. Which of the following is the most
(B) Mammography likely diagnosis?
(C) CT scan of the chest
(D) Ductal lavage (A) Bacterial vaginosis
(E) Mastectomy (B) Candidiasis
(C) Chlamydia trachomatis infection
(D) Lichen sclerosus
2. A 27-year-old nulligravid woman has had severe pain with (E) Scabies
menses that has caused her to miss at least 2 days of work (F) Trichomoniasis
during each menstrual cycle for the past year. She has
occasional pain during sexual intercourse. She weighs 50 kg
(110 lb) and is 160 cm (5 ft 3 in) tall; BMI is 20 kg/m2. 4. A 27-year-old nulligravid woman and her husband have been
Pelvic examination shows a normal-appearing vulva and unable to conceive for 12 months. She has never used
vagina. The cervix is pink with minimal endocervical gland contraception. Menses occur at 28-day intervals, and her last
eversion. The uterus is normal in size. The left ovary is menstrual period was 2 weeks ago. She had a single episode
2 × 3 cm; the right is 4 × 6 cm. Which of the following is the of pelvic inflammatory disease 4 years ago and was treated
most likely cause of her condition? with oral antibiotics. Vaginal examination shows no
abnormalities. Cervical cultures are normal. Which of the
(A) Chronic appendicitis following is the most appropriate next step in diagnosis?
(B) Endometriosis
(C) Pelvic congestion syndrome (A) Reevaluation in 6 months
(D) Polycystic ovarian syndrome (B) Ultrasonography of the abdomen
(E) Premenstrual syndrome (C) Sperm penetration assay
(D) Hysterosalpingography
(E) Endometrial biopsy

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5. A 30-year-old woman, gravida 2, para 1, comes for her first 9. A 32-year-old nulligravid woman comes to the physician
prenatal visit at 26 weeks’ gestation. Uterine size is greater because of a 6-week history of persistent foul-smelling
than expected for dates. Ultrasonography shows fetal hydrops. vaginal discharge and vaginal itching. Her symptoms have
Which of the following is the most appropriate next step in not improved despite 2 weeks of treatment with over-the-
diagnosis? counter antifungal medications and fluconazole. She has
been sexually active and monogamous with her boyfriend
(A) Maternal HIV antibody test during the past year, and they use condoms consistently.
(B) Maternal Rh status with antibody screening Examination shows excoriated labia and erythematous
(C) Cervical and urine cultures for group B vaginal mucosa. There is a frothy, watery-gray discharge in
streptococcus the posterior vaginal vault. A wet mount preparation of the
(D) MRI of the fetus discharge shows numerous multi-flagellated organisms the
(E) Amniocentesis for measurement of α- size of erythrocytes. Which of the following is the most
fetoprotein concentration likely causal organism?

(A) Haemophilus ducreyi

6. A 42-year-old woman, gravida 2, para 2, comes to the (B) Neisseria gonorrhoeae
physician because of increasingly frequent loss of urine (C) Pseudomonas aeruginosa
during the past year. She has loss of urine when she coughs, (D) Treponema pallidum
sneezes, exercises, or plays with her children. Her (E) Trichomonas vaginalis
incontinence is never preceded by a sudden urge to void, and
she does not have loss of urine at night. Her children were
born after uncomplicated vaginal deliveries. She has no 10. An asymptomatic 24-year-old primigravid woman at
history of other hospital admissions or serious illness. She 36 weeks’ gestation comes for a routine prenatal visit. A
takes no medications. Abdominal examination shows no grade 2/6, systolic ejection murmur is heard at the upper
abnormalities. The external genitalia, vagina, and cervix left sternal border. The S2 varies with inspiration, and the
appear normal. The uterus and adnexa are normal to pulmonic component is soft; diastole is clear. Which of the
palpation. There is loss of a small amount of urine with following is the most likely diagnosis?
Valsalva maneuver. Her postvoid residual volume is 50 mL.
Urinalysis shows no abnormalities. Which of the following (A) Anomalous pulmonary venous return
is the most likely diagnosis? (B) Atrial septal defect
(C) Flow murmur
(A) Overactive bladder with incontinence (D) Patent ductus arteriosus
(B) Overflow incontinence (E) Pulmonary valve stenosis
(C) Stress incontinence
(D) Urinary tract infection
(E) Vesicovaginal fistula 11. A 42-year-old woman, gravida 3, para 3, comes to the
physician because she has not had a menstrual period for
2 months. She reports that she had an episode of spotting
7. During a routine examination, a 25-year-old woman 3 weeks ago. She has had no other symptoms. She has no
expresses concern about her risk for ovarian cancer because history of abnormal Pap smears; her last Pap smear was
her mother died of the disease. Which of the following is the 10 months ago. She is sexually active with her husband and
most appropriate course of action? uses condoms. She is 163 cm (5 ft 4 in) tall and weighs
72 kg (160 lb); BMI is 28 kg/m2. On physical examination,
(A) Reassure her that ovarian cancer is not the abdomen is nontender to palpation. Pelvic examination
hereditary shows a slightly enlarged uterus; there are no palpable
(B) Obtain a more detailed family history of cancer adnexal masses. Which of the following is the most
(C) Recommend a diet high in beta-carotene appropriate next step in management?
(D) Annual CT scans of the abdomen
(E) Prophylactic oophorectomy (A) Measurement of serum β-hCG concentration
(B) Measurement of serum thyroid-stimulating
hormone concentration
8. At her 6-week postpartum visit, an 18-year-old woman, (C) CT scan of the pelvis
gravida 1, para 1, tells her physician that she has a pinkish (D) Oral contraceptive therapy
vaginal discharge that has persisted since her delivery, (E) Endometrial biopsy
although it is decreasing in amount. On physical
examination, the uterus is fully involuted and there are no
adnexal masses. Which of the following is the most
appropriate next step in management?

(A) Reassurance that this is normal

(B) Measurement of serum prolactin concentration
(C) Quantitative β-hCG test
(D) Administration of amplicillin
(E) Dilatation and curettage

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12. A 57-year-old woman comes to the physician for a routine 15. A 19-year-old primigravid woman at 8 weeks’ gestation is
health maintenance examination. She takes a multivitamin brought to the emergency department because of light
supplement and calcium (500 mg/d). She has followed a vaginal bleeding and mild lower abdominal cramps during
vegan diet for 30 years. She exercises daily for 30 minutes. the past 8 hours. Her temperature is 37°C (98.6°F), pulse is
She does not smoke cigarettes or drink alcohol. There is a 84/min, respirations are 18/min, and blood pressure is
family history of osteoporosis. She is 168 cm (5 ft 6 in) tall 110/70 mm Hg. Abdominal examination shows no
and weighs 60 kg (132 lb); BMI is 21 kg/m2. Examination tenderness or masses; bowel sounds are normal. On pelvic
shows no abnormalities. Bone densitometry shows examination, there is old blood in the vaginal vault and at
evidence of low bone density. She prefers not to be treated the closed cervical os. The uterus is consistent in size with a
with medications. The physician recommends that the 6- to 8-week gestation. Transvaginal ultrasonography
patient increase her daily dose of the calcium supplement. shows an intrauterine pregnancy. A fetal heartbeat is seen.
The most appropriate next step in management is Which of the following is the most appropriate next step in
supplementation with which of the following? management?

(A) Fish oil (A) Discharge home for observation

(B) Magnesium (B) Oral administration of misoprostol
(C) Vitamin C (C) Intramuscular administration of methotrexate
(D) Vitamin D (D) Operative laparoscopy
(E) Zinc (E) Dilatation and curettage

13 A 2778-g (6-lb 2-oz) male newborn is born at 37 weeks’ 16. A 16-year-old girl is brought to the emergency department
gestation to a 27-year-old woman, gravida 3, para 2, after 6 hours after the onset of moderate lower abdominal cramps
an uncomplicated labor and delivery. The mother has no and intermittent nausea. She has not vomited during this
medical insurance and did not receive prenatal care. She time. She says that her last menstrual period was 2 months
says she did not have any health problems during ago, but she has had intermittent bleeding since then,
pregnancy, but she continued to consume two bottles of including spotting for the past 2 days. Menarche was at the
beer weekly during her pregnancy. She does not take any age of 15 years. Menses occur at irregular 25- to 45-day
medications, vitamins, or herbal supplements. Her diet intervals. She is sexually active and uses condoms
consists mostly of rice and beans. Examination of the inconsistently. Her temperature is 38.1°C (100.6°F), pulse
newborn shows spina bifida. Which of the following is 94/min, respirations are 22/min, and blood pressure is
measures during the mother’s pregnancy is most likely to 120/80 mm Hg. Examination shows a soft abdomen with
have prevented this child’s deformity? lower quadrant tenderness, especially on the right. Bowel
sounds are normal. Pelvic examination shows scant vaginal
(A) Abstinence from alcohol bleeding and a palpable, tender right adnexal mass. The
(B) Increase dietary intake of omega-3 fatty acids cervix appears normal. There is no cervical motion
(C) Glucose tolerance test tenderness. Which of the following is the most appropriate
(D) Screening for group B streptococcal infection next step in management?
(E) TORCH titer screening
(F) Folic acid supplementation (A) Complete blood count
(B) Measurement of serum β-hCG concentration
(C) Abdominal x-ray
14. Two hours after vaginal delivery at term of a 3062-g (6-lb (D) Ceftriaxone and azithromycin therapy
12-oz) newborn, a 32-year-old woman, gravida 3, para 3, (E) Exploratory laparoscopy
has the onset of heavy vaginal bleeding. Labor was
augmented with oxytocin because of a prolonged first stage
and required forceps delivery over a midline second-degree 17. A 13-year-old girl is brought to the physician because of a
episiotomy. The abdomen is soft and nontender. 1-year history of intermittent irregular vaginal bleeding; the
Examination shows a boggy uterus palpated 4 cm above the bleeding ranges from spotting to heavier than a normal
umbilicus. The perineum is intact. Which of the following menstrual period, occurs every 2 to 8 weeks, and lasts 10 to
is the most likely cause of this patient’s hemorrhage? 30 days. Examination shows a pink, well-rugated vagina
with no discharge; the cervix appears normal. The uterus is
(A) Disseminated intravascular coagulation 6 cm in length, regular in contour, and nontender. There are
(B) Episiotomy site bleeding palpable, normal-sized, nontender ovaries. Which of the
(C) Uterine atony following is the most appropriate pharmacotherapy to
(D) Uterine infection alleviate this patient’s symptoms?
(E) Uterine rupture
(A) Continuous low-dose estrogen
(B) Gonadotropin-releasing hormone agonist
(C) Oral contraceptives
(D) Tetracycline
(E) Thyroid hormone

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18. A previously healthy 25-year-old woman, gravida 2, para 2, 20. A 15-year-old girl is brought to the physician by her mother
comes to the emergency department because of a 3-day because she believes that her daughter has become sexually
history of painful swelling of her vaginal area. Her last active and wants her to use contraception. During an
menstrual period was 2 months ago. She is sexually active interview with the patient alone, she reports that she has
with one male partner and uses depot medroxyprogesterone become sexually active with one male partner over the past
for contraception. Her temperature is 38.4°C (101.2°F), 3 months. She and her partner use condoms consistently,
pulse is 96/min, respirations are 16/min, and blood pressure and she is not interested in any other form of contraception
is 125/82 mm Hg. Examination shows a 4-cm, exquisitely at this time. Menarche was at the age of 12 years, and
tender mass in the inferior aspect of the left labium minus. menses occur at regular 28-day intervals. She has had no
The swelling and tenderness prevent insertion of either a symptoms of sexually transmitted diseases. Examination
speculum or fingers into the vagina. Which of the following shows no abnormalities. In addition to counseling the
is the most likely diagnosis? patient about all contraceptive methods, which of the
following is the most appropriate next step?
(A) Bartholin gland abscess
(B) Chancroid (A) Do not inform the mother that her daughter
(C) Condylomata acuminata and her partner use condoms, but encourage
(D) Herpes simplex the daughter to communicate the
(E) Lymphogranuloma venereum information
(F) Primary syphilis (B) Inform the mother that her daughter and her
partner use condoms
(C) Inform the mother that her daughter is
19. A 22-year-old primigravid woman at 34 weeks’ gestation is protecting herself appropriately against
brought to the emergency department by ambulance after pregnancy, but do not mention what form of
being found unconscious by her husband. Paramedics contraception
report that she was having tonic-clonic movements that (D) Inform the mother that you have administered
have now stopped. Her last visit to the physician was depot medroxyprogesterone to the patient
2 weeks ago. Pregnancy had been uncomplicated. On (E) Inform the mother that you have given the
arrival, she is awake, lethargic, and mildly confused. She patient a prescription for an oral
says that she had a headache and did not feel well earlier in contraceptive
the day. She has no history of serious illness. Her only
medication is a prenatal vitamin. Her temperature is 37°C
(98.6°F), pulse is 80/min, respirations are 18/min, and
blood pressure is 170/110 mm Hg. Examination shows a
nontender, soft uterus consistent in size with a 34-week
gestation. Cranial nerves are intact. Motor function is
normal. Deep tendon reflexes are 3+. Which of the
following is the most likely diagnosis?

(A) Absence seizures

(B) Cerebral infarction
(C) Eclampsia
(D) Migraine
(E) Pheochromocytoma

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 Answer Key for Obstetrics and Gynecology Sample Questions

(Questions 1-20)

1. B 11. A
2. B 12. D
3. B 13. F
4. D 14. C
5. B 15. A
6. C 16. B
7. B 17. C
8. A 18. A
9. E 19. C
10. C 20. A