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A 24-year~old woman comes to the office with a breast lump that she noticed 2 days ago. The patient’s menstrual periods
are regular, occurring every 26 days with 2 days of heavy bleeding and 2 days of light flow. Her last menstrual period was 3
_ 10 weeks ago. She is sexually active and recently started using combined oral contraceptives. The patient is an avid jogger
11 and wears a sports bra almost daily. Family history includes a paternal aunt diagnosed with breast cancer at age 62.
. 12 Physical examination shows a 2—cm, firm, round, mobile mass in the superior outer quadrant of the right breast.
13
Item 1 of 2
. 14
15 Which of the following is the most likely diagnosis?
. 16
17 O A. Ductal carcinoma
. 1s
0 B. Fat necrosis

- 2” O C. Fibroadenoma
. 21
_ 22 O D. Fibrocystic changes
23 O E. Galactocele
. 24
25 O F. Intraductalpapilloma
. 26 .
27 O G. Lobular carcmoma
. 23

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Which of the following is the best method for confirming this patient's diagnosis?

O B. Lumpectomy
10
11
O C. Mammogram
12 O D. MRI
13
14 0 E. Ultrasound
15
16
17 Proceed 10 Men llem
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A 15-year~old girl comes to the office because her menses have not started. She feels embarrassed because her friends
have been “developing" and she looks younger than her peers The patient has no headaches, visual changes, abdominal

10 pain, or behavior changes. Her mother and maternal grandmother began menstruating around age 13. The patient is not
11 sexually active and is not on contraception. Height is <3rd percentile and weight is at the 20th percentile. Vital signs are
12 normal. Physical examination shows no breast development, normal external female genitalia, and Tanner stage 1 pubic
13 hair development. Urine B—hCG is negative.
14
15
Item 1 of2
16 Which of the following is the best next step in management of this patient?
17
18 O A. 17—hydroxyprogesterone level
19
20 0 B. Brain MRI
21
0 C. Pelvic ultrasound
22
23 O D. Reassurance and observation
24
0 E, Serum testosterone level
25
26 0 F. Serum TSH level
27
28
29 Proceed to Next Item
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The patient undergoes further evaluation with a pelvic ultrasound, which reveals a prepubertal uterus with small ovaries.
Laboratory findings are as follows:

FSH 60 mU/mL (normal: <40)

. 1o LH 30 mUimL
. 11
_ 12 Which of the following is the most likely underlying cause of the patient's condition?
. 13
_ 14 O A. Abnormal development of Mullerian duct

15 O B. Congenital absence of an X chromosome

. 16
17 O C. Complete androgen receptor insensitivity

' 18 O D_ Congenital GnRH deficiency

. 19
. 20 O E. Excess endogenous glucocorticoid production
. 21
O F. Severe calorie restriction and deficiency
. 22

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A 14—yearrold girl is brought to the office for a routine physical examination. The patient is starting high school and is going
to be on the school's cross-country team She has no concerns today. She is healthy and takes no daily medications.
Family history is significant for hypertension in her mother. The patient has not undergone menarche and is not sexually
active. Height and weight are at the 25th percentile for age. Physical examination shows sexual maturity rating (Tanner)
stage 1 breast development. The abdomen is soft, nontender, and nondistended. Asmall, nonreducible mass is palpated
in the lefl inguinal area. On pelvic examination, the external genitalia appear normal, and there is no pubic hair. The vagina
ends in a blind pouch; Sonogram confirms the absence of a uterus, cervix, and ovaries. Karyotype is 46,XY. Which of the
following is the best next step in management of this patient?

O A. Elective gonadectomy procedure

0 B. Estrogen therapy

0 C. Growth hormone therapy

0 D. Hymenectomy

O E. Low—dose corticosteroid therapy

0 F. Reassurance and no further treatment

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A20—yearrold woman comes to the office due to 6 hours of right lower quadrant abdominal pain. The pain came on
suddenly and has become intense and constant. She has been unable to eat or drink anything today due to nausea and
frequent vomiting. The patient has a history of a 6—cm right ovarian cyst noted on ultrasound last year. She has had 2
sexual partners in the last 4 years and has a history of chlamydial cervicitis. Her last menstrual period was 3 weeks ago.
During menses, the patient takes ibuprofen to relieve cramps on the first day of flow. Her temperature is 37.2 C (99 F),
blood pressure is 110/80 mm Hg, and pulse is 104/min. BMI is 30 kg/mz. Abdominal examination shows tenderness to
10
11 deep palpation in the right lower quadrant. Urine pregnancy test is negative. Leukocyte count is 8,000lmm3. Which of the
12 following is the most likely explanation for this patient's symptoms?
13
14 O A. Acute appendicitis
15
O B. Ectopic pregnancy
16
17 0 C. Endometn'osis
18
19
O D. Nephrolithiasis
20 O E. Ovarian torsion
21
22 O F. Tubo—ovan‘an abscess
23
24
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A36—yearrold woman, gravida 2 para 2, comes to the office due to 2 days of right breast pain. She has also had fever,
chills, muscle aches, and fatigue The patient had a spontaneous vaginal delivery 6 weeks ago and has been breastfeeding
her infant, Her husband has been feeding their baby pumped breast milk so that she can rest at night. The patient has no
chronic medical conditions and takes a daily multivitamin. Her mother was diagnosed with metastatic breast cancer at age
as

55. Temperature is 38.3 C (101.8 F), blood pressure is 110/60 mm Hg, and pulse is 84lmin. Physical examination shows a
5—cm area of erythema, induration, and tenderness at the upper outer quadrant of the right breast as well as right axillary
H
O

11 lymphadenopathy, There is no fluctuance. The left breast has no abnormalities, Which of the following is the best next
12 step in management of this patient?
13
14 O A. Discontinue breastfeeding and prescribe antibiotic therapy
15
_ Order breast ultrasound and mammography
16
17 . Order mammography and core needle biopsy
18
_ Perform incision and drainage and prescribe antibiotic therapy
19
20 _ Prescribe antibiotic therapy and continue breastfeeding
21
22 Recommend nonsteroidal anti-inflammatories and warm compresses only
23
24
25 Proceed to Next Item

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A 14—yearrold girl is brought to the office by her parents to discuss her menstrual periods. The patient was born at 25 weeks
gestation and spent 4 months in the neonatal intensive care unit. She has cerebral palsy and her mobility is limited due to
spasticity, She has no intellectual disability. The patient started menstruating 1 year ago and has monthly bleeding for 8
days with passage of clots. Her parents often need to change the patient's pads every hour during menses. She has mild
intermittent asthma and migraines with aura. On examination, the patient is wheelchair—bound and has multiple
u:

. 10
contractures in the bilateral lower extremities that cause minimal active and passive range of motion. The abdomen is soft,

ll nontender, and has no palpable masses. Pelvic examination is deferred. Which of the following is the best treatment option
. 12 for this patient?
13
. 14 O A. Combination oral contraceptives
15
O B. Copper—containing intrauterine device
. 16
17 0 C. Endometn'al ablation
. 18
O D. GnRH agonist therapy
19
. 20 0 E. Progestin—releasing subdennal implant
21
. 22
23
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A 19—yearrold nulligravid woman comes to the emergency department due to abnormal vaginal discharge for the last 2
weeks. The patient has douched twice with no change in the discharge She had an episode of postcoital vaginal bleeding
a few days ago, followed by return of the abnormal yellow discharge, Her last menstrual period was 3 weeks ago. The
patient is sexually active and has had the same partner for 6 months; they use the withdrawal method for contraception.
Physical examination shows yellow cervical discharge. The cervix is friable and bleeds easily on cotton tip manipulation.
Urine pregnancy test is negative. Nucleic acid amplification testing is not available. Asample of the discharge is obtained
H
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11 for microscopic examination. Which of the following is the most likely microscopic finding in this patient?

13
O A. Clue cells
. 14
0 B. Hyphae
15
. 16 O C. No organisms
17
O D. Spirochetes
. 18
19 O E. Trichomonads
. 20
21
. 22 Proceed to Next Item
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A44—yearrold woman comes to the office for evaluation of abnormal uterine bleeding. The patient has had intermenstrual
.

bleeding over the past 3 months. Most of the time, she has had only spotting with wiping, but last week, she had slightly
heavier bleeding that required her to use a menstrual pad. In addition to this intennenstIual bleeding, the patient also has
monthly menses with 4—5 days of moderate bleeding and slight cramping on the first 2 days that typically resolves with
ibuprofen. She has no chronic medical conditions and takes no daily medications. The patient had a bilateral tubal ligation
after her last delivery at age 31. Vital signs are normal. BMI is 22 kg/m? Speculum examination reveals a multiparous
o
._.

11 cervix with a small amount of bright red blood at the 05 and no visible cervical or vaginal lesions. On bimanual pelvic
examination, the uterus is small, mobile, and nontender. No adnexal masses are palpated. FSH, TSH, and prolactin levels
13 are nonnat. Unne pregnancy test is negative. Which of the following is the most likely cause of this patient's abnormal
. 14 uterine bleeding?
15
. 16 O A. Adenomyosis
17
. 18 O B. Endometrial hyperplasia

19
O C. Endometrial polyp
. 20
21 O D. Invasive cervical cancer
. 22
0 E. Perimenopause
23
. 24 O F. Uterine leiomyomas
25
. 26
27 Proceed to Next Item
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A 60—yearrold woman comes to the office for a breast cancer follow—up visit. The patient recently underwent a right
.

mastectomy for a node-negative, estrogen« and progesterone«receptor—positive tumor‘ She was started on an aromatase
inhibitor for adjuvant therapy; however, the medication was discontinued due to severe fatigue and poor sleeps As a result,
she is scheduled to begin a 5—year course of adjuvant therapy with tamoxifen. The patient has no other chronic medical
conditions and her only medication is a daily multivitamin. Her last menstrual period was 5 years ago. The patient's father
had a myocardial infarction at age 65; family history is otherwise noncontributory. She does not use tobacco, alcohol, or
H
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illicit drugs. Vital signs are stable. BMI is 21 kglm? The patient has many concerns about tamoxifen therapy and asks
. 12 about potential side effects. Which of the following is the patient at greatest risk for developing due to tamoxifen therapy?
. 13
_ 14 O A Decreased bone density

15 O B. Dysplasia of the cervical transformation zone

. 16
17 O C. Ectopic endometrial tissue in the myometrium
. 1s
19 O D. Hyperplasra of the endometrium

- 2” O E. lntimal thickening of the coronary arteries

21
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. 23
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A53—yearrold woman comes to the office for a routine annual examination. Her last menstrual period was 2 years ago. The
.

patient has hot flashes throughout the day. She awakens several times each night drenched with sweat The patient has
tried weight loss and over—the—counter medications to manage these symptoms, but they have not improved. She has
hypertension and type 2 diabetes mellitus controlled with diet and exercise. The patient's mother had a bilateral hip
replacement after a fall at age 77. Blood pressure is 124/80 mm Hg and pulse is 76lmin. BMI is 28 kg/m2_
Cardiopulmonary examination is normal 0n pelvic examination, the uterus is small and nontender, and there are no
adnexal masses. The extremities have 2+ peripheral pulses. HbA1c is 6.9%. Which of the following is an indication for
systemic estrogen/progestin replacement therapy in this patient?

O A Coronary heart disease prevention

0 B. Endometrial cancer risk reduction

0 C. Osteoporosis prevention

0 D. Reduction of vasomotor symptoms

0 E. There is no indication

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A29—yearrold nulligravid woman comes to the office due to left breast pain. She noticed a "lump" in the left breast last week
.

while performing a breast examination in the shower The lump is painful to the touch to the extent that wearing a bra is
uncomfortable. The patient is concerned about this finding because her cousin, who was recently diagnosed with breast
cancer, is experiencing many adverse effects of chemotherapy. The patient has no history of medical problems or
surgeries. She occasionally smokes cigarettes and drinks 2—3 beers a week at social gatherings. \fital signs are normal.
Physical examination reveals a 4 x 5 x 6cm mobile mass in her left breast. Ultrasound shows a well—circumscribed mass
H
O

11 with posterior acoustic enhancement. No echogenic debris or solid components are seen. Needle aspiration yields clear
fluid with resolution of the mass. Which of the following is the best approach in management of this patient?

O A. Order breast MRI

15
0 B. Order mammogram
17 O C. Perform a core biopsy

0 D. Repeat breast examination in 1 year

19

0 E. Repeat breast examination in 2 months

21
0 F. Send the fluid for culture
23

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A20—yearrold woman comes to the office due to dysuria for the past 2 days. She also has had urinary frequency but no
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fevers, chills, nausea, or hematuria. The patient became sexually active with her boyfriend 6 months ago. Since then, she
has had 3 episodes of cystitis. The patient has no other medical conditions and no prior surgery. She takes no medications
and does not use tobacco, alcohol, or illicit drugs. The patient uses condoms for contraception, and her last menstrual
period was 2 weeks ago. Temperature is 37.2 C (99 F). 0n abdominal examination, there is mild suprapubic tenderness.
No costovertebral or flank tenderness is present. Antibiotic therapy is prescribed. A urine culture grows Escherichia so”.
O
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.

11 When the patient is called with the results, she reports complete resolution of her symptoms Repeat urine culture 2 weeks
later is negative. Which of the following is the best next step in management of this patient's recurrent cystitis?
13
O A. Cystoscopy
15
O B. Daily cranberryjuice

17 O C. Postcoital antibiotics

O D. Renal ultrasound
19

O E. Urodynamictesting
21

23
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A 53—yearrold woman, gravida 2 para 2, comes to the office due to right—sided pelvic pain that has worsened over the past 3
.

months. She has experienced bloating and hot flashes since her last menstrual period a year ago. The patient has recently
become sexually active with a new partner and is not using condoms. She was diagnosed and treated for chlamydia in her
405. She has no other medical problems and had a bilateral tubal ligation at age 35 after cesarean delivery of her second
child. The patient smokes 10 cigarettes daily and drinks alcohol socially. Her temperature is 36.7 C (98 F) and blood
pressure is 110/70 mm Hg. Leukocyte count is 8200/mm3_ B—hCG is undetectable. Pelvic ultrasonography shows a 7cm
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11 right ovarian mass with solid components, thick septations, and a moderate amount of peritoneal fluid. Which of the
following is the most likely explanation for these findings?
13
O A. Abnormal proliferation of tubal epithelium

O B. Ascending infection from the cervix

17 O C. Ectopic implantation of endometn'al glands

O D. Excessive growth of well-differentiated ectoderrnal cells

19

0 E. Obstruction from fluid accumulation in the fallopian tube

21

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ASS—yearrold woman comes to the office to follow up for osteoporosis, which was diagnosed by a screening bone mineral
.

density scan. The patient was prescribed alendronate, but she stopped taking it due to intense stomach pain from the
medication. She saw a television advertisement about raloxifene and is interested in this treatment option. The patient has
a history of deep venous thrombosis in her left leg while on an oral contraceptive at age 38 that was treated with several
months of heparin. She currently takes medications for hypertension and hyperlipidemia diagnosed after a minor heart
attack at age 63. Her mother had breast cancer at age 52 and died from ovarian cancer at age 61. A maternal aunt died
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11 from endometrial cancer at age 72. Blood pressure is 125/80 mm Hg, and physical examination is normal. Which of the
following is a contraindication to raloxifene in this patient?
13
O A. History of breast cancer in her mother
. 15
0 B. History of endometiial cancer in her maternal aunt

. 17 O C. History of myocardial infarction

O D. History of ovarian cancer in her mother

19
. 20 0 E. History of venous thrombosis
21
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A44—yearrold woman comes to the office with a 6—month history of painful sexual intercourse. She has no associated
.

itching or abnormal vaginal discharge. The patient has never had these symptoms before and has had no problems with
sexual desire or orgasm She has been monogamous with her husband for 15 years. The patient's menstrual periods are
regular and are not associated with unusual pain. She has no urinary or gastrointestinal symptoms. Her medical history is
notable for mild hypertension that has been well controlled with dietary changes and exercise. The patient has no history of
pelvic inflammatory disease or gynecologic surgery. Her only medications include a daily multivitamin and saline eye drops
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11 for chronic dry eyes. The patient does not use tobacco, alcohol, or illicit drugs. Temperature is 36.5 C (97.7 F), blood
pressure is 136/88 mm Hg, pulse is 72/min, and respirations are 12mm. The neck is supple. The patient has mild dental
caries. Chest auscultation reveals no abnormalities. The abdomen is soft and nontender. Pelvic examination shows
nonnal—appearing external genitalia and dry vaginal mucosa. The uterus and adnexa are normal with no cervical motion
tenderness. Which of the following is the most likely cause of this patient's current condition?

O A. Endometn'osis
O B. Estrogen deficiency

O C. Inadequate lubrication

O D, Interstitial cystitis
O E. Lichen sclerosus

O F. Vaginismus

O G. Vulvodynia

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A32—yearrold woman comes to the office due to difficulty conceiving despite frequent, unprotected intercourse with her
.

husband over the last 3 years She has had multiple sexual partners in the past and never became pregnant despite
inconsistent condom use. Menses started at age 12 and are irregular. The patient has had recurrent vaginal candidiasis for
which she uses an over-the—counter vaginal suppository. \fital signs are normal. The thyroid is not enlarged. She has thick,
dark, velvety plaques under her axillae. Breast examination is normal. Abdominal examination shows no masses. Pelvic

- 10
examination reveals normal external genitalia; a small, mobile uterus with no cervical motion tenderness; and bilaterally

11 enlarged ovaries. TSH, LH, and prolactin levels are nonnal Which of the following is the most appropriate therapy for this
u 12 patient's infertility?
13
u 14 O A. Bromocriptine
15
O B. Cyclic progesterone
. 16

. l7 O C. Laparoscopic fulguration of lesions

.
0 D. Letrozole
19
. 20 O E. Levothyroxine
21
u 22

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.

A 25-year~o|d woman presents to your office complaining of a seven-week history of amenorrhea. She also states that she
has had nausea and vomiting for five weeks. She is sexually active, Her medical and obstetrical histories are
unremarkable. Serum hCG level is elevated. Which of the following is the most important direct role of hCG in pregnancy?

O A. Inhibition of uterine contractions

O
_ Induction of prolactin production by the pituitary
11
_ 12 O C. Promotion and maintenance of implantation

13 O D. Maintenance of the corpus luteum

. 14
15 O E. Induction of early embryonic division and differentiation
. 16

- 18 Proceed to Next Item

. 20

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. 22

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. 24

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. 26

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A48—yearrold woman is undergoing evaluation of "copper—colored" fluid from her right nipple that was first noticed last week
.

during a breast self-examination. The patient's history includes schizophrenia, which was diagnosed in her 205; her
condition has been well controlled with antipsychotic therapy. She also takes acetaminophen intermittently for headaches.
She mns and plays tennis regular1y. She does not use tobacco, alcohol, or illicit drugs. Family history is significant for a
paternal aunt who died from metastatic breast cancer at age 50. The patient's temperature is 36.7 C (98 F). On physical
examination, 1 mL of reddish brown fluid is expressed from her right breast. No masses or lymphadenopathy is present on
G
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11 palpation Which of the following is the most likely cause of this patient's findings?

13
O A. Benign breast cyst

O B. Fat necrosis of the breast

15
O C. Fibroadenoma
17
O D. lnfiltrating ductal carcinoma

. 19 0 E. Intraductal papilloma

. 21
O F. Lactotroph adenoma

O G. Medication side effect

23

25
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A52—yearrold woman comes to the office due to a pruritic rash on the inguinal region and vulva. Over the last 2 weeks the
.

patient's inguinal and vulvar skin has become increasingly irritated and pruritic, particularly after she wears tight clothing.
Application of an over-the—counter moisturizing cream has not improved the symptoms. The patient was recently
hospitalized for an asthma exacerbation and treated with inhaled bronchodilators and systemic corticosteroids. She
underwent a cervical conization at age 36 for dysplasia; all subsequent Pap tests have been normal. The patient has been
sexually active with a new partner for the past few months, but the pruritus has prevented intercourse. Her last menstmal
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11 period was 8 months ago. BMI is 32 kg/mz. Vital signs are normal. Examination of the patient is seen in the exhibit. Which
of the following is the most appropriate treatment for this patient?

O A. Clotrimazole ointment

O B. Doxycycline

O C. Estrogen cream

0 D. Trichloroaoetic acid

0 E. Trimeflioprim—sulfamethoxazole

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A 19—yearrold woman comes to the office for evaluation of dyspareunia. The patient became sexually active with her
.

boyfriend 4 months ago but has been avoiding intercourse for the past month because it has become too painful. She has
tried using a water-based lubricant during intercourse, but it has not relieved her pain. The patient is using condoms for
contraception. She has regular menses with 3—4 days of heavy bleeding and lower abdominal cramping. There has been
an increase in cramping over the past 2 months but no abnormal vaginal discharge. The patient has type 1 diabetes

- 10
mellitus and uses an insulin pump; her most recent hemoglobin A1c was 7.2%. Vital signs are normal. BMI is 21 kglmz.

11 0n pelvic examination, the vulva and cervix appear noninflamed. Speculum examination reveals a laterally displaced
u 12 cervix. Bimanual examination reveals a small uterus with cervical motion tendemess, Which of the following is the most
13 likely cause of this palient's dyspareunia?
u 14

15 O A. Candida albicans vulvovaginitis

u 16
O B. Endometriosis
17
u 18 O C. Gentle—pelvic pain/penetration disorder
19
. 20 0 D. Pelvic inflammatory disease
. 21
0 E. Uterine leiomyomata

. 23 O F. Vulvodynia
. 24

25
u 26 Proceed to Next Item
27
u 28

29
u 30

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A 22—yearrold woman comes to the emergency department with right upper quadrant pain that has worsened over the past
.

day. The pain initially began 5 days ago in the lower abdomen after she returned from a trip to South America. The right
upper quadrant pain increases with deep breathing. She now has fevers, chills, and vomiting. The patient has no diarrhea,
constipation, or changes in stool color. She has no medical conditions or previous surgeries. The patient is sexually active
with a male partner and does not use contraception. She is currently on her menstrual period but reports increasing
irregularity over the last 3 months with occasional spotting. She does not use tobacco, alcohol, or illicit drugs. Temperature
G
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11 is 38.9 C (102 F), blood pressure is 100/70 mm Hg, and pulse is 104/min. BMI is 21 kglmz. Examination shows right upper
quadrant tenderness, and the lower abdomen is diffusely tender without guarding. Bowel sounds are present. There is no
13 costovertebral angle tenderness. Skin is normal without a rash. Urine pregnancy test is negative. Which of the following is
the most likely diagnosis for this patient?
15

O A. Acute appendicitis
17
O B. Acute cholecystitis
19
O C. Acute pancreatjtis

21 O D. Acute viral hepatitis

0 E. Pelvic inflammatory disease

0 F. Perforated peptic ulcer

25
O G. Ruptured ectopic pregnancy

27 0 H. Ruptured ovarian cyst

29

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AGO—yearrold woman comes to the office for evaluation of postmenopausal bleeding. The patient went through menopause
.

at age 53 and did not use menopausal hormone therapy. Four months ago, she noticed some postcoital bleeding that
resolved within a day. For the last 3 months, the patient has had daily vaginal spotting and sometimes has bleeding similar
to the first day of her menstrual cycle. She has obstructive sleep apnea and hypeflipidemia. Pap test last year was
normal. The patient does not use tobacco, alcohol, or illicit drugs. Blood pressure is 130/80 mm Hg and pulse is 68/min.

. 1o BMI is 34 kglml. The abdomen is soft and nontender. Speculum examination shows a small amount of blood in the vaginal
11 vault and a normal cervix. Bimanual examination reveals right adnexal fullness and a slightly enlarged uterus. Hemoglobin
. 12 is 11.8 gldL. Pelvic uttrasound shows an 11—cm solid ovarian mass and no free fluid in the pelvis. Endometrial biopsy
13 shows complex hyperplasia without atypia. Which of the following is the most likely diagnosis in this patient?
. 14
15 O A. Brenner tumor
. 16 .
17 O B. Embryonal carcrnoma
. 13 O C. Granulosa cell tumor
. 19
_ 20 O D. Mature teratoma
21 O E. Metastatic gastric carcinoma
. 22
23 O F. Yolk sac tumor

- 26 Proceed to Next Item

27
. 28

29
. 30
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A23—yearrold woman comes to the office due to 3 days of fever and dysuria. The patient also has had a pruritic,
.

erythematous vulvar rash that is particularly painful during urination She is sexually active with one partner, and they use
condoms inconsistently. Temperature is 38.7 C (101.7 F), blood pressure is 120/80 mm Hg, and pulse is B4/min. There is
suprapubic fullness on abdominal examination. Pelvic examination shows several tender, ulcerated lesions with circular
borders on the inside of the left labia minora. Speculum examination shows no cervical fn'ability or mucopurulent

. 10
discharge. The left inguinal lymph nodes are enlarged and tender. Urethral catheterization is performed due to difficulty

11 with spontaneous voiding. Urinalysis results are as follows:

. 12
Leukocyte esterase positive
13
. 14 Nitrites negative
15
Bacteria none
. 16
17 White blood cells 15mpf
. 18
19 Urine pregnancy test is negative. Which of the following tests would most likely establish this patient's diagnosis?
. 20
O A. Gram stain and culture of lesion for Haemophilus ducreyi

O B. KOH wet mount microscopy for Candida albicans

O C. Nucleic acid amplification testing for Chlamydia trachomatis

O D. Rapid plasma reagin testing for Treponema pallidum

27 O E. \firal culture of lesion for herpes simplex virus

. 28
29
. 30
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A 15—yearrold girl is brought to the office due to irregular menstrual periods. Menarche was at age 13, and since then her
.

periods have been irregular with cycles varying from 3 to 8 weeks. The patient has no chronic medical issues, has never
had surgery, and takes no medications. Her mother and older sister have polycystic ovary syndrome, and both take oral
contraceptives. The patient has never been sexually active. \fital signs are normal. Physical examination shows normal
hair distribution with Tanner V secondary sexual characteristics. Abdominal examination is normal. There is dark red blood

- 10
noted at the cervical 05 with no active bleeding. Serum prolactin and TSH levels are normal. Administration of micronized

11 oral progesterone results in withdrawal bleeding in 3 days. Pelvic ultrasound reveals normal ovaries and uterus. Which of
u 12 the following is the most likely explanation of this patient's irregular menstrual periods?
13
u 14 O A. Androgen excess
15
0 B. Estrogen deficiency
u 16

17 O C. Excess LH secretion
u 18
0 D. Insufficient gonadotropin secretion
19
u 20 0 E. Intrauterine adhesions
21
u 22

23
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. 24

. 25

. 27
. 28

29
u 30

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A29—yearrold woman, gravida 1 para 1, comes to the office for a routine postpartum visit. Six weeks ago, she delivered a
.

4.2-kg (9 lb 5 02) girl by cesarean delivery for cephalopelvic disproportion. The pregnancy was complicated by gestational
diabetes mellitus, which was controlled with diet and exercise, and preeclampsia without severe features. Since the
delivery, the patient has been feeling well but continues to have daily light vaginal bleeding of dark red or brown blood. She
is breastfeeding exclusively and is not on contraception. She has no chronic medical conditions and has had no other
surgeries. Her last Pap test 2 years ago was normal. Blood pressure is 122l78 mm Hg and pulse is 87/min. BMI is 30
G
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11 kg/mz. The lower abdominal incision is well healed 0n speculum examination, there is a small amount of scant brown
discharge in the vaginal vault and no cervical lesions. The remainder of the physical examination is normal. Which of the
following is the best next step in management of this patient?

O A. 2-hour (75-9) oral glucose tolerance test

0 B. 24-hour total urine protein collection

0 C. Endometrial biopsy

0 D. Pap test with human papillomavirus cotesting

O E. Urine culture

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A20-year»o|d woman comes to the emergency department due to vaginal bleeding and right lower quadrant pain that began
3 days ago. She describes the bleeding as heavier than a period. and she passed vaginal clots 3 hours prior to
.

presentation. Her menarche was at age 13 and she has often gone months without a menstrual period. The patient‘s last
period began approximately 7 weeks ago. She is sexually active and uses the withdrawal method for contraception. Her
temperature is 37.2 C (98.9 F), blood pressure is 120/74 mm Hg, and pulse is 80/min. Examination shows mild right lower
quadrant tenderness, but no rebound or guarding. There is no active vaginal bleeding and the cervical 05 is closed.
Laboratory results are as follows:
G
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11
Hemoglobin 11 gldL

fi—hCG 1000 lU/L

Blood type AB

Rh factor positive

A transvaginal ultrasound reveals no intrauterine or extrauten'ne pregnancy. Which of the following is the best next step in
management of this patient?

O A. Administer anti-D immune globulin

O B. Administer methotrexate

O C. Perform abdominal ultrasound

O D. Perforrnlaparoscopy

O E. Provide reassurance and observation

0 F. Repeat serum B—hCG in 2 days

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3
- 4 A39—yearrold woman, gravida 4 para 4, comes to the office for emergency contraception. The patient stopped
5 breastfeeding a month ago and has not restarted her oral contraceptives because her husband is scheduled for a
' 6 vasectomy in a few weeks. She had unprotected intercourse last night and is conoemed she might get pregnant. The
7 patient has no chronic medical conditions and takes no medications. She does not use tobacco, alcohol, or illicit drugs,
I 2 Her last menstal period was 9 days ago. Vital signs and physical examination are normal. Urine pregnancy test is
_ 10 negative. Which of the following is the best emergency contraceptive option for this patient?

_ i: O A. Combination oral contraceptives

13 O B. None because pregnancy is unlikely

I i: O C. Progestin—releasing subdermal implant

' 16 O D. Single dose of ulipnstal acetate

. 17
. 13 O E. Transdermal estrogen-progestin patch
19
. 20

.
21
22
23
. 24
25
. 26
27

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3
- 4 A22—yearrold woman comes to the office for routine annual examination. The patient has regular menses typically lasting 4
5 or 5 days with minimal cramping on the first day. Her last menstrual period was 3 weeks ago. She normally has no
' 6 midcycle pain, but for 2 days she has had a mild, sharp pain in her left lower abdomen. The patient has had no nausea,
7 vomiting, dysuria, or changes in bowel movements. She has no chronic medical conditions or previous surgeries. The
. s
9 patient is sexually active and uses a copper—containing intrauterine device (IUD) for contraception. She does not use
_ 1o tobacco, alcohol, or illicit drugs. Vital signs are normal. BMI is 22 kg/m2_ The abdomen is mildly tender over the left lower
11 quadrant. On speculum examination, the cervix appears normal and without lesions. The IUD strings are visualized at the
. 12 external cervical 05. The uterus is small and mobile, and a 4m nontender mass is palpable in the left adnexa. Pelvic
13 ultrasonography reveals a 4—cm simple left ovarian cyst with normal Doppler flow. Urine pregnancy test is negative. Which
- 14 of the following is the best next step in management of this patient?
15
. 16 O A. Aspiration of ovarian cyst fluid
17
_ 13 O B. CA-125 testing

19 O c. CT scan of the abdomen and pelvis

. 20
21 O D. Observation and repeat examination in 6 weeks

' 22 O E. Ovarian cystectomy

23
. 24
. 25
. 26
27
. 25

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3
4 A29—year»old woman comes to the clinic for evaluation of leakage of urine. For the past week, the patient has had to
5 urinate every hour and has had leakage of urine while trying to run to the bathroom She has had no hematuria, dysuria, or
_ 6 flank pain. The patient has no chronic medical conditions and has had no surgeries. She has had 2 vaginal deliveries
7 without complications. The patient drinks multiple cups of coffee and diet soda daily. Temperature is 99 F (37.2 C), blood
. 8 pressure is 122/76 mm Hg, and pulse is 84/min. BMI is 29 kglmz. 0n speculum examination, the bladder has no descent,
9 but the patient leaks urine with Valsalva maneuver. Urine dipstick shows:
. 1o
11 Protein none
. 12
13 Blood negative
. 14 Glucose negative
15
. 15 Ketones negative

17 Leukocyte esterase positive

. 1s
19 Nitriles negative
. 20
21 Pregnancy test is negative. Which of the following is the best next step in management of this patient?
. 22
23 O A. Continence pessary placement

' 24 O B. Hemoglobin A1c level

. 25
_ 26 O C. Midurethral sling procedure

27 O D. Oral antibiotic therapy

. 23
29 O E, Urodynamic testing

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3
- 4 A63—yearrold woman comes to the office for a routine annual examination. The patient feels well and has no concerns
5 today. She undewvent menopause at age 50 and has had no episodes of vaginal bleeding. The patient exercises multiple
' 6 days a week and has no un'nary or fecal leakage. BMI is 29 kg/mz. Blood pressure is 126/80 mm Hg and pulse is 80/min.
7 Cardiopulmonary examination is normal. The abdomen is soft and nontender without palpable masses or hernias. 0n
. s
9 pelvic examination, vulvar atrophy is present, and the vagina appears pale and has minimal rugation but no lesions. The
_ 1o cervix appears normal and has no lesions or discharge. On Valsalva maneuver, there is a bulge of the anterior vaginal wall
11 to the introitus. Postvoid bladder and renal ultrasound is normal. Which of the following is the best next step in
. 12 management of this patient's pelvic organ prolapse?
13
, 14 O A. Hormone replacement therapy
15
B. Pessa lacement
. 16 O ry p
17 O C. Reassurance and observation
. 1s
19 O D. Surgical anterior vaginal wall repair

- 2” O E. Urodynamic testing
. 21
. 22

. 23
24
25
. 26
27
. 23
29

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A63—yearrold woman comes to the office for a routine annual examination. The patient feels well and has no concerns
today. She undewvent menopause at age 50 and has had no episodes of vaginal bleeding. The patient exercises multiple
days a week and has no un'nary or fecal leakage. BMI is 29 kg/mz. Blood pressure is 126/80 mm Hg and pulse is 80/min.
Cardiopulmonary examination is normal. The abdomen is soft and nontender without palpable masses or hernias. 0n
pelvic examination, vulvar atrophy is present, and the vagina appears pale and has minimal rugation but no lesions. The
cervix appears normal and has no lesions or discharge. On Valsalva maneuver, there is a bulge of the anterior vaginal wall
to the introitus. Postvoid bladder and renal ultrasound is normal. Which of the following is the best next step in
management of this patient's pelvic organ prolapse?

O A. Hormone replacement therapy

0 B. Pessary placement

0 C. Reassurance and observation

0 D. Surgical anteriorvaginal wall repair

0 E. Urodynamictesting

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A39—yearrold woman, gravida 1 para 0 aborta 1, comes to the office for follow—up after an abnormal Pap test that showed
atypical glandular cells. Two years ago, the patient had a fireimester spontaneous abortion after conceiving via ovulation
induction. Since then, she has had menses every 2—3 months with frequent interrnenstrual spotting. The patient is not
using contraception because she is trying to conceive. She does not use tobacco, alcohol, or illicit drugs. \fital signs are
normal. BMI is 41 kg/m’. Physical examination shows dark, velvety lesions on her neck folds and axilla. A urine pregnancy
test is negative. Colposcopy and endocervical curettage are adequate and benign. Endometrial biopsy shows atypical
endometrial hyperplasia. This patient‘s biopsy results are most closely associated with which of the following?

O A. Chronic human papillomavirus infection

0 B. In utero diethylstilbestrol exposure

0 C. Malignant transformation of a leiomyoma

O D. Proliferation of persistent trophoblastic tissue

0 E. Unopposed estrogen exposure

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11
u 12 A 19—yearrold woman comes to the emergency department due to lower abdominal pain. The pain is intermittent and
13
started this morning during a yoga class. Over the past 10 hours, the pain has intensified and ibuprofen has provided no
u 14
relief. The patient has also vomited 3 times. Her last menstrual period was a week ago. She has never been sexually
15
active. The patient has no medical conditions or history of surgery. She takes no medications and does not use tobacco or
u 16

17
alcohol. Physical examination shows diffuse lower abdominal tenderness, left greater than right, without guarding or
u 18 rebound. Pelvic ultrasonography shows a complex left adnexal mass without Doppler flow. There is a small amount of free
19 fluid. Which of the following is the best next step in management of this patient?
u 20

21 O A. CT scan of the abdomen and pelvis

. 22
O B. Culdooentesis
23
. 24 O C. Laparoscopy
25
O D. Needle aspiration of the mass
. 26

27 0 E. Paracentesis
. 28

29 O F. X-ray of the abdomen

. 30

31
32 Proceed 10 NEXT Item

. 33

. 35

36

37
. 38

.
39
4D
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A 16—yearrold 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/mz. 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?

O A. Age at onset

O B. Associated symptoms

0 C. Location of pain

0 D. Pattern of menstrual bleeding

0 E. Response to medication

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A 13—yearrold girl is brought to the office due to lower abdominal pain for the past 4 days. The patient has rectal pain with
bowel movements, but no melena or frank blood She has had this pain several times over the past year, but it usually
resolves after 2 or 3 days. She has no fever, chills, nausea, vomiting, loss of appetite, dysun'a, hematuria, or abnormal
vaginal discharge. The patient has no chronic medical conditions or previous surgeries. She has not reached menarche
and has never been sexually active. Temperature is 36.7 C (98 F) and blood pressure is 110/70 mm Hg. BMI is 24 kg/m2_
Physical examination shows a nondistended abdomen without rebound or guarding There is lower abdominal tendemess
to deep palpation in the midline. The external genitalia are Tanner stage 3. On pelvic examination, a smooth, firm mass is
protruding between the labia majora. Which of the following is the most likely diagnosis?

O A Cenlical Ieiomyoma

O B. Choriocarcinoma

O C. Complete mullen‘an agenesis

O D. Foreign body

0 E. lmperforate hymen

O F. Pelvic organ prolapse

O G. Sarcoma botryoides

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An 18—year—old woman comes to the office after fracturing her distal radius when she fell off a chair. The patient had
ambiguous external genitalia noted at birth, and Iaparotomy performed at 17 months of age revealed a normal uterus and
fallopian tubes. Ovarian biopsy performed at that time revealed normal—appearing primordial follicles. She has never had a
menstrual cycle. Blood pressure is 120/78 mm Hg and height is 160 cm (5 fl 3 in). The patient has nodulocystic acne over
the chest and back. No breast development, normal pubic and axillary hair, and marked clitoromegaly are present.
Laboratory results show a normal female karyotype and normal glucose and serum electrolytes. Estradiol and estrone are
undetectable in the serum. Serum FSH, LH, testosterone, and androstenedione concentrations are high. Pelvic imaging
reveals multiple ovarian cysts. Which of the following is the most likely diagnosis in this patient?

O A. Aromatase deficiency

O B. Congenital adrenal hyperplasia

O C. Kallmann syndrome

0 D. McCune-Albright syndrome

0 E. Ovarian hyperthecosis

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A34—yearrold nulligravid woman comes to the office for evaluation of abdominal pain. For the last 3 months, the patient has
had intermittent abdominal cramping but no nausea, vomiting, or changes in bowel patterns. She stopped taking her
combined oral contraceptives 6 months ago to try for pregnancy. Since then, her menses have occured monthly with 5
days of moderate bleeding. The patient's mother had a hysterectomy at age 30 for heavy menstrual bleeding, and her
paternal grandmother had breast cancer at age 64. BMI is 24 kg/m’. Vital signs are normal. Pelvic examination reveals a
palpable right adnexal mass. On ultrasound, there is a 4—cm right adnexal mass that appears thin—walled and has multiple
irregular, thickened internal septations. The left ovary appears normal, and there is no free fluid in the pelvis. Urine
pregnancy test is negative. Which of the following features indicates a need for additional evaluation in this patient?

O A. Adnexal mass size

0 B. Associated symptoms

0 C. Contraceptive history

0 D. Family history

0 E. Mass internal features

0 F. Parity

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A 17—yearrold girl comes to the office for evaluation of vaginal discharge requiring the use ofa panty liner. She has had this
discharge intermittently for the past few months and notices it returns after menses end. The last menstrual period ended a
week ago. For the last 6 months, she has been sexually active with a new partner and uses condoms for contraception.
The patient has no medical problems or previous surgeries. She takes no medications and 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 78/min. On pelvic examination,
the external genitalia have no erythema or edema. There is copious white, mucoid, odorless vaginal discharge.
Microscopic examination reveals a predominance of squamous cells and rare polymorphonuclear leukocytes. Which of the
following is the most likely diagnosis?

O A. Bacterial vaginosis

O B. Candidiasis
O C. Gonococcalcervicitis

O D. Non-gonococcalcervicitis

O E. Physiologic leukormea

O F. Trichomonas vaginitis

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A26—yearrold woman comes to the emergency department due to a bump on her vaginal introitus. The patient first noticed
the mass 2 days ago, but it has increased in size and now causes discomfort when she walks or exercises She had
unprotected sex with a new partner 6 weeks ago and has had 10 lifetime partners. The patient had an abnormal Pap test
last year but had a normal colposcopy. She smokes a half pack of cigarettes daily but does not use alcohol or illicit drugs.
Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, and pulse is BOImin. On pelvic examination, the pubic
hair is shaved. There is a 4—cm, mobile, soft, nontender cystic mass behind the right posterior labium majus that extends
into the vagina. The remainder of the examination is normal. Which of the following is the most likely diagnosis in this
patient?

O A. Bartholin duct cyst

O B. Bartholin gland abscess

O C. Condylomata acuminata

O D. Condylomatalata

O E. Epidermal inclusion cyst

O F. Hidradenitis suppurativa

O G. Lymphogranuloma venereum

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