Obstetrics and Gynecology Test 1 — Questions and Answers
Question 1: A 57-year-old woman comes to the physician 1 week after noticing a mass in her left breast during breast self-examination. Menopause occurred 6 months ago. She was receiving estrogen therapy but discontinued it 6 weeks ago; she has had no menopausal symptoms. There is no family history of breast cancer. Examination shows a 2-cm, palpable, nontender, mobile mass in the upper outer quadrant of the left breast; no nipple discharge can be expressed. Examination of the right breast shows no abnormalities. Which of the following is the most appropriate next step in management?
- Reexamination in 3 months
- Mammography (Correct answer)
- CT scan of the chest
- Ductal lavage
- Mastectomy
Correct answer: Mammography
Any new palpable breast mass in a postmenopausal woman, even if mobile and nontender, requires prompt evaluation to rule out malignancy. Mammography is the most appropriate initial diagnostic step for a palpable breast mass in women over 40, as it can characterize the mass and identify other suspicious lesions. Depending on the mammography findings, further imaging or biopsy may be necessary.
Question 2: A 27-year-old nulligravid woman has had severe pain with menses that has caused her to miss at least 2 days of work 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. Pelvic examination shows a normal-appearing vulva and vagina. The cervix is pink with minimal endocervical gland eversion. The uterus is normal in size. The left ovary is 2 × 3 cm; the right is 4 × 6 cm. Which of the following is the most likely cause of her condition?
- Chronic appendiciti
- Endometriosis (Correct answer)
- Pelvic congestion syndrome
- Polycystic ovarian syndrome
- Premenstrual syndrome
Correct answer: Endometriosis
The patient's severe, debilitating dysmenorrhea (painful menses) causing missed work, occasional dyspareunia (painful intercourse), and a palpable enlarged right ovary (suggesting an endometrioma) are classic symptoms of endometriosis. This condition is characterized by the presence of endometrial-like tissue outside the uterus, leading to chronic pelvic pain and other gynecological symptoms.
Question 3: A 22-year-old woman comes to the physician because of a 2-day history of pain with urination, intense vaginal itching, and a thick discharge. She has no history of serious illness. She is sexually active and uses an oral contraceptive. Her temperature is 37°C (98.6°F). Abdominal examination shows no abnormalities. Genitourinary examination shows erythema of the vulva and vagina with an odorless curd-like discharge. The cervix appears normal. Bimanual examination shows no abnormalities. The pH of the vaginal discharge is 4. Wet mount preparations of the discharge with saline and with KOH are obtained. The saline slide shows mature squamous epithelial cells, and the KOH slide shows multiple budding yeasts with pseudohyphae. Which of the following is the most likely diagnosis?
- Bacterial vaginosis
- Candidiasis (Correct answer)
- Chlamydia trachomatis infection
- Lichen sclerosus
- Scabies
- Trichomoniasis
Correct answer: Candidiasis
The patient's symptoms of intense vaginal itching, pain with urination, and a thick, odorless, curd-like vaginal discharge, along with vulvar and vaginal erythema, are classic for vulvovaginal candidiasis. The definitive diagnosis is confirmed by the wet mount with KOH showing budding yeasts and pseudohyphae, which are characteristic of *Candida* species.
Question 4: A 27-year-old nulligravid woman and her husband have been unable to conceive for 12 months. She has never used contraception. Menses occur at 28-day intervals, and her last menstrual period was 2 weeks ago. She had a single episode of pelvic inflammatory disease 4 years ago and was treated with oral antibiotics. Vaginal examination shows no abnormalities. Cervical cultures are normal. Which of the following is the most appropriate next step in diagnosis?
- Reevaluation in 6 months
- Ultrasonography of the abdomen
- Sperm penetration assay
- Hysterosalpingography (Correct answer)
- Endometrial biopsy
Correct answer: Hysterosalpingography
Infertility is defined as the inability to conceive after 12 months of unprotected intercourse for women under 35. Given her history of pelvic inflammatory disease (PID), there is a significant risk of tubal damage and obstruction. Hysterosalpingography (HSG) is the most appropriate next step to evaluate tubal patency and uterine cavity abnormalities, which are common causes of infertility after PID.
Question 5: A 30-year-old woman, gravida 2, para 1, comes for her first prenatal visit at 26 weeks’ gestation. Uterine size is greater than expected for dates. Ultrasonography shows fetal hydrops. Which of the following is the most appropriate next step in diagnosis?
- Maternal HIV antibody test
- Maternal Rh status with antibody screening (Correct answer)
- Cervical and urine cultures for group B streptococcus
- MRI of the fetus
- Amniocentesis for measurement of α-fetoprotein concentration
Correct answer: Maternal Rh status with antibody screening
Fetal hydrops is a severe condition characterized by abnormal fluid accumulation in two or more fetal compartments. Rh incompatibility (hemolytic disease of the fetus and newborn) is a significant cause of non-immune hydrops, especially in women with previous pregnancies. Therefore, determining the mother's Rh status and screening for Rh antibodies is crucial to identify potential alloimmunization as the cause of fetal hydrops.
Question 6: A 42-year-old woman, gravida 2, para 2, comes to the physician because of increasingly frequent loss of urine during the past year. She has loss of urine when she coughs, sneezes, exercises, or plays with her children. Her 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 history of other hospital admissions or serious illness. She takes no medications. Abdominal examination shows no abnormalities. The external genitalia, vagina, and cervix appear normal. The uterus and adnexa are normal to palpation. There is loss of a small amount of urine with Valsalva maneuver. Her postvoid residual volume is 50 mL. Urinalysis shows no abnormalities. Which of the following is the most likely diagnosis?
- Overactive bladder with incontinence
- Overflow incontinence
- Stress incontinence (Correct answer)
- Urinary tract infection
- Vesicovaginal fistula
Correct answer: Stress incontinence
The patient's symptoms of involuntary urine leakage with activities that increase intra-abdominal pressure (coughing, sneezing, exercise) and the absence of urgency or nocturnal incontinence are classic for stress incontinence. The finding of urine loss with a Valsalva maneuver and a normal postvoid residual volume further supports this diagnosis, indicating urethral hypermobility or intrinsic sphincter deficiency.
Question 7: During a routine examination, a 25-year-old woman expresses concern about her risk for ovarian cancer because her mother died of the disease. Which of the following is the most appropriate course of action?
- Reassure her that ovarian cancer is not hereditary
- Obtain a more detailed family history of cancer (Correct answer)
- Recommend a diet high in beta-carotene
- Annual CT scans of the abdomen
- Prophylactic oophorectomy
Correct answer: Obtain a more detailed family history of cancer
Ovarian cancer can have a hereditary component, particularly with a first-degree relative affected. Before providing reassurance or recommending drastic measures, it is essential to obtain a more detailed family history of cancer, including types of cancer, age of onset, and affected relatives, to assess the true genetic risk and determine if genetic counseling or testing is warranted.
Question 8: At her 6-week postpartum visit, an 18-year-old woman, gravida 1, para 1, tells her physician that she has a pinkish vaginal discharge that has persisted since her delivery, 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?
- Reassurance that this is normal (Correct answer)
- Measurement of serum prolactin concentration
- Quantitative β-hCG test
- Administration of ampicillin
- Dilatation and curettage
Correct answer: Reassurance that this is normal
The presence of a pinkish vaginal discharge (lochia serosa) at 6 weeks postpartum, which is decreasing in amount and accompanied by a fully involuted uterus and no other abnormalities, is a normal physiological finding. Lochia can persist for several weeks after delivery, transitioning from rubra (red) to serosa (pink/brown) to alba (white/yellow). Therefore, reassurance is the most appropriate next step.
Question 9: A 32-year-old nulligravid woman comes to the physician because of a 6-week history of persistent foul-smelling vaginal discharge and vaginal itching. Her symptoms have not improved despite 2 weeks of treatment with over-the-counter antifungal medications and fluconazole. She has been sexually active and monogamous with her boyfriend during the past year, and they use condoms consistently. Examination shows excoriated labia and erythematous vaginal mucosa. There is a frothy, watery-gray discharge in the posterior vaginal vault. A wet mount preparation of the discharge shows numerous multi-flagellated organisms the size of erythrocytes. Which of the following is the most likely causal organism?
- Haemophilus ducreyi
- Neisseria gonorrhoeae
- Pseudomonas aeruginosa
- Treponema pallidum
- Trichomonas vaginalis (Correct answer)
Correct answer: Trichomonas vaginalis
The patient's persistent foul-smelling, frothy, watery-gray vaginal discharge, along with vaginal itching and excoriated labia, are highly characteristic of trichomoniasis. The definitive diagnosis is confirmed by the wet mount preparation showing numerous motile, multi-flagellated organisms the size of erythrocytes, which are *Trichomonas vaginalis*.
Question 10: An asymptomatic 24-year-old primigravid woman at 36 weeks’ gestation comes for a routine prenatal visit. A grade 2/6, systolic ejection murmur is heard at the upper left sternal border. The S2 varies with inspiration, and the pulmonic component is soft; diastole is clear. Which of the following is the most likely diagnosis?
- Anomalous pulmonary venous return
- Atrial septal defect
- Flow murmur (Correct answer)
- Patent ductus arteriosus
- Pulmonary valve stenosis
Correct answer: Flow murmur
During pregnancy, increased blood volume and cardiac output lead to a hyperdynamic circulatory state. This often results in a physiologic 'flow murmur,' typically a systolic ejection murmur heard at the left sternal border, which is usually grade 1-2/6 and not associated with other signs of cardiac disease. The varying S2 with inspiration and soft pulmonic component are also consistent with normal physiological changes in pregnancy.
Question 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 3 weeks ago. She has had no other symptoms. She has no history of abnormal Pap smears; her last Pap smear was 10 months ago. She is sexually active with her husband and 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, the abdomen is nontender to palpation. Pelvic examination shows a slightly enlarged uterus; there are no palpable adnexal masses. Which of the following is the most appropriate next step in management?
- Measurement of serum β-hCG concentration (Correct answer)
- Measurement of serum thyroid-stimulating hormone concentration
- CT scan of the pelvis
- Oral contraceptive therapy
- Endometrial biopsy
Correct answer: Measurement of serum β-hCG concentration
In any woman of reproductive age presenting with amenorrhea or abnormal uterine bleeding, especially with a slightly enlarged uterus, the most crucial initial step is to rule out pregnancy. Despite using condoms, contraception can fail, and a quantitative serum β-hCG concentration is the most sensitive and specific test to confirm or exclude pregnancy.
Question 12: A 57-year-old woman comes to the physician for a routine health maintenance examination. She takes a multivitamin supplement and calcium (500 mg/d). She has followed a vegan diet for 30 years. She exercises daily for 30 minutes. She does not smoke cigarettes or drink alcohol. There is a family history of osteoporosis. She is 168 cm (5 ft 6 in) tall and weighs 60 kg (132 lb); BMI is 21 kg/m2 . Examination shows no abnormalities. Bone densitometry shows evidence of low bone density. She prefers not to be treated with medications. The physician recommends that the patient increase her daily dose of the calcium supplement. The most appropriate next step in management is supplementation with which of the following?
- Fish oi
- Magnesium
- Vitamin C
- Vitamin D (Correct answer)
- Zinc
Correct answer: Vitamin D
While the patient takes calcium, her long-term vegan diet and family history of osteoporosis put her at increased risk for low bone density. Adequate vitamin D is essential for calcium absorption and bone mineralization. Given her preference against medications and the importance of vitamin D for bone health, supplementation with vitamin D is the most appropriate next step to improve calcium utilization and bone density.
Question 13: A 2778-g (6-lb 2-oz) male newborn is born at 37 weeks’ gestation to a 27-year-old woman, gravida 3, para 2, after an uncomplicated labor and delivery. The mother has no medical insurance and did not receive prenatal care. She says she did not have any health problems during pregnancy, but she continued to consume two bottles of beer weekly during her pregnancy. She does not take any medications, vitamins, or herbal supplements. Her diet consists mostly of rice and beans. Examination of the newborn shows spina bifida. Which of the following measures during the mother’s pregnancy is most likely to have prevented this child’s deformity?
- Abstinence from alcohol
- Increase dietary intake of omega-3 fatty acids
- Glucose tolerance test
- Screening for group B streptococcal infection
- TORCH titer screening
- Folic acid supplementation (Correct answer)
Correct answer: Folic acid supplementation
Spina bifida is a neural tube defect (NTD) that occurs early in pregnancy. Folic acid supplementation, ideally starting before conception and continuing through the first trimester, is highly effective in preventing NTDs. The mother's lack of prenatal care and a diet consisting mostly of rice and beans suggest inadequate folic acid intake, making supplementation the most likely preventive measure.
Question 14: Two hours after vaginal delivery at term of a 3062-g (6-lb 12-oz) newborn, a 32-year-old woman, gravida 3, para 3, 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 episiotomy. The abdomen is soft and nontender. Examination shows a boggy uterus palpated 4 cm above the umbilicus. The perineum is intact. Which of the following is the most likely cause of this patient’s hemorrhage?
- Disseminated intravascular coagulation
- Episiotomy site bleeding
- Uterine atony (Correct answer)
- Uterine infection
- Uterine rupture
Correct answer: Uterine atony
The most common cause of postpartum hemorrhage is uterine atony, which is characterized by a boggy, enlarged uterus that fails to contract after delivery. Risk factors present in this patient include prolonged labor and oxytocin augmentation. The intact perineum rules out significant lacerations, and the boggy uterus strongly points to atony as the cause of the heavy bleeding.
Question 15: A 19-year-old primigravid woman at 8 weeks’ gestation is brought to the emergency department because of light vaginal bleeding and mild lower abdominal cramps during the past 8 hours. Her temperature is 37°C (98.6°F), pulse is 84/min, respirations are 18/min, and blood pressure is 110/70 mm Hg. Abdominal examination shows no tenderness or masses; bowel sounds are normal. On pelvic examination, there is old blood in the vaginal vault and at the closed cervical os. The uterus is consistent in size with a 6- to 8-week gestation. Transvaginal ultrasonography shows an intrauterine pregnancy. A fetal heartbeat is seen. Which of the following is the most appropriate next step in management?
- Discharge home for observation (Correct answer)
- Oral administration of misoprostol
- Intramuscular administration of methotrexate
- Operative laparoscopy
- Dilatation and curettage
Correct answer: Discharge home for observation
The patient's symptoms of light vaginal bleeding and mild cramps at 8 weeks' gestation, with a closed cervical os and a viable intrauterine pregnancy confirmed by ultrasound, are diagnostic of a threatened abortion. In such cases, there is no specific medical or surgical intervention proven to prevent miscarriage, so the most appropriate management is reassurance and discharge home for observation, advising rest and follow-up.
Question 16: A 16-year-old girl is brought to the emergency department 6 hours after the onset of moderate lower abdominal cramps and intermittent nausea. She has not vomited during this time. She says that her last menstrual period was 2 months ago, but she has had intermittent bleeding since then, including spotting for the past 2 days. Menarche was at the age of 15 years. Menses occur at irregular 25- to 45-day intervals. She is sexually active and uses condoms inconsistently. Her temperature is 38.1°C (100.6°F), pulse is 94/min, respirations are 22/min, and blood pressure is 120/80 mm Hg. Examination shows a soft abdomen with lower quadrant tenderness, especially on the right. Bowel sounds are normal. Pelvic examination shows scant vaginal bleeding and a palpable, tender right adnexal mass. The cervix appears normal. There is no cervical motion tenderness. Which of the following is the most appropriate next step in management?
- Complete blood count
- Measurement of serum β-hCG concentration (Correct answer)
- Abdominal x-ray
- Ceftriaxone and azithromycin therapy
- Exploratory laparoscopy
Correct answer: Measurement of serum β-hCG concentration
Given the patient's amenorrhea, irregular bleeding, sexual activity with inconsistent condom use, lower abdominal pain, and a palpable, tender adnexal mass, an ectopic pregnancy must be ruled out immediately. Measuring serum β-hCG concentration is the most appropriate initial diagnostic step to confirm pregnancy and then guide further evaluation (e.g., ultrasound) to determine its location.
Question 17: A 13-year-old girl is brought to the physician because of a 1-year history of intermittent irregular vaginal bleeding; the bleeding ranges from spotting to heavier than a normal menstrual period, occurs every 2 to 8 weeks, and lasts 10 to 30 days. Examination shows a pink, well-rugated vagina with no discharge; the cervix appears normal. The uterus is 6 cm in length, regular in contour, and nontender. There are palpable, normal-sized, nontender ovaries. Which of the following is the most appropriate pharmacotherapy to alleviate this patient’s symptoms?
- Continuous low-dose estrogen
- Gonadotropin-releasing hormone agonist
- Oral contraceptives (Correct answer)
- Tetracycline
- Thyroid hormone
Correct answer: Oral contraceptives
Irregular and heavy menstrual bleeding in an adolescent, especially within the first few years post-menarche, is commonly due to anovulatory cycles, leading to dysfunctional uterine bleeding. Oral contraceptives (OCPs) are the most appropriate pharmacotherapy as they regulate the menstrual cycle, reduce bleeding, and provide contraception by stabilizing the endometrial lining and inducing regular withdrawal bleeds.
Question 18: A previously healthy 25-year-old woman, gravida 2, para 2, comes to the emergency department because of a 3-day history of painful swelling of her vaginal area. Her last menstrual period was 2 months ago. She is sexually active with one male partner and uses depot medroxyprogesterone for contraception. Her temperature is 38.4°C (101.2°F), pulse is 96/min, respirations are 16/min, and blood pressure is 125/82 mm Hg. Examination shows a 4-cm, exquisitely tender mass in the inferior aspect of the left labium minus. The swelling and tenderness prevent insertion of either a speculum or fingers into the vagina. Which of the following is the most likely diagnosis?
- Bartholin gland abscess (Correct answer)
- Chancroid
- Condylomata acuminata
- Herpes simplex
- Lymphogranuloma venereum
- Primary syphilis
Correct answer: Bartholin gland abscess
The patient's presentation with a rapidly developing, exquisitely tender, unilateral mass in the inferior aspect of the labium minus, accompanied by fever, is highly characteristic of a Bartholin gland abscess. This occurs when the duct of the Bartholin gland becomes obstructed and infected, leading to pus accumulation and significant pain, often preventing speculum insertion.
Question 19: A 22-year-old primigravid woman at 34 weeks’ gestation is brought to the emergency department by ambulance after being found unconscious by her husband. Paramedics report that she was having tonic-clonic movements that have now stopped. Her last visit to the physician was 2 weeks ago. Pregnancy had been uncomplicated. On arrival, she is awake, lethargic, and mildly confused. She says that she had a headache and did not feel well earlier in 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?
- Absence seizures
- Cerebral infarction
- Eclampsia (Correct answer)
- Migraine
- Pheochromocytoma
Correct answer: Eclampsia
The patient's presentation of new-onset tonic-clonic seizures at 34 weeks' gestation, accompanied by severe hypertension (170/110 mm Hg), headache, lethargy, confusion, and hyperreflexia, is classic for eclampsia. Eclampsia is defined as the occurrence of grand mal seizures in a woman with preeclampsia, a condition characterized by hypertension and often proteinuria during pregnancy. The combination of these symptoms in a pregnant woman makes eclampsia the most likely diagnosis.
Question 20: A 15-year-old girl is brought to the physician by her mother because she believes that her daughter has become sexually active and wants her to use contraception. During an interview with the patient alone, she reports that she has become sexually active with one male partner over the past 3 months. She and her partner use condoms consistently, and she is not interested in any other form of contraception at this time. Menarche was at the age of 12 years, and menses occur at regular 28-day intervals. She has had no symptoms of sexually transmitted diseases. Examination shows no abnormalities. In addition to counseling the patient about all contraceptive methods, which of the following is the most appropriate next step?
- Do not inform the mother that her daughter and her partner use condoms, but encourage the daughter to communicate the information (Correct answer)
- Inform the mother that her daughter and her partner use condoms
- Inform the mother that her daughter is protecting herself appropriately against pregnancy, but do not mention what form of contraception
- Inform the mother that you have administered depot medroxyprogesterone to the patient
- Inform the mother that you have given the patient a prescription for an oral contraceptive
Correct answer: Do not inform the mother that her daughter and her partner use condoms, but encourage the daughter to communicate the information
Minors have a right to confidential healthcare, especially concerning reproductive health, in many jurisdictions. While encouraging open communication between the daughter and mother is important, directly disclosing the daughter's confidential information without her consent would violate her privacy. The most appropriate step is to respect the patient's confidentiality while empowering her to share the information herself, fostering trust in the physician-patient relationship.
Obstetrics and Gynecology Test 1
A 57-year-old woman comes to the physician 1 week after noticing a mass in her left breast during breast self-examination.
Menopause occurred 6 months ago.
She was receiving estrogen therapy but discontinued it 6 weeks ago; she has had no menopausal symptoms.
There is no family history of breast cancer.
Examination shows a 2-cm, palpable, nontender, mobile mass in the upper outer quadrant of the left breast; no nipple discharge can be expressed.
Examination of the right breast shows no abnormalities.
Which of the following is the most appropriate next step in management?