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A78—yearrold woman is brought to the hospital for urinary incontinence. The patient has a history ofAteimer dementia
and has been living in a nursing home for the past 3 years. She requires assistance for most of her daily activities. The
patient can indicate to the nursing home staff when she needs to use the bathroom. She has been less active for the past
I

week and sleeps most of the time. She also has developed urinary incontinence, which she has never had before. Her
temperature is 36.7 C (98 F), blood pressure is 130/70 mm Hg, and pulse is 76/min. On examination, the patient is
somnolent but responsive to voice. She is disoriented but has no focal neurologic deficits. The abdomen is soft and
.

O
H

nontender. Genitourinary examination shows thin and pale vaginal mucosa with ill-defined labia minora. Which of the
H
H

following is the best next step in managing this patient's urinary incontinence?
.

N
H
H
u

O A. CT scan of the head

.

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0 B. Long—term un'nary catheter

H
a.
.

O C. Tolterodine therapy
\l
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.

a
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0 D. Urinalysis and culture

u:
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0 E. Urodynamic study
.

N
e
N
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0 F. Vaginal estrogen cream

.

N
N
N
u
.

N
.A

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U!
N
a.
.

N
\l
N
.

N
a
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.

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A46—yearrold nulliparous woman comes to the office for a routine examination She has been feeling well. Her last
menstrual period was a week ago. The patient has regular menses every 30 days that last 3 days, with crampy abdominal
I

pain on the first day relieved by ibuprofen. She has a history of heartburn, which is relieved by over-the-counter antacids.
The patient has never had any surgeries. She does not smoke cigarettes and drinks alcohol on social occasions. The
patient is sexually active with her husband; they do not use contraception as he has had a vasectomy. Abdominal
examination shows a symmetric, nontender, nondistended abdomen with normal bowel sounds. Speculum examination
.

O
H

shows a cervix with a closed external 05. Bimanual examination shows a 5-crn, irregular, right adnexal mass. Urine
H
H

pregnancy test is negative. Which of the following is the best next step in management?
.

N
H
H
u

O A. CT scan of the abdomen and pelvis

.

:5
H
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O B. MRI of the abdomen and pelvis

a.
.

O C. Pelvic ultrasonography
\l
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.

a
H

O D. Reassurance and routine follow-up

u:
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0 E. Serum (IA—125 level

.

N
e
N
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0 F. X-ray of the abdomen and pelvis

.

N
N
N
u
.

N
.A

Proceed to Next Item

U!
N
a.
.

N
\l
N
.

N
a
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N
.

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Block Tlme: 00:59:50

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A28—yearrold woman comes to the office due to a painful breast mass. She first noticed the mass during her last menstrual
period, and its size has not changed since then. The patient has no chronic medical conditions, and her only medication is
a daily combined oral contraceptive. On examination, there is a palpable, 1.5—cm right breast mass at the 8-o‘clock
position. The mass is tender, 5011, and mobile, and there are no skin changes or galactorrhea. Breast ultrasound shows a
single, thin—walled, fluid—filled cyst. Fine—needle aspiration of the mass reveals clear, yellow—tinged fluid. The mass is still
palpable after aspiration. Which of the following is the most appropriate next step in management of this patient?
.

O
H

O A. Breast MRI
H
H
.

N
H

0 B. Core needle biopsy

H
u
.

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0 C. Discontinuation of the combined oral contraceptive

U!
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O D. Observation and repeat examination in 6 weeks

a.
.

H
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0 E. Thermography
.

a
H
u:
H
.

N
e

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N
H
.

N
N
N
u
.

N
.A
U!
N
a.
.

N
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N
.

N
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A5—day—old girl is brought to the emergency department for evaluation of vaginal discharge. Her mother has noticed white
vaginal discharge mixed with a small amount of blood since yesterday. The girt does not appear to be in pain and has been
voiding and stealing adequately. She is exclusively breastfed every 2—3 hours The mother mentions that she was treated
“with a shot and a pill" for a sexually transmitted disease early in her pregnancy and subsequently tested negative. The girl
was born via forceps—assisted vaginal delivery due to protracted labor at 38 weeks gestation. Temperature is 36.7 C (98 F).
Physical examination reveals a thin, white, odorless vaginal discharge with blood streaking. The external genitalia are
.

O
H

othewvise unremaikable, and the abdomen is soft and nontender without palpable masses. What is the most likely cause of
H
H

this patient's vaginal discharge?

.

N
H
H
u

O A. Candidalvaginitis
.

:5
H
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O B. Chlamydia trachomatis infection

H
a.
.

0 C. Maternal hormone withdrawal

\t
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.

a
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0 D. Rhabdomyosarcoma
u:
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O E. Traumatic injury
.

N
e
N
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0 F. Vaginal foreign body

.

N
N
N
u
.

N
.A

Proceed to Next Item

U!
N
a.
.

N
\t
N
.

N
a
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N
.

u
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Block Time: 00:59:48

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A 14—yearrold girl is brought to the office by her mother because she has not started menstruating. She is otherwise healthy
and has no chronic medical conditions The patient takes no daily medications and does not use tobacco, alcohol, or illicit
drugs. She is not sexually active. Her mother and older sister underwent menarche at age 13. Height is at the 15th
percentile and weight is at the 20th percentile for age. \fital signs are normal. Physical examination shows normal heart
sounds without murmur. There is no breast development or axillary hair. The abdomen is soft, nontender, and
nondistended. Pelvic examination reveals normal external female genitalia and no pubic hair. Ultrasound confirms the
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presence of a uterus. Which of the following is the best next step in management of this patient?

O A. Estrogen level

0 B. FSH level
0 C. GnRH stimulation test
0 D. Karyotype analysis

0 E. MRI ofpituitary
O F. Reassurance and observation

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A 14—yearrold girl is brought to the office due to heavy vaginal bleeding. Since menarche at age 13, menses have been
irregular but not painful. Her last menstrual period was 6 weeks ago, and her current menses started 7 days ago. She is
soaking through a thick pad every 2 or 3 hours and bled through her clothing overnight. She has no history of recurrent
epistaxis or bruising. The patient has no chronic medical conditions or previous surgeries. Her mother required a blood
transfusion with delivery, but has had no other bleeding episodes. Blood pressure is 110/60 mm Hg and pulse is 65/min.
The external genitalia are normal and consistent with sexual maturity rating (Tanner stage) 4 development. The abdomen is
nontender, nondistended, and has no masses. On pelvic examination, there is dark red bleeding from the cervical os.
Urine pregnancy test is negative. Which of the following is the most likely cause of this patient's symptoms?

O A. Cenlical inflammation

0 B. Endometn'al implantation within the myometrium

O C. Hypothalamic-pituitary-ovarian axis immaturity

O D. Impaired platelet aggregation

O E. Monoclonal myometrial proliferation

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A 16—yearrold girl comes to the office for evaluation of painful menstrual periods. The patient undenNent menarche at age
13 and initially had irregular menses. Her menstrual cycles now occur every 30 days, with 4 days of moderate bleeding.
Her menses have become increasingly painful; lower abdominal pain starts a few hours prior to menses and lasts 1 or 2
days with associated fatigue, dizziness, and diarrhea. She misses school at least 1 day per month due to the pain but is
able to maintain her grades and has no pain or other symptoms after completion of menses. The patient has a history of
depression, for which she sees a therapist, but has had no recent changes in mood. She recently became sexually active
O
H

and uses condoms for contraception. Her last menstrual period was a week ago. Vital signs are normal. Pelvic
H
H

examination shows norrnal external genitalia and a clear discharge emerging from the cervical us. On bimanual
.

N
H

examination, the uterus is mobile, nontender, and normal in size and contour. Bilateral adnexa have no masses or
H
u

tenderness. Which of the following is the most likely diagnosis in this patient?
.

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H
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H

O A. Adenomyosis
a.
.

H
\l
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O B. Endometriosis
.

a
H

O C. Pelvic inflammatory disease

u:
H
.

N
e

0 D. Primary dysmenorrhea
N
H
.

N
N

O E. Somatic symptom disorder

N
u
.

N
.A
U!
N

Proceed to Next Item

a.
.

N
\l
N
.

N
a
u:
N
.

u
a

Block Time: 00:59:43

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A34—yearrold woman comes to the office to discuss the progestin—releasing intrauterine device. The patient previously used
condoms for contraception but is interested in starting a more reliable method. Her menses occur every 8 to 12 weeks, with
heavy vaginal bleeding and passage of clots, and she has intermittent light spotting in between. The patient's last
menstrual period was 1 week ago. She has no chronic medical conditions and takes no daily medications. The patient was
treated for Trichomonas vaginitis at age 16. Her maternal grandmother had metastatic breast cancer in her 705. Blood
pressure is 118/64 mm Hg and pulse is 80/min. BMI is 44 kglmz. Pelvic examination shows a nulliparous cervix with scant
physiologic discharge and a small, nontender utems. Urine pregnancy test is negative. Which of the following is this
patient's contraindication to a progestin-releasing intrauterine device?

O A. Age

0 B. Family history
0 C. Menstrual bleeding pattem

O D. Nulliparity

O E. Pn‘or sexually transmitted infection

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Block Time: 00:59:42

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A54—yearrold postmenopausal woman comes to the office due to involuntary loss of urine. The patient is unable to hold her
urine during the day but has no loss of urine while sleeping She is sexually active but has been avoiding intercourse for the
past few months because she sometimes has leakage of urine during intercourse. The patient also loses urine when
laughing and coughing. She has no chronic medical conditions and takes no daily medications. Her only surgery was a
.

cesarean delivery at age 30 for a pregnancy complicated by pyelonephn'tis and preterm labor at 34 weeks gestation. \fital
signs are normal, and BMI is 38 kg/mi. Pelvic examination shows dribbling of urine when the patient coughs. A postvoid
.

0
H

residual is 30 mL. Urinalysis shows no abnormalities. Which of the following is the most appropriate treatment for this
H
H

patient's incontinence?
N
H
H
u

O A. Alpha blocker
.

:5
H
U!

O B. Antimuscarinic agent
H
a.
.

0 C. Cholinergic agonist
\l
H
.

a
H

O D. lntennittent self-catheterization
u:
H

O E. Midurethral sling
.

N
e
N
H

O F. Postcoital antibiotics
.

N
N
N
u
.

N
.A

Proceed to Next Item

U!
N
a.
.

N
\l
N
.

N
a
u:
N
.

u
a

Block Tlme: 00:59:40

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A37—yearrold woman is brought to the emergency department by her boyfriend for severe abdominal pain that started
several hours ago. The pain started diffusely in the periumbilical area but is now mostly localized to the lower abdomen.
The patient has persistent nausea but no vomiting. Her last menstrual period was 25 days ago, but she has irregular
periods. She is sexually active with her boyfriend. Her temperature is 36.8 C (98.1 F), blood pressure is 130/80 mm Hg,
pulse is 110/min, and respirations are 25/min. The abdomen, especially in the lower quadrants, is tender on palpation with
.

mild guarding. There is no shifting dullness. Bowel sounds are diminished. Laboratory results are as follows:
I—t
-

o
.

H
H

Hemoglobin 13.1 g/dL

r-I
N

Hematocrit 43%
H
u
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.

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White blood cells 10,900/uL

In
H
at
r-I
.

Which of the following is the most appropriate next step in management of this patient?
\r
H
r-I
.

O A. Abdominal CT scan
u:
H

0 B. Diagnostic peritoneal lavage

.

N
e
N
H

O C. Pelvic ultrasound
.

N
N

O D. Pregnancy test
N
u
.

N
.A

0 E. Upright chest x—ray

In
N
at
.

N
\r
N

Proceed to Next Item

.

N
a
N
u:

Block Time: 00:59:39

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ASS—yearrold woman comes to the office due to blood—tinged vaginal discharge. The patient has had intermittent, slightly
malodorous discharge for the past several weeks but has not passed large clots or had heavy vaginal bleeding. Medical
history is significant for exposure to diethylstilbestrol in utero that resulted in infertility. She underwent menopause at age
55 and has used combined menopause hormone therapy for several years. Her mother was diagnosed with endometnal
cancer at age 54, and her uncle was diagnosed with colorectal cancer at age 70. The patient has smoked a pack of
cigarettes daily for the last 40 years and drinks a few glasses of wine each week. BMI is 32 kg/mz. Pelvic examination
H
D
.

demonstrates a blood-tinged watery discharge and a 3—cm ulcerated lesion on the posterior vaginal wall; the cervix appears
>—-
.

>-

normal. Transvaginal ultrasound shows a 2—mm endometn'al snipe. Biopsy of the lesion demonstrates squamous cell
.

N
H

carcinoma. Which of the following is the greatest risk factor for this patient's diagnosis?
u
H
A
H

O A. Body mass index

U!
H
at
.

0 B. Chronic tobacco use

\l
H

0 C. Diethylslilbestrol exposure in utero

.

a
H
u:
H

O D. Family history
.

e
N

0 E. History of infertility
N
H
.

N
N

O F. Pnor menopause hormone therapy

u
N
.

N
.A
U!
N

Proceed to Next Item

a.
.

N
\l
N
.

a
N
u:
N
.

a
u

Block Time: 00:59:31

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An 8—year—old girl is brought to the office after her mother noticed bloody spotting in the girl's undenivear The patient has no
chronic medical conditions and is up to date on her vaccinations. She plays soccer with her elementary school team, and
her parents are divorced. Vital signs are normal. Height and weight are at the 40th percentile. Physical examination
reveals sexual maturity rating (Tanner) stage 1 breast development and no acne or axillary hair. Pelvic examination shows
multiple 2—mm, raised, fleshy papules on the vulva and anus that bleed on contact with a cotton swab. Which of the
following is the best next step in evaluation of this pafient's lesions?
Hl-l
HO
.

O A. Administer scotch tape test

._.
-

0 B. Ask about vulvar hygiene

.

w
H
A
H

O C. Measure hemoglobin Me
01
H
at
.

O D. Perform wet mount microscopy

H
\l
H

0 E. Question about sexual abuse

.

a
H
u:
H

0 F. Review family history for malignancy

.

e
N
H
N
.

N
N

Proceed to Next Item

u
N
.

A
N
U!
N
at
.

N
\l
N
.

a
NN
u:

Block Tlme: 00:59:35

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A33—yearrold woman comes to the office for evaluation of "fluid coming out of both nipples." The fluid is pale gray and has
been leaking intermittently for the past week. She has 2 healthy children ages 5 and 8. The patient had a copper-
containing intrauterine device placed for contraception a few months after the delivery of her younger child and has not
used any hormonal contraceptives. She also has a history of mild gastroescphageal reflux for which she takes over—the—
ccunter antacids. Examination shows normal breasts without palpable lumps or nipple abnormalities. Brownish—gray
discharge is expressed from both nipples and is guaiac negative. Urine pregnancy test is negative. Which of the following
HHl—l
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is the most appropriate next step in management of this patient?

.

O A. Cytologic examination
u:
.

>-
A
.

0 B. Discontinue antacid therapy

H
or
H

0 C. Mammography
a
H
\l
H

O D. Measure prolactin and TSH levels

a
.

0 E. Reassurance and routine follow—up

u:
H
e
.

0 F. Ultrasound of the breasts

H
N
N
.

N
u
N

Proceed 10 NEXT Item

.

N
U!.A
N
a.
.

N
\l
N
a
.

NN
u:

Block Tlme: 00:59:34

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A 15—yearrold girl comes to the office due to yellow vaginal discharge for the past 2 days. The patient has also had bleeding
between menstrual periods for the past 2 months. She has no fevers, chills, or pelvic pain. She is sexually active. The
patient's parents are at work and she comes to the appointment alone. She does not have any medical conditions, takes no
medications, and has no allergies. Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, and pulse is 78/min.
Physical examination shows a nontender abdomen. Pelvic examination reveals mucopurulent discharge at the cervical cs;
there is no cervical motion or adnexal tenderness. Urine pregnancy test is negative. The patient is prescribed the
.

e
H

appropriate treatment and leaves the office. Several hours later, the patient's mother comes to the office asking for an
n-o
H

explanation for the visit and for the antibiotic prescription. Which of the following is the most appropriate response?
N
H
u

H
u

O A. ”Can you explain to me what you think is going on with your daughter?"
I—t
4‘-
-
u

01
H

0 B. "I need your daughter‘s permission before I discuss her care with you."
at
H

O C. "I recommend you discuss this diagnosis with your daughter."

\l
H
u

a
H

0 D. ”Let's schedule another appointment with your daughter to discuss the results together."
D
H

0 E. "Your daughter has a cervical infection and l prescribed antibiotics."

u

O
N
H
N
u

N
N
03
N

Proceed to Next Item

u

fi
N
Ul
N
Q
u

N
\I
N
a
u

NN
u:

Block Time: 00:59:33

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A33—yearrold woman comes to the office due to new—onset pain with intercourse. The patient has been in a relationship
with a male partner for the past 6 months and is using condoms for contraception. For the past 3 months, she has had
worsening dyspareunia and vaginal dryness, which has made her limit sexual activity despite no changes in libido. She has
had 6 lifetime partners and has not had this problem before. The patient has had no postooital spotting or abnormal vaginal
discharge. Family history is significant for a sister with infertility due to 45,X mosaicism. \fital signs are normal. Bilateral
breasts are atrophic. On pelvic examination, the vulvae are pale and thin, and the clitoris protrudes from the clitoral hood.
H
O
.

There is no tenderness to palpation over the perineum. The vagina has minimal rugation, and a large, mildly tender
H
H

adnexal mass is palpated. Pregnancy test is negative. Pelvic ultrasound reveals a 9-cm, solid adnexal mass. Which of the
H
N
H
N

following is the most likely etiology of this patient's presentation?

H
A
.

O A. Chromosome—mediated ovarian follicle depletion

U1
.

H
35
.

O B. Complex collection of pumlent, polymicrobial fluid

‘d
H

0 C. Endometn'al glands and stroma within the ovary

05
H
O
H

O D. Estrogen-secreting sex cord-stromal tumor

O
.

N
H

0 E. Lactate dehydrogenase—secreting germ cell tumor

N
N
.

0 F. Serous epithelial ovarian tumor

u
N
fi
.

0 G. Testosterone-secreting sex cord—stromal tumor

U!
N
Q
.

N
\l
N

Proceed to Next Item

a
.

NN
u:

Block Tlme: 00:59:32

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$3
A29—yearrold woman comes to the emergency department due to fever, chills, and lower abdominal pain. Two days ago,
the patient undenvent dilation and curettage for a 9—week missed abortion After the procedure, she initially had light
spotling, but the bleeding has become increasingly heavy and malodorous within the last few hours. She has also
developed increasing abdominal pain and a fever unrelieved by acetaminophen. The patient has no chronic medical
conditions and has had no other surgen'es. Temperature is 39.4 C (103 F), blood pressure is 88/50 mm Hg, and pulse is
118/min. 0n speculum examination, the cervix is visibly 1 cm dilated and has purulent discharge at the as. The utenis is
.

O
H

enlarged and has cervical motion tenderness. Transvaginal ultrasound shows a thickened endometrial stripe Urine
H
H

pregnancy test is positive. The patient is started on broad-spectrum intravenous antibiotics and undergoes a suction
.

N
H

dilation and sharp curettage This patient is at increased risk for which of the following conditions?
H
u
A
H

O A. Development of intrauterine synechiae

01
.

H
i—t
at
-

O B. Dysplaslic changes to the cervical epithelium

‘4
.

O C. Implantation of ectopic endometrial tissue

an
H
n-o
u:

0 D. Infarction of the pituitary gland

e
.

N
H

O E. Malignant transformation of trophoblaslic tissue

N
N
.

N
u
N
.

N
.A

Proceed to Next Item

U!
N
a.
.

N
\l
N
a
.

NN
u:

Block Time: 00:59:31

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A29—yearrold woman comes to the office due to infertility. She has had unprotected intercourse with her husband regularly
for the past year and has not become pregnant. The patient's last menstrual period was 3 weeks ago‘ Her menses occur
every 28—30 days and last 4-5 days. The patient has severe lower abdominal pain that begins the day before her menses
and is only partially relieved by ibuprofen. She was treated for gonococcal cervicitis at age 19. The patient takes a prenatal
vitamin daily and does not use tobacco, alcohol, or illicit drugs. Her husband, age 31, recently had a normal semen
analysis. The patient's blood pressure is 126/70 mm Hg and pulse is 85/min. BMI is 31 kg/m? Examination reveals a small
H
O
.

uterus with a cervix that appears laterally displaced; there is pain with cervical manipulation. Which of the following is the
H
H
H

most likely cause of this patient's infertility?

N
.

H
U

O A. Endometn'al polyp
H
a
H
01

O B. Endometriosis
H
Q
.

O C. Intrauterine adhesions
\J
.

H
on
.

O D. Submucosal fibroids
D
H

O E. Unicomuate uterus
a
N
H
N
N
.

N
u
N

Proceed to Next Item

.

N
.A
U!
N
a.
.

N
\l
N
a
.

NN
u:

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A 16—yearrold girl comes to the office for evaluation of acne. Around the time of her first menstrual period at age 10, the
acne appeared only on her face, but over the past 6 years, it has spread to her chest and back. Topical preparations are
not effective, and the patient feels anxious regarding social situations at school. She quit the soccer team and has since
gained 9.1 kg (20 lb). The patient has never been sexually active. Menses are irregular and her last menstrual peliod was
3 months ago. She has not had a Pap test but has completed the human papillomavirus vaccination series. The patient
takes no medications and does not use tobacco. Family history is noncontributory. Physical examination shows cystic and
.

O
H

nodular acne over the face, back, and upper chest. There is no goiter or thyroid masses. Terminal hairs are notable on the
H
H

upper lip and around the nipples. Development is Tanner stage V. The abdomen is obese and nontender, with no masses
.

N
H

and normal bowel sounds. Serum total testosterone and dehydroepiandrosterone sulfate levels are normal. This patient is
H
u

at greatest risk for developing malignancy of which of the following?

.

.5
H
01
H

O A. Adrenal gland
at
H
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.

O B. Cervix
-

on
H

O C. Endometrium
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.

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O D. Thyroid
N
H
.

O E. Vagina
N
N
N
u

O F. Vulva
.

N
.5
U!
N
a.
.

N
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Proceed to Next Item

N
.

N
a
u:
N

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A57—yearrold woman comes to the office for evaluation of vaginal pruritus, pain with urination, and increased urinary
frequency. The patient's symptoms have been present for several months but have intensified recently Her husband
passed away 4 years ago, and the patient had not been sexually active until 6 months ago with a new partner. She has had
some pain with intercourse and has tried over—the—counter, water—based lubricants with little relief. Her last menstrual period
was 7 years ago. She has poorly controlled type 2 diabetes mellitus with a recent hemoglobin A1c of 8.4%. BMI is 28
kg/m2_ Vital signs are normal. Pelvic examination shows thin vulvar skin with reduced elasticity. The vagina appears pale,
H
e
.

dry, and has multiple areas of petechiae. There is minimal clear discharge in the vault. Vaginal pH is 6.5. Urinalysis is
H
H
H

normal. Which of the following is the best next step in management of this patient?
N
.

H
u

O A. Oral metronidazole
H
.

.A
H
U!

O B. Oral nitrofurantoin
H
a
H

O C. Topical corticosteroid cream

‘d
H
on
.

0 D. Topical nystatin cream

H
.

to
N

0 E. Vaginal estrogen cream

.

a
N
H
N
N
N
u

Proceed to Next Item

N
.

.A
N
U!
N
at
.

N
\l
N
.

a
N
u:

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A29—yearrold woman comes to the office due to painful sores on her labia. The patient first noticed the sores 3 days ago
and has not had these symptoms before She has also had a headache and intermittent fever for the past 5 days that
temporarily resolved with acetaminophen The patient recently became sexually active with a new male partner and uses a
progestin—containing intrauterine device for contraception. She has no chronic medical conditions and takes no
medications. Temperature is 38.4 C (101.2 F), blood pressure is 110/70 mm Hg, and pulse is 88/min. Physical examination
shows several clusters of multiple small, vesicular lesions on the right Iabium minora and tender, right inguinal
.

O
H

lymphadenopathy. Speculum examination is normal. Urine pregnancy test is negative. If left untreated, this patient‘s
H
H

clinical course would most likely result in which of the following?

.

N
H
H
U

O A. Development of maculopapular rash that includes the palms and soles

.

fi
H
11‘
H

O B. Inflammation of the liver capsule and resultant perihepaljtis

at
.

O C. Persistent lesions with no additional sequelae

‘d
H
G
H

O D. Progression to CNS infection

u:
.

H
N

0 E. Spontaneous resolution within the next week

-

o
N
.

0 F. Suppuration of inguinal lymph nodes and formation of buboes

N
N
N
u
N
.

.5
N

Proceed to Next Item

U!
N
a.
.

N
\l
N
.

a
N
up

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A63—yearrold woman comes to the office for evaluation of postmenopausal bleeding. The patient initially had post—coital
bleeding only, but it has become more frequent despite the use of over~the«counter vaginal lubricants and moisturizers. For
the last month, the patient has had daily vaginal spotting and is beginning to have pain with intercourse. Until 6 months
ago, she had not been sexually active for 10 years. The patient has had no routine health care since the birth of her
children over 30 years ago. She smokes a pack of cigarettes a day. BMI is 30 kg/mQ. The vagina appears atrophic with
minimal rugation and has a 1-cm ulcerated lesion in the upper third of the posterior wall. There is a malodorous watery
H
e
.

discharge in the vagina. Numerous squamous epithelial cells with rare leukocytes are seen on wet mount microscopy.
H
H
H

Potassium hydroxide test is negative. Pelvic ultrasound shows an anteverted uterus with a 3—mm endometrial stripe, Which
N
.

of the following is the best next step in management of this patient?

u
H
.

.A

O A. Endometn'al biopsy
H
U!
H
at
.

0 B. Oral metronidazole
H
\l
H

O C. Topical corticosteroids
an
H
D

O D. Vaginal biopsy
N
a
.

0 E. Vaginal estrogen
.

H
N
.

O F. Wide local excision

N
u
N
A
N
U!
N

Proceed to Next Item

u

at
N
\l
N
u

a
N
u:
Q
U
u

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A 19—yearrold nulligravid woman comes to the office for a routine checkup. She is concerned about having gained 4.5 kg
(10 lb) over the last year and believes it is related to her oral contraceptive pills. The patient takes low—dose ethinyl
estradiol/norethindrone daily. Prior to starting the pills, she had regular, heavy periods lasting 4—5 days. The patient missed
school every month due to severe cramping on the first day of her period. Her pain symptoms resolved after 3 months on
the pills. She takes no other medications. Coitarche was at age 18 and she has had 2 partners since then. The patient
and her current partner use condoms inconsistenfly. Vital signs are normal. Her BMI is 27 kg/m1_ Physical examination is
.

e
H

unremarkable Which of the following is the most appropriate advice for this patient?
H
H
.

N
H

O A. Discontinue oral contraceptive pills (OCPs) and start nonsteroidal anti—inflammatory drugs
H
u
.

0 B. Reassure that the weight gain is not related to combined OCPs

.A
H
U!
H

O C. Recommend switching from combined OCPs to a copper intrauterine device

at
.

H
\l
H

0 D. Recommend switching from combined OCPs to medroxyprogesterone injections

.

a
H

0 E. Recommend switching from combined OCPs to progesterone—only pills

u:
H
N
a
.

N
H
N
-

Proceed to Next Item

m
N
.

w
N
A
N
or
N
a.
.

N
\l
N
.

a
N
u:

Block Time: 00:59:25

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A59—yearrold postmenopausal woman comes to the office for evaluation of breast tenderness. The patient first noticed
intermittent breast tenderness 4 months ago, which at first was relieved with ibuprofen, but for the past several weeks the
tenderness has occurred daily. She has had no breast masses or nipple discharge. The patient has also noticed an
increase in her weight, particularly around the abdomen, despite not being able to eat as much. She went through
menopause 5 years ago. Mammogram history is normal, including one performed earlier this year. The patient has no
chronic medical conditions and has had no previous surgeries. There is no family history of breast, ovarian, or endometrial
.

:
H

cancer. Vital signs are normal. BMI is 24 kg/m? Breast examination shows bilateral, difiuse fibrocystic changes. The
H
H

abdomen is distended, and a large right lower quadrant mass is palpable. Pelvic ultrasound reveals a 12—cm complex right
N
.

ovarian mass with solid components and multiple septations, a slightly enlarged uterus, and a 9—mm endometrial snipe.
u
H

Which of the following tumor markers is most likely to be elevated in this patient?
.

.A
H
In
H

O A. Alpha—fetoprotein
at
.

H
\r
H

O B. Estradiol
a
.

O c. hCG
u:
H
a
N

O D. Lactate dehydrogenase
H
N
N
N

O E. Testosterone
NNNNN
MGM-bl

O F. Thyroxine

Proceed to Next Item

N
a
.

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A 16—yearrold girl comes to the office due to recurrent, intermittent lower abdominal pain. The pain typically begins the day
prior to the onset of menses and subsides on the second day of bleeding. She has associated nausea and diarrhea during
this time but has no constipation or pain with defecation. These symptoms began 5 months ago and have progressively
worsened, causing the patient to miss 2 days of school last month. Menarche was at age 13 and her menses were irregular
until 6 months ago; now menses occur every 28 days with 4 to 5 days of moderate bleeding. The patient recently became
sexually active and uses condoms for contraception. Her last menstrual period was 2 weeks ago. \fital signs are normal.
.

:
H

0n speculum examination, a small amount of physiologic discharge is noted throughout the vaginal vault, and the cervix is
H
H

nonfriable. The uterus is small, mobile, and nontender. Pregnancy test is negative. Which of the following is the most likely
.

N
H

cause of this patient's pain?

H
u
.

.A
H

O A. Endometnal stroma and glands within the uterine muscle

U!
H
at
.

0 B. Implanted endometrial glands outside the uterus

\l
H

O C. Increased endometrial prostaglandin production

.

a
H
u:
H

0 D. lntennittent compression of the ovarian vessels

.

N
e

0 E. Peritoneal inflammation from ruptured ovarian follicle

N
H
N
N

O F. Polymicrobial infection within the endometrial cavity

N
u
Maul-L‘-
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Proceed to Next Item

N
a
.

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A37—yearrold woman comes to the office for evaluation of infertility. She and her 39—year—old husband have not been able
to conceive after 18 months of unprotected and frequent intercourse. Menstrual cycles occur every 28 days, last 5 days,
and have heavy bleeding and cramping on the first day. The patient had a miscarriage at age 27 that required a dilation
and curettage. The couple had another spontaneous pregnancy 6 years later that resulted in an uncomplicated term
vaginal delivery. The patient feels well and has no medical conditions. She has never had a sexually transmitted infection.
She does not use tobacco, alcohol, or illicit drugs. The patient is an aerobics instructor and teaches two 60—minute classes
e
.

daily. Blood pressure is 120180 mm Hg and pulse is 84Imin. BMI is 23 kg/mz. She has no thyromegaly. Breast
H
H

examination shows no palpable masses, axillary lymphadenopathy, or expressed nipple discharge. Pelvic examination
N
.

reveals normal external genitalia, a well—rugated vagina, a mobile uterus, and normal ovaries. Which of the following is the
u
H

most likely underlying cause of this couple's failure to conceive?

.

.A
H
U!
H

O A. Decreased ovan'an reserve

at
.

H
\l
H

0 B. Hypothalamic dysfunction
a
.

0 C. Hypothyroidism
u:
H
e
.

O D. Primary ovarian insufficiency

H
N
N
N

O E. Uterine leiomyomata
u
N

O F. Uterine synechiae
A
N
N
U1
N
O
MN
QM

Proceed to Next Item

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A 19—yearrold woman comes to the office for a routine physical examination. She feels well and has no concerns. The
patient has had 2 sexual partners in the past 3 months and uses condoms for contraception She has no significant medical
history, takes no medications, and has no drug allergies. Temperature is 37.2 C (99 F), blood pressure is 120/72 mm Hg,
and pulse is 72/min. Pelvic examination shows normal external genitalia. The cervix has no lesions, abnormal discharge,
or friabilily. On bimanual examination, the uterus is small and mobile and has no cervical motion or fundal tenderness. A
cervical swab is sent for Chlamydia trachomatis and Neisseria gonorrhoeae nucleic acid amplification testing. The tests
.

e
H

return positive for chlamydia but negative for gonorrhea. The patient is still asymptomatic. Which of the following is the
H
H

most appropriate next step in management of this patient?

.

N
H
H
u

O A. Azithromycin only
.

.A
H
U!

0 B. Cefinaxone and azithromycin

H
at
.

O C. Ceftriaxone only
\l
H
.

a
H

0 D. Reassurance and no treatment at this time

u:
H

0 E. Repeat test for confirmation

.

N
e
N
H
.

N
N
N
u

Proceed to Next Item

N
A
01
N
N
0‘
N
\l
G
N

Block Time: 00:59:20

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A41—yearrold woman, gravida 1 para 0, at 21 weeks gestation comes to the emergency department due to several hours of
vaginal spotting. She has also had increased vaginal discharge and pelvic pressure over the past few days but no
cramping or leakage of fluid. The patient first felt fetal movement last week and has an occasional headache without visual
changes or epigastn'c pain. She has chronic hypertension and type 2 diabetes mellilus. The patient had an abnormal Pap
test in her 205 that required a cone biopsy. She has a 20—pack—year smoking history but quit 2 years ago. Temperature is
36.7 C (98.1 F), blood pressure is 130/84 mm Hg, and pulse is 78/min. BMl is 24 kglm2_ The abdomen is soft and
e
.

nontender with no palpable contractions. 0n pelvic examination, minimal blood is present in the vaginal vault. The cervix is
H
H

visibly dilated to 2 cm, with smooth, shiny membranes bulging through the 05. Deep tendon reflexes are 2+ at the knees.
N
.

Transabdominal ultrasound reveals the fetus in a cephalic presentation with a low—lying antenor placenta. Fetal heart rate is
u
H

150/min. Urinalysis shows no protein. Which of the following is the most likely contributing factor to this patient's clinical
.

.A
H
U!
H

presentation?
at
.

O A. Advanced maternal age

\l
H
a
.

0 B. Chronic hypertension
u:
H
e
.

0 C. Cone biopsy
N
H
N

0 D. Placental location
N
.

N
u
N

0 E. Tobacco use
A
N

0 F. Type 2 diabetes mellitus

01
N
a
N
N
V
N
05

Proceed to Next Item

N
to

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A42—yearrold woman comes to the office for a routine health examination. She is sexually active with a male partner and
undenNent a tubal ligation for contraception The patient has had no abnormal bleeding or recent changes in weight.
Menses are regular and last 3—5 days; her last menstrual period was 3 weeks ago. Ten years ago, the patient had genital
warts successfully treated by laser ablation. Pap tests have been normal to date. She has had no other serious medical
illness or surgeries and takes no medications. She has a family history of hypertension but no history of cancer. Pelvic
examination shows a normal cervix without any visible lesions, a small anteverted uterus, and no adnexal masses. The
NNNNNNNHHHHHHHI—IHI—I
amfiwNHOOUMQUfiUND-‘O

Pap test shows atypical glandular cells. Which of the following is the next best step in management of this patient?

O A. Endometn'al biopsy

0 B. Hysterectomy

O C. Hysteroscopy

O D. Loop electrosurgical excision procedure

0 E. Return to routine Pap screening

0 F. Serum CA-125

Proceed 10 NEXT Item

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A24—yearrold woman comes to the office due to intimacy issues with her husband. They have been married for a year and
have been unable to have sexual intercourse. The husband has had erectile dysfunction for the past 3 months; he says
that it is due to his wife experiencing dyspareunia and his fear of causing her more pain. They now attempt intercourse only
once or twice a month due to lack of interest. The patient reports no dysun'a, unnary frequency, vaginal pruritus, or pain in
the perineum. She has no medical problems or previous surgeries. She has regular menses, lasting 4—5 days, with painful
cramping on the first day. The patient has been unable to use tampons due to vaginal pain. She has had no previous
e
.

sexual partners The patient takes no medications and does not use tobacco, alcohol, or illicit dmgs. Examination of the
H
H

external genitalia shows no lesions and no pain on external touch. An internal pelvic examination is attempted but not
N
.

completed due to the patient‘s intolerance. Which of the following is the most likely diagnosis?
u
H
.

.A
H

O A. Atrophic vaginitis
U!
H
at
.

O B. Endometn'osis
\l
H

O C. Female sexual interest/arousal disorder

a
.

H
u:
H

0 D. Genito-pelvic pain/penetration disorder

e
.

N
H

0 E. Localized provoked vulvodynia

N
N
.

O F. Pudendal neuralgia
u
N
.

N
.A
U!
N

Proceed to Next Item

a
N
at
N
on
N
N
o

30
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A36—yearrold woman comes to the office after discovering a lump in her right breast. She has no other symptoms. This
patient regularly performs breast self-examinations after menses, and her last menstrual period ended 2 days ago. She has
no significant medical history and has not seen a physician in 10 years. The patient takes no medications and has no
allergies. Her grandmother died at age 78, 2 years after being diagnosed with breast cancer. Breast examination shows a
1—cm firm, round mass in the upper outer quadrant of the right breast. No axillary lymph nodes are palpable. Which of the
following is the most appropriate next step in management of this patient?
NNNNNNNNHHHHHHHI—IHI—I
NatmfiuNHcomxiatmfiuNi—t:

O A. Core biopsy

0 B. Excisional biopsy

0 C. Mammography

O D. Reassurance

O E. Repeat examination in 6 months

Proceed to Next Item

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A74—yearrold woman, gravida 5 para 5, comes to the office due to vaginal spotting and discharge for several months. She
reports a mass coming out of her vagina She is now having difficulty defecating; increased straining causes the mass to
increase in size. The patient has hypertension, type 2 diabetes mellitus, and NYHA class I" heart failure. Her last
hemoglobin A1c was 11.8. She had 5 spontaneous vaginal deliveries and has no history of abnormal Pap tests. The
patient has a 40—pack—year smoking history. Blood pressure is 150/90 mm Hg, pulse is 84/min, and respirations are
16/min. Oxygen saturation is 89% on room air. BMI is 41 kg/mz. Cardiopulmonary examination reveals decreased breath
NNNNNNNNNHHHHHHHI—IHI—I
«NamauNHccauatmauNr—r:

sounds bilaterally. The abdomen is nontender and has no palpable masses. Pelvic examination reveals the cervix at the
level of the vaginal introitus. The vaginal mucosa is thin with multiple areas of excoriation and erosion. Ultrasonography
reveals a thin endometrial stripe. Which of the following is the best next step in management of this patient?

O A. Endometn'al biopsy

0 B. Hormone replacementtherapy

O C. Pelvic floor muscle exercises

O D. Pessary fitting

0 E. Surgical repair

Proceed 10 NEXT Item

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3
. 4
5 The following vignette applies to the next 2 items. The items in the set must be answered in sequential order. Once y

7
_ s A67-year~old woman comes to the office with severe vulvar itching and burning forthe past 6 months The patient has tried
9 over—the—counter, topical lubricants for her symptoms without relief. She is no longer sexually active because vaginal
. 1o penetration is not possible due to pain. Medical history includes type 1 diabetes mellitus that is well controlled with insulin.
11 The patient had a total vaginal hysterectomy at age 48 for adenomyosis. She previously had no abnormal Pap tests and
' 12 has not had cervical cancer screening since the hysterectomy. Vital signs are nonnal. Physical examination shows thin,
13 dry, white, plaque-like vulvar skin with loss of the labia minora. There is clitoral hood retraction. Excoriations are present
' i: bilaterally on the vulva.
. 16 Item 1 of 2
17
13 Which of the following is the best next step in evaluation of this patient?

19 O A. Potassium hydroxide preparation

. 2o
21 O B. Serum estrogen level
. 22
23 O C. Vaginal Pap test

' 24 O D. Vulvar punch biopsy

25
. 26 O E. Yeast culture
27

29
. 23

30
. 31 Block Time: 00:59:12 0

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£233
.

. 10 lbm 2 Of 2

The patient is diagnosed with lichen sclerosus. Which of the following is the best treatment option for this patient?

13 O A. Cryotherapy

15 O B. Radical vulvectomy
O C. Topical corticosteroids
. 13 O D. Topical estrogen

O E. Topical imiquimod

23 Proceed to Hen item

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11
12
A29—yearrold woman comes to the emergency department with chest pain and dyspnea for 10 days. The chest pain is
13
bilateral, dull, persistent, and not worsened by exertion. The patient's medical history is significant for a normal
14
spontaneous vaginal delivery 3 months ago, after which she has had frequent episodes of dark, bloody vaginal discharge.
15
16 The most recent bleeding episode was 6 days ago. The patient has no fever, chills, hemoptysis, orthopnea, or leg pain,

17 She does not use tobacco, alcohol, or illicit drugs. Temperature is 37.5 C (99.5 F), blood pressure is 110/68 mm Hg, pulse
18 is BDImin, and respirations are 16/min. BMI is 26.2 kg/mz. Physical examination reveals bilaterally clear lungs. The
19 extremities are warm and well perfused. There is no peripheral edema. Pelvic examination reveals an enlarged uterus, a
20
closed cervix, and minimal dark blood in the vagina. Complete blood count and serum electrolytes are within normal limits.
21
Chest x—rays reveal multiple bilateral infiltrates of various shapes. Which of the following would be most helpful in
22
establishing this patient's diagnosis?
23
24
O A. CT scan of the chest
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26 0 B. Echocardiogram
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28
O C. Pulmonary function tests
29 0 D. Quantitative B—hCG test
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0 E. Ventilation perfusion scan

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A38—yearrold nulliparous woman complains of lower abdominal discomfort and chronic constipation. She has cramping
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with her menses that causes her to miss a day of work each month. Menses occur regularly at 28-day intervals with no
. 14
bleeding or spotting between cycles. Past medical history is significant for asthma and an appendectomy at age 12. Her
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. 16 mother had breast cancer at age 55, and her maternal grandmother died of ovarian cancer at age 66. Vrtal signs are within

17 normal limits. Pelvic examination shows an enlarged uterus that is irregular and mobile with a prominent posterior mass.
. 18 Which of the following is the best next step in management of this patient?
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. 20 O A. BRCA1 and BRCA2 genetic testing
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0 B. CT scan of the abdomen and pelvis
. 22

23 O C. Diagnostic laparoscopy
. 24

25
O D. Endometnal biopsy
. 26
0 E. Pelvic ultrasound
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A21—yearrold woman is brought to the emergency department due to continuous vomiting, diarrhea, and high fever for a
day. The patient also has a severe headache that is unrelieved by acetaminophen She has no hematemesis or
hematochezia. The patient spent the last 3 months in Southeast Asia and returned yesterday on an international flight. She
has no chronic medical conditions or previous surgeries. The patient does not use tobacco or illicit drugs. She is currently
on the fiflh day of her menstrual period and has had to use both tampons and pads due to heavy bleeding. Temperature is
39.4 C (103 F), blood pressure is 80/40 mm Hg, and pulse is 124mm. Physical examination reveals a diaphoretic woman
with dry mucous membranes. There is no nuchal rigidity. An erythematous macular rash covers the entire body, including
the palms and soles. Which of the following microorganisms is most likely responsible for this patient's symptoms?

O A. Neisseria gononhoeae

O B. Rotavirus
O C. Shigella

O D. Staphylococcus aureus

0 E. Treponema pallidum

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A 17—yearrold nulligravid girl comes to the office due to 2 months of colicky left lower quadrant pain. The pain worsens with
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intercourse and exercise but resolves spontaneously. She has had no diarrhea, constipation, or urinary symptoms. Her last
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menstrual period was 3 weeks ago. Menses occur monthly and last 5-6 days with 2 days of heavy bleeding. The patient is
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16 sexually active with a new partner and uses condoms for contraception. She has no chronic medical conditions and has

17 had no surgeries. She does not use tobacco, alcohol, or illicit drugs. Her older sister recently had in vitro fertilization due to
18 infertility from endometriosis. Vital signs are normal. Pelvic examination shows a tender left adnexal mass and small,
19 mobile uterus. Urine pregnancy test is negative. Neisseria gonorrhoeae and Chlamydia trachomatis testing is negative.
20 Ultrasonography reveals an B-cm left ovarian cyst with calcifications and hyperechoic nodules. Which of the following is the
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best next step in management of this patient?
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23
O A. Broad-spectrum intravenous antibiotics due to suspected tuba-ovarian abscess
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25 O B. CA—125 and CEA serum level testing for monitoring of disease progression
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0 C. GnRH agonist therapy to reduce chronic pelvic pain
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28 0 D. Laparoscopic ovarian cystectomy to reduce the risk of ovarian torsion
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O E. Observation and repeat ultrasound in 6 weeks as symptoms will likely resolve
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A 2B-year~old woman, gravida 1 para 0, at 35 weeks gestation comes to the emergency department due to nausea,
vomiting, and epigastric and right upper quadrant pain, She has been followed closely for gestational hypertension since 26
weeks gestation. Her temperature is 37.2 C (98.9 F), blood pressure is 160/94 mm Hg, and pulse is 30/min. Physical
examination shows epigastric and right upper quadrant tenderness; bowel sounds are slightly reduced. Fetal heart rate
tracing shows a baseline of 1403 with moderate variability, no decelerations, and no accelerations. There is 2+ edema of
the lower extremities. A urine dipstick shows 3+ protein. Laboratory results are as follows:

Complete blood count

Hemoglobin 8.5 g/dL

Platelets 96,00tli’mm3

Serum chemistry

Creatinine 1 mgldL

Liver function studies

Total bilirubin 2.6 mgldL

Direct bilirubin 0.8 mgldL

Alkaline phosphatase 120 U/L

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Aspartate
308 U/L
aminotransferase

Alanine aminotransferase 265 UIL

Lipase 53 U/L

Coagulation studies

Prothrombin time 13 sec

Activated partial
25 sec
thromboplastin time

Peripheral blood smear shows numerous red blood cell fragments.

Item 1 of 2

Which of the following is the most likely cause of this patient's condition?

O A. Acute microvesicular fatty infiltration of hepatocytes

O B. Acute viral infection

0 C. Antibody—mediated platelet destmction

O D. Impaired bile acid flow

0 E. Premature placental separation

O F. Systemic inflammation and platelet consumption

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Item 2 of 2
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. 14 Which of the following is the most appropriate next step in management of this patient?
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. 16 O A. Administer ursodeoxycholic acid

17 O B. Amniocentesis for lung maturity

19 O C. Biophysical profile

21 O D. Delivery of the fetus

- 22 O E. Plasmapheresis
. 23
_ 24 O F. Transfuse platelets
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27 Proceed to N em Item

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A54—yeareold woman, gravida 3 para 3, comes to the office due to difficulty voiding for the past few weeks. When the
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patient voids, she has difficulty initiating the urine stream and emptying completely, but has no dysuria or hematuria. The
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patient has 2 episodes of nocturia every night, but no involuntary leakage of urine. She also has pelvic pressure that is
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16 worse with standing. Ten months ago, the patient underwent a total abdominal hysterectomy with bilateral salpingo—

17 oophorectomy for epithelial ovarian cancer and has completed a course of chemotherapy. Vital signs are normal. BMI is 36
18 kg/mz. The abdomen is without masses or ascites. Pelvic examination shows a protruding soft, nontender mass at the
19 level of the hymen that descends past the introitus with the Valsalva maneuver, which does not cause leakage of urine. The
20
uterus and ovaries are surgically absent. Sensation and deep tendon reflexes are intact. Urinalysis is normal. Which of the
21
following is the most likely cause of this patient's symptoms?
22
23
O A. Intrinsic sphincter deficiency
24
25 O B. Ovarian cancer metastasis
26
0 C. Pelvic organ prolapse
27
28 O D. Urethral diverticulum
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30
O E. Urgency incontinence
31 O F. Urinary tract infection
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33 0 G. Vesicovaginal fistula

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