Part 1

1. Asymptomatic 37yo F with 5-year history of HIV infection. Last visit 6 mo ago was normal. Pap
smear 2 years ago normal. CD4+ T count 2 weeks ago was 425, plasma HIV viral load undetectable.
Currently on antiretroviral Rx. Lipisd normal 3 years ago. Most appropriate screening test?
- Pap smear

2. Three days after cesarean for cephalopelvic disproportion, 27yo with T 38.4. No cough, SOB,
urinary frequency or urgency, or dysura. Labor lasted 18 hours. Lungs clear. Incision shows erythema
and induration. No CVA tenderness. Labs show WBC 14.8K (87% PMNs), 5-10 urine WBCs. Cause of
fever?
- Wound infection

3. 57-yo F with 2-month history of vulvar itching. Asymptomatic, no meds. Menopause 7 years ago.
Not been sexuallyACTIVE for 10 years. 1 x 1-cm ulcerated lesion on the inner right labium
majus surrounded by mild erythema. No inguinal adenopathy, Dx?
Vulvar carcinoma

4. 47-year-old G2P2 with 9-mo hx of irregular periods and bleeding between menses, which occurs at
2- to 3-month intervals and last 1- days. Has HTN. Smoked two packs of cigarettes daily for 30 years.
BP 160/50. Endometrial biopsy specimen show proliferative endometrium. Next step?
- Cyclic progestin therapy

5. Three days after cesarian for fetal distress, 42-year-old found unconscious. BMI 31. T 38C, pulse
120/min, resp 26/min, BP 60/40. Bilateral wheezing heard. Cardiac exam shows pleural friction rub.
Fundus is firm. Labs show: Hb 11, WBC 11k, plates 175k, plasma fibrinogen 300, fibrin split products
< 10 ug/mL. ABG shows pH 7.26, PCO2 28, PO2 60. CXR shows atelectasis. ECG shows tachycardia
with cor pulmomale. Dx?
- Pulmonary embolism

6. 32-year-old G3P2 at term admitted in labor. Contractions every minutes for the past 8 hours. VSS.
Cervix 100% effaced and 4 cm dilated, vertex at -2 station. Membranes suddenly rupture, yielding a
large amount of clear fluid. FHR decreases to 90/min. Next step?
- Pelvic examination

7. 15-year-old girl with nausea/vomiting, and lower abdominal pain for 4 days. LMP 9 days ago.
Sexually active and does not use contraception. Pulse 105/min. Bilateral lower abdominal tenderness
and peritoneal signs. Copiouis yellow cervical discharge and exquisite uterine tenderness. Next step?
- Admission to theHOSPITAL for intravenous antibiotic therapy

8. 19-year-old primi in labor for 16 hours. Membranes been ruptured for 11 hours, and she has had
nine vaginal examinations. T 38.4C. Fetal heart tracing shown. Cause of tracing?
- Maternal fever

9. 22-year-old G3P1A1, at 33 weeks. Ultrasonography at 24 weeks normal. Has type 1DIABETES

mellitus, and her postrandial serum glucose concentration was 95 at 28 weeks gestation. Fundal
height is 38 cm. Blood group is Rh-positive. Dx?
- Polyhydramnios? NOT Error in gestational age

10. 12-year-old girl with 1-year hx of progressive facial hair growth and acne. She has grown 4 inches
during the past 4 months. Breast development Tanner 1, and axillary and pubic hair development
Tanner 3. Dark hair over upper lip, cheeks, and chin. Acne vulgaris over the cheeks. 2-cm vaginal
canal, significant clitoromegaly, posterior laboscrotal fusion, and no cervix or palpable uterus.
Abdominal U/S shows bilateral gonads without follicles. No uterus. Chromosomal analysis will show?
- 46, XY
11. 28-ear-old G2P1 at first prenatal visit. LMP 10 weeks ago. First child was 10-lb male. During this
rpenancy, she is at increased risk for?
- GestationalDIABETES

12. 22-year-old F with bump on vulva for 1 week. Sexually active with 1 partner. Uses OCP. Multiple
0.25-cm raised, crusty papules on the posterior fourchette. Pap smear shows low-grade squamous
intraepithelial lesions. Dx?
- Condylomata acuminata

13. 32-yo G3P2 delivers 9-lb 1oz newborn at term following 2-hr second stage of labor assisted by a
medial episiotomy. Placenta delivers 12 minutes later using gental cord traction. Following delivery of
placenta, firm pale mass noted in lower vagina. Moderate vaginal bleeding. Pt develops SOB, HR
68/min, BP 60/40. Uterus cannot be palpated. Dx?
- Uterine inversion

14. 27-year-old primi at 30 weeks delivers 1530-gNEWBORN . Complicated by premature rupture

of the membranes at 25 weeks; observation prior to spontaneous labor showed little to absent
amniotic fluid. Apgar scores at 3 and 1 and 1 and 5 min. Explanation for the neonatal condition?
- Pulmonary hypoplasia

15. 37-year-old G2P2 wants contraceptive advice. Sexually active with husband, and use condoms,
wbut would like to switch. Smoked one pack of cigarettes daily for 20 years. No STDs, HTN,
headaches, venous thromboembolism, or depression. Neisseria gonorrhoeae and Chlamydia
trachomatis negative. Which contraceptive is contraindicated?
- Triphasic oral contraceptives

16. 25-year-old nulligravid has not had a menstrual period for 1 year. Menarche at 13, menses at
regular 2-d intervals. 2 years ago, period irregular, 45- to 90-day intervals until she became
amenorrheic. No illness, no meds, no tobacco/etoh/drugs. Runs 7 miles daily. BMI 17. Serum hormone
concentration will show?
- Decreased estrogen and follicle-stimulating hormone (FSH) concentrations

17. 57-year-old with 6-month history of urinary urgency and loss of urine that requires use of
absorbent pad. Rarely leaves her house because she is afraid of having loss of urine in public.
Awakens once each night to void. No fever, pain with urination, or blood in urine. Urine stream
normal. U/A normal. Pelvic u/s shows a 3-cm, anterior uterine mass consistent with a benign
leomyoma uteri. Cause of incontinence?
- Detrusor instability

18. 32-year-old nulligravid with 34-year-old husband unable to conceive for 3 years. Menarche at 12,
menses regular. Used OCPs for 3 years. Has had multiple sex partners. Cervical cultures are negative.
Semen analysis normal. Next step?
- Hysterosalpingography?

19. 27-year-old primi at 14 weeks. Endovaginal exam shows a viable twin gestation consistent in
size with an 8-week gestation. There are two yolk sacs and a thick dividing membrane. Ultrasound is
shown. Most likely has which of the following types of twin gestation?
- Dichorionic

20. 24-yo primi African American at 11 weeks. OnlyMEDICATION is prenatal vitamins. BP 120/70.
No peripheral edema. FHR is 150/min. At first visit 4 weeks ago, labs showed: Hb 10.2, MCH 20, MCV
72, WBC 10.9k, plates 140k. U/A today shows no glucose, protein, orKETONES . Cause of these lab
findings?
- Iron deficiency

21. 5-yo girl brought in by father 1 day after he noticed blood on her underpants. Had been rubbing
and scratching her genital area for the past 5 days. Has had a foul-smelling discharge and burning
and itching in that area, worse when she urinates. Also had runny nose. No fever, no illness. Green
vaginal discharge and diffuse inflammation of the vulva. Hymen intact. Wet mount shows occasional
erythrocytes and numerous leukocytes. Polymicrobial infection. Cause?
- Vaginal foreign body

22. 27-year-old nulligravid with dyspareunia and dysmenorrhea for 2 years. Menses regular.
Nodularity over the uterosacral area. Uterus is retroverted. Adnexa are normal-sized but tender. Next
step?
- Laparoscopy

23. 42yo F undergoes amniocenteses and is informed that the fetal karyotype is 46,CC. At birth, the
full-termNEWBORN has a phallus and scrotum. Explanation b/w amnio and physical finding?
- ACTH oversecretion

24. 16-year-old girl has never had a menstrual period. Otherwise healthy. Breast Tanner 3, no axillary
or pubic hair. Vagina is 2 cm in length. Pelvic ultrasonography shows no uterus. Dx?
Androgen insensitivity syndrome

25. 18-year-old primi at 10 weeks follow-up exam. At first prenatal visit 2 weeks ago, HIV was
positive. Lungs are clear. No axillary or cervical lymphadenopthy. PPD shows 9 mm of induration.
Next step?
- X-ray of the chest

part 2

1. 32-year-old woman G1P1 with fever and right breast tenderness for 1 day. Breast-feeding her
14d old newborn. Has type 1 DM well controlled withINSULIN . T 39.3C, HR 122/min, Engorgement
of the breasts bilaterally. Erythematous, nonfluctuant, tender area in the upper outer quadrant of the
right breast. Dx?
- Mastitis

2. 17-year-old girl at studentHEALTH services because of moderately severe pelvic pain with
nausea and vomiting during menses since menarche at the age of 13yrs. Symptoms begin soon after
onset of menses and last 48 hours. Ibuprofen provides moderate relief. No fever. Menses regular.
Never sexually active. Pelvic exam normal. Dx?
- Primary dysmenorrhea

3. 32-year-old nulligravid has not had a menstrual period since she stopped taking OCP 6 months
ago. Menses were regular. Has had increased libido, increased facial acne, increased facial hair
growth that requires shaving every other day, and scalpHAIR LOSS . 11.3-kg weight gain. Sexually
active with 1 partner. BMI 33. Has hair between breasts and above the umbilicus. Pelvic exam shows
clitoris protruding completely from the clitoral hood. U/S shows 2-cm solid mass in right ovary.
Measurement of which serum hormone will be abnormal?
- Testosterone

4. 32-year-old primigravid at 10 weeks gestation with 5-day history of nausea and vomiting and
decreased appetite. Unable to keep solids or liquids down. No fever, chills, sweating, abdominal pain,
or vaginal bleeding. NKDA. T 37C, HR 95/min, BP 100/65. Uterus consistent with 10wk gestation.
Labs:
Hb 11.5, WBC 8.5k, platelets 168k, Na 130, Cl 95, K 2.8, HcO3 30. Large Urine ketones.
Serum thyroid-stimulating hormone and free thyroxine pending. Next step?
- Admission to the hospital for intravenous hydration and parenteral antiemetic therapy

5. 67-year-old woman with moderate vulvar itching for 2 years. Otherwise healthy. 1-cm areas of
white epithelium over the left labium majus. No inguinal adenopathy or vulvovaginal discharge. Next
step?
- Punch biopsy of the affected areas

6. 15-year-old girl with 1-week hx of severe abdominal pain. Has had 10 episodes of cramps, each
lasts 3 to 5 days. No serious illness, no meds. Never had a menstrual period. Sexually active with one
male, no contraception. 80th %ile for height/weight. Tanner stage 5. Mass is palpated in the
suprapubicREGION at the midline. Pelvic exam shows normal-appearing external genitalia and
lower vagina. Cervix cannot be visualized because of bluish bulging vaginal tissue that obscures the
upper vagina. Urine pregnancy negative. Dx?
- Hematocolpos

7. 27-year-old G2P1 3 days after episode of bright red vaginal bleeding with no uterine contractions
or cramping. Has had increasing breast size, morning sickness, and extreme fatigue. LMP 8 weeks
ago. Vaginal ultrasonography shows normal fetal heart activity. Dx?
- Normal pregnancy

8. 42-year-old woman G3P3. Menses have occurred at regular 2- to 3-month intervals and have
lasted 7 to 21 days. LMP 6 weeks ago. Has type 2 DM rx w/METFORMIN . BMI 32. Irregular
enlarged uterus measuring 12 x 8 x 6 cm. Endometrial biopsy specimen shows atypical complex
hyperplasia. Which is strongest predisposing factor to this condition?
- Anovulation

9. 47-year-old woman 2 weeks after found lump in left breast during self exam. Started estrogen
replacement therapy 3 months ago and has had breast engorgement since that time. Left breast
shows a 2-cm, tense, mobile cyst-like structure at 11 o-clock.No breast discharge or palpable axillary
nodes. Mammography 3 mo ago normal. Next step?
- Repeat mammography?
- Answer is NOT discontinue estrogen replacement therapy

10. 42-year-old G8P7 at 42 weeks admitted in labor. Contractions q3-4 hours, last 50 to 60 seconds,
and have been uncomfortable for the last hour. Has urge to push. Uterus extends 36 cm above pubic
symphysis. Fetal weight is 3500 g. Fetal heart tones 144/min. Vaginal exam shows pooling of copious
fluid. Cervix completely dilated and effaced. Vertex +2 station in a left occiput anterior presentation.
Fetal heart tracing shown. Explanation?
- Umbilical cord compression

11. Four weeks after low transverse c-section for cephalopelvic disproportion, 27yo G1P1 with pulling
feeling on the right side of her incision for the past 4 days. Exacerbated by movement. Within the
past 2 weeks, has initiated n exercise regimen to get back in shape, resumed sexual activity. BMI 29.
T 37 C. Abdomen nontender without rebound. Tenderness to deep palpation just lateral to the right
and left aspects of the incision. Wound is clear, dry, and intact. Explanation?
- Normal postoperative course

12. 23-year-old 3 weeks after diagnosed with a urinary tract infection. Rx with trimethoprim-
sulfamethoxazole has relieved her symptoms. This is her third UTI over the past year. No serious
illness. T 37 C. No flank tenderness. U/A normal. Daily administration of which is prophylaxis?
- Trimethoprim-sulfamethoxazole

13. 21-year-old woman has vaginal discharge and discomfort for 2 days. Sexually active w/ new
partner for 2 weeks; he is asymptomatic. Pelvic exam shows a purulent cervical discharge and
cervical motion tenderness. Gram stain shown. Organism?
- Neisseria gonorrhoeae

14. 22-year-old with 3-day history of pain with urination, intense vaginal itching, and a watery
discharge. Smoked one pack of cigarettes daily for 5 years. Sexually active and does not use
contraception. T 37C. GU exam shows erythema of the vulva and vagina; there is a yellow-gray
frothy discharge with a mildly fishy odor. Cervix normal. pH of the vaginal discharge is 5. A wet
mount will show?
- Flagellated protozoa

15. 67-year-old woman with 9-month hx of persistent vulvar itching despite rx with OTC zinc oxide,
vitamin E, hydrocortisone cream, and miconazole. HasTYPE 2 DM and hypercholesterolemia. BMI
53. Erythematous, swollen vulva, papules and pustules on the medial aspect of the thights, and
several excoriations. KOH shows pseudohyphae and budding yeast. Underlying cause of Rx failure?
- Type 2 diabetes mellitus

16. 32-year-old woman G5P4 at 18 weeks' gestation for prenatal visit. Rh-negative, hx of c-section for
premature labor and breech presentation. Father with HTN, mother has type 2 DM, vitals normal.
Ultrasonography shows an intrauterine pregnancy of a single fetus with normal anatomy in breech
presentation, uterus is bicornuate. Patient is at risk for which?
- Preterm labor and delivery

17. 57-year-old woman routine exam. HTN, Type 2 DM, and generalized anxiety disorder. Great-aunt
has a history of breast cancer. Pt receiving hormone therapy with conjugated estrogen and
medroxyprogesterone daily since menopause 5 years ago. On HCTZ, metformin, and various herbal
medications. Breast shows no masses or nipple discharge. Greatest riskFACTOR for breast
cancer?
- Hormone therapy

18. 11-year-old girl. Has had recent mood changes, and mother concerned menstural periods will
start soon. 75th %ile for height and 90%ile for weight. Tanner stage 3. Recent pubic hair is most
predictive of which?
- Mehnarche is imminent

8 yo female with presents with 3 dayPRODUCTIVE cough (with sputum) and fever. normal exam
at birth but h/o respiratory issues. T37.5, HR 100, RR32, pulse ox (room air) 84%. clubbing, cyanosis
around mouth, diffuse rhonchi, expiratory wheeze. CXR: hyperinflation, chronic interstitial changes,
atelectasis (scattered). diagnosis=??

a asthma
b BPD
c CHD with R to L shunt
d CF
e HoCM
F idiopathic pulm HTN
g methemoglobinemia
h PFO
I persistent pulm HTN
J pneumococcal PNA
K RDS

I would need the question written out a bit more like it was in the step to get a better idea of what
they were asking. However, based on the h/o respiratory issues, low O2 saturation, clubbing, and
pulmonary signs, I would guess the answer is Cystic Fibrosis.

She could have had a fever due to an infection (remember pseudomonas!). The stem can push you
away form CF as the patient had a normal exam at birth. If my memory serves me right, there aren't
a ton of things that can cause clubbing in a child, but CF is one of them. In addition, atelectasis,
hyperinflation, and interstitial changes point me towards CF.

- Asthma is a possibility, although 'h/o respiratory issues' doesn't make me confident in that
- BPD would have been known at birth
- CHD wouldn't cause hyperinflation
- HoCM wouldn't cause these s/s
- idiopathic pulm HTN isn't usually seen in kids this young
- methemoglobinemia doesn't fit
- PFO wouldn't cause hyperinflation
- persistent pulm HTN would have been known at birth
- PNA is also a possibility, but I have no indication it's penumococcal, and it sounds more like in this
case, it's a complication of an underlying disease.