272. A 54-year-old woman is scheduled for laparotomy due to a pelvic mass. At the time of exploratory laparotomy, a unilateral ovarian neoplasm is discovered that is accompanied by a large omental metastasis. Frozen section diagnosis confirms metastatic serous cystadenocarcinoma. Which of the following is the most appropriate intraoperative course of action?

273. A 68-year-old woman is seen for evaluation of a swelling in the right, posterior aspect of her vaginal opening. She has noted pain in this area when walking and during intercourse. At the time of pelvic examination, a mildly tender, firm mass is noted just outside the introitus in the right vulva at approximately 8 o’clock. Which of the following is the most appropriate treatment?

274. A 51-year-old woman is diagnosed with invasive cervical carcinoma by cone biopsy. Pelvic examination and rectal-vaginal examination reveal the parametrium to be free of disease, but the upper portion of the vagina is involved with tumor. Intravenous pyelography (IVP) and sigmoidoscopy are negative, but a computed tomography (CT) scan of the abdomen and pelvis shows grossly enlarged pelvic and periaortic nodes. This patient is classified at which of the following stages?

275. A 45-year-old G1P1 presents for her routine annual examination. The patient is a healthy smoker who has no medical problems. Her surgical history is significant for a cesarean delivery with bilateral tubal interruption. You perform a Pap smear, which returns showing high grade squamous intraepithelial lesion (HSIL). She undergoes colposcopy, which is inadequate.

What is the next step in management?

276. A 45-year-old G1P1 presents for her routine annual examination. The patient is a healthy smoker who has no medical problems. Her surgical history is significant for a cesarean delivery with bilateral tubal interruption. You perform a Pap smear, which returns showing high grade squamous intraepithelial lesion (HSIL). She undergoes colposcopy, which is inadequate.

Cone biopsy of the cervix shows squamous cell cancer that has invaded only 2 mm beyond the basement membrane with a lateral spread of 5 mm. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. How should you stage this patient’s disease?

277. A 45-year-old G1P1 presents for her routine annual examination. The patient is a healthy smoker who has no medical problems. Her surgical history is significant for a cesarean delivery with bilateral tubal interruption. You perform a Pap smear, which returns showing high grade squamous intraepithelial lesion (HSIL). She undergoes colposcopy, which is inadequate.

Which lymph node group would be the first involved in metastatic spread of this disease beyond the cervix and uterus?

278. A 45-year-old G1P1 presents for her routine annual examination. The patient is a healthy smoker who has no medical problems. Her surgical history is significant for a cesarean delivery with bilateral tubal interruption. You perform a Pap smear, which returns showing high grade squamous intraepithelial lesion (HSIL). She undergoes colposcopy, which is inadequate.

This patient now asks you for your advice on how to treat her cervical cancer. Your best recommendation is for the patient to undergo which of the following?

279. A woman is found to have a unilateral invasive vulvar carcinoma that is 3 cm in diameter but not associated with evidence of lymph node spread. Initial management should consist of which of the following?

280. A woman is found to have a unilateral invasive vulvar carcinoma that is 3 cm in diameter but not associated with evidence of lymph node spread.

If this woman had multiple medical comorbidities, what would be the best option for management?

281. A pregnant 35-year-old patient is at highest risk for the concurrent development of which of the following malignancies?

282. Stage Ia2 microinvasive cervical cancer is diagnosed based on cervical biopsy in a 34-year-old woman who is 12 weeks’ pregnant. What is the best next step in management?

283. A 54-year-old woman presents for well-woman examination. On pelvic examination you palpate an enlarged, tender right adnexal mass. You order a pelvic ultrasound as the next step in this patient’s evaluation. Which of the following sonographic characteristics of the cyst in this patient would warrant further evaluation for possible ovarian malignancy?

284. A 70-year-old woman presents for evaluation of a pruritic lesion on the vulva. Examination shows a white, friable lesion on the right labia majorum that is 3 cm in diameter. No other suspicious areas are noted Biopsy of the lesion confirms squamous cell carcinoma. In this patient, lymphatic spread of the cancer would be first to which of the following lymph nodes?

285. A 17-year-old girl is seen by her primary care physician for the evaluation of left lower quadrant pain. The physician felt a pelvic mass on physical examination and ordered a pelvic ultrasound. You are consulted because an ovarian neoplasm is identified by the ultrasound. Which of the following is the most common ovarian tumor in this type of patient?

286. A 41-year-old woman undergoes exploratory laparotomy for a persistent adnexal mass. Frozen section diagnosis is serous carcinoma. What is the likelihood that the contralateral ovary is involved in this malignancy?

287. A postmenopausal woman presents with pruritic white lesions on the vulva. Punch biopsy of a representative area is obtained and is consistent with lichen sclerosus. Which of the following is the most appropriate treatment for this patient?

288. A 22-year-old woman returns to your office for evaluation of an abnormal Pap smear. The Pap smear was reported as HSIL. Colposcopic biopsy confirms the presence of a cervical lesion consistent with severe cervical dysplasia (CIN III). Which of the following human papilloma virus (HPV) types is most often associated with this type of lesion?

289. A 20-year-old woman presents complaining of bumps around her vaginal opening. The bumps have been there for several months and are getting bigger. Her boyfriend has the same type of bumps on his penis. On physical examination, the patient has multiple 2- to 10-mm lesions around her introitus consistent with condyloma. Her cervix has no gross lesions. A Pap smear is performed. One week later, the Pap smear returns showing atypical squamous cells of undetermined significance (ASCUS). Reflex HPV typing showed no high-risk HPV. Which of the following viral types is most likely responsible for the patient’s condyloma?

290. A 26-year-old G2P1 presents to the gynecologist complaining of increasing hair growth on her face, chest, and abdomen, but the hair on her head is receding in the temporal regions. She also has had problems with acne. On physical examination, the patient has significant amounts of coarse, dark hair on her face, chest, and abdomen. On pelvic examination she has an enlarged clitoris. She has a 7-cm left adnexal mass.

Select the ovarian tumor from the following list that is most likely to be associated with the clinical picture.

291. A 56-year-old postmenopausal woman presents complaining of vaginal bleeding. Her uterus is slightly enlarged and she has a 6-cm right adnexal mass. Endometrial biopsy shows adenocarcinoma of the endometrium.

Select the ovarian tumor from the following list that is most likely to be associated with the clinical picture.

292. A 67-year-old woman is found to have bilateral adnexal masses while undergoing evaluation of her recently diagnosed colon cancer.

Select the ovarian tumor from the following list that is most likely to be associated with the clinical picture.

293. A 17-year-old woman is referred by her primary care physician for the evaluation of primary amenorrhea. On physical examination, the patient has evidence of virilization. She also has a pelvic mass. During the workup of the patient, she is found to have sex chromosome mosaicism (45, X/46, XY).

Select the ovarian tumor from the following list that is most likely to be associated with the clinical picture.

294. A 19-year-old woman is undergoing diagnostic laparoscopy for a 9-cm right ovarian mass. The final pathology report shows evidence of glial tissue and immature cerebellar and cortical tissue.

Select the ovarian tumor from the following list that is most likely to be associated with the clinical picture.

295. A 51-year-old menopausal woman is undergoing exploratory laparotomy for bilateral adnexal masses. A frozen section is performed on the excised ovaries and shows significant numbers of signet cells.

Select the ovarian tumor from the following list that is most likely to be associated with the clinical picture.

296. Cyclophosphamide

Match the chemotherapeutic agents with the most common side effects. Each lettered option may be used once, more than once, or not at all.

297. Cisplatin

Match the chemotherapeutic agents with the most common side effects. Each lettered option may be used once, more than once, or not at all.

298. Paclitaxel

Match the chemotherapeutic agents with the most common side effects. Each lettered option may be used once, more than once, or not at all.

299. Bleomycin

Match the chemotherapeutic agents with the most common side effects. Each lettered option may be used once, more than once, or not at all.

300. Doxorubicin

Match the chemotherapeutic agents with the most common side effects. Each lettered option may be used once, more than once, or not at all.

301. Vincristine

Match the chemotherapeutic agents with the most common side effects. Each lettered option may be used once, more than once, or not at all.

302.

Match each figure with the correct description.

303.

Match each figure with the correct description.

304.

Match each figure with the correct description.

305.

Match each figure with the correct description.

306.

Match each figure with the correct description.

307.

Match each figure with the correct description.

308.

Match each figure with the correct description.

309. A patient is diagnosed with carcinoma of the breast. Which of the following is the most important prognostic factor in the treatment of this disease?

310. A 25-year-old woman presents to you for routine well-woman examination. She has had two normal vaginal deliveries and is healthy. She smokes one pack of cigarettes per day. She has no gynecologic complaints. Her last menstrual period was 3 weeks ago. During the pelvic examination, you notice that her left ovary is enlarged to 5 cm in diameter. Which of the following is the best recommendation to this patient?

311. A 23-year-old woman presents to your office complaining of a growth around her vaginal opening. Recently, the growth has been itching and bleeding. On physical examination, she has a broad-based lesion measuring 2 cm in diameter on the posterior fourchette. Although there is no active bleeding, the lesion has some crusted blood along the right lateral margin. Which of the following is the best way to treat this patient?

312. At the time of annual examination, a patient expresses concern regarding possible exposure to sexually transmitted diseases. During your pelvic examination, a single, indurated, nontender ulcer is noted on the vulva. Venereal Disease Research Laboratory (VDRL) and fluorescent treponemal antibody (FTA) tests are positive. Without treatment, the next stage of this disease is clinically characterized by which of the following?

313. A 24-year-old patient recently emigrated from the tropics. Four weeks ago she noted a small vulvar ulceration that spontaneously healed. Now there is painful inguinal adenopathy associated with malaise and fever. You are considering the diagnosis of lymphogranuloma venereum (LGV). The diagnosis can be established by which of the following?

314. One day after a casual sexual encounter with a bisexual man recently diagnosed as antibody-positive for human immunodeficiency virus (HIV), a patient is concerned about whether she may have become infected. An HIV antibody titer is obtained and is negative. To test for seroconversion, when is the earliest you should reschedule repeat antibody testing after the sexual encounter?

315. A 32-year-old G3P0030 obese woman comes to your office for a routine gynecologic examination. She is single, but is currently sexually active. She has a history of five sexual partners in the past, and became sexually active at the age of 15 years. She has had three first-trimester pregnancy terminations. She uses Depo-Provera for birth control, and reports occasionally using condoms. She has a history of genital warts, but has never had an abnormal Pap smear. The patient says she does not use illicit drugs, but admits to smoking about one pack of cigarettes a day. Her physical examination is normal. Three weeks later, you receive the results of her Pap smear, which was reported as

316. A 23-year-old woman presents for a routine annual examination. Her Pap smear returns as HSIL.

Select the management option from the following list that is most appropriate as the next step in the treatment of the patient described.

317. A 21-year-old woman presents for her first Pap smear. The following week, the results return as low grade squamous intraepithelial lesion (LSIL).

Select the management option from the following list that is most appropriate as the next step in the treatment of the patient described.

318. A 55-year-old postmenopausal woman has a Pap smear that returns as atypical glandular cells of undetermined significance (AGUS).

Select the management option from the following list that is most appropriate as the next step in the treatment of the patient described.

319. A 35-year-old with an LSIL Pap smear undergoes colposcopy. Directed biopsies return showing severe dysplasia (CIN III).

Select the management option from the following list that is most appropriate as the next step in the treatment of the patient described.

320. A 43-year-old has negative cytology results but absent endocervical cells are reported.

Select the management option from the following list that is most appropriate as the next step in the treatment of the patient described.

321. A 24-year-old G0 presents to your office complaining of vulvar discomfort, with intense burning and pain during intercourse. The discomfort occurs at the vaginal introitus, primarily with penile insertion into the vagina. The patient also experiences the same pain with tampon insertion and when the speculum is inserted during a gynecologic examination. The problem has become so severe that she can no longer have intercourse, which is causing problems in her marriage. She is otherwise healthy. She has regular menses without dysmenorrhea. On physical examination, the region of the vulva around the vaginal vestibule has several punctate, erythematous areas of epithelium measuring 3 to 8 mm in diameter. Most of the lesions are located on the skin between the two Bartholin glands. Each inflamed lesion is tender to touch with a cotton swab. Which of the following is the most likely diagnosis?

322. A 24-year-old G0 presents to your office complaining of vulvar discomfort, with intense burning and pain during intercourse. The discomfort occurs at the vaginal introitus, primarily with penile insertion into the vagina. The patient also experiences the same pain with tampon insertion and when the speculum is inserted during a gynecologic examination. The problem has become so severe that she can no longer have intercourse, which is causing problems in her marriage. She is otherwise healthy. She has regular menses without dysmenorrhea. On physical examination, the region of the vulva around the vaginal vestibule has several punctate, erythematous areas of epithelium measuring 3 to 8 mm in diameter. Most of the lesions are located on the skin between the two Bartholin glands. Each inflamed lesion is tender to touch with a cotton swab.

You recommended that she wear loose clothing and cotton underwear and stop using tampons. After 1 month she returns, reporting that her symptoms of intense burning and pain with intercourse have not improved. Which of the following treatment options is the best next step in treating this patient’s problem?

323. A 29-year-old G0 comes to your office complaining of a vaginal discharge for the past 2 weeks. The patient describes the discharge as thin in consistency and of a grayish white color. She has also noticed a slight fishy vaginal odor that seems to have started with the appearance of the discharge. She reports no vaginal or vulvar pruritus or burning. She admits to being sexually active in the past, but has not had intercourse during the past year. She has no history of sexually transmitted diseases. The only medication she takes are oral contraceptives. Last month, she took a course of amoxicillin for the treatment of sinusitis. On physical examination, the vulva appears normal. There is a discharge present at the introitus. A copious, thin, whitish discharge is in the vaginal vault. The vaginal pH is 5.5. The cervix is not inflamed and there is no cervical discharge. Wet smear of the discharge indicates the presence of clue cells. Which of the following is the most likely diagnosis?

324. A 29-year-old G0 comes to your office complaining of a vaginal discharge for the past 2 weeks. The patient describes the discharge as thin in consistency and of a grayish white color. She has also noticed a slight fishy vaginal odor that seems to have started with the appearance of the discharge. She reports no vaginal or vulvar pruritus or burning. She admits to being sexually active in the past, but has not had intercourse during the past year. She has no history of sexually transmitted diseases. The only medication she takes are oral contraceptives. Last month, she took a course of amoxicillin for the treatment of sinusitis. On physical examination, the vulva appears normal. There is a discharge present at the introitus. A copious, thin, whitish discharge is in the vaginal vault. The vaginal pH is 5.5. The cervix is not inflamed and there is no cervical discharge. Wet smear of the discharge indicates the presence of clue cells.

which of the following is the best treatment?

325. A 20-year-old G2P0020 with an LMP 5 days ago presents to the emergency department with a chief complaint of a 24-hour history of increasing pelvic pain. This morning she experienced chills and fever, although she did not take her temperature. She reports no changes in her bladder or bowel habits. She has had nausea or vomiting, and has not been able to tolerate liquids. She reports no medical problems, and her only surgery was a laparoscopy performed last year for an ectopic pregnancy. She reports regular menses without dysmenorrhea. She is currently sexually active with a new sexual partner, and had intercourse with him just prior to her last menstrual period. She reports no history of abnormal Pap smears or sexually transmitted diseases. Urine pregnancy test is negative. Urinalysis is normal. WBC is 18,000. Temperature is 38.8°C (102°F). On physical examination, her abdomen is diffusely tender in the lower quadrants with rebound and voluntary guarding. Bowel sounds are present but diminished. Which of the following is the most likely diagnosis?

326. A 20-year-old G2P0020 with an LMP 5 days ago presents to the emergency department with a chief complaint of a 24-hour history of increasing pelvic pain. This morning she experienced chills and fever, although she did not take her temperature. She reports no changes in her bladder or bowel habits. She has had nausea or vomiting, and has not been able to tolerate liquids. She reports no medical problems, and her only surgery was a laparoscopy performed last year for an ectopic pregnancy. She reports regular menses without dysmenorrhea. She is currently sexually active with a new sexual partner, and had intercourse with him just prior to her last menstrual period. She reports no history of abnormal Pap smears or sexually transmitted diseases. Urine pregnancy test is negative. Urinalysis is normal. WBC is 18,000. Temperature is 38.8°C (102°F). On physical examination, her abdomen is diffusely tender in the lower quadrants with rebound and voluntary guarding. Bowel sounds are present but diminished.

Which of the following is the most appropriate initial antibiotic treatment regimen for this patient?

327. A 43-year-old G2P2 comes to your office reporting intermittent right nipple discharge that is bloody. She says the discharge is spontaneous and not associated with any nipple pruritus, burning, or discomfort. On physical examination, you do not detect any dominant breast masses, skin changes, or axillary lymphadenopathy. Which of the following conditions is the most likely cause of this patient’s problem?

328. A 20-year-old G0, LMP 1 week ago, presents to your clinic reporting a mass in her left breast that she discovered during routine breast self-examination in the shower. When you perform a breast examination on her, you palpate a 2-cm firm, nontender mass in the upper inner quadrant of the left breast that is smooth, well-circumscribed, and mobile. You do not detect any skin changes, nipple discharge, or axillary lymphadenopathy. Which of the following is the most likely diagnosis?

329. A 55-year-old G3P3 with a history of fibroids presents to you complaining of irregular vaginal bleeding. Until last month, she had not had a period in over 9 months. She thought she was in menopause, but because she started bleeding again last month she is not sure. Over the past month she has had irregular, spotty vaginal bleeding. The last time she bled was 1 week ago. She also complains of frequent hot flushes and emotional lability. She does not have any medical problems and is not taking any medications. She is a nonsmoker and does not consume alcohol or drugs. Her gynecologic history is significant for cryotherapy of the cervix 10 years ago for mild dysplasia. She has had three cesarean deliveries and a tubal ligation. On physical examination, her uterus is 12 weeks in size, mobile, nontender, and irregularly shaped. Her ovaries are not palpable. A urine pregnancy test is negative. Which of the following is the most reasonable next step in the evaluation of this patient?

330. A 57-year-old menopausal patient presents to your office for evaluation of postmenopausal bleeding. She is morbidly obese and has chronic hypertension and adult onset diabetes. An office endometrial biopsy shows complex endometrial hyperplasia with atypia, and a pelvic ultrasound demonstrates multiple, large uterine fibroids. Which of the following is the best next step in management for this patient?