Gynecology: What Do You Know About Pelvic Mass? Trivia Questions Quiz

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Gynecology: What Do You Know About Pelvic Mass? Trivia Questions Quiz - Quiz

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Questions and Answers
  • 1. 

    Examination of an asymptomatic 2-day-old infant girl shows a distended abdomen. The urinary bladder and rectal ampulla are empty. A solitary unilocular cyst is visualized with ultrasonography. Which of the following is the best next step in the management of this patient?

    • A.

      Observation

    • B.

      Intravenous pyelogram (IVP)

    • C.

      Cystoscopy

    • D.

      Barium enema

    • E.

      Exploratory surgery

    Correct Answer
    A. Observation
    Explanation
    The best next step in the management of this patient is observation. Since the infant is asymptomatic and the cyst is unilocular, it is likely a benign finding. Observation allows for monitoring of the cyst to ensure it does not cause any complications or grow in size. This approach avoids invasive procedures or unnecessary interventions in a young and otherwise healthy patient.

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  • 2. 

    You are called to the operating room to evaluate a pelvic mass in an infant girl. Laparoscopy shows a 3-cm cystic mass in the broad ligament between the fallopian tube and ovarian hilum. Which of the following is the best next step?

    • A.

      Observation

    • B.

      Cyst aspiration

    • C.

      Cystectomy

    • D.

      Adnexectomy

    • E.

      Hysterectomy

    Correct Answer
    B. Cyst aspiration
    Explanation
    In this scenario, the best next step would be cyst aspiration. Cyst aspiration involves using a needle and syringe to drain the fluid from the cystic mass. This procedure can help to relieve symptoms and provide diagnostic information about the nature of the cyst. It is a less invasive option compared to surgical interventions like cystectomy, adnexectomy, or hysterectomy, which may be considered if the cyst is large, causing symptoms, or if there are concerns about malignancy. Observation alone may not be appropriate if the cyst is causing symptoms or if there are concerns about its nature.

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  • 3. 

    A young girl presents with abdominal distention and a mass. Ultrasound and serum tumor markers confirm a neoplastic origin to her ovarian mass. Childhood neoplastic ovarian masses most commonly originate from which of the following?

    • A.

      Gonadal epithelium

    • B.

      Gonadal stroma

    • C.

      Germ cells

    • D.

      Sex cords

    • E.

      Metastatic disease

    Correct Answer
    C. Germ cells
    Explanation
    Childhood neoplastic ovarian masses most commonly originate from germ cells. This means that the tumor arises from the cells that would normally develop into eggs. This is supported by the presence of a mass and confirmation through ultrasound and serum tumor markers. The other options, including gonadal epithelium, gonadal stroma, sex cords, and metastatic disease, are less likely to be the origin of the ovarian mass in a young girl.

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  • 4. 

    A 6-year-old girl has a history of 2 weeks of abdominal pain. She is significantly taller than her peers. Physical examination shows early breast development and abdominal distention. Blood is present at the introitus, and pelvic examination is attempted but cannot be accomplished. Serum gonadotropin levels are in the prepubertal range and do not change after gonadotropin-releasing hormone (GnRH) administration. Abdominal sonography shows a 6-cm solid right adnexal mass. Which of the following is the most likely diagnosis?

    • A.

      Epoöphoron

    • B.

      Granulosa cell tumor

    • C.

      Corpus luteum cyst

    • D.

      Endometrioma

    • E.

      Fibroma

    Correct Answer
    B. Granulosa cell tumor
    Explanation
    The most likely diagnosis in this case is a granulosa cell tumor. This is supported by the findings of early breast development, abdominal distention, and the presence of a solid right adnexal mass on abdominal sonography. Additionally, the fact that serum gonadotropin levels are in the prepubertal range and do not change after GnRH administration suggests an ovarian neoplasm. Granulosa cell tumors are a type of ovarian neoplasm that can cause precocious puberty in young girls and are often associated with abdominal distention due to the presence of a large pelvic mass.

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  • 5. 

    A colleague asks you to evaluate a 5-year-old Caucasian girl with sexual precocity. Areas of mucocutaneous pigmentation are present. Rectal examination demonstrates a 4-cm pelvic mass. Prepubertal levels of serum gonadotropins do not change after GnRH administration. In addition to the findings noted above, the patient is most likely to have which of the following?

    • A.

      Dextrocardia

    • B.

      Renal agenesis

    • C.

      Gastrointestinal polyps

    • D.

      Skeletal anomalies

    • E.

      Müllerian anomalies

    Correct Answer
    C. Gastrointestinal polyps
  • 6. 

    An 8-year-old girl has acute right lower abdominal pain. The pain began last night in the periumbilical area and shifted this morning to the right lower abdomen. She noted a loss of appetite over the past day and has vomited three times since yesterday. She has not had a bowel movement today. Vital signs are blood pressure, 120/60 mm Hg; pulse, 90 bpm; and temperature, 101.8°F. Abdominal examination demonstrates tenderness halfway between the umbilicus and the right anterior superior iliac spine. Bowel sounds are absent. Rectal examination shows a fluctuant, fixed, ill-defined right pelvic mass. A hematocrit is 34% (normal, 35% to 45%); white blood count, 23,000/mL (normal, 3–10,000/mL). Stool guaiac is negative for occult blood. An abdominal radiogram shows a calcified fecalith in the right lower quadrant. What is the most likely diagnosis in this patient?

    • A.

      Regional enteritis

    • B.

      Ulcerative colitis

    • C.

      Meckel’s diverticulum

    • D.

      Appendicitis

    • E.

      Ovarian torsion

    Correct Answer
    D. Appendicitis
    Explanation
    The most likely diagnosis in this patient is appendicitis. Appendicitis is characterized by acute right lower abdominal pain that typically starts in the periumbilical area and shifts to the right lower abdomen. Loss of appetite, vomiting, and absence of bowel movements are common symptoms. The tenderness halfway between the umbilicus and the right anterior superior iliac spine, along with a fluctuant, fixed, ill-defined right pelvic mass on rectal examination, suggests inflammation and infection of the appendix. The presence of a calcified fecalith in the right lower quadrant on abdominal radiogram further supports the diagnosis of appendicitis.

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  • 7. 

    A 22-year-old female patient presents with 3 months of amenorrhea and some gastrointestinal complaints. On examination, she is bloated with a masses appreciated in the lower pelvis approximately 12 cm in diameter and cystic feeling. Which is the most probable diagnosis?

    • A.

      Follicular cyst

    • B.

      Corpus luteum cyst

    • C.

      Benign cystic teratoma

    • D.

      Leiomyoma

    • E.

      Pregnancy

    Correct Answer
    E. Pregnancy
    Explanation
    The most probable diagnosis for a 22-year-old female patient with 3 months of amenorrhea, gastrointestinal complaints, bloating, and a pelvic mass is pregnancy. These symptoms are consistent with early pregnancy, and the presence of a cystic feeling mass in the lower pelvis further supports this diagnosis. The other options, such as follicular cyst, corpus luteum cyst, benign cystic teratoma, and leiomyoma, are less likely given the patient's age, symptoms, and presentation.

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  • 8. 

    A 14-year-old girl has had progressively increasing cyclic left pelvic pain since menarche. She is not sexually active. Menses occur at monthly intervals. Pelvic examination demonstrates a uterus deviated to the right. An elongated left adnexal structure is palpable above a left-sided vaginal mass. You should suspect the presence of which of the following?

    • A.

      An ovarian cyst

    • B.

      a uterine anomaly

    • C.

      Cervical stenosis

    • D.

      Vaginal adenosis

    • E.

      A pelvic kidney

    Correct Answer
    B. a uterine anomaly
    Explanation
    Based on the given information, the 14-year-old girl is experiencing cyclic left pelvic pain since menarche, and her pelvic examination shows a deviated uterus to the right and an elongated left adnexal structure above a left-sided vaginal mass. These findings suggest a uterine anomaly, which could be a structural abnormality of the uterus such as a septate uterus, bicornuate uterus, or unicornuate uterus. These anomalies can cause pain and menstrual irregularities. The other options, such as an ovarian cyst, cervical stenosis, vaginal adenosis, or a pelvic kidney, do not fully explain the findings described in the question.

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  • 9. 

    A 23-year-old woman desiring conception has amenorrhea of 5 weeks’ duration. She noticed a persistent elevation in her basal body temperatures (BBTs) since unprotected coitus 3 weeks ago. Her vital signs are blood pressure, 120/80 mm Hg; pulse, 80 bpm; and temperature, 98.6°F. Physical examination is normal with the exception of the pelvic examination, which demonstrates a tender 3-cm right adnexal mass. A hematocrit is 38% (normal, 35% to 45%). A serum pregnancy test is negative. What is the best next step?

    • A.

      Observation

    • B.

      Estrogen therapy

    • C.

      Progesterone therapy

    • D.

      RU-486 therapy

    • E.

      Laparoscopy

    Correct Answer
    A. Observation
    Explanation
    The best next step would be observation because the patient has a negative serum pregnancy test and a tender adnexal mass. This suggests the possibility of an ectopic pregnancy, which is a medical emergency. Observation allows for monitoring of the patient's condition and for further diagnostic tests to be performed if necessary.

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  • 10. 

    You are asked to evaluate a 28-year-old unconscious woman involved in a motor vehicle accident. An abdominal radiogram shows two teeth in the right pelvis. Pelvic examination demonstrates a 7-cm semisolid mass in the right adnexa. Which of the following is the most likely diagnosis?

    • A.

      Severe head and facial trauma

    • B.

      Fetal demise

    • C.

      Fetus papyraceus

    • D.

      Calcified leiomyoma

    • E.

      Mature teratoma

    Correct Answer
    E. Mature teratoma
    Explanation
    The most likely diagnosis in this case is a mature teratoma. The presence of two teeth in the right pelvis on the abdominal radiogram suggests the presence of a teratoma, which is a type of germ cell tumor that can contain tissues from all three germ cell layers. The 7-cm semisolid mass in the right adnexa further supports this diagnosis, as teratomas commonly occur in the ovaries. The other options, such as severe head and facial trauma, fetal demise, calcified leiomyoma, and fetus papyraceus, do not fit the clinical presentation and findings described.

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  • 11. 

    A 39-year-old woman with acute right lower abdominal pain is seen in the emergency department. She is nauseated and has vomited four times today. She is monogamous and uses a diaphragm for contraception. Vital signs are blood pressure, 90/40 mm Hg; pulse, 110 bpm; and temperature, 102.4°F. Physical examination demonstrates a rigid abdomen with rebound tenderness. Pelvic examination shows a fluctuant 3-cm right adnexal mass. A hematocrit is 35% (normal, 35% to 45%); white blood cell (WBC) count, 28,000/mL (normal, 3000–10,000/ mL). At laparotomy, you find a pelvic abscess and a ruptured fingerlike pouch arising 40 cm proximal to the ileocecal junction. Which of the following is the most likely diagnosis?

    • A.

      Regional enteritis

    • B.

      Diverticulitis

    • C.

      Meckel’s diverticulum

    • D.

      Chronic appendicitis

    • E.

      Walthard rest

    Correct Answer
    C. Meckel’s diverticulum
    Explanation
    The patient in this scenario presents with acute right lower abdominal pain, nausea, vomiting, and a rigid abdomen with rebound tenderness. The pelvic examination reveals a fluctuant 3-cm right adnexal mass. These findings, along with a high white blood cell count and a pelvic abscess found during laparotomy, suggest an inflammatory process. Meckel's diverticulum is a congenital abnormality of the small intestine that can become inflamed and present with symptoms similar to appendicitis. The ruptured fingerlike pouch found 40 cm proximal to the ileocecal junction is consistent with Meckel's diverticulum. Therefore, Meckel's diverticulum is the most likely diagnosis in this case.

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  • 12. 

    You are asked to see a 34-year-old woman with intermittent abdominal pain and bloody diarrhea. She has experienced similar symptoms previously but has always recovered. She is married and uses a diaphragm for contraception. Vital signs are blood pressure, 130/80 mm Hg; pulse, 90 bpm; and temperature, 101.0°F. A localized area of tenderness is present in the right lower abdominal quadrant. Pelvic examination shows a fluctuant 4-cm right adnexal mass. A hematocrit is 35% (normal, 35% to 45%); WBC count, 27,000/mL (normal, 3–10,000/mL). Stool testing shows blood intermixed with WBC. Gastrointestinal imaging studies show mucosal changes and narrowing of the terminal ileum. Which of the following is the best next step?

    • A.

      Corticosteroid therapy

    • B.

      Estrogen therapy

    • C.

      Appendectomy

    • D.

      Colectomy

    • E.

      Salpingo-oophorectomy

    Correct Answer
    A. Corticosteroid therapy
    Explanation
    The patient's symptoms, including intermittent abdominal pain, bloody diarrhea, and a fluctuant adnexal mass, along with the findings of mucosal changes and narrowing of the terminal ileum on imaging, suggest a diagnosis of Crohn's disease. The elevated WBC count and presence of blood and WBC in the stool further support this diagnosis. Corticosteroid therapy is the best next step in the management of Crohn's disease to reduce inflammation and control symptoms. The other options, including estrogen therapy, appendectomy, colectomy, and salpingo-oophorectomy, are not indicated in this case.

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  • 13. 

    A 23-year-old woman has left lower abdominal pain of 1 week’s duration. Her last menstrual period (LMP) was 8 weeks ago. Vital signs are blood pressure, 130/72 mm Hg; pulse, 76 bpm; and temperature, 98.6°F. An abdominal examination is unremarkable. Pelvic examination demonstrates an enlarged uterus and a tender 4.5-cm left adnexal mass. A serum human chorionic gonadotropin (hCG) level is 3,500 mlU/mL. Transvaginal sonography shows a single viable intrauterine pregnancy and a left echogenic adnexal mass. The cyst most likely represents which of the following?

    • A.

      Heterotopic ectopic pregnancy

    • B.

      Follicular cyst

    • C.

      Hemorrhagic corpus luteum

    • D.

      Cystic teratoma

    • E.

      Degenerated leiomyoma

    Correct Answer
    C. Hemorrhagic corpus luteum
    Explanation
    The patient's symptoms, physical examination findings, and imaging results are consistent with a hemorrhagic corpus luteum. The presence of an enlarged uterus and a single viable intrauterine pregnancy on transvaginal sonography indicates a normal pregnancy. The tender adnexal mass and elevated hCG level suggest the presence of a hemorrhagic corpus luteum, which is a common finding in early pregnancy. The other options, such as heterotopic ectopic pregnancy, follicular cyst, cystic teratoma, and degenerated leiomyoma, do not fit the clinical presentation and imaging findings.

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  • 14. 

    A 21-year-old woman has amenorrhea, mild vaginal spotting, pelvic pain, and left shoulder pain. Her vital signs are blood pressure, 90/50 mm Hg; pulse, 110 bpm; and temperature, 98.6°F. Abdominal examination shows left lower quadrant tenderness with rebound. Pelvic examination demonstrates a painful 4-cm left adnexal mass. A serum pregnancy test is positive. A hematocrit is 22% (normal, 35% to 45%). Which of the following is the best next step?

    • A.

      Observation

    • B.

      Estrogen therapy

    • C.

      Progesterone therapy

    • D.

      Methotrexate therapy

    • E.

      Surgery

    Correct Answer
    E. Surgery
    Explanation
    The patient presents with symptoms of amenorrhea, vaginal spotting, pelvic pain, and left shoulder pain, along with a positive serum pregnancy test. These findings, in addition to the presence of a painful adnexal mass and rebound tenderness on examination, suggest a possible ectopic pregnancy. Ectopic pregnancy is a potentially life-threatening condition that requires immediate intervention. Surgery is the best next step to remove the ectopic pregnancy and prevent further complications. Observation, estrogen therapy, progesterone therapy, and methotrexate therapy are not appropriate in this case as they do not address the underlying problem of the ectopic pregnancy.

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  • 15. 

    A 38-year-old healthy woman comes for prenatal care. Her medical history is unremarkable. General physical and pelvic examinations before conception were normal. She undergoes chorionic villus sampling, which shows a 46,XX karyotype. She has noticed progressive hirsutism during pregnancy. She eventually delivers an infant with ambiguous genitalia. A maternal pelvic examination in the delivery room confirms a 6-cm left adnexal mass. Which of the following is the most likely diagnosis?

    • A.

      Luteoma

    • B.

      Theca lutein cyst

    • C.

      Persistent corpus luteum

    • D.

      Luteinized unruptured follicle

    • E.

      Luteinized endometrioma

    Correct Answer
    A. Luteoma
    Explanation
    The most likely diagnosis in this case is luteoma. Luteoma is a rare benign tumor of the ovary that occurs during pregnancy. It is characterized by the presence of luteinized cells, which produce androgens. This can lead to symptoms such as hirsutism (excessive hair growth) in the mother. In this case, the presence of a 6-cm left adnexal mass on pelvic examination further supports the diagnosis of luteoma.

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  • 16. 

    A 8-cm cystic ovarian tumor is detected during routine prenatal examination. Which of the following is the most common complication of such a tumor during the first trimester of pregnancy?

    • A.

      Torsion

    • B.

      Rupture

    • C.

      Intracystic hemorrhage

    • D.

      Solid degeneration

    • E.

      Luteinization

    Correct Answer
    A. Torsion
    Explanation
    During the first trimester of pregnancy, the most common complication of an 8-cm cystic ovarian tumor is torsion. Torsion occurs when the tumor twists on its own blood supply, leading to compromised blood flow. This can cause severe abdominal pain and potentially lead to tissue death if not promptly treated. Rupture, intracystic hemorrhage, solid degeneration, and luteinization are less common complications that may occur with ovarian tumors, but torsion is the most frequent in the first trimester.

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  • 17. 

    Which of the following is the most common pelvic mass in a postmenopausal woman?

    • A.

      Follicular cyst

    • B.

      Corpus luteum cyst

    • C.

      Germ-cell tumor

    • D.

      Leiomyoma

    • E.

      Endometrioma

    Correct Answer
    D. Leiomyoma
    Explanation
    Leiomyoma, also known as uterine fibroids, is the most common pelvic mass in postmenopausal women. These are benign tumors that develop in the muscular wall of the uterus. They are more common in women of reproductive age but can still be found in postmenopausal women. Leiomyomas are usually asymptomatic but can cause symptoms such as pelvic pain, heavy menstrual bleeding, and urinary frequency. They are typically diagnosed through imaging studies such as ultrasound or MRI. Treatment options vary depending on the symptoms and may include medication, minimally invasive procedures, or surgery.

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  • 18. 

    The cell line that produces a neoplastic ovarian mass will influence imaging modalities and which, if any, serum tumor markers will be of help. Most neoplastic ovarian masses in postmenopausal women originate from which of the following?

    • A.

      Ovarian epithelium

    • B.

      Ovarian stroma

    • C.

      Ovarian germ cells

    • D.

      Ovarian sex cords

    • E.

      Metastatic disease

    Correct Answer
    A. Ovarian epithelium
    Explanation
    The correct answer is ovarian epithelium. Neoplastic ovarian masses in postmenopausal women usually originate from the ovarian epithelium. This is important because the cell line that produces the mass will determine the imaging modalities that can be used to detect it and the serum tumor markers that can be helpful in diagnosis.

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  • 19. 

    A large adnexal/ovarian mass is removed in a perimenopausal patient. Prognosis of cure depends on the origin of the tumor. Signet ring cells are characteristic findings in which tumor of the ovary?

    • A.

      Brenner tumor

    • B.

      Krukenberg’s tumor

    • C.

      Dermoid cyst

    • D.

      Endometrioid carcinoma

    • E.

      Dysgerminoma

    Correct Answer
    B. Krukenberg’s tumor
    Explanation
    Krukenberg's tumor is a type of ovarian tumor that is characterized by the presence of signet ring cells. These cells have a characteristic appearance under the microscope, with a large vacuole pushing the nucleus to the periphery of the cell. Krukenberg's tumor is usually metastatic, meaning it has spread from another primary site, most commonly the stomach or colon. The prognosis of cure in a perimenopausal patient with a large adnexal/ovarian mass depends on the origin of the tumor, and in the case of Krukenberg's tumor, the prognosis is generally poor.

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  • 20. 

    A 1-year-old girl has an abdominal mass. Rectal examination demonstrates a mass extending into the right pelvis. The cervix is not palpable. Abdominal sonography shows that the uterus and vagina are absent. Both ovaries appear normal. Which of the following is the most likely origin of the mass?

    • A.

      Gastrointestinal

    • B.

      Renal

    • C.

      Musculoskeletal

    • D.

      Hepatic

    • E.

      Pancreatic

    Correct Answer
    B. Renal
    Explanation
    The most likely origin of the mass in this 1-year-old girl is renal. The absence of the uterus and vagina on abdominal sonography suggests a congenital anomaly known as Mayer-Rokitansky-Küster-Hauser syndrome, which is characterized by the absence or underdevelopment of the uterus and upper part of the vagina. This syndrome is often associated with renal anomalies, such as renal agenesis or dysplasia. Therefore, the presence of an abdominal mass in this case is likely due to a renal abnormality.

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  • 21. 

    A 23-year-old woman with right-sided lower abdominal pain and chills is seen in the emergency department. The pain began 3 days ago and is associated with a vaginal discharge. Her LMP was 5 days ago. She uses an intrauterine device for contraception and had coitus 1 week ago with her new boyfriend. There is no history of nausea, vomiting, or diarrhea. Her vital signs are blood pressure, 120/80 mm Hg; pulse, 100 bpm; and temperature, 101.4°F. Abdominal examination shows bilateral lower quadrant guarding with rebound tenderness on the right side. Pelvic examination shows pus at the cervical os and a tender 6-cm right adnexal mass. Laboratory data are hematocrit, 38% (normal, 35% to 45%); WBC count, 25,000/mL (normal, 3–10,000/mL); and serum pregnancy test, negative. Transvaginal sonography shows a 6-cm complex right adnexal mass. The uterus and left adnexa are normal. Which of the following is the most likely diagnosis?

    • A.

      Appendicitis

    • B.

      Adnexal torsion

    • C.

      Pyosalpinx

    • D.

      Hydrosalpinx

    • E.

      Endometritis

    Correct Answer
    C. Pyosalpinx
    Explanation
    The patient's presentation is consistent with pyosalpinx, which is an infection of the fallopian tube. The patient has lower abdominal pain, chills, vaginal discharge, and an elevated temperature. The pelvic examination shows pus at the cervical os and a tender adnexal mass, further supporting the diagnosis. The transvaginal sonography also reveals a complex adnexal mass, indicating an infection. Appendicitis can cause lower abdominal pain, but it is unlikely in this case as the pain is localized to the right lower quadrant and there is no history of nausea, vomiting, or diarrhea. Adnexal torsion and hydrosalpinx do not typically present with pus or infection. Endometritis is an infection of the uterine lining and does not explain the adnexal mass.

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  • 22. 

    A 35-year-old woman complains of constant, deep, pelvic pain that is increasing in intensity over the past few years. It worsens during menstruation, sexual intercourse, and bowel movements. Her LMP was 1 week ago. Vital signs are blood pressure, 110/70 mm Hg; pulse, 80 bpm; and temperature, 98.6°F. Abdominal examination elicits bilateral lower quadrant tenderness without rebound. Pelvic examination demonstrates a tender 6-cm left adnexal mass and fixation of the uterus and uterosacral ligaments. Laboratory data are hematocrit, 40% (normal, 35% to 45%); WBC count, 7,000/mL (normal, 3–10,000/mL); and serum pregnancy test, negative. Transvaginal sonography shows a 6-cm echogenic left adnexal mass. The uterus and right adnexa are normal. Which of the aforementioned options is the most likely diagnosis?

    • A.

      Follicular cyst

    • B.

      Adnexal torsion

    • C.

      Benign cystic teratoma

    • D.

      Leiomyomata

    • E.

      Endometrioma

    • F.

      Corpus luteum cyst

    • G.

      Ovarian fibroma

    • H.

      Theca lutein cysts

    • I.

      Distended bladder

    Correct Answer
    E. Endometrioma
    Explanation
    The patient's history, physical examination findings, and imaging results are consistent with the diagnosis of an endometrioma. Endometriomas are cystic masses that form when endometrial tissue implants and grows outside the uterus, typically within the ovaries. The patient's symptoms of deep pelvic pain that worsens during menstruation and the presence of a tender adnexal mass and fixation of the uterus and uterosacral ligaments on examination are all suggestive of endometriosis. The transvaginal sonography showing a 6-cm echogenic left adnexal mass further supports the diagnosis of an endometrioma.

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  • 23. 

    A 25-year-old woman has had intense right lower abdominal pain and nausea since jogging yesterday afternoon. Intermittent episodes of similar pain have occurred over the past several days. She has vomited twice today, but her bowel movements are normal. Her vital signs are blood pressure, 108/60; pulse, 90 bpm; and temperature, 100.4°F. Abdominal examination shows right lower quadrant tenderness. Pelvic examination demonstrates a tender 5-cm right adnexal mass anterior to the uterus. The uterus and left adnexa are normal. Laboratory data are hematocrit, 39% (normal, 35% to 45%); WBC count, 11,000/mL (normal, 3–10,000/mL); and serum pregnancy test, negative. Which of the aforementioned options is the most likely diagnosis?

    • A.

      Follicular cyst

    • B.

      Adnexal torsion

    • C.

      Benign cystic teratoma

    • D.

      Leiomyomata

    • E.

      Endometrioma

    • F.

      Corpus luteum cyst

    • G.

      Ovarian fibroma

    • H.

      Theca lutein cysts

    • I.

      Distended bladder

    Correct Answer
    B. Adnexal torsion
    Explanation
    The most likely diagnosis in this case is adnexal torsion. The patient presents with intense right lower abdominal pain, nausea, and a tender 5-cm right adnexal mass. Adnexal torsion occurs when the ovary twists on its pedicle, leading to compromised blood flow and subsequent pain. The symptoms of intermittent pain, nausea, and vomiting are consistent with this condition. The presence of a tender adnexal mass further supports the diagnosis. Other options such as follicular cyst, benign cystic teratoma, and leiomyomata are less likely given the specific clinical findings.

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  • 24. 

    A 35-year-old woman is seen for annual examination. Her LMP was 1 week ago. Menses occur at 30- day intervals but are heavier than they were 5 years ago. She has experienced three spontaneous abortions over the past 5 years. Abdominal examination is normal. Pelvic examination demonstrates an enlarged, firm, irregular uterus and a 4-cm left adnexal mass fixed to the uterus. A complete blood cell (CBC) count is normal, and a serum pregnancy test is negative. Which of the aforementioned options is the most likely diagnosis?

    • A.

      Follicular cyst

    • B.

      Adnexal torsion

    • C.

      Benign cystic teratoma

    • D.

      Leiomyomata

    • E.

      Endometrioma

    • F.

      Corpus luteum cyst

    • G.

      Ovarian fibroma ovarian fibroma ovarian fibroma

    • H.

      Theca lutein cysts

    • I.

      Distended bladder

    Correct Answer
    D. Leiomyomata
    Explanation
    The most likely diagnosis in this case is leiomyomata, also known as uterine fibroids. This is suggested by the patient's history of heavy menses and an enlarged, firm, irregular uterus on pelvic examination. The presence of a 4-cm left adnexal mass fixed to the uterus further supports this diagnosis. Leiomyomata are benign smooth muscle tumors that commonly occur in women of reproductive age and can cause symptoms such as heavy menstrual bleeding and pelvic pain. The other options listed are less likely based on the given information.

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  • 25. 

    A 7-year-old child is referred for evaluation of sexual precocity, cystic bone lesions, and café au lait spots. Right adnexal fullness is noted on rectal examination. Which of the aforementioned options is the most likely diagnosis?

    • A.

      Follicular cyst

    • B.

      Adnexal torsion

    • C.

      Benign cystic teratoma

    • D.

      Leiomyomata

    • E.

      Endometrioma

    • F.

      Corpus luteum cyst

    • G.

      Ovarian fibroma

    • H.

      Theca lutein cysts

    • I.

      Distended bladder

    Correct Answer
    A. Follicular cyst
    Explanation
    The most likely diagnosis in this case is a follicular cyst. This is suggested by the presence of sexual precocity, cystic bone lesions, café au lait spots, and right adnexal fullness on rectal examination. Follicular cysts are fluid-filled sacs that form on or within the ovaries. They are common in women of reproductive age and can cause symptoms such as pelvic pain, bloating, and irregular menstrual cycles. In this case, the presence of sexual precocity and other symptoms suggest that the follicular cyst may be hormonally active, leading to the development of secondary sexual characteristics at an early age.

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  • 26. 

    A 28-year-old woman with a twin gestation is found to have bilateral adnexal masses at 26 weeks’ gestational age. Which of the aforementioned options is the most likely diagnosis?

    • A.

      Follicular cyst

    • B.

      Adnexal torsion

    • C.

      Benign cystic teratoma

    • D.

      Leiomyomata

    • E.

      Endometrioma

    • F.

      Corpus luteum cyst

    • G.

      Ovarian fibroma

    • H.

      Theca lutein cysts

    • I.

      Distended bladder

    Correct Answer
    H. Theca lutein cysts
    Explanation
    The most likely diagnosis in this case is theca lutein cysts. Theca lutein cysts are associated with high levels of human chorionic gonadotropin (hCG), which is commonly seen in twin pregnancies. These cysts are typically bilateral and can be quite large. They are usually benign and resolve on their own after pregnancy.

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  • 27. 

    You are called to evaluate a 1-day-old female neonate with a palpable anterior abdominal mass. The baby was born by vaginal breech delivery. Which of the aforementioned options is the most likely diagnosis?

    • A.

      Follicular cyst

    • B.

      Adnexal torsion

    • C.

      Benign cystic teratoma

    • D.

      Leiomyomata

    • E.

      Endometrioma

    • F.

      Corpus luteum cyst

    • G.

      Ovarian fibroma

    • H.

      Theca lutein cysts

    • I.

      Distended bladder

    Correct Answer
    I. Distended bladder
    Explanation
    In a 1-day-old female neonate with a palpable anterior abdominal mass, the most likely diagnosis is a distended bladder. This is because the neonate was born by vaginal breech delivery, which can cause compression of the urethra and obstruct urine flow, leading to bladder distention. The other options listed are not commonly associated with a palpable abdominal mass in a neonate.

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  • 28. 

    A 45-year-old woman is found to have a 4-cm adnexal mass, ascites, and bilateral pleural effusions. Which of the aforementioned options is the most likely diagnosis?

    • A.

      Follicular cyst

    • B.

      Adnexal torsion

    • C.

      Benign cystic teratoma

    • D.

      Leiomyomata

    • E.

      Endometrioma

    • F.

      Corpus luteum cyst

    • G.

      Ovarian fibroma

    • H.

      Theca lutein cysts

    • I.

      Distended bladder

    Correct Answer
    G. Ovarian fibroma
    Explanation
    The most likely diagnosis in this case is ovarian fibroma. Ovarian fibromas are typically solid tumors that can cause a palpable mass in the adnexal area. They can also lead to the accumulation of fluid in the abdomen (ascites) and pleural effusions. This presentation is consistent with Meigs syndrome, which is characterized by the triad of ovarian fibroma, ascites, and pleural effusions. Other options such as follicular cyst, adnexal torsion, benign cystic teratoma, leiomyomata, endometrioma, corpus luteum cyst, theca lutein cysts, and distended bladder do not typically present with the same combination of findings.

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  • 29. 

    A 58-year-old postmenopausal woman has pelvic pain of 3 months’ duration. She has recently noticed irregular vaginal bleeding, urinary frequency, and rectal pressure. Last year a physician remarked that her uterus was 12 gestational weeks in size. Physical and pelvic examination shows a firm, irregular, midline abdominal mass approximately 20 gestational weeks in size. Stool guaiac is negative for occult blood. Which of the aforementioned options is the most likely diagnosis?

    • A.

      Fallopian tube carcinoma

    • B.

      Ovarian carcinoma

    • C.

      Endometrial hyperplasia

    • D.

      Uterine sarcoma

    • E.

      Endometrial carcinoma

    • F.

      Uterine leiomyoma

    • G.

      Fallopian tube cancer

    • H.

      Cervical carcinoma

    Correct Answer
    D. Uterine sarcoma
    Explanation
    The most likely diagnosis for this patient is uterine sarcoma. The patient's symptoms of pelvic pain, irregular vaginal bleeding, urinary frequency, and rectal pressure, along with the physical and pelvic examination findings of a firm, irregular, midline abdominal mass, suggest the presence of a malignant tumor in the uterus. Uterine sarcoma is a rare type of cancer that occurs in the muscle and supporting tissues of the uterus. The size of the mass, as well as the negative stool guaiac test, helps to differentiate it from other possible diagnoses such as uterine leiomyoma or endometrial hyperplasia.

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  • 30. 

    A 63-year-old woman has bloating associated with tightening of her clothing around her abdomen. She recently has developed dyspepsia and has lost 15 pounds unintentionally. She is short of breath. Pulmonary auscultation shows loss of breath sound. Abdominal percussion causes a wavelike movement of fluid around a central tympanitic area. Pelvic examination demonstrates a fixed, irregular nodular adnexal mass with cul-de-sac nodularity. A chest radiogram shows bilateral pleural effusions. Which of the aforementioned options is the most likely diagnosis?

    • A.

      Fallopian tube carcinoma

    • B.

      Ovarian carcinoma

    • C.

      Endometrial hyperplasia

    • D.

      Uterine sarcoma

    • E.

      Endometrial carcinoma

    • F.

      Uterine leiomyoma

    • G.

      Fallopian tube cancer

    • H.

      Cervical carcinoma

    Correct Answer
    B. Ovarian carcinoma
    Explanation
    The most likely diagnosis in this case is ovarian carcinoma. The patient's symptoms, such as bloating, unintentional weight loss, dyspepsia, and shortness of breath, along with the findings on physical examination and imaging studies, are consistent with advanced ovarian cancer. The presence of a fixed, irregular nodular adnexal mass with cul-de-sac nodularity on pelvic examination, along with bilateral pleural effusions on chest radiogram, further supports the diagnosis of ovarian carcinoma.

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  • 31. 

    A 51-year-old woman is hospitalized for treatment of right pyelonephritis. An IVP shows right-sided hydronephrosis and a dilated ureter. Physical examination is unremarkable. During pelvic examination, you observe a malodorous vaginal discharge. A firm, irregular right adnexal mass extends to the pelvic sidewall. The patient experiences vaginal bleeding after examination. Which of the aforementioned options is the most likely diagnosis?

    • A.

      Fallopian tube carcinoma

    • B.

      Ovarian carcinoma

    • C.

      Endometrial hyperplasia

    • D.

      Uterine sarcoma

    • E.

      Endometrial carcinoma

    • F.

      Uterine leiomyoma

    • G.

      Fallopian tube cancer

    • H.

      Cervical carcinoma

    Correct Answer
    E. Endometrial carcinoma
    Explanation
    The most likely diagnosis in this case is endometrial carcinoma. The patient's symptoms and findings, such as malodorous vaginal discharge, vaginal bleeding after examination, and a firm, irregular right adnexal mass, are consistent with endometrial carcinoma. This type of cancer can cause abnormal vaginal bleeding and can spread to the adnexa, which includes the fallopian tubes and ovaries. Other options such as fallopian tube carcinoma, ovarian carcinoma, and uterine sarcoma are less likely based on the given information.

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  • 32. 

    A 75-year-old woman has long-standing, self-limited episodes of left lower abdominal pain. An episode of pain occurred yesterday and has progressed to severe left lower abdominal pain. She vomited once this morning. Vital signs are blood pressure, 150/90 mm Hg; pulse, 90 bpm; and temperature, 102.4°F. Abdominal examination demonstrates guarding over the left lower quadrant. There is no rebound tenderness. Pelvic examination shows a fluctuant, fixed, ill-defined left adnexal mass. A hematocrit is 38% (normal, 35% to 45%); WBC, 15,000/mL (normal 3–10,000/mL). Stool guaiac is positive for occult blood. Which of the following is the most likely diagnosis?

    • A.

      Regional enteritis

    • B.

      Ulcerative colitis

    • C.

      Meckel’s diverticulum

    • D.

      Appendicitis

    • E.

      Diverticulitis

    • F.

      H?

    Correct Answer
    C. Meckel’s diverticulum
    Explanation
    The most likely diagnosis in this case is Meckel's diverticulum. Meckel's diverticulum is a congenital abnormality of the small intestine that can cause intermittent abdominal pain, which can progress to severe pain if the diverticulum becomes inflamed or infected. The presence of a fluctuant, fixed, ill-defined left adnexal mass on pelvic examination suggests an abnormality in the lower abdomen, which is consistent with Meckel's diverticulum. The positive stool guaiac test indicates the presence of occult blood in the stool, which can be a sign of gastrointestinal bleeding associated with Meckel's diverticulum.

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  • 33. 

    A 69-year-old woman noticed a reduction in the size of her stool over 6 months. Abdominal examination elicits left-sided abdominal tenderness. Pelvic examination shows a hard, tubular mass with a transverse orientation behind the left adnexa. The patient is afebrile, and her vital signs are normal. A CBC count is unremarkable. Stool guaiac is positive for occult blood. Which of the following is the most likely diagnosis?

    • A.

      Regional enteritis

    • B.

      Ulcerative colitis

    • C.

      Ovarian carcinoma

    • D.

      Colorectal carcinoma

    • E.

      Diverticulitis

    Correct Answer
    D. Colorectal carcinoma
    Explanation
    The most likely diagnosis in this case is colorectal carcinoma. The patient's symptoms, such as a reduction in stool size, left-sided abdominal tenderness, and a hard, tubular mass behind the left adnexa, are consistent with colorectal carcinoma. Additionally, the positive stool guaiac test for occult blood further supports this diagnosis. Other options like regional enteritis, ulcerative colitis, ovarian carcinoma, and diverticulitis do not fit the clinical presentation and findings described in the question.

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  • 34. 

    A 26-year-old woman undergoes a laparoscopic tubal ligation using Falope rings. Approximately 8 hours after the procedure, she presents to the emergency department, complaining of increasing lower abdominal pain, nausea, but no vomiting. Examination finds a diffusely tender abdomen with an ill- defined midline fullness rising to 4 cm below the umbilical incision. Which of the following is the most like cause of this patient’s symptoms?

    • A.

      Abdominal wall hematoma

    • B.

      Broad ligament hematoma

    • C.

      Urinary retention

    • D.

      Ovarian ischemia

    • E.

      Normal postoperative pain

    Correct Answer
    C. Urinary retention
    Explanation
    The patient's symptoms of increasing lower abdominal pain and a diffusely tender abdomen with an ill-defined midline fullness rising to 4 cm below the umbilical incision suggest a possible urinary retention. Urinary retention can occur after laparoscopic procedures due to bladder distension caused by the effects of anesthesia and postoperative pain medications. This can lead to lower abdominal pain and discomfort. The absence of vomiting suggests that there is no bowel obstruction or peritonitis, making abdominal wall hematoma or broad ligament hematoma less likely causes. Ovarian ischemia would present with more specific symptoms related to the ovary, and normal postoperative pain would not present with such severe symptoms.

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  • 35. 

    A 62-year-old woman undergoes a computed tomography examination for left hip pain and a 4-cm simple adnexal mass is seen on the patient’s right side. The patient went through natural menopause at age 51 and has had no other complaints. Which of the following is the most appropriate management of this radiographic finding?

    • A.

      Exploratory laparotomy

    • B.

      Diagnostic laparoscopy

    • C.

      Measurement of serum CA-125

    • D.

      BRCA-1/2 testing

    • E.

      Ultrasonographic evaluation in 3 months

    Correct Answer
    E. Ultrasonographic evaluation in 3 months
    Explanation
    The most appropriate management of the radiographic finding of a 4-cm simple adnexal mass in a postmenopausal woman with no other complaints is ultrasonographic evaluation in 3 months. This is because simple adnexal masses in postmenopausal women have a low risk of malignancy, and many of them resolve spontaneously. Therefore, it is recommended to repeat the ultrasonographic evaluation in 3 months to assess for any changes in the size or characteristics of the mass before considering further interventions such as exploratory laparotomy or diagnostic laparoscopy. Measurement of serum CA-125 or BRCA-1/2 testing is not indicated in the absence of additional risk factors or symptoms.

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  • 36. 

    A 27-year-old woman is undergoing ovulation induction for assisted reproductive treatment of infertility. On an ultrasonographic evaluation of follicular maturation, bilateral 4-cm solid ovarian tumors and moderate collections of peritoneal fluid are found. Which of the following is the most appropriate management of these findings?

    • A.

      Exploratory laparotomy

    • B.

      Diagnostic laparoscopy

    • C.

      Measurement of serum CA-125

    • D.

      Human menopausal gonadotropin therapy

    • E.

      delay conception for at least 1 month

    Correct Answer
    E. delay conception for at least 1 month
    Explanation
    The most appropriate management for a 27-year-old woman with bilateral 4-cm solid ovarian tumors and moderate collections of peritoneal fluid on ultrasonographic evaluation is to delay conception for at least 1 month. This is because the presence of ovarian tumors and peritoneal fluid may indicate a potential risk for malignancy. Delaying conception allows for further evaluation and investigation to determine the nature of the ovarian tumors and peritoneal fluid, and to ensure the safety and success of assisted reproductive treatment.

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  • 37. 

    An 18-year-old patient is seen for a school physical examination. Mild right lower abdominal tenderness is noted, and on pelvic examination, a smooth, mobile, mildly tender 4-cm cystic mass is found in the right adnexa. The patient has had regular periods since her menarche at age 12. She is not sexually active. What is the most appropriate next step in the management of this lesion?

    • A.

      Exploratory laparotomy

    • B.

      Diagnostic laparoscopy

    • C.

      Measurement of serum CA-125

    • D.

      Oral contraceptive therapy

    • E.

      Reexamination in 1 to 2 months

    Correct Answer
    E. Reexamination in 1 to 2 months
    Explanation
    The most appropriate next step in the management of this lesion is reexamination in 1 to 2 months. This is because the patient is young, not sexually active, and has regular periods, which makes it less likely for the cystic mass to be malignant. Reexamination allows for observation and monitoring of the mass to see if it resolves on its own. If the mass persists or grows, further evaluation and intervention may be necessary.

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  • 38. 

    A 38-year-old multiparous patient transfers her care from another city and presents for an annual health-maintenance examination. The patient is married and sexually active and underwent a sterilization procedure a year after the birth of her last child. She has been healthy, takes no medications, and has not sought care for several years. A review of symptoms is negative. Her menstrual periods are regular, though they have become somewhat heavier over the past year. On bimanual examination, the uterus is found to be firm, irregular, nontender, mobile, and the size of a 14- week gestation. A cervical cytologic specimen is obtained. Which of the following is the most appropriate next step in this patient’s management?

    • A.

      Diagnostic laparoscopy

    • B.

      Pelvic ultrasonography

    • C.

      Measurement of serum CA-125

    • D.

      Reexamination in one month

    • E.

      Reexamination in 1 year

    Correct Answer
    E. Reexamination in 1 year
    Explanation
    The patient is a 38-year-old multiparous woman who presents for an annual health-maintenance examination. She is married, sexually active, and underwent sterilization after her last child. She has been healthy and has not sought care for several years. On examination, her uterus is found to be firm, irregular, nontender, mobile, and the size of a 14-week gestation. Her menstrual periods have become heavier over the past year. Given her age and symptoms, the most appropriate next step in her management is to reexamine her in 1 year. This is because the findings are consistent with leiomyomas (fibroids), which are common in women of reproductive age and typically do not require immediate intervention. Reexamination in 1 year allows for monitoring of symptoms and growth of the fibroids.

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  • 39. 

    Cancer antigen 125 (CA-125) is expressed by approximately what percentage of ovarian epithelial carcinomas?

    • A.

      20

    • B.

      40

    • C.

      60

    • D.

      80

    • E.

      100

    Correct Answer
    D. 80
    Explanation
    Approximately 80% of ovarian epithelial carcinomas express the cancer antigen 125 (CA-125). This means that a majority of these types of ovarian cancers have elevated levels of CA-125, which can be detected through blood tests. CA-125 is a protein that is often used as a tumor marker for ovarian cancer, as it can help in diagnosis, monitoring treatment response, and detecting recurrence of the disease.

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  • 40. 

    When compared to age-matched women, those with higher parity are at lower risk for uterine leiomyomata due to which of the following?

    • A.

      Reduced estrogen exposure

    • B.

      Myometrial stretch

    • C.

      Inhibition of cellular growth hormones

    • D.

      Lower levels of sex hormone-binding globulin

    • E.

      Reduced number of lifetime ovulations

    Correct Answer
    A. Reduced estrogen exposure
    Explanation
    Higher parity refers to women who have had multiple pregnancies. During pregnancy, estrogen levels are naturally elevated. However, after giving birth, there is a period of reduced estrogen exposure. This reduced estrogen exposure is believed to be the reason why women with higher parity have a lower risk for uterine leiomyomata, also known as uterine fibroids. Estrogen is known to stimulate the growth of these fibroids, so when estrogen exposure is reduced, the risk is also reduced.

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  • 41. 

    A 42-year-old woman with a uterus the size of a 16-week gestation undergoes bilateral uterine artery embolization for the treatment of suspected uterine leiomyomata. Five days after the procedure she presents to the emergency department with pelvic pain and cramping, nausea and vomiting, a low-grade fever, and malaise, which have been getting progressively worse over the past 48 hours. What is the most appropriate next step in the management of this condition?

    • A.

      intravenous antibiotic therapy

    • B.

      Exploratory laparotomy

    • C.

      Exploratory laparoscopy

    • D.

      Computed tomography of the pelvis and abdomen

    • E.

      Analgesics and reassurance

    Correct Answer
    E. Analgesics and reassurance
    Explanation
    The most appropriate next step in the management of this condition is to provide analgesics and reassurance. The patient's symptoms of pelvic pain, cramping, nausea, vomiting, low-grade fever, and malaise are likely due to post-procedural complications such as uterine artery embolization syndrome. This syndrome is characterized by pain and inflammation resulting from ischemia and necrosis of fibroids. It is a self-limiting condition that can be managed with supportive care, including analgesics for pain relief and reassurance for the patient. Intravenous antibiotic therapy, exploratory laparotomy, exploratory laparoscopy, and computed tomography are not indicated in this case as there is no evidence of infection or need for surgical intervention.

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