Question of the Week # 457

A 33 year old gravida 2 para 1 female presents for prenatal care at 35 weeks gestation. She was previously seen at 8 weeks gestation for her only prenatal visit. She has had weight gain of only 21 pounds during her pregnancy, but reports her appetite has been good. She has experienced heat intolerance and fatigue for several months. Her heart rate is 112, blood pressure is 124/86 mm Hg. On examination, she has fullness in her neck and exhibits a fine tremor. You should advise this patient that her child will be at risk for which of the following complications ?

a. Thrombocytopenia
b. Macrocephaly
c. Heart failure
d. Heart block
e. Constipation

Question of the Week # 456

Your patient is a 48-year-old postmenopausal female with recent onset of stage I hypertension.  She has a history of osteoporosis. On exam, her blood pressure is 155/90, heart rate is 80 and regular, and respirations are 16. Cardiovascular examination is unremarkable. She has no other medical history. She has previously been controlling her hypertension with lifestyle modifications and diet. Which of the following medications is the best choice for initial pharmacological treatment of her hypertension?

A. Calcium channel blocker

B. Thiazide diuretics

C. Angiotensin receptor blocker

D. Alpha-adrenergic blocker

E. Angiotensin converting enzyme inhibitor

Question of the Week # 455

You are evaluating a 63-year-old female with a complaint of abdominal pain radiating to her back. She has diminished appetite and pruritus. Her past history is significant for a 40-year history of tobacco use. She has three glasses of wine once a week.

The patient is afebrile, with blood pressure of 123/85, and her heart rate is 74. She appears jaundiced, with scleral icterus. Her abdomen is tender to palpation in the epigastric region, and her liver is palpable 2 cm below the right costal margin. Laboratory tests reveal total bilirubin of 6.0. direct bilirubin of 4.8, alkaline phosphatase of 1000, and AST is 42, with and ALT of 40. Which of the following initial diagnostic test will you order?

A. Abdominal ultrasound

B. Percutaneous liver biopsy

c. Percutaneous transhepatic cholangiography

D. CT abdomen and pelvis

E. Endoscopic retrograde cholangio-pancreatography.

Question of the Week # 454

Your patient presents at 33 weeks gestation. She is a 27 year old gravida 2 para 1 female with a previous pregnancy complicated by pre-eclampsia, with a vaginal delivery of a healthy infant at 37 weeks. Her current pregnancy has been uncomplicated, but today she is experiencing abdominal pain and uterine contractions that began 5 hours prior to presentation. She states that she has had some fluid leaking from her vagina since the previous evening, but denies vaginal bleeding, trauma, urinary urgency or frequency.

Her temperature is 101.6 degrees Fahrenheit. Blood pressure is 98/60, heart rate is 100/minute, with respirations of 18/minutes. On pelvic examination, she has clear fluid in the posterior fornix, which causes nitrazine paper to turn blue in color. She is dilated to 4 centimeters and her cervix is 60% effaced. Her uterus is diffusely tender on examination and the fetal heart rate is 175 beats per minute, with frequent accelerations. Maternal white blood cell count is 13,000/mm3.

What is the next step in the management of this patient?

A. Initiation of ciprofloxacin

B. Urine culture

C. Initiation of ampicillin and gentamycin

D. Cesarean delivery

E. Induction of labor.

Question of the Week # 453

Your patient is a gravida 1 para 0,  19 year old female at 33 weeks gestation that presents with a complaint of heavy vaginal bleeding and severe abdominal pain for an hour. Her pregnancy has been uneventful, and she is in good health, although she continues to smoke cigarettes, admitting to one pack per day.

Blood pressure is 110/80 with a heart rate of 110. The patient is afebrile, with respirations of 20/minute. Examination reveals a contracted uterus with a closed cervical os. The patient expels a large amount of blood from her closed cervix during the examination. Fetal heart rate monitoring reveals severe late decelerations. What is the best treatment option for this patient?

A. Expectant management with bed resT

B. Terbutaline

C. Oxytocin

D. Magnesium sulfate

E. Caesarean section delivery

Question of the Week # 452

Your patient is a gravida 2 para 2 female with a complaint of a vaginal discharge, vulvar irritation, and dysuria. Her symptoms have recurred 4 times within the past year. She had a recent urinary tract infection that was treated with ciprofloxacin, but is in otherwise good health. She is afebrile with normal vital signs, and pelvic examination reveals vulvar and vaginal erythema with a thick white discharge in the vaginal vault. KOH prep reveals pseudo hyphae. Which of the following treatments is most appropriate for this patient?

hyphae

a. Oral fluconazole 150 mg x 1
b. Probiotic lactobacilli
c. No treatment is necessary
d. Oral Fluconozole induction followed by maintenance.
e. Topical miconazole x 7 days

Question of the Week # 450 and #451

450) A 74 year old man with poorly controlled Diabetes Type II presents to your office with complaints of severe right ear pain since yesterday night. The Pain was particularly worse in the night and interfered with his sleep. He took some Advil but pain persisted. He also reports headache on right temporal aspect. On examination, his right external auditory canal is slightly red and swollen and extremely tender to touch. There is some white debris and granulation tissue at the junction of bone and the cartilage. Laboratory studies show normal WBC count with no left shift. Which of the following additional tests is useful in supporting the diagnosis? 

A) Comprehensive metabolic panel

B) Erythrocyte Sedimentation Rate

C) Anti-nuclear antibodies

D) Hemoglobin A1C.

E) Screening nares for MRSA ( Methicillin Resistant Staph. Aureus)

451) What is the most important next step in management?

A) Oral Cephalexin

B) Surgical resection

C) Intravenous Ciprofloxacin

D) Intravenous Ceftriaxone

E) Ciprofloxacin ear drops

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