Question of the Week # 478

478) You are evaluating a 24-year-old female patient who presented with severe abdominal pain two hours prior to admission. She states the pain began in the periumbilical region and has moved to the low abdomen, and she had one episode of emesis with nausea, but no diarrhea. Her last menstrual period was normal and began 27 days ago. On examination, she has a temperature of 98.9, heart rate of 118 beats per minute, and respirations 20/min. Her blood pressure is 100/80. Examination of the abdomen reveals diffuse tenderness to palpation, and she is guarding moderately and has diminished bowel sounds. Complete blood count reveals a hemoglobin of 12 g/dL and a hematocrit of 38%. White blood cell count is 12,500/mm3 with a left shift. Urinalysis reveals 2-5 WBC/hpf. Which of the following is the next best step in management of this patient?

A. Flat and upright abdominal film

B. Pelvic ultrasound

C. Urine b HCG

D. CT abdomen and pelvis

E. Serum beta HCG

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 # 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 # 392

392)  A 28 year old woman presents with a history of amenorrhea of about 6 month duration. She does not have any breast discharge, visual deficits or headaches. Her home pregnancy test was negative a week ago. Her past medical history is significant for three missed abortions for which she underwent dilatation and curettage. On examination, her vitals are stable. Body mass index is about 22 . Breast examination is normal with out any discharge.  Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  A trial of medroxyprogesterone and a later trial of estrogen-progesterone combination fails to induce bleeding. Which of the following is the most appropriate next step?

A) Anti-phospholipid Antibodies

B) Hysteroscopy

C) Dehydro-epiandrosterone level

D) Pituitary MRI

E) Ultrasound of Ovaries

Question of the Week # 391

391)  A 26 year old woman is seen in the outpatient clinic for amenorrhea of about 6 months. The patient ah d been on oral contraceptives but discontinued 6 months ago. She reports having regular menstrual cycles prior to  starting oral contraceptives. She denies any excessive stress or physical activity. She does not have any breast discharge, visual deficits or headaches. presents to your office with complaints of change in her menstrual cycles. On examination, her vitals are stable. Body mass index is about 28 . Breast examination is normal with out any discharge. Pelvic exam is normal. Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  The patient is started on  medroxyprogesterone acetate at 10 mg/ day for 10 days and experiences menstrual bleeding a week after stopping progesterone. This patient is at increased risk for which of the following conditions?

A) Visual Deficits

B) Endometrial Cancer

C) Osteoporosis

D) Pituitary Necrosis

E) Vertebral Compression Fractures

Question of the Week # 390

390)  A 28 year old woman has had amenorrhea for the past 4 months. She reports having regular menstrual cycles prior to these episodes. She is sexually active and a home pregnancy test was negative on two occasions over the last one week. She denies any excessive stress or physical activity. She has had headaches almost daily over the past three months. She denies any visual deficits. Her past medical history is significant for schizophrenia for which she is using risperdal for several years with good control of her disease. On examination, her vitals are stable. Body mass index is about 28 . There is milky discharge on breast examination. Pelvic exam is normal. Serum pregnancy test is negative. A serum prolactin level is 30mcg/ml (5 to 20 mcg/L). A serum Thyroid Stimulating Hormone and Follicle Stimulating Hormone level are within normal limit. An MRI of the brain reveals 10 cm lobulated mass in the anterior skull base. Which of the following is the initial step in evaluating this patient?

A) Repeat Prolactin after Serum Dilution

B) Discontinue Risperdal

C) Trans-Sphenoidal Resection of the Tumor

D) Pituitary Irradiation

E) Bromocriptine

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