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 # 284

284) A 32 year old pregnant woman is evaluated in the emergency room for new onset abdominal pain. She has mild nausea and vomited once prior to arrival in the emergency room. She denies any bleeding . This is her first pregnancy and she is at 34 weeks gestation.  Physical examination reveals normal blood pressure. There is mild tenderness in epigastric region. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 7 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 50k/µl

Lactic Dehydrogenase  1200U/L

AST 120U/L

ALT 180U/L

Serum Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. Amylase and lipase are normal. A peripheral blood smear shows reduced number of platelets and some fragmented red blood cells. Antinuclear antibodies, Anti-phospholipid antibodies, Lupus anticoagulant profile, HIV testing and Hepatitis C are negative.

Which of the following is the most appropriate next step in management?

A) Platelet transfusion

B) Intravenous Methyl Prednisolone

C) Induction of labor

D) Observation

E) Plasmapheresis

Question of the week # 282

282) A 32 year old woman is seen in the antenatal clinic during her regular antenatal visit. This is her first pregnancy and she is at 32 weeks gestation. She takes prenatal vitamins. She currently has no complaints. Physical examination  is benign. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 14 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 70k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative. The patient is concerned about her abnormal platelet counts. She denies any easy bruising or nose bleeds or gross bleeding. Her complete blood count 3 months ago was completely normal.

Which of the following is the most appropriate response?

A) “You will require treatment with steroids”

B) “Urgent delivery with cesarean section is required.”

C) “Your platelet count will normalize within 2 to 12 weeks after delivery”

D) “You will require Bone marrow biopsy”

E) “No treatment needed since it is immune thrombocytopenia”

Question of the Week # 260

260 )  A 30 year old woman is evaluated  in your office during a routine antenatal visit. Her previous pregnancy 2 years was uneventful. She is now presenting at 12 week gestation. The patient has been compliant with antenatal vitamin supplements. She reports mild early morning nausea and vomiting. On physical examination, her vitals are with in normal limits. Cardiovascular examination reveal exaggerated heart sounds ( S1 and S2) and  a new systolic ejection murmur across the lower left sternal border. An S3 gallop is present.  A grade 1 diastolic murmur is heard at the left ventricular apex that increases in the left lateral decubitus position. Which of the following cardiovascular abnormalities would be best tolerated during an otherwise normal pregnancy?

A)     Mitral Stenosis with pulmonary hypertension

B)     Marfan syndrome with aortic valve involvement

C)     Peri-partum cardiomyopathy in prior pregnancy

D)     Atrial Septal Defect, Secundum type

E)    Bicuspid aortic valve with mean gradient 55mmHg.

Question of the Week # 259

259)  A 32 year old woman presents to your office after she discovered that she is pregnant based on a positive home pregnancy test. A repeat urine Beta-HCG is positive in the office. Her past medical history is significant for recurrent deep vein thromboses and homozygosity for  Factor V leiden mutation. She has been on coumadin for the past three years. Her physical examination is benign with out any clinical evidence of deep vein thromboses. You advice her to stop coumadin. You prescribe unfractionated heparin at a dose of 5000 IU twice daily  to be used through out her pregnancy . This patient is at risk for which of the follwing?

A) Hypokalemia

B) Fetal malformations

C) Vertebral fractures

D) Complete abortion

E) Thrombocytosis

Question of the Week # 258

258 )  A 32 year old woman is evaluated  in your office during a routine antenatal visit. She is a primigravida and is now presenting at 14 week gestation. The patient has been compliant with antenatal vitamin supplements. She reports mild early morning nausea and vomiting. On physical examination, her vitals are with in normal limits. Cardiovascular examination reveal exaggerated heart sounds ( S1 and S2) and  a new systolic ejection murmur across the lower left sternal border. An S3 gallop is present.  A grade 1 diastolic murmur is heard at the left ventricular apex that increases in the left lateral decubitus position. There is an exaggerated drop in systemic blood pressure by 16m Hg during inspiration ( Pulsus paradoxus). Which of the following physical examination findings in this patient is most likely to be pathological?

A)     New Systolic murmur

B)     Pulsus paradoxus

C)      S3 gallop

D)     Diastolic murmur

E)     Exaggerated heart sounds

Question of the Week # 237

237 )  A 25-year old primi-para is evaluated for soreness in her breasts. She just started breast feeding her three day old male infant. She also reports low grade fever over the past few hours. On examination, her temperature is 99.2F. Her breasts are hard and swollen. They are warm to touch. She has pain on movement of the breast. Which of the following is the most appropriate recommendation?

A) Hand expression of milk between feedings

B) Use of  ”Breast Pump”

C) Correction of improper “Latch on”

D) Re-assurance

E) Breast massage

Question of the Week # 236

236)  A 25-year woman presents to your office with complaints of soreness in her right nipple. She had a uneventful delivery 10 days ago. She has been breast feeding for the past ten days. She had some nipple soreness initially however, it resolved after five days. The soreness returned on the eighth day and is persistent since then . The pain is present through out the nursing episode. On examination, she is afebrile. Her right breast is full. There is no erythema or tenderness. Which of the following is the most appropriate recommendation to the patient?

A) Hand expression of milk between feedings

B) Use of  “Breast Pump”

C) Correction of improper “Latch on”

D) Re-assurance

E) Breast massage

Question of the Week # 235

235)  A 25-year woman presents to your office with complaints of soreness in her right nipple. She had a uneventful delivery 10 days ago. She has been breast feeding for the past ten days. She had some nipple soreness initially however, it resolved after five days. The soreness returned on the eighth day and is persistent since then . The pain is present through out the nursing episode. On examination, she is afebrile. Her right breast is full. There is no erythema or tenderness. Which of the following is the most likely cause of her clinical presentation?

A) Poor positioning of infant while feeding

B) Prolonged suckling

C) Inadequate feeding

D) Infection

E)  “Normal” Nipple Sensitivity

 

Question of the Week # 234

234 )  A 25-year old primi-para is evaluated for soreness in her breasts. She just started breast feeding her three day old male infant. She also reports low grade fever over the past few hours. On examination, her temperature is 99.2F. Her breasts are hard and swollen. They are warm to touch. She has pain on movement of the breast. Which of the following is the most likely cause of her clinical presentation?

A) Poor positioning of infant while feeding

B) Prolonged suckling

C) Inadequate feeding

D) Infection

E) Plugged ducts

Question of the Week # 207

207)  A 30 year old  pregnant woman with 32 week gestation presents with severe itching that is present through out the day and  interferes with her sleep at night. The itching is more on palms and soles. She had a similar problem during her previous pregnancy. She denies any history of eczema or liver disease in the past. Physical examination reveals excoriations on the skin. There are no papules, wheals or plaques. There is no scleral icterus. Laboratory investigations reveal an elevated Asparate aminotransferase ( AST) 140u/l , Alanine Aminotransferase (ALT) 150u/l, alkaline phosphatase at 280U/L ( Normal 40 to 120U/L) and Total bilirubin 2.2mg%. Complete blood count is with in normal limits. Hepatitis profile is negative. Which of the following is the most common complication associated with this entity:

A) Hepatic Failure

B) Fetal Prematurity

C) Renal Failure

D) Disseminated Intravascular Coagulation

E) Severe Post-Partum Hemorrhage

Question of the Week # 206

206)  A 30 year old  pregnant woman with 32 week gestation presents with severe itching that is present through out the day and  interferes with her sleep at night. The itching is more on palms and soles. She had a similar problem during her previous pregnancy. She denies any history of eczema or liver disease in the past. Physical examination reveals excoriations on the skin. There are no papules, wheals or plaques. There is no scleral icterus. Laboratory investigations reveal an elevated Asparate aminotransferase ( AST) 140u/l , Alanine Aminotransferase (ALT) 150u/l, alkaline phosphatase at 280U/L ( Normal 40 to 120U/L) and Total bilirubin 2.2mg%. Complete blood count is with in normal limits. Hepatitis profile is negative. The most appropriate next step in managing this patient?

A) Serum Bile Acid level

B) Liver Biopsy

C) Ursodeoxycholic acid

D) Immediate delivery

E) Long-chain 3-hydroxyacyl CoA dehydrogenase (LCHAD) mutation testing

Question of the Week # 205

205) A 27 year old woman, primigravida at 35 week gestation is evaluated in your office for extreme itching associated with rash. The rash and itching first started on her abdomen but now spread to her buttocks and legs as well. She denies similar complaints in any of her family members. On physical examination, an eruption consisting of small erythematous wheals is noted mostly in the abdominal striae with sparing of the peri-umbilical skin. Some rash is also noted on her lower extremities.  There is no involvement of palms and soles. A picture of her abdomen is shown below:

Most likely diagnosis:

A)           Scabies

B)            Pemphigoid Gestationis

C)            Intahepatic Cholestasis of Pregnancy (ICP)

D)            Pruritic Urticarial Papules of Pregnancy (PUPP)

E)            Pruritic folliculitis of Pregnancy

Question of the Week # 200

200)  A 26 year old pregnant woman is evaluated in the emergency Room for severe weakness and dehydration from persistent vomiting. She is a primigravida at 9 weeks gestation. She reports that her nausea and vomiting started at 5 weeks of pregnancy and have progressively become worse. She denies any abdominal pain or vaginal bleeding. She denies any headache. Her bowel movements are normal. Her past medical history is unremarkable. Her pre-pregnancy weight was 60lbs but now she weighs about 55lbs. Physical examination reveals dry oral mucosa. Laboratory tests reveal Serum sodium 140 meq/l, potassium 3.2meq/L, Chloride 102meq/l, Bicarbonate 34meq/L. hematocrit of 52 (normal = 36 to 46%).  Urine reveals ketonuria. The most appropriate next step in investigating this patient:

A)     Hemoglobin A1C level

B)      Serum Uric acid

C)      Urine for total protein

D)     Ultrasound Pelvis

E)      Plain X-Ray abdomen

Question of the Week # 199

199)  A 32 year old pregnant woman with 32 week gestation is evaluated in your office during a regular follow up visit. She denies any abdominal pain or vomiting or vaginal bleeding or headache.  She denies any headache or pruritis. She feels healthy and is hoping for a normal delivery. Physical examination is consistent with 32 week gestation. Extremities do not reveal any edema. Laboratory investigations reveal a mild anemia at 12.0gm%. Rest of the lab results are normal except for elevated alkaline phosphatase at 280U/L ( Normal 40 to 120U/L) . The patient is very concerned. Most appropriate next step in managing this patient?

A) Ultrasound of the liver and gall bladder

B) Immediate Delivery

C) Ursodeoxycholic acid

D) Reassurance

E) Obtain Peripheral Smear

Question of the Week # 198

198)  A 26 year old pregnant woman is evaluated in the emergency Room for severe weakness and dehydration from persistent vomiting. She is a primigravida at 9 weeks gestation. She reports that her nausea and vomiting started at 5 weeks of pregnancy and have progressively become worse. She denies any abdominal pain or vaginal bleeding. She denies any headache. Her bowel movements are normal. Her past medical history is unremarkable. Her pre-pregnancy weight was 60lbs but now she weighs about 55lbs. Physical examination reveals dry oral mucosa. Laboratory tests reveal Serum sodium 140 meq/l, potassium 3.2meq/L, Chloride 102meq/l, Bicarbonate 34meq/L. hematocrit of 52 (normal = 36 to 46%); Total bilirubin of 2mg/dl; ALT of 160U/L and AST of 140U/L. Urine is positive for ketones. Ultrasound reveals normal fetus appropriate for 9 week gestation. Which of the following explains her jaundice and elevated liver function tests:

A) Acute pancreatitis

B) Acute Fatty Liver of pregnancy

C) Cholestatis of Pregnancy

D) Hyperemesis Gravidarum

E) HELLP Syndrome

Question of the Week # 197

197)  A 26 year old pregnant woman is evaluated in the emergency Room for severe weakness and dehydration from persistent vomiting. She is a primigravida at 9 weeks gestation. She reports that her nausea and vomiting started at 5 weeks of pregnancy and have progressively become worse. She denies any abdominal pain or vaginal bleeding. She denies any headache. Her bowel movements are normal. Her past medical history is unremarkable. Her pre-pregnancy weight was 60lbs but now she weighs about 55lbs. Physical examination reveals dry oral mucosa. Laboratory tests reveal hematocrit of  52 ( normal = 36 to 46%) ; Total bilirubin of 2mg/dl; ALT of 160U/L and AST of 140U/L . Urine is positive for ketones. Ultrasound reveals normal fetus appropriate for 9 week gestation. The most likely diagnosis:

A) Diabetic Ketoacidosis

B) Acute Pancreatitis

C) Hyperemesis Gravidarum

D) Cholestasis of Pregnancy

E) Morning Sickness

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