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

%d bloggers like this: