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 # 421

421) A 34-year-old woman with history of oligomenorrhea presents to your clinic to discuss her results of recent work-up. One week ago, she has undergone extensive work-up for her menstrual abnormality. A serum pregnancy test is negative. Thyroid stimulating hormone, serum prolactin  level and Follicle Stimulating Hormone levels are within normal limits. Serum total testosterone is 120ng/dl ( N = 30 to 90ng/dl) and serum free testosterone is 0.9 ng/dl ( N= 0.4 to 0.8 ng/dl) . A dehydro-epiandrosterone level is 400 mcg/dl (45- 270 ug/dL) . A pelvic ultrasound reveals multiple cysts in the ovaries bilaterally. On examination, she is obese with a BMI of 32. She has excess thick and pigmented hair above her upper lip and on the chin. Which of the following is indicated in this patient at this time?

A) Fasting Plasma Glucose

B) Random Blood Glucose

C) Hemoglobin A1C

D) Oral Glucose Tolerance Test

E) Start Metformin

Question of the Week # 394

394)  A 36 year old woman with Type I diabetes mellitus presents to your office because she just learned that she is pregnant. She is excited and seeks your advise. Her home blood sugars are well controlled on a basal-bolus regimen of Glargine and Lispro insulin. Her other medications include Atorvastatin and aspirin. Her most recent HgbA1C was 6.0%. Her records also reveal that her most recent fasting lipid profile met the therapeutic goals at LDL of 80mg% and Non-HDL cholesterol of 100mg%. On examination, she is comfortable. Vitals are stable and reminder of the examination is unremarkable. An office based serum pregnancy test is positive. A repeat fasting lipid profile reveals Total Cholesterol : 250 mg% LDL cholesterol (calculated) 140mg%, HDL – cholesterol 40 mg%, Triglycerides 350mg%.  Liver function tests , Serum electrolytes, Creatinine and Complete blood count are within normal limitsWhich of the following is the most appropriate next step?

A) Therapeutic Abortion

B) Add Niacin to her Lipid Regimen

C) Discontinue Statin and Start Niacin

D) Discontinue Statin and advise Diet modification alone

E) Increase Atorvastatin

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

Question of the Week # 389

389)  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. Which of the following explains her amenorrhea?

A) Past use of Oral Contraceptive Pills

B) Uterine Adhesions

C) Hypothalamic amenorrhea

D) Polycystic Ovarian Syndrome

E) Premature Ovarian Failire

Question of the Week # 370

370)  A 47  year old woman presents to your office with complaints of change in her menstrual cycles. Lately, she has had very irregular periods and sometimes, they have been heavy. She reports her cycles have been irregular for past 8 months. Her most recent period was two weeks ago and was much heavier than usual. She also has started experiencing hot flashes. She is not on oral contraceptive pills. She does not smoke or use alcohol. She has no other past medical problems and otherwise, feels healthy. Her family history is unremarkable. Physical examination including pelvic examination is unremarkable. A urine pregnancy test and Thyroid stimulating hormone are within normal limits. Urinalysis is normal. Which of the following is the most appropriate initial step in management?

A) Reassure that she is menopausal transition and observe

B) Obtain Serum FSH level

C) Start Oral Contraceptive Pills

D) Endometrial Biopsy

E) Oral Progestin

Question of the Week # 369

369)  A 56 year old post-menopausal woman presents to your office for evaluation of occasional vaginal spotting for past two weeks. She has not had a menstrual period for the past five years.  She  has never taken hormone replacement therapy.  She denies any fever or dysuria. She is sexually active and enjoys it. Her bleeding is unrelated to sexual activity. She has no other past medical problems and otherwise, feels healthy. Physical examination is unremarkable. A transvaginal ultrasound reveals endometrial stripe thickness of 3mm. She is reassured and sent home. Two months later she is re-evaluated in your office for persistent vaginal spotting that has not resolved. She has seen another primary care physician a week ago for a second opinion because she was concerned. He repeated a transvaginal ultrasound which showed endometrial stripe thickness unchanged at 3 mm.  Which of the following is the most appropriate management recommendation?

A) A trial of vaginal estrogen

B) Reassure and Observe

C) Vaginal pH testing

D) Oral Progestin Trial

E) Endometrial Biopsy

Question of the Week # 368

368)  A 58 year old post-menopausal woman presents to your office with intermittent vaginal bleeding for the past 1 month. She has not had a menstrual period for the past six years.  She  has never taken hormone replacement therapy. She reports burning and irritation upon sexual intercourse. She denies any fever or dysuria. She has no other past medical problems and otherwise, feels healthy. On pelvic examination, vaginal epithelium is smooth, dry and shiny with complete loss of rugae. There are no obvious masses or polyps. Vaginal pH is 6.5 . Urinalysis is normal and is negative for nitrite or leucoesterase. A transvaginal ultrasound reveals endometrial stripe thickness of 2mm. Which of the following is the most appropriate next step in management?

A) Endometrial biopsy

B) Vaginal Estrogen Cream

C) Vaginal Lubricant Cream

D) Oral Estradiol

E) Check serum estradiol levels

Question of the Week # 367

367)  A 62 year old woman presents to your office with complaints of vaginal spotting for the past three months. Occasionally, she also had vaginal bleeding. She is concerned with this new development because she has not has not had a menstrual period for the past  ten years. She  has never taken hormone replacement therapy. She also reports burning and irritation upon sexual intercourse. She denies any fever or dysuria. She has no other past medical problems and otherwise, feels healthy. On pelvic examination, vaginal epithelium is smooth, dry and shiny with complete loss of rugae. There are no obvious masses or polyps. Vaginal pH is 6.5 . Urinalysis is normal and is negative for nitrite or leucoesterase. Which of the following is the most appropriate next step in management?

A) Endometrial biopsy

B) Vaginal Estrogen Cream

C) Vaginal Lubricant Cream

D) Oral Estradiol

E) Check serum estradiol levels

Question of the Week # 366

366)  A 59 year old woman is evaluated in your office for vaginal bleeding. The patient has not had a menstrual period for the past eight years. She  has never taken hormone replacement therapy. Over the past 6 months she has had several episodes of spotting. The bleeding is more pronounced after sexual activity. Physical examination including pelvic examination is unremarkable. Which of the following is the most common cause of post-menopausal bleeding?

A) Endometrial Carcinoma

B) Endometrial Hyperplasia

C) Cervical polyps

D) Vaginal Atrophy

E) Fibroids

Question of the Week # 365

365)  A 26 year old woman presents to the outpatient gynecology clinic with complaints of for intermittent vaginal bleeding. She has started Combination oral contraceptive pills 3 months ago. Initially, she had spotting in the first month after starting OC pills however, she now has frank bleeding for past 4 weeks. Her scheduled menstrual period usually, occurs during the pill free period of the month.  She denies any dysuria , fever, vaginal discharge or post-coital bleeding. She smoked about 1 pack per day for the past eight years. She denies alcohol or drug use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative. Which of the following is the first step in managing this patient’s intermenstrual bleeding?

A) Observation

B) Smoking Cessation

C) Pelvic ultrasound

D) Increase Estrogen component of the pill

E) Change the progesterone component to Levonorgestrel

Question of the Week # 364

364)  A 28 year old woman seeks your advice regarding an effective contraception method. She is sexually active with her long term boy-friend. He has been using condoms however, he prefers not to use them on a regular basis . She tells you that she does not want to consider an Intra-Uterine Device Her past medical history is significant for Gastro-esophageal reflux disease and well- controlled Epilepsy. Her medications include omeprazole and carbamazepine.  She does not smoke. On examination, she is age appropriate with normal vitals. Physical examination including pelvic examination is normal. Which of the following contraceptive methods is most appropriate for this patient?

A) Continuous Combination Oral Contraceptive Pills

B) Cyclical Combination Oral Contraceptive Pills

C) Diaphragm with Spermicides

D) Estrogen-Progesterone vaginal ring ( Nuva-Ring)

E) Depot Medroxy Progesterone

Question of the Week # 363

363)  A 25 year old woman presents to your office with complaints of inter-menstrual vaginal bleeding  for the past one month. She is sexually active. She never used barrier methods for contraception but she has been on cyclical combination oral contraceptive pills ( Ethinyl estradiol + Levonorgestrol) for the past 3 months. She denies any fever or vaginal discharge or dysuria or pain. Her menstrual periods occur as scheduled every month during the pill free period however, she also has been experiencing inter-menstrual bleeding only for the past one month and sometimes, more after sexual activity. She never had irregular bleeding in the past and her scheduled periods have always been regular and on time. She denies smoking , alcohol or drug use. Upon physical examination, she is afebrile. There is no obvious vaginal discharge. When gentle endocervical swabbing is attempted, bleeding from endocervix is noted. On bimanual examination, she has no adnexal tenderness. A urine pregnancy test is negative. Which of the following is the most appropriate first management option?

A) Reassure that this is OC Pill related bleeding and will abate.

B) Test for N. gonorrhoeae and C. trachomatis

C) Increase the dose of Ethinyl Estradiol

D) Empiric antibiotic therapy for Gonorrhea and Chlamydia

E) Discontinue OC pills

Question of the Week # 362

362)  A 26 year old woman presents to your office with complaints of intermittent vaginal bleeding  after she started using oral contraceptive pills 1 month ago. She uses continuous oral contraceptive pill combination of ethinyl estradiol and norethindrone. She reports her bleeding is troublesome and interferes with activity. Because of the bleeding, she is considering discontinuing the oral pills but her partner does not want to use barrier methods of contraception. She is distressed and seeks some remedy to address this issue. She never had irregular bleeding in the past and her scheduled periods have always been regular and on time. Her bleeding is unrelated to sexual activity and is not associated with pain. She denies any dysuria, fever or vaginal discharge. She denies smoking or alcohol use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative and serum thyroid stimulating hormone as well as prolactin level are within normal limits. Which of the following is the most appropriate management option?

A) Observation

B) Stop the pills for 3 days and then resume at least 21 days

C) Pelvic ultrasound

D) Discontinue Oral Contraceptive pills

E) Vaginal fluid Nucleic Acid Test for Chlamydia Trachomatis

Question of the Week # 361

361)  A 22 year old woman is seen in the outpatient clinic for intermittent vaginal bleeding. For the past two months, she has had spotting and occasionally, frank bleeding  even before her scheduled menstrual period. It is unrelated to sexual activity and is not associated with pain. She denies any dysuria or fever.  She is sexually active with her fiancee and she reports taking cyclical combined oral contraceptive pills ( OC pills) for the past 2 months. She has been following the exact directions regarding the use of oral contraceptive pills and her scheduled period occurs during the contraceptive free interval however, this unscheduled spotting and bleeding is bothering her. She denies smoking or alcohol use. Physical examination including pelvic examination is unremarkable. There is no vaginal discharge or adnexal tenderness. A urine pregnancy test is negative and serum thyroid stimulating hormone as well as prolactin level are within normal limits. Which of the following is the most appropriate management option?

A) Pelvic ultrasound

B) Reassure and counsel on consistent OC pill use

C) Increase estrogen component of the pills

D) Switch to continuous combined OC pill regimen

E) Discontinue Oral Contraceptive pills

Question of the Week # 360

360)  A 30 year old woman presents to your office accompanied by her husband. She is concerned about her inability to conceive despite having regular intercourse for the past six months.  Her menstrual cycles have always been regular and she has not been using oral contraceptives for the past 10 months. She denies any cold or heat intolerance. She has no other complaints. She does not smoke or drink alcohol. On examination, she is age-appropriate. Pelvic examination is benign. A urine pregnancy test is negative. You counsel the couple and  advise them on continuing regular sexual intercourse. Which of the following is the most appropriate next step?

A) Semen analysis

B) Re-evaluate in 6 months

C) Obtain luteal-phase progesterone level

D) Serum FSH level

E) Hysterosalpingography

Question of the Week # 308

308)  A 76-year-old man presented with a 4-month history of recurrent vertigo. He reports feeling a sensation of spinning dizziness on turning the neck to his left. He also reports left sided headaches and decreased hearing on the left. Each episode lasted about 15 to 20 minutes and occurred when he turned his head to the left. He denies any ringing sensation in ears,  nausea or vomiting. He denies any chest-pain, shortness of breath or palpitations.  His past medical history is significant for hypertension and diet controlled diabetes. His medications include  hydrochlorothiazide and enalapril. He also has history chronic neck pain due to cervical spondylosis for which he uses tylenol. On examination, his blood pressure in supine position is 140/88 mmHg and  blood pressure on standing is is 130/86. Tympanic membranes are visible and there is some cerumen in the left ear. Using a 512Hz tuning fork , bone conduction is found to be better than air conduction on the left and Weber test shows lateralization to the left. Dix-Hallpike’s and Lhermitte’s signs are negative. There are no other neurological deficits. Gait is normal. Range of motion of the neck is limited on lateral movements and neck pain is elicited by turning to left side. An X-ray of cervical spine shows severe spondylosis with discopathy and osteophytes from C2 to C4 vertebrae.  Which of the following is the most likely explanation for his Vertigo?

A) Orthostatic Hypotension

B) Vertebral artery occlusion from cervical spondylosis

C) Cerumen Impaction

D) Meniere’s disease

E) Labyrinthitis

Question of the Week # 307

307) A 35 year old woman is evaluated in your office during an antenatal visit. Her last menstrual period was 8 weeks ago. She tells you that 2 weeks after she missed her regular menstrual period she checked herself with home pregnancy kit and tested positive. She works in a day-care center. She is concerned now because she received Rubella vaccination 4 weeks ago after an exposure to a sick child without knowing that she was pregnant. She read about the dangers to fetus on the internet and is very worried. Physical examination is benign.

Which of the following is the most appropriate course of action?

A. Refer her to medical termination of pregnancy
B. Tell her that there is a high established risk to fetus and she should strongly consider termination of pregnancy
C. Counsel her about theoretical risk to fetus and continue pregnancy care
D. Administer Rubella immunoglobulin
E. Reassure her that there is no risk to fetus.

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 # 250

250 )  A 30 year old woman presents to your office with complaints of fatigue and headache.  She reports that the headaches occur almost daily and are mild to moderate. They are not associated with nausea or vomiting and are unrelated to menstrual cycles. She also reports chronic diffuse abdominal pain and pelvic pain for the past several months for which she did not seek any medical attention. Her chart reveals that she was seen by your colleague few months ago for similar complaints. She was asked to return after few laboratory investigations but she had been non-compliant with her follow-ups. Physical examination reveals an anxious appearing woman who otherwise appears healthy. She does not make an eye contact. Abdominal and pelvic examination is benign. There are no tender points. There are no neurological deficits. The most appropriate next step in managing this patient:

A)     Support and Counseling

B)     Refer to Psychiatry

C)      Start Selective Serotonin Reuptake Inhibitors

D)     Trial of Tricyclic anti-depressants

E)     Screen for Domestic Violence

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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