Part 7 (1563 -1596 ) (1530- 1784) Pogba KH2

A 35-year-old woman comes to the clinic because of a left breast “thickness.” She noted this 5months ago and it has not receded. She has no family history of breast cancer. There is no drainage. She denies any pain. She has no other medical issues. She takes no birth control pills or any other medication. Examination shows a palpable mass in the left breast at 9 o’clock. A mammogram is nondiagnostic. Which of the following is the appropriate course of action?
Schedule breast ultrasound
Observe and repeat mammogram in 1 month
Prescribe hormone replacement therapy
. Schedule a lumpectomy
Schedule a mastectomy
A patient in your practice calls you in a panic because her 14-yearold daughter has been bleeding heavily for the past 2 weeks and now feels a bit dizzy and light-headed. The daughter experienced menarche about 6 months ago, and since that time her periods have been irregular and very heavy. You instruct the mother to bring her daughter to the emergency room. When you see the daughter in the emergency room, you note that she appears very pale and fatigued. Her blood pressure and pulse are 110/60 mm Hg and 70 beats per minute, respectively. When you stand her up, her blood pressure remains stable, but her pulse increases to 100. While in the emergency room, you obtain a more detailed history. She denies any medical problems or prior surgeries and is not taking any medications. She reports that she has never been sexually active. On physical examinations, her abdomen is benign. She will not let you perform a speculum examination, but the bimanual examination is normal. She is 5ft 4in tall and weighs 95 lb. Which of the following blood tests is not indicated in the evaluation of this patient?
Estradiol level
BHCG
Bleeding time
CBC
Type and screen
A 53-year-old postmenopausal woman, G3P3, presents for evaluation of troublesome urinary leakage 6 weeks in duration. Which of the following is the most appropriate first step in this patient’s evaluation?
Urinalysis and culture
Urethral pressure profiles
Cystourethrogram
Intravenous pyelogram
Cystourethrogram
A 29-year-old woman comes to the physician for follow-up of a right breast lump. The patient first noticed the lump 4 months ago. It was aspirated at that time, and cytology was negative, but the cyst recurred about 1 month later. The cyst was re-aspirated 2 months ago and, again, the cytology was negative. The lump has recurred. Examination reveals a mass at 10 o'clock, approximately 4 cm from the areola. Ultrasound demonstrates a cystic lesion. Which of the following is the most appropriate next step in management?
Open biopsy
Mastectomy
Mammography in 1 year
Ultrasound in 1 year
Tamoxifen therapy
A 43-year-old African American woman comes to the physician because of her concern regarding breast cancer. She has no complaints at present. In past years, she had noted bilateral breast tenderness prior to her menses, but this has since abated. She has no medical problems. She had two cesarean deliveries, but no other surgeries. She takes a low-dose oral contraceptive pill and has no known drug allergies. She does not smoke, and her family history is negative. Physical examination is normal. All mammograms (yearly since age 40) have been negative to date. She wants to know whether BRCA1 and BRCA2 screening would be appropriate for her. Which of the following is the correct response?
BRCA1 and 2 screening is not recommended
BRCA1 and 2 screening should be performed after age 50
BRCA1 and 2 screening should be performed if breast pain recurs
BRCA1 screening is recommended
BRCA2 screening is recommended
A 28-year-old primigravid woman at term comes to the labor and delivery ward with a gush of fluid and regular contractions. Her prenatal course was remarkable for her being Rh negative and antibody negative. Her husband is Rh positive. Over the following 10 hours, she progresses in labor and delivers a 3600-g boy via a normal spontaneous vaginal delivery. The placenta does not deliver spontaneously, and a manual removal is required. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send?
Kleihauer-Betke
Complete blood count
Liver function tests
Prothrombin time
Serum potassium
A 33-year-old woman, gravida 3, para 3, comes to the physician for an annual examination. She has no complaints. Past medical history is significant for two episodes of Chlamydia and one episode of gonorrhea. Obstetric history is significant for three normal spontaneous vaginal deliveries with gestational diabetes during the last two pregnancies. She takes no medications. Family history is significant for paternal coronary artery disease. Physical examination is unremarkable. Which of the following interventions should this patient most likely have?
Fasting glucose testing every 3 years
Chest x-ray every 3 years
Mammography every 3 years
Coronary angiography every 3 years
Pap testing every 3 years
A 40-year-old woman comes to the physician for an annual examination. She has no complaints. She has menses every 28-30 days that last for 3 days. She has no intermenstrual bleeding. She has asthma, for which she uses an occasional inhaler. She had a tubal ligation 10 years ago. She has no known drug allergies. Examination is unremarkable, including a normal pelvic examination. One of her friends was recently diagnosed with endometrial cancer, and the patient wants to know when and if she needs to be screened for this. Which of the following is the most appropriate response?
Screening for endometrial cancer is not cost effective or warranted
Screening is with endometrial biopsy and starts at age 40
Screening is with endometrial biopsy and starts at age 50
Screening is with ultrasound and starts at age 40
. Screening is with ultrasound and starts at age 50
A 53-year-old woman comes to the physician for an annual examination. She has no complaints. She has hypertension, for which she takes a thiazide diuretic, but no other medical problems. Her past gynecologic history is significant for normal annual Pap tests for many years, her last being 2 months ago. A recent mammogram was negative. Heart, lung, breast, abdomen, and pelvic examination are unremarkable. Which of the following procedures or tests should most likely be performed on this patient?
Rectal examination
Chest x-ray
Pap test
Pelvic ultrasound
Prostate-specific antigen (PSA)
A 22-year-old woman, gravida 2, para 0, at 8 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her first pregnancy resulted in a 22-week loss when she presented to her physician with bleeding from the vagina, was found to be fully dilated, and delivered the fetus. Examination of the patient today is unremarkable. She declines to have a cerclage placed. When should this patient begin having regular cervical examinations?
16 weeks
10 weeks
28 weeks
22 weeks
37 weeks
A 25-year-old woman who is “about 5 months” pregnant with her first child presents for the first time to an obstetrician. She has had no prenatal care. When asked about her medical history, she states she sometimes takes medicine for “depression,” and she produces a prescription bottle with lithium tablets in it. She is otherwise healthy and her pregnancy has been uncomplicated to date. The fundus of her uterus is 22 cm from the pubic symphysis, fetal movement is felt, and fetal heart tones are present at 130/min. Which of the following tests should be advised given the patient’s lithium ingestion?
Fetal echocardiography
Chorionic villus sampling
Fetal renal ultrasound
Maternal oral glucose tolerance test
Measurement of α-fetoprotein, β-human chorionic gonadotropin, and estriol levels
23-year-old primigravid woman at 9 weeks gestation presents to the emergency room because of generalized weakness and lightheadedness. For the past 4 weeks she has not been able to keep anything down and over the past week her nausea and vomiting have worsened. She has no fever, abdominal pain, diarrhea, headache, dysuria, polyuria, tremor, or heat intolerance. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2C (98.9 F); orthostatic vitals are as follows: BP 136/86 mm Hg and pulse 98/min supine, and 11 0/70 mm Hg and 115/min standing. Physical examination shows dry mucus membranes. The remainder of the examination is unremarkable. Laboratory studies show: Hematocrit: 50 %, Platelets: 200,000/mm3, Serum sodium: 130 mEq/L, Serum potassium: 2.8 mEq/L, Chloride: 86 mEq/L, Bicarbonate: 30 mEq/L, Blood urea nitrogen (BUN): 30mg/dl, Serum creatinine: 1.6 mg/dl, Blood glucose: 98 mg/dl. Which of the following is the most appropriate next step in management?
Quantitative beta HCG levels
Right upper quadrant ultrasonogram
Pelvic ultrasonogram
CT scan of the head
Upper GI endoscopy
A 24-year-old primigravid woman comes for her initial prenatal visit at 24 weeks' gestation. Her only complaint is low back pain. She has no significant past medical history, and she has had no complications of pregnancy thus far. She does not use tobacco, alcohol, or drugs. Her vital signs are within normal limits. Complete physical examination shows no abnormalities. During the interview she requests screening for diabetes because her friend was diagnosed with gestational diabetes at 26-weeks of gestation. Which of the following is the most appropriate screening procedure for this patient?
One hour 50gram oral glucose tolerance test
Fasting and random urine sugar
One time fasting blood sugar
75gram oral glucose tolerance test
Three hour 100gram oral glucose tolerance test
A 27-year-old healthy woman comes to the office for evaluation of infertility. She and her 31 -year-old husband have not been able to conceive after 12 months of unprotected and frequent intercourse. Her husband is healthy and takes no medications. He has a normal semen analysis. She has regular 28-day menstrual cycles. The patient has mid-cycle pelvic pain and an egg white like consistency to her discharge mid-cycle. She has no pain during sexual intercourse. The patient does report having been hospitalized with a pelvic infection in her late teens, during which time she had pain with intercourse, discharge, and fever. Her sister was diagnosed with polycystic ovarian disease. Her blood pressure is 128/76 mm Hg and pulse is 82/min. Physical examination shows no abnormalities. Which of the following is most likely to be abnormal in this patient?
Hysterosalpingogram
Serum prolactin level
Serum testosterone level
Mid-luteal phase progesterone
Serum inhibin B level
A 30-year-old obese woman comes to the physician with a six-month history of oligomenorrhea. She has never had this problem before. She has no galactorrhea. She has gained significant weight over the past two years despite a regular exercise program. She has also experienced hair loss during this time. She has had regular Pap smears since the age of 21; none of which have shown any abnormalities. She takes no medications. She does not use tobacco, alcohol, or drugs. Her mother has a history of endometrial carcinoma and her grandmother had a history of ovarian carcinoma. Physical examination shows male pattern baldness. Abdominal and pelvic examination shows no abnormalities. A urine pregnancy test is negative. Serum prolactin level and thyroid function tests are normal. Which of the following is indicated in the initial workup of this patient?
Oral glucose tolerance test
. Screening mammogram
CA-125 levels, annually
Diagnostic laparoscopy
Iron studies
One of your obstetric patients presents to the office at 25 weeks complaining of severe left calf pain and swelling. The area of concern is slightly edematous, but no erythema is apparent. The patient demonstrates a positive Homans sign, and you are concerned that she may have a deep vein thrombosis. Which of the following diagnostic modalities should you order?
Real-time ultrasonography
. MRI
Venography
Computed tomographic scanning
X-ray of lower extremity
On postpartum day 2 after a vaginal delivery, a 32-year-old G2P2 develops acute shortness of breath and chest pain. Her vital signs are blood pressure 120/80 mm Hg, pulse 130 beats per minute, respiratory rate 32 breaths per minute, and temperature 37.6C (99.8F). She has new onset of cough. She appears to be in mild distress. Lung examination reveals clear bases with no rales or rhonchi. The chest pain is reproducible with deep inspiration. Cardiac examination reveals tachycardia with 2/6 systolic ejection murmur. Pulse oximetry reveals an oxygen saturation of 88% on room air and oxygen supplementation is initiated. Which of the following is the best diagnostic tool to confirm the diagnosis?
CT angiography
Arterial blood gas
. Chest x-ray
Lower extremity Dopplers
Ventilation-perfusion scan
A 75-year-old G2P2 presents to your gynecology office for a routine examination. She tells you that she does not have an internist and does not remember the last time she had a physical examination. She says she is very healthy and denies taking any medication, including hormone replacement therapy. She has no history of abnormal Pap smears. She is a nonsmoker and has an occasional cocktail with her dinner. She does not have any complaints. In addition, she denies any family history of cancer. The patient tells you that she is a widow and lives alone in an apartment in town. Her grown children have families of their own and live far away. She states that she is self-sufficient and spends her time visiting friends and volunteering at a local museum. Her blood pressure is 140/70 mm Hg. Her height is 5ft 4 in and she weighs 130 lb. Her physical examination is completely normal. Which of the following are the most appropriate screening tests to order for this patient?
Mammogram, colonoscopy, and bone densitometr
Pap smear and mammogram
Pap smear, mammogram, and colonoscopy
Mammogram, colonoscopy, bone densitometry, and TB skin test
Mammogram, colonoscopy, bone densitometry, TB skin test, and auditory testing
A 65-year-old G3P3 presents to your office for annual checkup. She had her last well-woman examination 20 years before when she had a hysterectomy for fibroids. She denies any medical problems, except some occasional stiffness in her joints early in the morning. She takes a multivitamin daily. Her family history is significant for cardiac disease in both her parents and breast cancer in a maternal aunt at the age of 42 years. Her physical examination is normal. Which of the following is the most appropriate set of laboratory tests to order for this patient?
Lipid profile, fasting blood sugar, TSH, and urinalysis
Lipid profile and fasting blood sugar
Lipid profile, fasting blood sugar, and TSH
Lipid profile, fasting blood sugar, TSH, and CA-125
Lipid profile, fasting blood sugar, TSH, urinalysis, and CA-125
You are following up on the results of routine testing of a 68-year-old G4P3 for her well-woman examination. Her physical examination was normal for a postmenopausal woman. Her Pap smear revealed parabasal cells, her mammogram was normal, lipid profile was normal, and the urinalysis shows hematuria. Which of the following is the most appropriate next step in the management of this patient?
Urine culture
Colposcopy
Endometrial biopsy
. Renal sonogram
No further treatment/evaluation is necessary if the patient is asymptomatic.
A 17-year-old G1P1 presents to your office for her yearly wellwoman examination. She had an uncomplicated vaginal delivery last year. She has been sexually active for the past 4 years and has had six different sexual partners. Her menses occurs every 28 days and lasts for 4 days. She denies any intermenstrual spotting, postcoital bleeding, or vaginal discharge. She denies tobacco, alcohol, or illicit drug use. Which of the following are appropriate screening tests for this patient?
. Pap test and gonorrhea and chlamydia cervical cultures
Pap test
Pap test and herpes simplex cultures
Pap test and hemoglobin level assessment
Pap test and hepatitis C antibody
A 15-year-old woman presents to your office for her first well-woman examination. She has a history of asthma, for which she uses an inhaler as needed. She denies any prior surgeries. Her menses started at the age of 13 and are regular. She has recently become sexually active with her 17-year-old boyfriend. She states that they use condoms for contraception, but she is interested in something more effective. Which of the following is the most appropriate instrument to use when performing the Pap smear test in this patient?
Pederson speculum
Graves speculum
Pediatric speculum
Vaginoscope
Nasal speculum
A 40-year-old G3P2012 presents for her well-woman examination. She has had two vaginal deliveries and her largest baby weighed 4000 g. She had a postpartum bilateral tubal ligation. Her menstrual cycles are regular every 28 days and last 5 days. She states that with cough she may occasionally lose some urine; otherwise she has no complaints. She denies any medical problems. On examination she weighs 56 kg and her blood pressure is 132/81 mmHg. What type of speculum would be most appropriate to use when performing this patient’s Pap test?
Graves speculum
Pederson speculum
Vaginoscope
Hysteroscope
Pediatric speculum
A 50-year-old G4P4 presents for her well-woman examination. She had one cesarean delivery followed by three vaginal deliveries. Her menses stopped 1 year ago and she occasionally still has a hot flash. She tells you that about 10 years ago she was treated with a laser conization for carcinoma in situ of her cervix. Since that time, all of her Pap tests have been normal. What recommendation should you make regarding how frequently she should undergo Pap smear testing?
Every year
Every 3 months
Every 2 years
Every 6 months
Every 3 years
A 45-year-old G3P3 presents for her yearly examination. She last saw a doctor 7 years ago after she had her last child. She had three vaginal deliveries, the last of which was complicated by gestational diabetes and preeclampsia. She has not been sexually active in the past year. She once had an abnormal Pap smear for which she underwent cryotherapy. She denies any medical problems. Her family history is significant for coronary artery disease in her dad and a maternal aunt who developed ovarian cancer at the age of 67. Which of the following is best screening approach for this patient?
Pap smear, mammography, cholesterol profile, and fasting blood sugar
Pap smear, mammography, cholesterol profile, fasting blood sugar, and serum CA-125
Pap smear, mammography, and cholesterol profile
Pap smear and mammography
. Pap smear
A pregnant woman is being followed by a nephrologist for chronic glomerulonephritis. Which of the following findings is normal at 28 weeks’ gestation?
Glomerular filtration rate (GFR) of 130 mL/min
Glycosuria with a plasma glucose of 130 mg/100 mL
Serum creatinine of 1.1 mg/100 mL
Blood urea nitrogen (BUN) of 21 mg/100 mL
Blood pressure of 132/86 mmHg
A 37-year-old pregnant woman with type 2 diabetes mellitus and chronic hypertension is 35 weeks’ pregnant. Which of the following is the best test to screen for fetal well-being?
Fetal biophysical profile
Fetal movement counting
Amniocentesis
Oxytocin challenge test
Nonstress test (NST)
A 28-year-old G2, P 1woman in her 26th week of gestation comes to the office due to intermittent episodes of abdominal pain. She has been having these episodes for the past 4 days, and thinks that her fetus may be in distress. She points to her right flank when asked about the location of the pain, and says that it occasionally radiates to the groin area. She cannot identify any exacerbating or relieving factors. Her pregnancy has been uncomplicated so far. Her past medical history is significant for pelvic inflammatory disease. Her temperature is 37.5 C (99.5 F), blood pressure is 130/80 mm Hg, and pulse is 88/min. She is in considerable pain at the moment. Deep palpation of the right flank reveals tenderness. There is no CVA tenderness. Urinalysis shows: Specific gravity: 1.020, Blood: ++, Glucose: negative, Ketones: negative, Protein: negative, Leukocyte esterase: negative, Nitrites: negative. What is the best next step in the management of this patient?
Ultrasound of the abdomen
CT scan of the abdomen and pelvis
Intravenous pyelogram
Shockwave lithotripsy
Cervical cultures
A 15-year-old girl is being evaluated for primary amenorrhea. Her previous medical history is unremarkable and she denies taking any medications. Examination reveals absent breasts as well as pubic and axillary hair. Vaginal examination could not be performed. Olfactory exam reveals an inability to identify different odors. Ultrasound shows a uterus and two ovaries; serum FSH level is 2 U/L (Normal is 4-30). Which of the following is the most likely karyotype to be found in this patient?
. 46 XX
. 45 XO
. 46 XY
45 YO
47 XXY
A 36-year-old woman comes to your office complaining of a 12-month history of inter-menstrual bleeding and heavy menses. She has had type-2 diabetes for the past 4-years, managed with glipizide and metformin. She has no family history of gynecological malignancies. She does not use tobacco or alcohol. Her temperature is 37.2 C (98.9 F), and blood pressure is 126/76 mm Hg. Her BMI is 30 Kg/m2. Physical examination shows pale mucus membranes. Pelvic examination is within normal limits; no vaginal lesions are noted. Urine pregnancy test is negative. Her hemoglobin is 10.8 g/dl and platelet count is 223,000/mm3. Coagulation studies are within normal limits. Which of the following is the most appropriate next step in management?
Endometrial biopsy
Endometrial ablation
Cyclic progestins
Conjugated estrogens for 3-months
Prescribe combined oral contraceptive pills
A 45-year-old woman presents to her physician's office complaining of night sweats and insomnia. She states that for the past month she has woken up completely soaked with perspiration on several occasions. She has had irregular menstrual periods for the past six months. She consumes one ounce of alcohol nightly before going to the bed, and quit smoking 5 years ago. She has a history of hypertension controlled with hydrochlorothiazide. She denies illicit drug use. Her temperature is 36.7 C (98 F), blood pressure is 140/90 mmHg, pulse is 80/min, and respirations are 14/min. Physical examination shows no abnormalities. Which of the following is the best next step in management?
Measure serum TSH and FSH
Measure 24-hour urinary catecholamines
Reassure her that she is reaching menopause
Obtain a urine toxicology screen
. Prescribe a short course of oral hormone replacement therapy
A 14-year-old girl is being evaluated for short stature. She has not yet had any menstrual periods. She is not sexually active. She is at 6th percentile for height and 20th percentile for weight. Blood pressure is elevated in the upper extremities and low in the lower extremities. Lungs are clear to auscultation. If measured, which of the following is most likely to be present in this patient?
High FSH
High testosterone
High estrogen
Low growth hormone
High inhibin
A 32-year-old multiparous African-American woman comes for her initial prenatal visit at 14 weeks gestation. She complains of the recent appearance of facial hair and acne. The beta-HCG level is consistent with gestational age. Examination shows hirsutism. Ultrasonogram shows an intrauterine gestation consistent with dates and bilateral solid nodular masses in both ovaries. Which of the following is the most appropriate next step in management?
Reassurance and follow-up with ultrasonogram
Diagnostic laparoscopy
Ultrasound guided aspiration of the mass
Exploratory laparotomy
Suction evacuation of uterus
A 16-year-old girl comes to the emergency department because of abdominal pain and vaginal bleeding. She has been sexually active with her boyfriend for the past year; they occasionally use condoms. This is their only means of contraception. Her last menstrual period was eight weeks ago. Previous menses occurred at regular 28-day intervals. She has had two episodes of pelvic inflammatory disease in the past year. Which of the following is the most appropriate next step in management?
Obtain a pregnancy test and an abdominal ultrasonogram
Prescribe antibiotics and see her back in three days
Call her parents to discuss the problem and obtain their consent for treatment
Admit the patient and start high dose estrogen therapy
Obtain a urinalysis and CT scan of the abdomen
A Caucasian couple presents to your office for infertility evaluation. They are unable to conceive after 14 months of unprotected sex. The woman is 23 years of age. Her menstrual periods are regular, occurring every 26 days. She denies perimenstrual pain or pelvic discomfort. Her last menstrual period was six days ago. Her past medical history is insignificant, and bimanual examination is normal. The man is 27 years old. He is not taking any medications. Physical examination, including external genitals, is normal. What is the best next step in the management of this couple?
Semen analysis
Serum progesterone level
Hysterosalpingography
Serum prolactin level of the woman
Laparoscopy
Which feature of fibrocystic disease of the breast is associated with the greatest risk of developing breast cancer?
Presence of epithelial hyperplasia
Presence of a palpable axillary node
Size of the dominant mass
Serous nipple discharge
Number of nodules
A 25-year-old woman, gravida 2 para 1, presents to your office at 20 weeks' gestation for a routine prenatal check-up. She is known to be 0 (-) while her husband is 0 (+). Her obstetric history is significant for intrapartum placental abruption, which did not require caesarian delivery. She received a standard dose of anti-0 immune globulin at 28 weeks of her first pregnancy and immediately postpartum. You decide to determine her anti-0 antibody titers, and they turn out to be 1:34. Which of the following is the most likely explanation of the positive antibody screen in this patient?
Low dose of anti-D immune globulin postpartum
No prophylaxis between the pregnancies
Low dose of anti-D immune globulin at 28 weeks of her first pregnancy
Too early administration of anti-0 immune globulin postpartum
No prophylaxis early in this pregnancy
A 75-year-old woman comes to the physician complaining of vulvar itch that has been worsening for the past 2 years. She has had no bleeding from the vagina since she underwent menopause at the age of 52. She smokes five cigarettes per day. On physical examination she has a raised, pigmented lesion on the right labia majora. The rest of her physical examination is unremarkable. Which of the following is the most appropriate next step in the management of this patient?
Biopsy the lesion
Refer to psychiatry
Prescribe steroid cream
Prescribe an antifungal
Prescribe an antibiotic
A premenopausal, 48-year-old woman undergoes a routine mammographic screening. Physical examination is normal. Mammography identifies a suspicious focus with clustered micro-calcifications located deeply in the lateral upper quadrant of the right breast. No abnormality can be detected in this area on breast examination. Which of the following is the most appropriate next step in diagnosis?
Biopsy guided by mammographic localization
Large needle (core needle) biopsy
Ultrasonography
Fine-needle aspiration cytology
Mammographic reexamination in 1 year
A 35-year-old G3P3 with a Pap smear showing high-grade squamous intraepithelial lesion of the cervix (CIN III) has an inadequate colposcopy. Cone biopsy of the cervix shows squamous cell cancer that has invaded only 1 mm beyond the basement membrane. There are no confluent tongues of tumor, and there is no evidence of lymphatic or vascular invasion. The margins of the cone biopsy specimen are free of disease. How should you classify or stage this patient’s disease?
Microinvasive cancer, stage Ia1
Carcinoma of low malignant potential
. Carcinoma in situ
Atypical squamous cells of undetermined significance
Invasive cancer, stage IIa
An intravenous pyelogram (IVP) shows hydronephrosis in the workup of a patient with cervical cancer otherwise confined to a cervix of normal size. This indicates which one of the following stages?
. III
IIa
Microinvasive stage
. I
. II
A 24-year-old woman presents with new-onset right lower quadrant pain, and you palpate an enlarged, tender right adnexa. Which of the following sonographic characteristics of the cyst in this patient suggests the need for surgical exploration now instead of observation for one menstrual cycle?
Papillary vegetation
Lack of ascites
Unilocularity
Diameter of 5 cm
Demonstration of arterial and venous flow by Doppler imaging
A 20-year-old woman presents complaining of bumps around her vaginal opening. The bumps have been there for several months and are getting bigger. Her boyfriend has the same type of bumps on his penis. On physical examination the patient has multiple 2- to 10-mm lesions around her introitus consistent with condyloma. Her cervix has no gross lesions. A Pap smear is done. One week later, the Pap smear returns showing atypical squamous cells of undetermined significance (ASCUS). Reflex HPV typing showed no high-risk HPV. Which of the following viral types is most likely responsible for the patient’s condyloma?
HPV type 11
HPV type 16
. HPV type 18
HPV type 45
. HPV type 56
A 24-year-old patient recently emigrated from the tropics. Four weeks ago she noted a small vulvar ulceration that spontaneously healed. Now there is painful inguinal adenopathy associated with malaise and fever. You are considering the diagnosis of lymphogranuloma venereum (LGV). The diagnosis can be established by which of the following?
The presence of serum antibodies to Chlamydia trachomatis
Staining for Donovan bodies
Positive Frei skin test
Culturing Haemophilus ducreyi
Culturing Calymmatobacterium granulomatis
A 33-year-old woman, gravida 1, para 0, comes for a routine prenatal visit, for the first time. According to her history, she is at 18-weeks gestation. Her family history is significant for Down syndrome on her maternal side. She does not use tobacco, alcohol or drugs. Vital signs are normal, and physical examination is unremarkable. Initial laboratory studies show a decreased maternal serum alpha-fetoprotein (MSAFP). Which of the following is the most appropriate next step in management?
Ultrasonogram
Amniocentesis
Chorionic villus sampling
Cordocentesis
Urinary estradiol levels
A 15-year-old girl is brought to the physician by her mother because she has not begun menstruating. She is otherwise healthy and has no medical problems. Vitals signs are within normal limits. Physical examination shows absence of breast development and no pubic hair is seen. Examination shows no other abnormalities. Ultrasound confirms the presence of a uterus. Which of the following is the most appropriate next step in management?
Serum FSH level
Estrogen level
MRI of pituitary
Karyotyping
GnRH stimulation test
A 24-year-old woman, G1 P1, comes to your office because she has been amenorrheic for two months. She has been taking low dose combined oral contraceptive pills (OCPs) for the past three months. She had withdrawal bleeding after the first month, but has had no bleeding over the past two months. Over the past few days, she has had nausea, vomiting and abdominal bloating. She does not use alcohol, tobacco, or drugs. Menarche occurred at the age of 14; menses have always been irregular. She is requesting a change in her contraception regimen because of these problems. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?
Measure serum beta-HCG
Measure serum FSH and LH
Advise her to stop taking oral contraceptives temporarily and advise condom use until symptoms resolve
Discontinue OCP and recommend intrauterine contraceptive device
Tell her this is normal with patients who have recently begun taking oral contraceptives, and that her symptoms will resolve eventually
A 28-year-old woman, gravida 3, para 2, at 28 weeks gestation comes to the physician because she has only felt 2-3 fetal movements in the past 12 hours. As in her previous pregnancies, she has gestational diabetes, which is under good control with diet and mild exercise. She does not use tobacco, alcohol or drugs. Vital signs are normal. Physical examination is unremarkable. Fetal heart tones are heard. Which of the following is the next most appropriate step in management?
Non-stress test
Biophysical profile
Contraction stress test
. Ultrasonography
Deliver the baby immediately
A 27-year-old woman, gravida 2, para 1, at 12 weeks gestation comes to the physician because of a dark brown vaginal discharge. She had a mild brown vaginal discharge 3 weeks ago, which resolved without any intervention. She noticed similar discharge again two days ago. For the past two weeks, she has not had nausea or breast tenderness, which she used to have before. She does not use tobacco, alcohol or drugs. Her temperature is 37.0C (98.7F), blood pressure is 110/60 mmHg, pulse is 85/min and respirations are 15/min. Physical examination shows a soft uterus and a closed cervix. Fetal heart tones are not present. Which of the following is the most appropriate next step in management?
Pelvic ultrasonography
Quantitative beta-HCG measurement
Chorionic villous sampling
Check PT/INR and PTT
Reassurance and routine follow-up
A 22-year-old woman comes to the physician for an annual examination. She has normal periods every month and has no complaints. She has no medical problems but does smoke one pack of cigarettes per day. She has intercourse with more than one partner. Examination is unremarkable, including a normal pelvic examination. A Papanicolaou smear shows a high-grade squamous intraepithelial lesion. Which of the following is the most appropriate next step in management?
Perform colposcopy
Repeat Pap smear in 6 months
Perform a cone biopsy
Repeat Pap smear in 1 year
Perform a hysterectomy
A 22-year-old woman presents for her first Pap smear. She has been sexually active with only one boyfriend since age 19. Her physical examination is completely normal. However, 2 weeks later her Pap smear results return showing HGSIL. There were no endocervical cells seen on the smear. Which of the following is the most appropriate next step in the management of this patient?
Perform colposcopy and directed cervical biopsies
Perform random cervical biopsies
Order HPV typing on the initial Pap smear
Repeat the Pap smear to obtain endocervical cells
Perform a cone biopsy of the cervix
A 32-year-old woman consults with you for evaluation of an abnormal Pap smear done by a nurse practitioner at a family planning clinic. The Pap smear shows evidence of a high-grade squamous intraepithelial lesion (HGSIL). You perform colposcopy in the office. Your colposcopic impression is of acetowhite changes suggestive of human papilloma virus infection (HPV). Your biopsies show chronic cervicitis but no evidence of dysplasia. Which of the following is the most appropriate next step in the management of this patient?
Conization of the cervix
Cryotherapy of the cervix
Laser ablation of the cervix
. Hysterectomy
Repeat the Pap smear in 3 to 6 months
A 55-year-old postmenopausal female presents to her gynecologist for a routine examination. She denies any use of hormone replacement therapy and does not report any menopausal symptoms. She denies the occurrence of any abnormal vaginal bleeding. She has no history of any abnormal Pap smears and has been married for 30 years to the same partner. She is currently sexually active with her husband on a regular basis. Two weeks after her examination, her Pap smear comes back as atypical glandular cells of undetermined significance (AGUS). Which of the following is the most appropriate next step in the management of this patient?
Colposcopy, endometrial biopsy, endocervical curettage
. Cone biopsy
HPV testing
Hysterectomy
Repeat the Pap in 4 to 6 months
A 55-year-old G3P3 with a history of fibroids presents to you complaining of irregular vaginal bleeding. Until last month, she had not had a period in over 9 months. She thought she was in menopause, but because she started bleeding again last month she is not sure. Over the past month she has had irregular, spotty vaginal bleeding. The last time she bled was 1 week ago. She also complains of frequent hot flushes and emotional lability. She does not have any medical problems and is not taking any medications. She is a nonsmoker and denies any alcohol or drug use. Her gynecologic history is significant for cryotherapy of the cervix 10 years ago for moderate dysplasia. She has had three cesarean sections and a tubal ligation. On physical examination, her uterus is 12 weeks in size and irregularly shaped. Her ovaries are not palpable. A urine pregnancy test is negative. Which of the following is the most reasonable next step in the evaluation of this patient?
Perform an office endometrial biopsy.
Arrange for outpatient conization of the cervix
Arrange for outpatient endometrial ablation.
Insert a progesterone-containing intrauterine device (IUD).
Schedule her for a hysterectomy.
A 25-year-old nulligravid woman comes to the physician because of chronic pelvic and low sacral back pain for several months. The pain is usually worse premenstrually. She tried over the counter anti-inflammatory medications but had little relief. She has been in a monogamous relationship with her boyfriend for the past 4 years. She has no fever or abnormal vaginal discharge. Her temperature is 37.2 C (98.9 F), and blood pressure is 120/78 mm Hg. Physical examination shows tender posterior vaginal fornix and pain upon uterine motion. Complete blood count is normal. Pelvic ultrasonogram is normal. Urine pregnancy
Laparoscopy
Endometrial biopsy
CA-125 levels
Hysterosalpingogram
CT scan of the pelvis
A 23-year-old G1POfemale presents for her first prenatal visit at 14 weeks gestation. A pap smear is done at that time and a high grade squamous intraepithelial lesions (HSIL) is seen at cytology. A test for HPV discloses the presence of a strain with high oncogenic risk. A satisfactory colposcopy is done and shows no site of abnormalities. At this time the next best step is?
Repeat colposcopy and biopsy after delivery
Endocervical curettage
Loop electrosurgical excision procedure (LEEP)
Termination of pregnancy
Repeat pap smear 12 months
A 26-year-old woman, gravida 3, para 2, comes to the physician for the first time for a prenatal checkup. She changed her physician and in the interim has missed two prenatal checkups. She states that she is at 7months gestation. According to her prenatal records and an ultrasound performed at 16 weeks gestation, she is now at 30 weeks, but her fundal height is only 26 cm (10.2 inches). Fetal heart tones are heard by Doppler. Blood pressure is 140/90 mm Hg. You suspect fetal growth restriction (FGR) and order a repeat ultrasonogram. Which of the following is the single most useful parameter for predicting fetal weight by ultrasonogram in suspected FGR?
Abdominal circumference
Biparietal diameter
Femur length
Head to abdomen circumference ratio
Calculated fetal weight
A 75-year-old woman comes to the physician because of irregular vaginal bleeding. She has been menopausal for the past 25 years, but has noted on-and-off spotting for the past 2 years, which she finds intolerable. She has a complicated past medical history including hypertension, diabetes, and severe chronic obstructive pulmonary disease. Examination is unremarkable. An endometrial biopsy is performed that demonstrates an endometrial polyp with atypical cells that are difficult to grade. Which of the following is the most appropriate next step in management?
Hysteroscopy
. Laparoscopy
Hysterectomy
Oral contraceptive pill
Hormone replacement therapy
A 68-year-old woman comes to the physician because of a painful lump in her vagina. She states that the lump has been there for a few months, but has recently begun to cause her pain. She has hypertension, for which she takes a diuretic, but no other medical problems. Examination shows a 4 cm cystic mass near the patient's introitus by the right labia. The mass is mildly tender. The remainder of the pelvic examination is normal. Which of the following is the most appropriate next step in management?
Biopsy of the mass
Expectant management
Oral antibiotics
Sitz baths
Word catheter placement
28-year-old primigravid woman at 8 weeks' gestation comes to the physician for her first prenatal visit. A home pregnancy test was positive. She has no complaints. She is concerned, however, because she is a carrier of the fragile X mutation. Her husband is also known to be a carrier. This is a highly desired pregnancy. She wants to know whether there is a way to determine whether the fetus is affected. Which of the following is the most appropriate next step in management?
Offer 2nd trimester amniocentesis
Offer termination of the pregnancy
Offer MRI of the fetus
Offer testing of the parents
There is nothing to offer this couple
A 23-year-old woman calls her physician for the results of her Pap test. She has a history of Chlamydia. She has never had an abnormal Pap. She occasionally has unprotected intercourse. The physician informs her that the Pap was normal. The patient is relieved, but wants to know whether this result could be wrong. The physician explains that a Pap test detects abnormal cells in roughly 4 of every 5 women who have abnormal cervical cells. Which of the following represents the sensitivity of the Papanicolaou test?
80%
100%
20%
. 1%
. 0%
A 34-year-old woman, gravida 3, para 2 at term comes to the labor and delivery ward with a gush of blood, abdominal pain, and irregular, painful contractions. Her prenatal course was significant for her being Rh negative and antibody negative. Her temperature is 37 C (98.6 F), pulse is 110/minute, blood pressure is 110/70 mm Hg, and respirations are 12/minute. Abdominal examination shows a tender abdomen and cervical examination shows the cervix to be closed and long with a significant amount of blood in the vagina. The fetal heart rate is in the 170s with moderate to severe variable decelerations with contractions. The diagnosis of placental abruption is made and an emergent cesarean delivery is performed. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send?
Kleihauer-Betke
Apt test
Partial thromboplastin time
Complete blood count
Serum potassium
A 23-year-old primigravid woman comes to the physician because of vaginal bleeding. Her last menstrual period was 6 weeks ago. She has no other symptoms. Examination shows a 10-week sized uterus, but is otherwise unremarkable. Pelvic ultrasound reveals a snowstorm pattern consistent with a complete mole. Serum beta-hCG is markedly elevated over normal pregnant values. A chest x-ray film is negative. A dilation and evacuation is performed and the pathologic diagnosis is complete hydatidiform mole. Which of the following is the most appropriate next step in management?
Follow beta-hCG levels to 0
Evaluation in one year
. Dactinomycin
. Methotrexate
Hysterectomy
An infant is born to a woman who has received very little prenatal care. The mother is anxious, complains of heat intolerance and fatigue, and reports that she has not gained much weight despite having an increased appetite. On examination the mother is tachycardic, has a tremor, and has fullness in her neck and in her eyes. The infant is most likely at risk for development of which of the following?
Heart failure
In her neck and in her eyes. The infant is most likely at risk for development of which of the following? . Constipation
. Macrocephaly
Third-degree heart block
. Thrombocytosis
An otherwise healthy 7-year-old girl is brought to your office by her father because she has some acne, breast development, and fine pubic hair. Which of the following is the most likely etiology for her condition?
Early onset of “normal” puberty (constitutional)
Exogenous estrogens
A lesion of the central nervous system (CNS)
A gonadotropin-producing tumor
A feminizing ovarian tumor
A primiparous woman whose blood type is O positive gives birth at term to an infant who has A-positive blood and a hematocrit of 55%. A total serum bilirubin level obtained at 36 hours of age is 12 mg/dL. Which of the following additional laboratory findings would be characteristic of ABO hemolytic disease in this infant?
. A positive direct Coombs test
A normal reticulocyte count
Crescent-shaped red blood cells in the blood smear
Elevated hemoglobin
Petechiae
A 14-year-old girl presents to clinic for an annual check up. Her parents are concerned that the child is not meeting normal milestones of adolescent growth. The patient reports no recent illnesses. She is up-to-date on her vaccines, and is not having any trouble in school. She denies drug use and is active in sports. On examination, her vital signs are stable. Her lungs are clear and heart is regular in rate and rhythm. Breast and areolar enlargement is noted with no contour separation of the areola. Pubic hair is noted to be dark. The patient also reports that she started menstruating 8 months ago. Which of the following is the most likely Tanner stage of development in this patient?
Stage III
. Stage V
. Stage II
Stage IV
Stage I
A 7-year-old boy presents to the physician's office with a 3-week history of left-sided anterior cervical lymph node enlargement. The enlarged nodes are not tender to palpation. A few papules developed on the left forearm at the onset of lymphadenopathy. The boy has a kitten at home. Which of the following is the most likely organism causing lymphadenopathy in this child?
Bartonella henselae
Actinomyces israelii
Francisella tularensis
Mycobacterium tuberculosis
Staphylococcus aureus
A 10-year-old boy comes to the office with fever and chills for 5 days and myalgia. He has recently returned from a 2-week vacation to New England with his family. On physical examination he has mild splenomegaly. Which of the following is the most likely cause of his symptoms?
Babesiosis
Pneumococcus
Kawasaki disease
Leptospirosis
Psittacosis
A female infant develops cyanosis. She was delivery vaginally at 43 weeks' gestation, and the amniotic fluid had a greenish color. She has dry, peeling skin, emaciated extremities and long fingernails. Tachypnea, nasal flaring, and sub- and intercostal retractions are observed. Auscultation reveals rales and rhonchi. The chest radiograph reveals flattening of the diaphragm, hyperinflation of the lungs, and patchy opacities diffusely distributed over both lung fields. Arterial blood gases reveal hypoxia and hypercarbia. What is most likely impairing the normal respiratory function of this newborn?
Meconium
Fetal lung fluid
Poor alveolar compliance
Paralysis of the diaphragm
Fibrosis of the lungs
A 5-month-old boy is brought in for a routine check-up. He was born at 37 weeks' gestation and has had persistent wheezing since shortly after birth despite inhaled bronchodilator and oral corticosteroid therapy. His diet consists of 32 ounces of iron-fortified cow's milk-based formula daily. On physical examination, the child appears well-nourished and happy. You note moderate relief of his wheezing with neck extension. Which of the following is the most likely mechanism of this infant's wheezing?
Compression of the airway by a vascular ring
Allergic reaction to cow's milk
Chronic upper respiratory tract infection
. Aspiration of a foreign body
Asthma
A mother delivers a neonate with meconium staining and Apgar scores of 3 at 1 and 5 minutes of life. She had no prenatal care and the delivery was by emergency cesarean section for what the obstetricians report as “severe fetal bradycardia.”Which of the following sequelae could be expected to develop in this intubated neonate with respiratory distress?
Sustained rise in pulmonary arterial pressure
Hyperactive bowel sounds
Microcephaly with micrognathia
Cataracts
Thrombocytosis
. A neonate is noted to have an abnormally shaped face with a very small jaw. Several hours after birth, the baby develops convulsions and tetany. Serum chemistries show the following: Sodium 1 40 mEq/L, Potassium 4 mEq/L, Chloride 100 mEq/L, Bicarbonate 24 mEq/L, Magnesium 2 mEq/L, Calcium 5 mg/dL, Glucose 100 mg/dL. This child's disorder is associated with aplasia or hypoplasia of which of the following organs?
Thymus
Thyroid
Ovaries
Pancreas
Pituitary
A 1-year-old boy is brought to the physician by his parents for evaluation of bruising and blood in his stool. The child has had multiple episodes of otitis media and has been hospitalized twice with pneumonia, but has never had bleeding or easy bruising in the past. He has been eating and drinking well with no vomiting or diarrhea. He is afebrile with a heart rate of 150/min and a blood pressure of 80/40 mmHg. On examination, he is well-developed, well-nourished, and has a fair complexion. There are dry, scaly patches on his cheeks and lower extremities. He also has bruising and purpura on his lower extremities. His diaper contains a small amount of occult blood positive stool, but no fissures are seen on rectal examination. The remainder of the physical examination is unremarkable. Laboratory studies show: Complete blood count: Hemoglobin 11 .5 g/dL, Platelet count 20,000/mm3, Leukocyte count 6,500/mm3, Neutrophils 76%, Eosinophils 1%, Lymphocytes 13%, Monocytes 10%. A peripheral smear reveals a low number of platelets, and the platelets that are seen are small. Which of the following is the most likely cause of his bleeding?
Impaired platelet production
Platelet activation and consumption
. Platelet antibodies
Nutritional deficiency
Bone marrow infiltration
 
UntitledA 2-day-old boy in the newborn nursery was born at 39 weeks gestation to a 38-year-old woman by vaginal delivery. The mother received epidural fentanyl for severe painful contractions during labor, but the delivery was uncomplicated. Since birth, the boy has shown little interest in breast or bottle feeding. He spit up the last feed but has not vomited. He has not yet passed meconium. Physical examination shows a newborn with generalized hypotonia, a flat facial profile, low-set folded earlobes, and a single transverse crease on each palm. His abdomen is firm and distended. Digital rectal examination is notable for a tight anal canal and relieves an expulsion of gas and stool. Abdominal x-ray shows markedly distended loops of bowel with no gas in the rectum. What is the mostly likely mechanism for his findings?
Failure of neural crest cell migration during fetal intestinal development
Constipation from decreased levels of thyroxine
Intestinal obstruction from inspissated meconium
.. Intestinal ileus from exposure to maternal epidural analgesia
Invagination of a part of the intestine into itself
Otitis media occurring during the first 8 weeks of life deserves special consideration, because the bacteria responsible for infections during this time may be different from those that affect older infants and children. Which of the following organisms is the most likely to cause otitis media in these infants?
E. coli
Chlamydia trachomatis
Neisseria gonorrhoeae
Treponema pallidum
Toxoplasma gondii
A 3-month-old girl is brought to the pediatrician for a scheduled visit. She has been meeting all development milestones but has been vomiting after each feeding. The infant weighed 3 kg (6 lb 10 oz) at birth and now weighs 6 kg (13 lb 3 oz). She does not have diarrhea and is afebrile. The remainder of the physical examination is unremarkable. Which of the following is the most likely cause of this patient's vomiting?
Overfeeding
Pyloric stenosis
Inborn error of metabolism
Child abuse
Adrenogenital syndrome
A 16-year-old Asian boy presents with a two-day history of fever, malaise, and painful enlargement of his parotid glands. He has no significant past medical history. He was born in India, and has not received any childhood vaccinations. He recently returned from a one-week vacation in India. His vital signs are stable, except for a mild fever. Examination shows bilateral parotid enlargement. The rest of the examination is unremarkable. Which of the following organs is most likely to be affected by this patient's illness?
. Testes
. Pancreas
Liver
Kidney
. Spleen
A pregnant woman has premature rupture of membranes. Her baby is born 3 days later, at 37 weeks' gestation. The 5-minute APGAR score is 4. Lung sounds are reduced, and the infant appears to be in respiratory distress. Peripheral blood smear with differential counts demonstrates a neutrophil count of 30,000/mL, with toxic granules evident in many neutrophils. Gram stain of buffy coat demonstrates small gram-positive cocci in chains. Which of the following is the most likely causative organism?
Group B Streptococcus
Group A Streptococcus
Methicillin-resistant Staphylococcus aureus
Methicillin-sensitive Staphylococcus aureus
Neisseria meningitides
A 14-year-old boy is evaluated for short stature. He has no significant past medical history and is considered otherwise healthy by his parents. He eats a normal diet and has regular meals. His height and weight have been consistently at the 5th percentile since early childhood. His physical examination is normal, with genitalia at Tanner stage 3. Which of the following is the most likely laboratory finding for this boy?
Bone age that is equivalent to chronologic age
Decreased complement C3 level
Decreased thyroid stimulating hormone
Decreased serum albumin concentration
Increased serum creatinine concentration
The recent suicide of a well-known high school cheerleader in your community has generated an enormous amount of community concern and media coverage. A girl who was close friends with the deceased makes an appointment and comes in to your office to discuss the event with you. You ask, and she denies suicidal ideation, but she has many questions about suicide. Correct statements about adolescent suicide include which of the following?
Those who are successful have a history of a prior attempt or prior serious suicidal ideation
Girls tend to use more lethal means
The number of attempted suicides is much higher among boys
Inquiry by pediatricians, high school teachers, parents, or friends about suicidal thoughts typically precipitates the act
The number of suicides in adolescents 10 to 19 years of age has decreased significantly since the 1950s
A 2-month-old male is brought to the emergency department for evaluation of cyanosis, which occurred earlier in the day while the infant was taking his bottle. Initially, he became fussy and sweaty, then his mother noticed that his lips turned blue. He became intermittently tachypneic and continued to cry. As the crying continued, the cyanosis worsened. His temperature is 37C (98.6 F), blood pressure is 80/50 mmHg, pulse is 150/min, and respiratory rate is 45/min. On examination, the child is alert, cyanotic, and tachypneic. Cardiac auscultation reveals a normal S 1 followed by a systolic ejection click. A grade 2/6 crescendo-decrescendo systolic ejection murmur is heard at the left upper sternal border. The patient is immediately placed in a knee-chest position. This maneuver will improve this patient's condition by which of the following mechanisms?
Increased systemic vascular resistance
Decreased pulmonary blood flow
Increased respiratory drive
Increased systemic venous return
Increased right to left shunting
You are called to the ER to see one of your patients. The father of this 14-year-old mildly retarded child says that he found the child about 20 minutes ago in the neighbor’s garden shed with an unknown substance in his mouth. The child first had a headache, but then became agitated and confused; while you are talking to the father in the ER the child begins to have a seizure and dysrhythmia on the cardiac monitor. The blood gas demonstrates a severe metabolic acidosis. Which of the following agents is most likely the culprit?
. Sodium cyanide
Warfarin
Chlorophenothane (DDT)
Paraquat
Organophosphate
A 17-year-old sexually active girl comes to your office complaining of acne that is unresponsive to the usual treatment regimen. Physical examination reveals severe nodulocystic acne of her face, upper chest, and back. You consider prescribing isotretinoin (Accutane), but you are concerned about side effects. Reviewing the literature, you find which of the following to be true about isotretinoin?
Its efficacy can be profound and permanent
It is not known to be a teratogen
. Most patients experience excessive tearing and salivation
Severe arthritis necessitating cessation of the drug occurs in about 15% of patients
Significant decrease in serum triglyceride levels are noted in 25% of patients
The parents of a 1-month-old infant bring him to the emergency center in your local hospital for emesis and listlessness. Both of his parents wanted a natural birth, so he was born at home and has not yet been to see a physician. On examination, you find a dehydrated, listless, and irritable infant. Although you don’t have a birth weight, the parents do not feel that he has gained much weight. He has significant jaundice. His abdominal examination is significant for both hepatomegaly and splenomegaly. Laboratory values include a total bilirubin of 15.8 mg/dL and a direct bilirubin of 5.5 mg/dL. His liver function tests are elevated and his serum glucose is 38 mg/dL. Serum ammonia is normal. A urinalysis is negative for glucose, but it has a “mouse-like” odor. These findings are consistent with which of the following conditions?
Galactosemia
Ornithine transcarbamylase deficiency
Phenylketonuria
. Maple syrup urine disease
. Homocystinuria
After an uneventful labor and delivery, an infant is born at 32 weeks’ gestation weighing 1500 g (3 lb, 5 oz). Respiratory difficulty develops immediately after birth and increases in intensity thereafter. At 6 hours of age, the child’s respiratory rate is 60 breaths per minute. Examination reveals grunting, intercostal retraction, nasal flaring, and marked cyanosis in room air. Auscultation reveals poor air movement. Physiologic abnormalities compatible with these data include which of the following?
Decreased lung compliance, reduced lung volume, right-to-left shunt of blood
Decreased lung compliance, increased lung volume, left-to-right shunt of blood
Normal lung compliance, increased lung volume, right-to-left shunt of blood
Normal lung compliance, reduced lung volume, left-to-right shunt of blood
Decreased lung compliance, reduced lung volume, left-to-right shunt of blood
A 15-year-old girl is seen in your clinic with a sprained ankle, which occurred the previous day while she was exercising in her room. You realize that you have not seen her for quite some time, and begin to expand your examination beyond the ankle. You find relatively minimal swelling on her right ankle. She has dental decay, especially of anterior teeth and a swollen, reddened, irritated uvula. She seems to be somewhat hirsute on her arms and legs, but has thinning of her hair of the head. She has a resting heart rate of 60 beats per minute, and her oral temperature is 35.5°C (96°F). Further questioning suggests that she has developed secondary amenorrhea. Which of the following is the most appropriate next step in the management of this girl?
Comparison of current and past weights
Pregnancy testing
Thyroid function panel
. Radiograph of ankle
Human immunodeficiency virus (HIV) testing
You have been recently named as the medical director of the normal newborn nursery in your community hospital and have been asked to write standardized admission orders for all pediatricians to follow. Which of the following vaccines will you include on these orders?
Hepatitis B vaccine
Hepatitis A vaccine
Combination diphtheria, tetanus, and acellular pertussis vaccine
Inactivated polio virus
Haemophilus influenza B vaccine
A small-for-gestational-age infant is born at 30 weeks’ gestation. At 1 hour of age, his serum glucose is noted to be 20 mg/dL (normally greater than 40 mg/dL). Which of the following is the most likely explanation for hypoglycemia in this infant?
Inadequate stores of nutrients
Adrenal immaturity
Pituitary immaturity
Insulin excess
. Glucagondeficiency
Your sister who lives in another state sends via e-mail photographs of her 6-month-old infant. You note the child has a white reflection from one of his eyes. You hastily assist in arranging an urgent pediatric ophthalmologic evaluation. Your sister immediately accesses the Internet and begins to ask questions of you. Which of the following statements found by your sister is correct?
Cure rates for retinoblastoma treated in the United States exceed 90%
Most cases of retinoblastoma are unilateral and hereditary
Biopsy is usually performed to confirm the diagnosis
Intraocular calcifications are an unusual finding and suggest worse prognosis
. Patients with the hereditary form of retinoblastoma are at significantly increased risk of leukemia in later years
A 2950-g (6.5-lb) black baby boy is born at home at term. On arrival at the hospital, he appears pale, but the physical examination is otherwise normal. Laboratory studies reveal the following: mother’s blood type A, Rh-positive; baby’s blood type O, Rh-positive; hematocrit 38%; and reticulocyte count 5%. Which of the following is the most likely cause of the anemia?
Fetomaternal transfusion
ABO incompatibility
. Sickle-cell anemia
. Physiologic anemia of the newborn
Iron-deficiency anemia
A 1-week-old male newborn is seen in the office for "noisy breathing." The mother says that the "noisy breathing" is more prominent when the infant is lying on his back, and improves when he is in a prone position with his chin up. The newborn is afebrile and has no cough, vomiting, or cyanosis. There are no inspiratory retractions or wheezes. On direct laryngoscopy, the epiglottis is rolled in from side to side. Which of the following statements is true about the child's condition?
The child should be held in an upright position for 30 minutes after feeding and never fed while lying down
The child requires immediate tracheostomy
The child should be treated with intravenous ceftriaxone
The child's condition is likely to deteriorate as the age advances
In this condition the stridor improves when the child cries
A 2-month-old infant comes to the emergency center with fever for 2 days, emesis, a petechial rash, and increasing lethargy. In the ambulance he had a 3-minute generalized tonic/clonic seizure that was aborted with lorazepam. He does not respond when blood is drawn or when an IV is placed, but he continues to ooze blood from the skin puncture sites. On examination, his anterior fontanelle is open and bulging. His CBC shows a WBC of 30,000 cells/μL with 20% band forms. Which of the infant’s problems listed below is a contraindication to lumbar puncture?
. Uncorrected bleeding diathesis
. Bulging fontanelle
Dehydration
History of recent seizure
Significantly elevated WBC count consistent with bacteremia
A 3-day-old infant, born at 32 weeks’ gestation and weighing 1700 g (3 lb, 12 oz), has three episodes of apnea, each lasting 20 to 25 seconds and occurring after a feeding. During these episodes, the heart rate drops from 140 to 100 beats per minute, and the child remains motionless; between episodes, however, the child displays normal activity. Blood sugar is 50 mg/dL and serum calcium is normal. Which of the following is most likely true regarding the child’s apneic periods?
They are due to an immature respiratory center
They are a part of periodic breathing
They are secondary to hypoglycemia
. They are manifestations of seizures
They are evidence of underlying pulmonary disease
A 10-year-old boy presents with a 1-day history of fever, cough, and chest pain. He has not been eating and has been listless. He does not have any previous history of health problems. On physical examination, his temperature is 40°C, and he is tachypneic. He looks ill. He has rales on his left posterior lower lung fields. You order a chest x-ray. Which of the following organisms is most likely responsible for his pneumonia?
 
Untitled
Streptococcus pneumoniae
Staphylococcus aureus
Pneumocystis carinii
Mycoplasma pneumoniae
Haemophilus influenzae
A patient has the sudden onset of fretfulness and pain. He curls up with his legs drawn in to his abdomen. Over the next few hours he continued to have episodes of pain and cries with tears, but between these times he acts normally. The patient's mother fears something is terribly wrong and brings him to the hospital. His past medical history was unremarkable. The previous week he had had a cold with a runny nose. His stools had been normal that day. On examination he is quiet and his abdomen is surprisingly soft and normal. In the emergency room there is a semi-soft stool with some blood mixed with mucus. This classic presentation of intussusception is most likely to occur in which of the following age groups?
6 to 12 months of age
. Birth to 4 weeks of age
. Early adolescence
3 to 5 years of age
Late adolescence
A 10-year-old girl has bullous target lesions and mucosal erythema, which developed after her third dose of trimethoprim-sulfamethoxazole for a urinary tract infection. Which of the following is a likely associated clinical finding?
Fever
Diarrhea
Lymphadenopathy
Vomiting
Nausea
A 16-year-old boy is brought into the emergency department by his friends. He is semicomatose, with a pulse of 60/min and respirations of 6-8/min. His pupils are constricted. Which of the following will most likely be revealed on a urine toxicology screen?
. Opiate intoxication
Tricyclic antidepressant intoxication
. Ethanol intoxication
Cocaine intoxication
Amphetamine intoxication
An 8-month-old female infant is brought to the clinic for a well-baby examination. She was born prematurely at 35 weeks gestation. She weighs 2.3kg (5 Ib). She cannot sit unsupported. Physical examination reveals mild facial hypoplasia, epicanthal folds, micrognathia, long nasal philtrum, thin upper lip and short palpebral fissures. Auscultation of the heart reveals an III/ IV harsh holosystolic murmur over the precordium. Her karyotype is normal. What is the most likely cause of these findings?
Moderate or excessive intake of alcohol during pregnancy
Maternal age
Treatment with lithium for manic disorder
Maternal hyperglycemia
Infection with rubella during pregnancy
A 12-year-old boy is brought to the clinic by his parents because "he cannot walk anymore." Yesterday, he became irritable, uneasy, and complained of tingling and weakness in both his legs. This morning, he couldn't stand up or move his legs, and complained of pain in his leg and thigh muscles. He denies any headaches, nausea or vomiting. He had an episode of febrile diarrhea 10 days ago. His family history is unremarkable. Physical examination reveals symmetric flaccid paralysis of both legs, absent deep tendon reflexes, and decreased superficial touch and vibratory sense. There is no nuchal rigidity. What structure is most likely affected in this patient's condition?
Peripheral nerves
Gracile fasciculus
Medial lemniscus
Corticospinal tract
Cerebral cortex
{"name":"Part 7 (1563 -1596 ) (1530- 1784) Pogba KH2", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"A 35-year-old woman comes to the clinic because of a left breast “thickness.” She noted this 5months ago and it has not receded. She has no family history of breast cancer. There is no drainage. She denies any pain. She has no other medical issues. She takes no birth control pills or any other medication. Examination shows a palpable mass in the left breast at 9 o’clock. A mammogram is nondiagnostic. Which of the following is the appropriate course of action?, A patient in your practice calls you in a panic because her 14-yearold daughter has been bleeding heavily for the past 2 weeks and now feels a bit dizzy and light-headed. The daughter experienced menarche about 6 months ago, and since that time her periods have been irregular and very heavy. You instruct the mother to bring her daughter to the emergency room. When you see the daughter in the emergency room, you note that she appears very pale and fatigued. Her blood pressure and pulse are 110\/60 mm Hg and 70 beats per minute, respectively. When you stand her up, her blood pressure remains stable, but her pulse increases to 100. While in the emergency room, you obtain a more detailed history. She denies any medical problems or prior surgeries and is not taking any medications. She reports that she has never been sexually active. On physical examinations, her abdomen is benign. She will not let you perform a speculum examination, but the bimanual examination is normal. She is 5ft 4in tall and weighs 95 lb. Which of the following blood tests is not indicated in the evaluation of this patient?, A 53-year-old postmenopausal woman, G3P3, presents for evaluation of troublesome urinary leakage 6 weeks in duration. Which of the following is the most appropriate first step in this patient’s evaluation?","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
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