DES C_Management (3) Prepared : CHILLY

A 24-year-old female presents to you for the evaluation of acne. Further questioning, reveals that she also has had irregular periods for a long time. She is single and not sexually active. On examination, her BMI is 31 Kg/m2 and she has evidence of hirsutism. Further evaluation reveals increase in serum free testosterone and LH/FSH ratio of 2.4. Glucose tolerance testing reveals two-hour blood glucose of 155 mg/dl. Apart from prescribing oral contraceptive pills, which of the following is indicated in this patient?

A 24-year-old female veterinary assistant is referred to a psychiatrist for the presumptive diagnosis of dysthymia. She reports having a three-year history of low energy levels and gradual worsening in her ability to focus on her work. She feels "sad, hopeless," and experiences little pleasure. She denies any suicidal thoughts. She has never been on any psychotropic medications before, and denies any family history of psychiatric illness. She has gastroesophageal reflux disease, for which she takes omeprazole. She has no known allergies, and does not drink alcohol or smoke cigarettes. The psychiatrist decides to treat her dysthymia with bupropion. Which of the following is a contraindication to the use of bupropion?

A 24-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He complains of severe back pain and abdominal discomfort. He was placed on a board in the field for spinal immobilization.His blood pressure is 111/78 mm Hg, pulse is 55/min and regular, and respirations are 16/min. Pulse oximetry shows 96% on room air. He is alert and fully oriented. There are several lacerations on the face and anterior chest. Air entry is bilaterally symmetric. There is weakness and decreased pain sensation in both legs. Proprioceptive sensation is preserved. Chest x-ray and CT scans of the abdomen and spine are performed. Which of the following is the most appropriate next step in managing this patient?

A 24-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He has severe low back pain. Examination shows weakness and decreased pain and temperature sensation in both legs. Fine touch, vibration, pressure and proprioceptive sensations are intact. He is immobilized and his airway, breathing and circulation are restored. Which of the following is the most appropriate next step in management of his spinal injury?

A 24-year-old man is found to be HIV positive. He is asymptomatic. Physical examination is unremarkable. Laboratory tests show: CD4 count 400/micro-L, HIV viral load 9,000 copies/mL, VDRL negative, Toxoplasma serology negative, PPD test 6mm induration. His chest x-ray is unremarkable. What is the most appropriate next step in the management of this patient?

A 24-year-old patient comes to the doctor because she has concerns regarding her sexuality. She states that for as long as she can remember she has been sexually attracted to other women. She was raised in a family where homosexuality is considered "unacceptable," so she has never discussed these feelings before. Now, however, she feels that she can no longer hide her feelings, but she is concerned that she will cause deep and irreparable harm to her relationship with her parents if she tells them. Which of the following is the most appropriate next step in the management of this patient?

A 24-year-old primigravid woman at 10 weeks gestation is brought to the emergency department because of vaginal bleeding. She has colicky pain in the suprapubic region radiating to the back. Her temperature is 37.0 C (98.7F), blood pressure is 110/76 mmHg, pulse is 84/min and respirations are 14/min. Physical examination shows a dilated cervix and products of conception are seen through it. Blood for grouping and typing is sent. The patient is treated appropriately, and all products of conception are evacuated. She is stabilized and transferred to the ward. Laboratory studies there show: Hematocrit: 33%; WBC: 6,000/mm3; Blood type: AB; Rh negative; Antibody titer: 1:4. Which of the following is the most appropriate next step in management?

A 24-year-old primigravid woman at 28 weeks gestation comes to the physician because she has not felt her baby's movements for the past two weeks. Fetal heart tones are not heard by Doppler. Ultrasound shows absence of fetal cardiac activity. Fetal demise is diagnosed. Laboratory studies show: Serum fibrinogen level: 160 mg/dl (normal is 150 - 450 mg/dL), Platelets: 150, 000/mm3, Prothrombin time: 14 sec, Partial thromboplastin time: 28 sec, First trimester platelets were: 250,000/mm3. There are no signs of active bleeding. Which of the following is the most appropriate next step in management?

A 24-year-old primigravid woman at 35 weeks gestation comes to the emergency department with uterine contractions. She started these contractions six hours earlier, and they have not increased in intensity since then. The contractions started in the lower abdomen and are irregular. Her pregnancy has been uncomplicated. Her prenatal course, prenatal tests and fetal growth have been normal. She has no history of trauma. She does not use tobacco, alcohol or drugs. Vital signs are normal. Examination shows a firm, posterior and closed cervix. Ultrasonogram in the emergency department shows a gestational age of 35-weeks and the fetus in the vertex presentation. Fetal heart tones are heard. She feels better after mild sedation. Which of the following is the most appropriate next step in management?

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?

A 24-year-old primigravid woman comes to the physician because of recent onset amenorrhea. Her last menstrual period was 7 weeks ago, and she has had nausea for the past 2 weeks. A urine pregnancy test is positive. She is being evaluated for dysphagia, and one-week ago she had a barium swallow examination. She is concerned for the baby because of her recent exposure to radiation. Which of the following is the most appropriate next step in management?

A 24-year-old woman asks her physician about the possibility of genetic screening for BRCA1 mutations. Her mother died of breast carcinoma at age 44, and a sister had a diagnosis of in situ ductal carcinoma at age 38. Which of the following is the most appropriate advice to give this woman?

A 24-year-old woman comes to the physician's office because of breast pain. She has a 2-month-old baby who she breastfeeds. Her temperature is 38.5C (101.9F). Examination shows a hard, red, tender and swollen area on her right breast. There is no fluctuance noted. Which of the following is the most appropriate next step in management?

A 24-year-old woman comes to your office with vaginal spotting 2 weeks after a missed menstrual period. Her past medical history is significant for pelvic inflammatory disease. She has never had surgery. She takes no medications and is allergic to penicillin. Examination demonstrates scant blood in the vaginal vault and minimal right adnexal tenderness. Laboratory evaluation reveals a beta-hCG value of 1600 mIU/mL. Blood type is O positive. Hematocrit is 39%. Pelvic ultrasound demonstrates nothing in the uterus and a right adnexal mass consistent with ectopic pregnancy. The decision is made to proceed with intramuscular methotrexate for medical treatment of the ectopic pregnancy. Which of the following is the most likely side effect from this treatment?

A 24-year-old woman is brought to the emergency department after being stabbed by her boyfriend. The examining physician notes a 1.5 cm puncture wound lateral to her sternum. She has a blood pressure of 70/min palpable, distended neck veins, and muffled heart sounds. Which of the following is the most appropriate next step in management?

A 24-year-old woman presents for her first prenatal visit at 12 weeks gestation. She was diagnosed with HIV two years ago, and her most recent CD4 count three months ago was 600cells/mm3. She does not use tobacco, alcohol, or illicit drugs. Physical examination is within normal limits. Which of the following is the single most important intervention for reducing maternal-fetal transmission of HIV infection?

A 24-year-old woman presents to your office with a self-palpated breast lump. She discovered the mass 2 days ago while taking a shower and noted that it is mildly tender. Her menstrual periods are regular, occurring every 26 days. Her last menstrual period (LMP) was 3 weeks ago. Her past medical history is insignificant. She has no family history of breast cancer. Physical examination reveals a lump in the superior outer quadrant of the right breast without palpable lymphadenopathy. Which of the following is the most reasonable next step in the management of this patient?

A 24-year-old woman presents with lethargy, anorexia, tachypnea, and weakness. Laboratory studies reveal a BUN of 150 mg/dL, serum creatinine of 16 mg/dL, and potassium of 6.2 mEq/L. Chest x-ray shows increased pulmonary vascularity and a dilated heart. Which of the following is the most appropriate management of this patient?

A 24-year-old woman with chronic hypothyroidism presents to her gynecologist for her annual examination. She recently got married, and she and her husband would like to conceive. Her hypothyroidism is well controlled and stable on thyroxine, and she has no other medical conditions. She is healthy and does not smoke or drink alcohol. She would like to know if she should keep taking her thyroxine. Which of the following is the best advice to give this patient?

A 24-year-old woman, gravida 2, para 1, at 16 weeks' gestation comes to you for a routine prenatal visit. She has had mild constipation. She has had no nausea, vomiting, fever, burning urination, back pain, or other complaints. She has no history of urinary tract infections. She takes iron and folic acid supplements. She does not use tobacco, alcohol, or drugs. She is afebrile; her blood pressure is 124/74 mm Hg and pulse is 78/min. Examination shows a uterus consistent in size with a 16-week gestation. Physical examination shows no abnormalities. Urinalysis is within normal limits. A routine clean-catch urine culture grows greater than 100,000 colonies/ml of Escherichia coli. Which of the following is the most appropriate next step in management?

A 24-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the physician complaining of aching and swelling in both legs. The aching of her legs is worst at night. She has no shortness of breath or chest pain. She has no past medical history. Her temperature is 36.9 C (98.2F), blood pressure is 110/70 mm Hg, and pulse is 78/min. Physical examination shows symmetrical pitting edema of both calves with no tenderness of either calf. Urinalysis shows no abnormalities. Which of the following is the most appropriate next step in management?

A 24-year-old woman, gravida 2, para 1, at 34 weeks' gestation comes for a routine prenatal visit. Her dates were confirmed by first trimester ultrasonogram. She has no painful uterine contractions. Her previous pregnancy was uncomplicated and ended with a normal vaginal delivery. Her vitals are stable and fetal heart tones are reassuring. Physical examination shows a closed cervix, vertex is palpable at the fundus, and the presenting part is not engaged. Which of the following is the appropriate next step in management?

A 24-year-old woman, gravida 2, para 2, comes to the physician for a yearly physical and birth control counseling. She is currently using the rhythm method of birth control, but has heard that this method has a high failure rate and would like to try a different method. Several of her friends use the intrauterine device (IUD), and she is wondering whether she could also use this method. Past medical history is significant for eczema. Past surgical history is significant for a right ovarian cystectomy 2 years ago. Past gynecologic history is significant for multiple episodes of Chlamydia cervicitis and two episodes of pelvic inflammatory disease (PID), the most recent episode occurring 1 year ago. She takes acetaminophen for occasional tension headaches. She is allergic to penicillin. She smokes onehalf pack of cigarettes per day. Physical examination is unremarkable. Which of the following would be the best recommendation for this patient regarding her birth control method?

A 24-year-old woman, gravida 3, para 2, comes to the physician for her first prenatal visit. Her last menstrual period was 8 weeks ago, and a home pregnancy test was positive. She states that this pregnancy, like her last two pregnancies, was unintended. She had been using condoms for birth control in all three instances. She had normal vaginal deliveries 2 and 4 years ago. Which of the following is the most likely reason for condom failure?

A 25-year-old Caucasian woman, gravida 1, para 0, at 26 weeks' gestational age presents to her physician's office complaining of spotting from the vagina. She has no contractions and reports normal fetal movement. She denies any history of a bleeding disorder. Her temperature is 37.3 C (99.1 F), blood pressure is 100/60 mm Hg, pulse is 75/min, and respirations are 14/min. Her abdomen is gravid and benign, with a fundal height of 26 cm. A placenta previa is ruled out by ultrasound examination. Pelvic examination reveals some scant blood in the vagina, a closed os, and no uterine tenderness. Leukocyte count is 12,000/mm3, hematocrit is 33%, and platelet count is 140,000/mm3. Her blood type is A, Rh negative. Which of the following is the most appropriate pharmacotherapy?

A 25-year-old female comes to the physician because of abdominal bloating, headache, fatigue, weight gain, anxiety, and decreased libido. She experiences these symptoms seven to ten days before the start of each menstrual cycle. She has a past history of postpartum depression, but she denies any recent feelings of hopelessness or guilt. Physical examination shows no abnormalities. Complete blood count, serum chemistries and thyroid stimulating hormone levels are within normal limits. Which of the following is the most appropriate next step in management?

A 25-year-old G2 P1 woman at 12 weeks gestation comes to the physician because of foul smelling vaginal discharge. She is sexually active and reports no previous problems. Speculum examination reveals a grayish, foul smelling discharge, but no erythema or edema is noted on the vaginal walls or the vulva. There is no cervical or adnexal tenderness. A saline wet mount examination reveals numerous epithelial cells coated with bacteria. No white blood cells are seen. Which of the following is the most appropriate pharmacotherapy for this patient?

A 25-year-old G2P0 at 30 weeks gestation presents with the complaint of a new rash and itching on her abdomen over the last few weeks. She denies any constitutional symptoms or any new lotions, soaps, or detergents. On examination she is afebrile with a small, papular rash on her trunk and forearms. Excoriations from scratching are also noted. Which of the following is the recommended first-line treatment for this patient?

A 25-year-old G3P2 at 39 weeks is admitted in labor at 5 cm dilated. The fetal heart rate tracing is reactive. Two hours later, she is reexamined and her cervix is unchanged at 5 cm dilated. An IUPC is placed and the patient is noted to have 280 Montevideo units (MUV) by the IUPC. After an additional 2 hours of labor, the patient is noted to still be 5 cm dilated. The fetal heart rate tracing remains reactive. Which of the following is the best next step in the management of this labor?

A 25-year-old male comes to the clinic because of a painless ulcer on his penis. He denies fever or urethral discharge, but admits to recent sexual activity with a prostitute. He describes severe rash and face swelling with penicillin. Physical examination reveals a shallow, non-tender ulcer. There is no lymphadenopathy. Darkfield microscopy reveals spirochetes. Which of the following is the most appropriate treatment for this patient?

A 25-year-old man comes to the physician because of a mass in his mouth. He has just noticed this mass and has had no trauma to his oral cavity. He does not use tobacco, alcohol or drugs. He has had no weight loss. Physical examination shows a large mass located on the hard palate of the mouth. On palpation, the mass is immobile, fleshy with bony surroundings and measures 3x 3 cm. Which of the following is the most appropriate next step in management?

A 25-year-old man is brought to the emergency room after sustaining burns during a fire in his apartment. He has blistering and erythema of his face, left upper extremity, and chest. He also has circumferential frank charring of his right upper extremity with decreased capillary refill. He is agitated, hypotensive, and tachycardic. Which of the following is the most appropriate initial management of his wounds?

A 25-year-old man is found on a pre-employment chest x-ray film to have a 3-cm peripheral coin lesion. The patient has never smoked, and a chest x-ray film that he had 2 years ago when he enrolled in graduate school had been normal. Prompted by this finding, he undergoes a more thorough physical examination, which discloses the presence of a firm, 2-cm testicular mass of which he was not previously aware. There are also palpable inguinal nodes on the same side. Which of the following is the most appropriate next step in management?

A 25-year-old man is involved in a gang shoot-out and sustains an abdominal gunshot wound from a .22 pistol. At laparotomy, it is discovered that the left transverse colon has incurred a through-and-through injury with minimal fecal soilage of the peritoneum. Which of the following is the most appropriate management of this patient?

A 25-year-old man is shot with a .22 caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, and the exit wound is about 3 inches lower, in the posterolateral aspect of the thigh. He has a large, expanding hematoma in the upper inner thigh. There are no palpable pulses in the foot. The bone is intact by physical examination and x-ray films. Which of the following is the most appropriate next step in management?

A 25-year-old man is shot with a .22-caliber revolver. The entrance wound is in the anterior, lateral aspect of his thigh, and the bullet is seen on x-ray films to be embedded in the muscles posterolateral to the femur. The emergency department physician cleans the wound thoroughly. Which of the following is the most appropriate next step in management?

A 25-year-old man is stabbed in the right chest. He comes in fully awake and alert, and, in a normal tone of voice, he states that he feels short of breath. His vital signs are normal and stable. On physical examination, he has no breath sounds at the right base, and only faint breath sounds at the apex. He is dull to percussion over the right base. A chest x-ray film confirms that he has a hemothorax on that side. Which of the following is the most appropriate next step in management?

A 25-year-old man is stabbed once in the right chest. The entrance wound is on the midaxillary line, at the level of the fifth intercostal space. He arrives at the emergency department moderately short of breath, but he is fully awake and alert, is talking with a normal tone of voice, and has no distended veins visible in his neck or forehead. His blood pressure is 130/75 mm Hg, and his pulse is 82/min. Physical examination of the chest shows the wound, which is not visibly "sucking air," and demonstrates no breath sounds at all on the right side, which is tympanitic to percussion. There is no evidence of mediastinal displacement. Which of the following would be the most appropriate next step in management?

A 25-year-old man presents to the physician's office because of a clenched fist injury ("fight bite") incurred during a gang fight. The injury occurred two days ago and he has now started to develop pain, swelling, and redness around the wound. His immunizations are up to date. His wounds are cleaned in the clinic. Plain films of hand do not show evidence of foreign body or osteomyelitis. Which of the following is the most appropriate antibiotic for his current condition?

A 25-year-old man presents with a painless, hard, 3-cm testicular mass that he discovered serendipitously while taking a shower. Physical examination confirms that the mass arises from the testicle itself, is not part of the epididymis, and is solid rather than a fluid collection. The rest of the physical examination is unremarkable. Which of the following would be the most appropriate next step?

A 25-year-old nulliparous woman at 35 weeks' gestation comes to the labor and delivery ward complaining of contractions, a headache, and flashes of light in front of her eyes. Her pregnancy has been uncomplicated except for an episode of first trimester bleeding that completely resolved. She has no medical problems. Her temperature is 37 C (98.6 F), blood pressure is 160/110 mm Hg, pulse is 88/minute, and respirations are 12/minute. Examination shows that her cervix is 2 centimeters dilated and 75% effaced, and that she is contracting every 2 minutes. The fetal heart tracing is in the 140s and reactive. Urinalysis shows 3+ proteinuria. Laboratory values are as follows: leukocytes 9,400/mm3, hematocrit 35%, platelets 101,000/mm3. Aspartate aminotransferase (AST) is 200 U/L, and ALT 300 U/L. Which of the following is the most appropriate next step in management?

A 25-year-old primigravid woman at 37 weeks gestation is brought to the emergency department because of severe uterine contractions and moderate vaginal bleeding. She has been followed for pre-eclampsia since her 32nd week of gestation. She is currently having intermittent bleeding. Ultrasonogram in the emergency department shows placental abruption and an intrauterine gestation consistent with dates. Placenta previa is ruled out. Her temperature is 37.0 C (98.7 F), blood pressure is 90/60 mmHg, pulse is 99/min and respirations are 20/min. Physical examination shows uterine tenderness and hyperactivity, increased uterine tone and vaginal bleeding. Her cervix is 1cm dilated and 10% effaced at the time of admission. Fetal heart tracing shows a rate of 110/min, a long-term variability of 4 cycles/min and a beat-to-beat variability of 20/min. Which of the following is the most appropriate next step in management?

A 25-year-old primigravid woman comes to the physician for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had some nausea and vomiting but otherwise has no complaints. Past medical and surgical history are unremarkable. Her family history is significant for cystic fibrosis with an affected aunt. Her husband has an affected cousin. Physical examination is unremarkable. Given her family history, she is concerned about the risks of having a child with cystic fibrosis. She inquires about cystic fibrosis screening. Which of the following is the appropriate response?

A 25-year-old unhelmeted man involved in a motorcycle collision has multiple cerebral contusions on head computed tomographic (CT) scan. He is agitated but hemodynamically stable, with a heart rate of 80 beats per minute and a mean arterial pressure (MAP) of 90 mm Hg. An intracranial pressure monitor is placed, and the initial ICP reading is 30 mm Hg. Which of the following is the most appropriate in the management of his traumatic brain injury (TBI) over the next few days?

A 25-year-old woman at 28 weeks gestation comes to the ER because of strong, regular and painful uterine contractions that started 4 hours earlier with the passage of clear fluid from her vagina. She denies any vaginal bleeding. She has had no prenatal care. Vital signs are normal. A sterile speculum examination shows pooling of amniotic fluid within the vagina, and a cervix that is 4cm dilated and 80% effaced. Ultrasonogram in the emergency department shows an amniotic fluid index of 4 and bilateral renal agenesis in the fetus. Which of the following is the most appropriate next step in management?

A 25-year-old woman comes to the physician for an annual examination. She has been feeling well over the past year. Her past medical and surgical histories are unremarkable. Past obstetrical history is significant for the term vaginal delivery two years ago of a male infant with spina bifida. Examination is within normal limits. The patient states that she would like to try to become pregnant within the next few months and wants to know if she needs to start taking any vitamins or medications. Which of the following supplements should this patient take?

A 25-year-old woman complains of dysuria, frequency, and suprapubic pain. She has not had previous symptoms of dysuria and is not on antibiotics. She is sexually active and on birth control pills. She has no fever, vaginal discharge or history of herpes infection. She denies back pain, nausea, or vomiting. On physical examination she appears well and has no costovertebral angle tenderness. A urinalysis shows 20 white blood cells per high power field. Which of the following statements is correct?

A 25-year-old woman delivered a baby boy at 38 weeks gestation. The newborn has a small body size with microcephaly, hypoplasia of the distal phalanges of the fingers and toes, excess hair and a cleft palate. He weighs 2.5kg (5.51b). Further history or evaluation of the mother would most likely reveal which of the following?

A 25-year-old woman has a positive cervical culture for Neisseria gonorrhoeae. She has had at least two positive cultures for gonorrhea treated in the past. She is afebrile and has no symptoms. The incidence of penicillin-resistant gonorrhea in some areas of the United States is currently as great as 10%. Because of this, the recommended treatment for gonorrhea includes which of the following?

A 25-year-old woman is referred to the physician for lactation suppression after the death of her 1-month-old infant from severe sepsis. She is very depressed and complains of breast fullness and tenderness. Examination shows both breasts are warm, firm and tender to palpation. Prenatal records show no abnormalities except mild varicosities. Which of the following is the most appropriate next step in management?

A 25-year-old woman with no PMH, no PSH, and no allergies presents for unilateral nipple discharge. The patient states that it started about 3 weeks ago, appears whitish, and is unilateral. She does not think she felt any changes in her breast. She denies relation to her menstruation and uses condoms for contraception. She has never been pregnant and her last menstrual period (LMP) was 2 weeks ago. BP, 120/78 mm Hg; P, 85 beats/min; R, 15 breaths/min. Review of systems: Denies fever, chills, and weight loss, Denies chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea, and constipation. Physical examination: Gen: Awake, alert, oriented x3, no acute distress, CVS: S1S2+RRRno m/r/g, Lungs: Clear to auscultation bilaterally, Abdomen: Soft, nontender, nondistended, + bowel sounds, Ext: No edema bilaterally, Breasts: Symmetric, no masses palpated, clear/whitish fluid expressed on manipulation of left breast. What is the next step in the management of this patient?

A 25-year-old woman, gravida 2, para 1, at 22 weeks' gestation comes to the physician with complaints of burning with urination and frequent urination. Her prenatal course has been uncomplicated except for a urinary tract infection (UTI) with E. Coli at 12 weeks' gestation, which was treated at that time. Physical examination is unremarkable. Urine culture demonstrates greater than 100,000 colony-forming units per milliliter of E. coli. After treating this patient for her current infection, which of the following is the most appropriate next step in management?

A 25-year-old, G3P0 white female in her 8th week of gestation comes to the antenatal clinic. Her obstetric history is significant for two second trimester abortions. She is currently taking folic acid and iron supplementation. She does not smoke, but she drinks alcohol on social occasions. She is in a monogamous relationship with her husband. She has never been diagnosed with or treated for any STDs. Laboratory studies reveal the following: VDRL positive, FTA-ABS negative, Hct 33%, WBC 7,000/mico-L, Platelets 70,000/micro-L, PT 10 sec, APTT 40 sec. What is the most appropriate next step in the management of this patient?

A 26-year-old G1 P1 woman requests contraception after delivering a healthy baby three weeks ago. She is breastfeeding the child and plans to continue for at least six months. She does not want to get pregnant for at least one year. She has no medical problems and does not take any medication. She does not use tobacco, alcohol or drugs. Physical examination shows no abnormalities. Which of the following is the most preferred method of contraception you can advise for this patient?

A 26-year-old G1P1 woman requests contraception after delivering a healthy baby three weeks ago. She does not want to get pregnant for at least one year. She has no medical problems and does not take any medication. She does not use tobacco, alcohol or drugs. Physical examination shows no abnormalities. Which of the following is the most preferred method of contraception you can advise for this patient?

A 26-year-old graduate student presents at her husband's urging, complaining of severe pain during sexual intercourse. She says that she was a virgin when she married her husband two years ago, and that she has been experiencing severe "genital pain" during sex since then. As a result, she avoids sexual intimacy with her husband, which is placing a strain upon their marriage. She also complains of intense pain with her menses and when passing stool. She admits to sporadic pelvic pain that waxes and wanes with no discernible trigger. What would be the most appropriate treatment given this woman's condition?

A 26-year-old man presents to the physician's office with a two-day history of multiple symptoms, including rash on his trunk, headache, fatigue, malaise, myalgias, and high-grade fever. The rash is not associated with pain, itching, or burning. It has expanded over the last two days. He went on a camping trip in Vermont two weeks ago, and recalls a tick bite at that time. There is a single lesion on his trunk, which is erythematous with central clearing. The rest of the examination is unremarkable. What is the most appropriate next step in the management of this patient?

A 26-year-old primigravid woman at 10-weeks' gestation comes to the physician for a routine prenatal appointment Her dating is based on a 6-week ultrasound. She has sickle-cell anemia. She has no past surgical history, takes prenatal vitamins, and has no known drug allergies. She tells the physician that she recently learned that the father of the baby has sickle-cell trait. On examination, her uterus is appropriate for a 10-week gestation, and fetal heart tones are heard. Her hematocrit is 37%. What is the most appropriate next step in the management of this patient?

A 26-year-old primigravid woman at 12 weeks' gestation comes to the physician because of pain and swelling in her right thigh. She first noted the onset of the pain 2 days ago, and since then it has grown worse. An ultrasound study performed on her lower-extremity venous system reveals evidence of a proximal thrombus in the right leg. She is started on low-molecular-weight heparin injections. Which of the following is an advantage of low molecular-weight heparin compared with unfractionated heparin?

A 26-year-old primigravid woman at 35 weeks' gestation comes to the labor and delivery ward because of painful uterine contractions and a gush of fluid. Sterile speculum examination reveals a pool of clear fluid in the vagina that is nitrazine positive. When the fluid is examined under the microscope, a "ferning" pattern is seen. Cervical examination shows the patient to be 4 cm dilated, 100% effaced, and at 0 station. Fetal fingers can be felt along side the fetal head. External uterine monitoring shows contractions every 2 minutes. External fetal monitoring shows the fetal heart rate to be in the 130s and reactive. Which of the following is the most appropriate next step in management?

A 26-year-old primigravida at 20th week gestation presents to the emergency room with a sudden onset of tearing chest pain radiating to her back and left arm. The patient is pale and diaphoretic. Her PR: 116/min; BP: 192/ 104 mmHg in left arm, and 123/65 mmHg in right arm; RR: 36/min. Her cardiac examination reveals a diastolic murmur along the left sternal border. Her previous prenatal care is not known. She is a smoker with a 10 pack/year history and drinks alcohol. Her ECG reveals mild left axis deviation and ST segment depression in lead II, III, and AVF. What is the most appropriate next step in the management of this patient?

A 26-year-old woman comes to the physician because of a lump in her vagina. The lump is nontender but is uncomfortable when she walks. She states that for the last 6 years this lump has appeared about once a year. When it occurs she goes to the doctor who puts a catheter into it, which is taken out in a few weeks. She has no other medical problems. She is sexually active with two partners. Examination shows a cystic mass approximately 4 cm in diameter on the right side of the vagina near the hymeneal ring. The mass feels like a discrete cyst. The rest of the pelvic examination is unremarkable. Which of the following is the most appropriate next step in management?

A 26-year-old woman comes to the physician for a routine annual visit. She has no complaints. She has no significant previous medical problems. She has been sexually active since the age of 19 with the same partner. They married 4 years ago. She has never had any sexually transmitted diseases. She had her last Pap smear 4 years ago and was within normal limits. She does not use tobacco, alcohol or illicit drugs. Pelvic examination shows no abnormalities. A repeat Pap smear now shows atypical squamous cells of undetermined significance (ASC-US). Which of the following is the most appropriate next step in management?

A 26-year-old woman presents to your office for her well-woman examination. She denies any medical problems or prior surgeries. She states that her cycles are monthly. She is sexually active and uses oral contraceptive pills for birth control. Her physical examination is normal. As part of preventive health maintenance, you recommend breast self-examination and instruct the patient how to do it. Which of the following is the best frequency and time to perform breast self-examinations?

A 26-year-old woman, gravida 2, para 1 at 28 weeks' gestation, comes to the physician for a follow-up ultrasound after a previous ultrasound demonstrated a marginal placenta previa. The present ultrasound shows complete resolution of the marginal previa, but the fetus is noted to be in breech presentation. The patient has otherwise had an unremarkable prenatal course. She has no medical problems and has never had surgery. She takes prenatal vitamins and is allergic to sulfa drugs. Assuming that the fetus stays in breech presentation, when should an external cephalic version be attempted?

A 26-year-old woman, gravida 2, para 2, complains of loss of small amounts of urine immediately after a spontaneous vaginal delivery. She received epidural anesthesia during labor and delivery because of severe pain. She has no fever, dysuria, urgency, or hematuria. She has no other medical problems, takes no medication except prenatal vitamins, and has no known drug allergies. Her vital signs are normal. Examination shows a soft, non-tender abdomen. Pelvic examination is normal. The patient voids 30-40ml of urine each time; her postvoid residual volume is 400 ml. The patient's labs reveal: Urine: Specific gravity: 1.020, Blood: trace, glucose: negative, Leukocytes esterase: negative, Nitrite: negative, WBC: 1-2/hpf, RBC: 3-4hpf. Which of the following is the most appropriate treatment for her incontinence?

A 26-year-old, drug-addicted man develops congestive heart failure over a period of a few days. He is febrile, has a loud, diastolic murmur at the right second intercostal space, and has a blood pressure of 120/20 mmHg. A physical examination performed a few weeks ago, when he attempted to enroll in a detoxification program, was completely normal. His blood pressure at that time was 120/80 mm Hg, and no murmurs were noted. In addition to long-term antibiotic therapy, which of the following is the most appropriate next step in management?

A 27-year-old African American woman presents with several months of prolonged menstrual bleeding and increased volume of menstrual flow. She also has a sensation of heaviness in her abdomen. She denies abdominal pain, nausea, vomiting, diarrhea, and constipation. She fatigues easily. Vital sign: Physical examination: Gen: Awake, alert, oriented x3, no acute distress, CVS: Regular rate and rhythm, no murmurs, rubs, or gallops, Lungs: Clear to auscultation bilaterally, Abd: Soft, nontender, nondistended, + bowel sounds, Pelvis: Cervix appears normal, no cervical motion tenderness, no adnexal masses felt. What is the term for what this patient is experiencing?

A 27-year-old Caucasian female with multiple sclerosis (MS) comes to the office for a follow-up visit. Six months ago, she experienced monocular vision impairment and clumsiness of the right hand, and both symptoms resolved completely. Three weeks ago, she experienced incoordination, weakness and spasticity in the right extremities. She was admitted in the hospital for treatment of an acute MS flare, and rapidly improved thereafter. Physical examination currently demonstrates slight weakness of the right leg with a hyperactive knee jerk. Which of the following medications may slow the long-term progression of this patient's disease?

A 27-year-old female comes to the physician's office for evaluation of infertility. She has not been able to conceive for 12 months despite frequent intercourse. Her menses started at age 12 and have always been irregular. She uses over the counter acne medications. She is also obese and has been unsuccessful with weight loss. Physical examination shows an obese woman with sparse hair over the upper lip. There is no galactorrhea, thyromegaly or clitoromegaly. Which of the following is the most appropriate therapy for this patient's infertility?

A 27-year-old female presents to your office for a follow-up. The previous two visits revealed an elevated blood pressure in the range of 150- 155/90-95 mmHg. She has no present complaints. Her past medical history is insignificant. She smokes 1/2 pack of cigarettes per day and does not consume alcohol. Her current medications include a combination oral contraceptive for the last 2 years, and an occasional acetaminophen for tension headache relief. There is no family history of hypertension or heart attacks. This visit, her blood pressure is 155/95 and her heart rate is 80/min. The physical examination is unremarkable. The ECG is normal. Her total cholesterol level, measured 6 months ago, was 170 mg/dL. Which of the following is the most appropriate next step in the management of this patient?

A 27-year-old G2P1 at 38 weeks gestation was admitted in active labor at 4 cm dilated; spontaneous rupture of membranes occurred prior to admission. She has had one prior uncomplicated vaginal delivery and denies any medical problems or past surgery. She reports an allergy to sulfa drugs. Currently, her vital signs are normal and the fetal heart rate tracing is reactive. Her prenatal record indicates that her Group B streptococcus (GBS) culture at 36 weeks was positive. What is the recommended antibiotic for prophylaxis during labor?

A 27-year-old G3P2002, who is 34 weeks gestational age, calls the oncall obstetrician on a Saturday night at 10:00 PM complaining of decreased fetal movement. She says that yesterday her baby has moved only once per hour. For the past 6 hours she has felt no movement. She is healthy, has had regular prenatal care, and denies any complications so far during the pregnancy. Which of the following is the best advice for the on-call physician to give the patient?

A 27-year-old G1 woman is 20 weeks pregnant. She is currently in her third year of a family practice residency and would like to travel to Africa and Asia as part of an outreach mission with her program. She has received all of her childhood immunizations. She presents to the obstetric clinic inquiring about the safety of immunizations during pregnancy. Which of the following vaccines is contraindicated in pregnancy?