DES 2016-2017 : 2040-2299 (Fabien) 7

85) A 4-year-old boy is seen 1 hour after ingestion of a lye drain cleaner. No oropharyngeal burns are noted. The CXR is normal, but the patient continues to complain of significant chest pain. Which of the following is the most appropriate next step in his management?

86) A 71-year-old West Texas farmer of Irish ancestry has a nonhealing, indolent, punched out, clean-looking 2-cm ulcer over the left temple. The ulcer has been slowly growing over the past 3 years. There are no enlarged lymph nodes in the head and neck. Which of the following would best dictate proper management?

87) Ten days after undergoing liver transplantation, a patient's levels of gamma-glutamyl transferase (GGT), alkaline phosphatase, and bilirubin begin to rise. Which of the following is the most appropriate next step in diagnosis?

88) A 62-year-old man reports an episode of gross, painless hematuria. There is no history of trauma, and further questioning determines that he had total hematuria, rather than initial or terminal hematuria. The man does not smoke and has had no other symptoms referable to the urinary tract. He has no known allergies. Physical examination, including rectal examination, is unremarkable. His serum creatinine is 0.8 mg/dL, and, except for the presence of many red cells, his urinalysis is normal and shows no red cell casts. His hematocrit is 46%. Which of the following is the most appropriate initial step in the workup?

89) A 54-year-old obese man gives a history of burning retrosternal pain and heartburn that is brought about by bending over, wearing a tight belt, or lying flat in bed at night. He gets symptomatic relief from over-the-counter antiacids or H2 blockers, but has never been formally studied or treated. The problem has been present for many years and seems to be progressing. Which of the following is the most appropriate next step in management?

90) A pedestrian is hit by a car and knocked unconscious. Within a few minutes, he starts to move around and moan. When the ambulance arrives, he is moving all four extremities and mumbling that his neck hurts. Shortly thereafter, he lapses again into a deep coma. In the emergency department, it is noted that his left pupil is fixed and dilated, and he has clear fluid dripping from the left ear. The trauma team intubates him nasally over a fiberoptic bronchoscope and does a quick initial survey that reveals no other obvious injuries. He is hemodynamically stable. Which of the following is the most appropriate next step in management?

91) A 68-year-old woman presents with an obviously incarcerated umbilical hernia. She has gross abdominal distention, is clinically dehydrated, and reports persistent fecaloid vomiting for the past 3 days. Although tired, weak, and thirsty, she is awake and alert and her sensorium is not particularly affected. Laboratory analysis reveals a serum sodium concentration of 118mEq/L. Which of the following is the most likely physiologic explanation for the serum sodium?

92) The unrestrained front-seat passenger in a car that crashes at high speed is brought to the emergency department by paramedics. At the site of injury, the patient was unconscious and had gurgly respiratory sounds, and the EMTs successfully accomplished blind nasotracheal intubation. The initial survey in the emergency department shows normal vital signs, multiple facial lacerations, and an unresponsive, comatose patient with fixed dilated pupils. Preparations are made to do a CT scan of the head. It is imperative that which of the following should be obtained as well?

93) A 59-year-old man is referred for evaluation because he has been fainting at his job, where he operates heavy machinery. He is pale and gaunt, but otherwise his physical examination is remarkable only for 4+ occult bloods in the stool. Laboratory studies show haemoglobin of 5gm/dL with microcytosis, as well as decreased levels of serum iron and increased iron binding capacity. Which of the following will most likely establish the diagnosis?

94) A 42-year-old woman hit her breast with a broom handle while doing housework. She noticed a lump in that area at the time, and 1 week later the lump was still present. She then sought medical advice. On physical examination, she has a 3-cm, hard mass deep inside the affected breast and some superficial ecchymosis over the area. Which of the following is the most appropriate next step, or steps, in management?

95) On the 7th postoperative day after the pinning of a broken hip, a 76-year-old man suddenly develops severe pleuritic chest pain and shortness of breath. When examined, he is found to be anxious, diaphoretic, and tachycardic, with a blood pressure of 140/85 mm Hg. He has prominent distended veins in his neck and forehead. Blood gases show hypoxemia and hypocapnia. His chest x-ray film is unremarkable. The nurses have placed him on supplemental oxygen by face mask. Which of the following is the most appropriate next step in management?

96) A 44-year-old woman complains bitterly of severe headache that has been present for several weeks and has not responded to the usual over-the-counter headache remedies. She locates the headache to the center of her head. It is pretty much constant but is worse in the mornings. She has no other neurologic signs or symptoms. She has had "tension headaches" in the past, but she says that those were located in the back of her head and felt different from the present pain. She is currently under considerable stress because she has been unemployed since undergoing modified radical mastectomy for T3, N1, M0 breast cancer 2 years ago. She had several courses of post-operative chemotherapy, which she eventually discontinued because of the side effects. Which of the following is the most appropriate next step in diagnosis?

97) A 59-year-old black man has a rock-hard, discrete, 1.5-cm nodule that is felt in his prostate during a routine physical examination. He is completely asymptomatic, and his prostatic specific antigen (PSA) done 3 months ago was normal for his age. His last rectal examination was performed a year earlier and was unremarkable. Which of the following will best establish the diagnosis?

98) A 34-year-old immigrant from Mexico presents following an episode of massive hemoptysis. He describes bringing up large amounts of bright red, foamy sputum. He denies any recent trauma. On physical examination, the patient is agitated and has difficulty speaking. His blood pressure is 100/60 mmHg and his heart rate is 110/min. On physical examination, breath sounds are audible bilaterally. You immediately initiate intravenous infusion of crystalloid. Portable chest x-ray shows opacity in the right upper lobe. Which of the following is the best next step in the management of this patient?

99) A 53-year-old male presents to the emergency room complaining of chest pain localized to the left chest wall and following a linear pattern along the fifth intercostal space. His past medical history is significant for polycystic kidney disease and hypertension. His current medications are metoprolol and amlodipine. He has a ten pack-year smoking history but quit 14 years ago. He consumes alcohol occasionally. His blood pressure is 160/90 mmHg and his heart rate is 90/min. Physical examination is noncontributory. His laboratory findings are as follows: Sodium 142 mEq/L, Potassium 4.2 mEq/L, Hemoglobin 9.5 mg/dl, WBC 10,000/mm3, Creatinine 1 .9 mg/dl, BUN 28 mg/dl. Chest x-ray reveals a solitary round lesion in the left upper lung field that measures 2 cm in diameter. It does not about the pleura. Which of the following is the best next step in managing this patient?

100) A 34-year-old man complains of severe abdominal pain. He describes the pain as "sharp" and "unbearable." It is located in the lower left abdomen and radiates to the perineum. He has vomited twice since the pain began. He denies dysuria. On exam, he is afebrile. He cannot lie still on the examination table due to his discomfort. Mucus membranes appear slightly dry. Lungs are clear to auscultation. Heart sounds are normal and there are no murmurs or gallops. His abdomen is soft and non-tender to palpation. Inspection and palpation of his genitalia is unrevealing. Extremities have no cyanosis, clubbing, or edema. Which of the following is the best test to diagnose this patient's condition?

101) A 34-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. His cervical spine is immobilized. At the scene of the accident, his blood pressure is 80/40 mm Hg and heart rate is 130/min. He is able to communicate and follows simple commands. Lungs are clear to auscultation. Abdominal wall ecchymosis is present. Abdomen is mildly distended. Bowel sounds are decreased. Neck veins are collapsed. After two liters of intravenous fluids, his blood pressure is 90/60 mmHg. Which of the following is the most appropriate next step in management of this patient?

102) A 42-year-old man comes to the physician because of a 3-month history of substernal chest pain after every meal. He has chronic alcoholism and a long history of heartburn. Upper endoscopy shows mucosal irregularity and ulceration of the squamocolumnar junction above the lower esophageal sphincter (LES). Multiple biopsies were taken. 4 hours later he is complaining of worsening substernal pain radiating to the back, left chest pain, and shortness of breath. His temperature is 37.10C (98.90F), blood pressure is 110/70 mm Hg, pulse is 140/min, and respirations are 34/min. An x-ray film of the chest shows minimal left pleural effusion. Which of the following is the most appropriate next step in management?

103) A 65-year-old man comes to the physician four years after suffering a burn injury to his entire right leg. One area of the leg never healed and has now started increasing in size. He has constant pain and drainage from the site of the lesion. Several topical creams and antibiotics have not helped. Biopsy of the lesion is attempted. Which of the following is most likely be identified on biopsy?

104) A 47-year old woman comes to the clinic because of worsening left breast swelling and pain. She had mastitis when she nursed her first child 20 years ago. She has not seen a doctor since that time. She is afebrile. Breast examination shows the left breast is enlarged with a 7 x 6 cm area of edema and erythema. A poorly localized mass without fluctuation is palpated in that area. Scant non-bloody discharge is noted on the nipple, and several large axillary nodes are palpated. Which of the following is the most appropriate next step in management?

105) A 50-year-old man comes to the physician because of a 2-day history of constipation and not passing flatus. For the last 3 days he has been having intermittent, but worsening, right lower quadrant (RLQ) pain. He has vomited several times today and feels nauseated. Examination shows a distended abdomen with tenderness in the RLQ; there is no rebound; there are no masses or hernias; bowel sounds are absent. Rectal examination shows an enlarged prostate. An upright x-ray film of the abdomen shows gas distributed throughout the small and large bowel, and some fluid levels. After nasogastric tube placement and hydration, his temperature is 36.50C (97.60F), blood pressure is 140/80 mm Hg, pulse is 57/min, and respirations are 12/min. Laboratory studies show: RBC count 4.5 million, WBC 7,400, Na 140, K 3.5, Cl 100, BUN 15 mg/dl, Creatinine 1.0 mg/dl, Urine pH 5.5, Urine sediment: 2 W BC and 15 RBC/high power field, and needle-shaped crystals are present. Which of the following is the most appropriate next step in management?

106) A 25-year-old male is brought to the trauma center by the paramedics after being involved in a road traffic accident that occurred 90 minutes ago. He was a front seat passenger in a 3-car accident. His initial blood pressure at the scene of the accident was 90/60 mm Hg and pulse was 126/min. The paramedics administered 2 liters of normal saline in the ambulance. In the ED, his blood pressure is 110/70 mm Hg and pulse is 90/min. His abdomen is tender in the left upper quadrant. Ultrasound shows fluid in the spleno-renal angle. The most appropriate next step is?

107) A 62-year-old man complains of right knee pain. He says that the pain started two days ago and has been limiting his daily activities. He required 2 grams of acetaminophen in order to sleep through the previous night. He has a long history of rheumatoid arthritis treated with daily low-dose prednisone. Physical examination reveals swelling, limited flexion, and tenderness to palpation of the right knee. Synovial fluid aspiration is performed. Which of the following synovial fluid characteristics would warrant immediate surgical intervention?

108) A 38-year-old woman comes to the emergency department because of the sudden onset of severe abdominal pain. The pain started one hour ago in the epigastrium but now it is mostly localized to the lower abdomen. She has some nausea but denies any vomiting. Her last menstrual period (LMP) was 25 days ago. Her temperature is 36.8C (98.1F), blood pressure is 160/90 mm Hg, pulse is 110/min, and respirations are 25/min. The abdomen is tender on palpation with prominent guarding and positive rebound. There is no shifting dullness, and bowel sounds are absent. Laboratory studies show: Hb 13.1 g/dl, Hct 43%, WBC 10,900/mm3. Which of the following is the most appropriate next step in management?

109) A 36-year-old forest worker is brought to the emergency department after being hit by a falling tree, 3 hours ago. He has pain in the left subscapular region. His temperature is 36C (96.9F), blood pressure is 120/76 mm Hg, pulse is 90/min, and respirations are 18/min. Physical examination shows aggravation of the pain in the left subscapular region with taking a deep breath and with anteroposterior and lateral chest compression. He has ecchymoses on the anterior and posterior chest and on the upper abdominal wall. His abdomen is vaguely tender to palpation in the left upper quadrant (LUQ) and he has left costovertebral angle (CVA) tenderness. Examination otherwise shows no abnormalities. An x-ray film of the chest shows posterior factures of the 8th, 9th and 1Oth ribs on the left. An x-ray film of the abdomen shows blunting of the left psoas shadow. Abdominal ultrasound shows no abnormalities. Laboratory studies show: Hb 15.3 g/dL, Hematocrit 43%, WBC 6,200/mm3, Urinary sediment Many erythrocytes; WBC 4-5/hpf; oxalate crystals. Which of the following is the most appropriate next step in management?

110) A 35-year-old woman presents to the physician's office after she palpated a lump in her right breast. She has no other complaints. She has not seen a doctor for 10 years. She regularly performs breast self-exams after menses. She has no significant past medical history. Her mother died of breast cancer at the age of 40. Breast examination shows a 1 x 1 cm, rubbery, firm, freely mobile round mass in the upper, outer quadrant of the right breast; no axillary lymph nodes are palpable. Which of the following is the most appropriate next step in management?

111) A 45-year-old male comes to the hospital because of severe retrosternal chest pain that started suddenly a few hours ago. He says that he has been having mild chest pain for the past few days, but that this pain is completely different. His past medical history is significant for nonischemic cardiomyopathy for which he takes furosemide, carvedilol, spironolactone, lisinopril and potassium chloride. He also has HIV infection but is not taking any edications related to this diagnosis by his own choice. On physical examination, his temperature is 38.9C (102F), blood pressure is 110/65 mm Hg, pulse is 110/min, and respirations are 22/min. He is in obvious distress secondary to pain. His lungs are clearto auscultation and the remainder of his physical examination is unremarkable. His EKG is within normal limits. Chest X-ray shows a widened mediastinum and mediastinal air. W hich of the following is the most appropriate next step in the management of this patient?

112) A 78-year-old man with Alzheimer's disease was brought to the ER because of bright red bleeding per rectum. He has chronic constipation and is being treated with bisacodyl. On admission, his temperature was 36.6C (97.9F), blood pressure was 130/80 mm Hg with no orthostatic change, pulse was 90/min and respirations were 14/min. Nasogastric tube drainage showed normal stomach contents without blood. His bleeding stopped a few hours after dmission, and he remained hemodynamically stable during that time. Colonoscopy showed extensive diverticulosis but no active bleeding source. Later that night he started bleeding again, and he is now hypotensive with a BP of 100/70 mm Hg. Packed red cells and intravenous fluid are started. Which of the following is the most appropriate next step in management?

113) A 44-year-old unrestrained male driver is brought to the ER after a motor vehicle accident. Cervical spine is immobilized. His breathing is normal. At the scene of the accident, his blood pressure is 70/30 mm Hg. After receiving two liters of intravenous fluid, his blood pressure is 80/40 mmHg. Neck veins are collapsed. Lungs are clear to auscultation. Abdomen is mildly distended. There is no obvious source of external bleeding. No intraperitoneal blood or solid organ damage is seen on ultrasonogram or diagnostic peritoneal lavage. Imaging studies reveal a pelvic fracture and fracture of the right fourth rib. Which of the following is the most appropriate next step in management?

114) A full-term, female infant is born to a 26-year-old, primigravid mother via C-section secondary to breech position. The mother has lived in New York City for the past 5 years. She denies the use of any drugs, alcohol or cigarettes during her pregnancy. She denies having any sexually transmitted infections. Her lead levels were within the normal range throughout her pregnancy. Prenatal ultrasound done at 30 weeks gestation showed normal anatomy of the fetus. The Apgar scores at 1 and 5 minutes are 7 and 9, respectively. There are some bluish-brown spots located on the infant's lumbosacral area. Flexion and abduction of the lower extremities reveal a palpable clunk. The rest of the physical examination is normal. Which of the following is the best next step in the management of this patient?

115) A 36-year-old woman is brought to the emergency department after she jumped from the second floor of a burning building. On arrival examination shows an unconscious woman with blood coming from her nose and with an open tibial fracture of left leg. Her eyes are closed and her pupils are equal and responsive bilaterally. She makes muffled sounds and responds to pain by opening the eyes and moving all the limbs. After the initial resuscitation, which of the following is the most appropriate next step in management?

116) A 34-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He was the restrained front passenger. He has had epigastric pain since the accident. He is hemodynamically stable and has no obvious injury or other complaints. An x-ray of the abdomen shows retroperitoneal air. Which of the following is the most appropriate test to confirm the diagnosis?

117) A 22-year-old football player comes to the physician because of difficulty in extending his right knee. This started one month ago after he twisted his knee while playing. There was mild swelling immediately; he took pain relievers which relieved both the pain and swelling. However, now the knee motion is limited and this is significantly restricting his physical activities. Physical examination shows no swelling of the knee. While passively flexed and extended, a popping sensation is noted under the examiner's finger (which is placed at the right knee). Which of the following is the most appropriate next step in management?

118) A 48-year-old man with a strong history of cigarette use and heavy alcohol intake presents with an intraoral mass. Biopsy shows squamous cell cancer. Chest xray shows hyperinflated lungs but is otherwise normal. Which of the following is indicated as part of his staging workup?

. 119) A 42-year-old man is brought to the emergency department after a motor vehicle accident. He was a restrained driver and hit a car from behind on a highway. He drank one glass of wine before driving. He occasionally uses cocaine. His medical problems include mild intermittent asthma and peptic ulcer disease. On initial evaluation, his blood pressure is 112/92 mm Hg and pulse is 96/min. His pulse oximetry shows 95% on room air. Examination shows bruises on the anterior chest wall and abdominal wall. X-rays reveal a fracture of the eighth left rib but no pneumothorax or pleural effusion. Cervical C-spine series are negative. An ultrasound does not show free intraperitoneal fluid. An ECG shows normal sinus rhythm with no ST-segment or T-wave changes. He is treated with intravenous fluids and analgesics. Eight hours later, he complains of epigastric discomfort, left shoulder pain, and mild nausea. His blood pressure is 97/62 mm Hg and pulse is 112/min. His pulse oximetry shows 96% on room air. Which of the following is most likely to diagnose this patient's current condition?

120) A 56-year-old previously healthy physician notices that his eyes are yellow and he has been losing weight. On physical examination the patient has jaundice and scleral icterus with a benign abdomen. Transcutaneous ultrasound of the abdomen demonstrates biliary ductal dilation without gallstones. Which of the following is the most appropriate next step in the workup of this patient?

121) A 42-year-old man with no history of use of NSAIDs presents with recurrent gastritis. The patient was diagnosed and treated for Helicobacter pylori 6 months ago. Which of the following tests provides the least invasive method to document eradication of the infection?

122) A 45-year-old executive experiences increasingly painful retrosternal heartburn, especially at night. He has been chewing antacid tablets. An esophagogram shows a hiatal hernia. In determining the proper treatment for a sliding hiatal hernia, which of the following is the most useful modality?

123) A 62-year-old man has been noticing progressive difficulty swallowing, first solid food and now liquids as well. A barium study shows a ragged narrowing just below the carinal level. Endoscopic biopsy confirms squamous cell carcinoma. Which of the following provides the most accurate information regarding the T stage of an esophageal carcinoma?

124) A 53-year-old woman with a history of a vagotomy and antrectomy with Billroth II reconstruction for peptic ulcer disease presents with recurrent abdominal pain. An esophagogastroduodenoscopy (EGD) demonstrates that ulcer and serum gastrin levels are greater than 1000 pg/mL on three separate determinations (normal is 40-150). Which of the following is the best test for confirming a diagnosis of gastrinoma?

126) A 28-year-old woman presents with hematochezia. She is admitted to the hospital and undergoes upper endoscopy that is negative for any lesions. Colonoscopy is performed and no bleeding sources are identified, although the gastroenterologist notes blood in the right colon and old blood coming from above the ileocecal valve. Which of the following is the test of choice in this patient?

127) A 36-year-old man is in your intensive care unit on mechanical ventilation following thoracotomy for a 24-hour-old esophageal perforation. His WBC is markedly elevated, and he is febrile, hypotensive, and coagulopathic. His NG tube fills with blood and continues to bleed. Which of the following findings on upper endoscopy would be most suspicious for stress gastritis?

128) A 2-month-old boy is examined because he has been straining while passing stool and has a distended abdomen. He is very low on the growth chart for age. The primary care physician suspects that the boy has Hirschsprung disease. Which of the following findings on workup is diagnostic?

129) A patient is brought to the ER after a motor vehicle accident. He is unconscious and has a deep scalp laceration and one dilated pupil. His heart rate is 120 beats per minute, blood pressure is 80/40 mm Hg, and respiratory rate is 35 breaths per minute. Despite rapid administration of 2 L normal saline, the patient’s vital signs do not change significantly. Which of the following is the most appropriate next step in the workup of his hypotension?

130) A 47-year-old man is extricated from an automobile after a motor vehicle accident. He is hypotensive with a systolic blood pressure of 80. The patient has a steering wheel bruise on the anterior chest. His electrocardiogram (ECG) shows some premature ventricular complexes, and his cardiac isoenzymes are elevated. Which of the following is the best next test for evaluation for a blunt cardiac injury?

131) A 36-year-old man sustains a gunshot wound to the left buttock. He is hemodynamically stable. There is no exit wound, and an x-ray of the abdomen shows the bullet to be located in the right lower quadrant. Which of the following is most appropriate in the management of his suspected rectal injury?

132) A 32-year-old man is in a high-speed motorcycle collision and presents with an obvious pelvic fracture. On examination, he has a scrotal hematoma and blood at his urethral meatus. Which of the following is the most appropriate next step in his management?

133) An intoxicated 22-year-old man is a restrained driver in a high-speed motor vehicle collision. Examination reveals normal vital signs, but the rest of the examination is unreliable secondary to the patient’s intoxicated state from alcohol. Which of the following sole findings on a CT scan of the abdomen and pelvis mandates an exploratory laparotomy?

134) A 23-year-old man arrives in the ER after a motor vehicle collision. Examination reveals an unstable pelvis and blood at the urethral meatus. Which of the following studies would most accurately identify a urethral injury?

135) A 2-year-old asymptomatic child is noted to have a systolic murmur, hypertension, and diminished femoral pulses. Which of the following should be performed as part of the preoperative workup and management of this child’s disorder?

136) A 16-year-old boy was brought to the emergency department because of left shoulder and left hand pain after falling on his outstretched hand while playing soccer. He heard a crunching sound and had intense pain in his left shoulder area following the injury. Examination shows bruising around the clavicle area. He is holding his left arm with his right hand. There is a palpable gap in the middle of the clavicle. Auscultation shows a loud bruit just beneath the clavicle. An x-ray film of the left shoulder and chest shows the middle of the clavicle is fractured and displaced. Which of the following is the most appropriate next step in management?

137) A 36-year-old woman presents to the physician's office after she palpated a lump in her right breast. She has no other complaints. She has not seen a doctor for 10 years. She regularly performs breast self-exams after menses. She has no significant past medical history. Her mother died of breast cancer at the age of 40. Breast examination shows a 1 x 1 cm rubbery, firm, freely mobile, round mass in the upper, outer quadrant of the right breast. No axillary lymph nodes are palpable. Which of the following is the most appropriate next step in management?

138) A 78-year-old man with Alzheimer's disease was brought to the ER because of bright red bleeding per rectum. He has chronic constipation and is being treated with bisacodyl. On admission, his temperature was 36.6°C (97.9°F), blood pressure was 130/80 mm Hg with no orthostatic change, pulse was 90/min, and respirations were 14/min. Nasogastric tube drainage showed normal stomach contents and bile but no blood. His bleeding stopped a few hours after admission, and he remained hemodynamically stable during that time. Colonoscopy showed extensive diverticulosis but no active bleeding source. Later that night he started bleeding again from the rectum. Packed red cells and intravenous fluid are started. Which of the following is the most appropriate next step in management?

139) A 45-year-old man is brought to the emergency department after being involved in a motor vehicle collision. He is unable to void. Examination shows blood at the urethral meatus and a scrotal hematoma. His temperature is 37°C (98.6°F), blood pressure is 100/50, pulse is 100/min and respirations are 16/min. Examination shows a high-riding prostate with no other signs of trauma. Which of the following is the most appropriate next step in management?

140) A 23-year-old man comes to the emergency department because of a painful swollen left knee. The pain began after he twisted his leg while playing football. Examination shows a swollen left knee with marked tenderness of the medial side of the knee. When compared to the right knee, on valgus stressing the left knee shows exaggerated laxity at the joint line. Which of the following is the most appropriate next step to confirm the diagnosis?

141) A 36-year-old male comes to the emergency department because of worsening right lower quadrant (RLQ) abdominal pain. One week ago he was started on cephalexin for furunculosis. He has had type I diabetes mellitus for 1Oyears and is on insulin. His temperature is 38.83°C (101.9°F). Examination shows multiple furuncles on the inner side of both thighs; most of them are in regression. Abdominal examination shows tenderness on deep palpation in RLQ without rebound or guarding; no masses are palpated; psoas sign is positive; bowel sounds are present. Rectal examination shows no abnormalities. Laboratory studies show: Hemoglobin 13.0 g/L, Leukocyte count 17,500/mm3. Which of the following is the most appropriate next step in management?

1) A 50-year-old man comes to the clinic seeking help for a skin condition he has had for the last 6 months. He has developed hyperpigmented, “velvety” lesions in his axilla, neck, and groin, and particularly prominent lesions on the soles of his feet and palms of his hands. Additionally, he has developed small skin tags on his neck. Since immigrating 10 years ago, he reports being in excellent health, watching his diet, and exercising regularly. Review of systems reveals some mild dyspepsia but is otherwise unremarkable. Family history includes an aunt with breast cancer but no diabetes or heart disease. He does not smoke cigarettes and only rarely drinks. Vital signs are within normal limits. The patient is a thin Japanese man in no apparent distress. Physical examination confirms the lesions about which the patient was complaining. Additionally, a firm, 3-cm left supraclavicular lymph node is palpable. Which of the following is the most likely underlying condition?

2) A 58-year-old professional race car driver has an episode of gross, painless, total hematuria. CT scan reports the presence of a 2 cm mass arising from the cortex of the left kidney, and the radiologist confidently makes a diagnosis of renal cell carcinoma. The same study, however, is inconclusive as to the presence or absence of tumor growth into the renal vein, and the radiologist adds an MRI for that purpose. The MRI clearly excludes the existence of such growth into the vein. Chest x-ray is normal. Which of the following is the most appropriate next step in management?

3) A 62-year-old woman comes in for her scheduled chemotherapy administration for her metastatic cancer of the breast. Although she is asymptomatic, the laboratory reports that her serum sodium concentration is 122 mEq/L. If it were deemed advisable to correct this electrolyte abnormality, which of the following is the best way to do it?

4) A 52-year-old woman returns to the clinic for a followup appointment. She has had fatigue and anorexia for the past 6 months that, despite an extensive workup, including age-appropriate cancer screening, thyroid testing, routine blood studies, and psychiatric screening, has eluded a diagnosis. She now returns with the same complaints of fatigue and diminished appetite, but now is complaining also of lower abdominal bloating and pressure. Before these 6 months, she had been in excellent health. Her past medical history is unremarkable, though she does have an uncle who had diabetes and colon cancer, an aunt with breast cancer, and a mother who died of uterine cancer. Vital signs are within normal limits. Physical examination reveals a mildly distended, nontender abdomen that is increased in size since her last visit. Additionally, the pelvic examination reveals a possible nontender adnexal mass, though it is difficult to palpate. A CA-125 level is within normal limits. Which of the following is the most appropriate next diagnostic study?

5) A 62-year-old woman is suffering from advanced colorectal cancer. Despite aggressive surgery and adjuvant chemotherapy, the disease has spread throughout her pelvis and eroded into her left acetabulum. Her pain from the disease has increased dramatically over the last few months. Understandably, her need for pain medications has increased proportionately, and she is now requiring a combination of COX-2 inhibitors, oxycodone and acetaminophen combinations, and gabapentin to take the edge off of her pain. Her pain control plan involves transitioning her to a long-acting sustained-release form of fentanyl. She is extremely worried about her need for increasing doses of narcotics; she has heard that they have awful side effects, and fears becoming “hooked.” Regarding the side effects of narcotic pain medications, she can confidently be told that which of the following is the most common, clinically significant side effect she is likely to experience?

6) A 19-year-old woman is being treated for Hodgkin's disease that originally presented as a painless, rubbery, enlarged right supraclavicular lymph node. She has recently completed a cycle of chemotherapy protocol that consists of Adriamycin, bleomycin, vinblastine, and dacarbazine (ABVD), and was reported to have tolerated the chemotherapy well. Shortly before her next planned cycle of chemotherapy, however, the patient comes to the emergency department complaining of diffuse abdominal pain and bloating. She has not had a bowel movement in 3 days, though she thinks she is still passing gas. Vital signs at this time are: temperature 37.0 C (98.6 F), blood pressure 128/78 mm Hg, pulse 115/min, and respirations 20/min. Examination reveals a diffusely distended abdomen that is mildly tender to palpation in all four quadrants, without rebound pain or guarding. The supraclavicular mass is not palpable. An abdominal radiograph reveals dilated loops of small bowel with air fluid levels and gas present throughout the colon and rectum. The patient is admitted to the medicine floor for management. Which of the following is the most likely cause of her current condition?

7) A 25-year-old woman, 8 weeks pregnant, is found to have a 1-cm mass in the upper outer quadrant of the right breast. Core biopsy diagnoses infiltrating ductal carcinoma. Technically, the tumor is amenable to a lumpectomy. Palpation of the axilla is negative. When confronted with her therapeutic options, the patient indicates that her first consideration is the welfare of her unborn child, the second consideration is her own chance of cure, and the last consideration is the cosmetic outcome of the treatment. To help her achieve those ends, which of the following is the most appropriate first step of her treatment?

8) An 81-year-old nursing home resident is brought to the hospital because of altered mental status for the past day. Her husband states that she was in her usual state of health yesterday. He states she had a “coughing fit” after he fed her dinner last night. Her past medical history is significant for noninsulin-dependent diabetes mellitus and cerebral vascular accident that had left her with some residual dysarthria. Her blood pressure is 95/55 mm Hg, pulse is 97/min, and respirations are 19/min. Her temperature is 38.3 C (101.0 F) and oxygen saturation is 94% on room air (corrects to 99% with 4 liters of oxygen). She is awake, minimally responsive, and in no respiratory distress. On her lung examination you note localized rales at the right lower lung field. You suspect aspiration pneumonia and place an intravenous line and obtain a chest x-ray. The x-ray shows a right-sided consolidation that obscures the right heart border. Which of the following is the most appropriate course of management?

9) A 64-year-old man with chronic obstructive pulmonary disorder (COPD) is hospitalized for an acute exacerbation of chronic bronchitis (AECB). At the time of admission, the patient is suffering from dyspnea, a productive cough with green-tinged sputum, and pleuritic chest pain. At that time his oxygen saturation is 80%. A blood gas reveals a pH of 7.35, a pO2 of 51 mm Hg, and a pCO2 of 58 mm Hg. The patient is treated with oxygen therapy, nebulized ipratropium and albuterol treatments, and azithromycin. Over the course of 5 days, the patient’s respiratory status improves. His cough and sputum production diminish and he is weaned from supplemental oxygen. At the time of discharge, his oxygen saturation is 90% on room air. A blood gas reveals a pH of 7.37, a pCO2 of 50 mm Hg, and a pO2 of 70 mm Hg. At this time, which of the following is an appropriate treatment for this patient?

10) A 35-year-old man complains of increasing shortness of breath with exercise. These symptoms have been ongoing for the last year. Previously he has been healthy. He denies any fever, chills, shakes, nausea, vomiting, diarrhea, chest pain, palpitations, hemoptysis, or weight loss. He denies any occupational exposure. He also reports a dry cough. He does not take any medications and has no known drug allergies. He denies a smoking history. His oxygen saturation is 93% on room air. Lungs have a fine crackle pattern. Heart is regular. Examination of the extremities shows clubbing. Chest x-ray reveals diffuse linear capacities. Pulmonary function tests show a restrictive pattern. He has a decreased diffusion capacity. Which of the following is the most likely diagnosis?

11) A 60-year-old man comes to the emergency department with shortness of breath and a left-sided dull chest pain. He has had a low-grade fever for the past 3 days. He was treated recently for pneumonia with antibiotics, but says that he never quite returned to baseline. He has no other medical issues and has no allergies. He denies alcohol abuse or drug use. His temperature is 37.8 C (100.0 F), blood pressure is 120/80 mm Hg, and pulse is 70/min. Examination reveals decreased breath sounds on the left and deceased tactile fremitus. Chest x-ray is consistent with a large left-sided pleural effusion greater than 15 mm. A thoracentesis reveals turbid fluid with a white blood cell count of 70,000, red blood cell count of 20,000, LDH of 500 IU/L, and serum LDH of 600 IU/L (normal 50-150 IU/L). A repeat chest x-ray reveals pneumonia in the right upper lobe. Gram stain of the fluid obtained reveals multiple gram-positive diplococci. Pleural fluid pH is 7.1. Which of the following is the most appropriate initial management?

12) A 36-year-old migrant farm worker comes to a community outreach health clinic complaining of hemoptysis. For the past 2 months, while she has traveled from Tijuana, Mexico, up through California’s central agricultural valley, she has suffered from intermittent episodes of a hacking cough, as well as intermittent joint pain. Physical exam reveals some faint crackles in her left upper lobe, and three small, tender, violaceous subcutaneous nodules on her right pretibial region. Laboratory studies are unremarkable, but a chest radiograph reveals a 3-cm thin-walled cavity in the left upper lobe with no surrounding infiltrate. A PPD skin test shows 4 cm of induration 72 hours after placement. On the basis of this patient’s history and findings, which of the following is the most likely diagnosis?

13) You are called to the emergency department to consult on a 34-year-old woman at 22 weeks’ gestation with a skin rash and shortness of breath. She states that the skin rash started 2 days ago on her trunk and has spread to her extremities. Earlier today she developed shortness of breath. She has been feeling like she has fever and chills, but she has not taken her own temperature. She has no other medical problems and has never had surgery. She works as a third-grade teacher. She has not been traveling recently, but one of her students recently had the chicken pox. On physical examination, her temperature is 38.1 C (100.6 F), blood pressure is 100/70 mm Hg, pulse is 116/min, and respirations are 18/min. Her lungs have diminished breath sounds bilaterally. Chest x-ray demonstrates diffuse, nodular, peribronchial infiltrates. Which of the following is the most appropriate next step in management?

14) A 26 years old man is about to undergo an orchiectomy for testicular cancer. The anesthesiologist begins isoflurance and succinylcholine, and about 30 minutes later, the patient develops muscle rigidity, herthermia, an elevated heart rate, and abnormal ventilation patterns. There are numerous atrial premature complexes (APCs) and ventricular premature complexes (VPCs) noted on the monitor. The anesthesiologist is unable to open’s mouth because of masseter muscle rigidity. The patient become fever. Vital signs: BP 90/50 mm Hg, HR 140 beats/min, R 18 breaths/min, T 105F (40.38C). What is the best next step management?

15) A 70-year-old man with a history of congestive heart failure (CHF) secondary to nonischemic cardiomyopathy presents to the office for preoperative evaluation for total hip replacement. The previous echocardiogram revealed an ejection fration (EF) of 30%, and he occasionally has shortness of breath with exertion. His vital signs: BP 185/60 mm Hg, HR 95 beats/min, R 20 breaths/min, T 98,6F (37.92C). Which of the following factors in this patient’s history and physical examination puts him most at a high risk for perioperative mortality?

16) A 72-year-old retired banker is brought to the ED by his daughter for increasing confusion, lethargy, cough, and fever. You remember the patient because he was discharged just 3 days earlier after being treated for urinary retention secondary to benign prostatic hypertrophy (BPH). The patient’s cough has been present since discharge and is accompanied by dark green sputum. He has not returned to work, and he has not been able to ambulate. His vital signs: BP 86/40 mm Hg, R 32 beats/min, P 121 beats/min, T 101.9F (39.19F). What is the best next step in the management of this patient?

17) A 54-year-old man presents to the emergency department with severe chest pain that radiates to his back. The pain is 9 of 10, increasing in intensity, and constant and is described as a tearing sensation. It began earlier this morning and has progressively gotten worse. He denies shortness of breath but does state he feels dizzy and lightheaded. His vital signs: BP 200/100 mm Hg, P 101 beats/min, afebrile. What is the best next step in the management of this patient?

18) A 66-year-old man presents to the office for a well visit. He has no complaints and feels well. His wife has been complaining that his belly has been increasing in girth over the past year. His vital sign is stable. What is the best next step in the management of this patient?

19) A 1-day-old boy is evaluated in the nursery for minimal right arm movement. He was born at 41 weeks gestation to a woman with poorly controlled type 1 diabetes mellitus. Attempted vaginal delivery was complicated by shoulder dystocia and became a cesarean section delivery. Family history is positive for obesity in the boy's father and osteoporosis in both grandmothers. Birth weight was 4.5 kg. Examination shows crepitus and irregularity over the right clavicle. Moro reflex is absent on the right. Bilateral biceps and grasp reflexes are intact and symmetric. The infant is plethoric and has excessive fat accumulation in the abdominal and scapular regions. The remainder of the examination is normal. Which of the following is the most significant risk factor for this patient's condition?

20) A 6-day-old female neonate is admitted to the hospital for the evaluation of jaundice. She was born to a 17-year-old German mother at 39 weeks gestation. Her mother's blood type is B+, and was treated for newborn jaundice due to presumed ABO incompatibility. Her other family members also had neonatal jaundice. The infant's vital signs are normal. On examination, she is visibly jaundiced, and her spleen tip is palpable. Her total bilirubin level is 25mg/dl and direct bilirubin level is 0.4mg/dl. Her hemoglobin was initially 15.7g/dl, but is now 10.7g/dl. Her reticulocyte count is 4% and platelet count is 230,000/mm3. The peripheral smear shows moderate schistocytes with burr cells and moderate spherocytes. Her blood type is B+ and Coombs' test is negative. Her stools are negative for occult blood. Her mother's incubated red cell osmotic fragility study is abnormal. What is the most likely cause of this neonate's symptoms?

21) A 36-year-old G3P2002 with an IUP at 38 weeks presents for shortness of breath. Shortness of breath has been gradually getting worse for the past 2 weeks. The patient states that she now needs to sleep with three pillows to feel like she can breathe. Vital sign: BP, 135/80 mm Hg; P, 78 beats/min; R, 26 breaths/min; T, 98.6°F. She said: chest pain: Negative, cough: Negative, hemoptysis: Negative, fever: Negative, edema: Positive, fetal movement: Positive, contractions: Negative, vaginal bleeding: Negative, leakage of fluid: Negative. Physical Exam: cardiovascular system (CVS): S1S2 +Regular Rate and Rhythm (RRR) no murmurs, lungs: + Crackles bilaterally, Abdominal: gravid, Extremities: 2+ edema bilaterally. What is the next best step in the management of this patient?

22) A 28-year-old Glo with an IUP at 26 weeks' gestation presents to the emergency department for shortness of breath. She receives regular prenatal care, and her pregnancy has been uncomplicated thus far. She developed shortness of breath suddenly after a long drive in traffic. She has chest pain when she takes a deep breath. Vital sign: BP, 120/80 mm Hg; P, 120 beats/min; R, 24 breaths/min; T, 98.9°F; pulse ox, 89% on room air. Physical examination: general: awake, alert, oriented x3, mild respiratory distress, cardiovascular: S1S2+RRR no m/r/g, lungs: clear to auscultation bilaterally. Abdomen: gravid; fundal height 25 cm; no tenderness, extrimies: 1+ edema bilaterally; no erythema, chest radiography with an abdominal shield is within normal limits. What is the next best step?

23) A 21-year-old woman G1P0 with an intrauterine pregnancy (IUP) at 8 weeks' gestation presents for her first prenatal visit. The patient states that she would like to have a termination of the pregnancy. She denies any medical history, surgical history, allergies, and taking any medications. Vital sign: BP, 115/75 mm Hg; P, 78 beats/min; R, 20 breaths/min; T, 98.6°F. Fetal movement: Negative, contractions: Negative, vaginal bleeding: Negative, leakage of fluid: Negative. What laboratory studies need to be done before consideration of this request?

24) A 29-year-old G2P1001 with an IUP at 7 weeks' gestation presents to the emergency department (ED) for vaginal bleeding. She started to have abdominal pain and vaginal bleeding overnight. No clots were expressed per the vagina. She denies any other medical history, surgical history, and allergies. The patient is takingprenatal vitamins. The bleeding started after sexual relations. Vital sign: BP, 120/80 mm Hg; P, 76 beats/min; R, 12 breaths/min; T, 98.6°F. Fetal movement: Negative, contractions: Unsure what the abdominal pain is, vaginal bleeding: Positive, leakage of fluid: Negative. Physical examination: CVS: Normal, Lungs: Normal, abdomen: Soft, nontender, nondistended, +BS, Extrimities: No edema, sterile speculum exam: Cervix closed; blood in vaginal vault. What is the next step?

25) A 29-year-old G2P1001 with an IUP at 35 weeks' gestation presents to the ED for vaginal bleeding. The patient states that she woke up in a puddle of blood. She denies abdominal pain. She also denies other medical history, surgical history, and allergies. The patient is taking prenatal vitamins. Fetal movement: Present, Contractions: Absent, Vaginal bleeding: Present, Leakage of fluid: Absent. Physical examination: CVS: Normal, Lungs: Clear bilaterally, Abd: Gravid, nontender, nondistended, +BS, Ext: No edema bilaterally. What is the next step in the management of this patient?

26) A 32-year-old woman with a history of diabetes presents with an IUP at 5 weeks. She has been taking metformin, glyburide, and lisinopril. Her glucose has been well controlled on these medications. Vital sign: BP, 120/80 mm Hg; P, 75 beats/min; R, 12 breaths/min; T, 98°F (37 C). She denies leakage of fluid, denies contractions, denies fetal movement, denies vaginal bleeding, and denies abdominal pain. What is the mechanism of action of glyburide?

27) A 32-year-old woman with a history of diabetes presents with an IUP at 5 weeks. She has been taking metformin, glyburide, and lisinopril. Her glucose has been well controlled on these medications. Vital sign: BP, 120/80 mm Hg; P, 75 beats/min; R, 12 breaths/min; T, 98°F (37 C). She denies leakage of fluid, denies contractions, denies fetal movement, denies vaginal bleeding, denies abdominal pain. What is the definition of gestational diabetes?

28) A 28-year-old woman with no past medical history presents for her initial prenatal visit. Her last menstrual period (LMP) was 6 weeks ago. Vital sign: BP, 125/78 mmi P, 73 beats/mini R, 13 breaths/min, T: 98°F (37 C). She denies leakage of fluid, denies vaginal bleeding, denies fetal movement, denies contractions, nausea and vomiting present. Labs: Complete blood count (CBC): white blood cells (WBCs), 8 x l03/ [1L hemoglobin(Hgb), 11.0 g/dL hematocrit (Hct), 33.5%; platelets, 167 x103/microL. CMP: Sodium, 128 mmol/ L; potassium, 4.5 mmol/L; chloride, 100 mmol/L; bicarbonate, 22 mmol/ L; blood urea nitrogen (BUN), 0.9 mg/dL; creatinine, 1 mg/dL; glucose, 97 mg/dL. Rubella IgG: positive. HIV: positive. CD4 count: 750. Viral load: 20,000 copies/mL. Hepatitis B sAg: Negative. HgbAlc: 5.6%. What drug is contraindicated in pregnancy?

29) A 35-year-old woman, gravida 3, para 2, underwent a spontaneous vaginal delivery at 39 weeks’ gestation of a 3,295 g (7 lb 4 oz) male neonate who has done well. She had a prolonged third stage of labor, resulting in an attempted manual removal of the placenta. The placenta was not completely removed, and bleeding progressed to hemorrhage. Ultimately, she underwent an emergency total abdominal hysterectomy due to placenta accreta. She received 5 units of packed red blood cells (PRBCs). Her blood pressure was in the hypotensive range for 30 minutes during the procedure. Which of the following pituitary hormones is most likely to be affected by her clinical course?

30) A 30-year-old woman, gravida 3, para 1, abortus 1, is at 30 weeks’ gestation by dates. She has been married for 7 years to the same husband. Her first pregnancy ended in a spontaneous first-trimester loss. Her second pregnancy was unremarkable until delivery at term, when she underwent an emergency lowtransverse cesarean section because of double footling breech presentation. She has worked in a child daycare center for the past 5 years. She vacationed in Thailand for 2 weeks last year. On routine prenatal laboratory testing, you find that she is hepatitis B surface antigen positive, and anti-HBc IgM negative. She inquires about the significance of this finding concerning herself, as well as her baby. Which of the following statements best summarizes what you will say?

31) A 48-year-old woman has been married for 8 years and desperately wants to have a child of her own before it is too late. She consults a new obstetrician for help because she has experienced multiple early secondtrimester losses due to painless cervical dilation leading to expulsion of immature stillborn fetuses. She reports that she was exposed in utero to diethylstilbestrol (DES), explaining that when her mother was pregnant with her she experienced early pregnancy bleeding and, as a consequence, was treated with DES to prevent the pregnancy from being terminated. At this time, this patient is most likely to demonstrate which of the following conditions on physical examination?

32) A 3-year-old girl who has been experiencing vaginal bleeding is brought for evaluation by her worried mother. The girl’s medical history is unremarkable, with normal physical growth and appropriate developmental landmarks. She has had all the recommended immunizations. On visual examination of the perineum, bleeding and multiple cystic masses resembling grapes are seen at the introitus. Which of the following is the most likely diagnosis?

33) For the past 6 months, a 32-year-old multiparous woman has complained about intermittent vaginal bleeding between normal menstrual periods. The bleeding is painless and is not associated with cramping. She denies postcoital bleeding. Her last Pap smear, 6 months ago, was negative for dysplasia or malignancy. She underwent a tubal sterilization after her last pregnancy 3 years ago. Pelvic examination reveals normal external genitalia and vulva. Her vagina and cervix are without lesions. Her uterus is asymmetrically enlarged, about 8-week size, and nontender. Results of a qualitative urine –human chorionic gonadotropin (-hCG) test are negative. Which of the following is the most likely diagnosis?

34) Starting over 9 months ago, a 39-year-old multiparous woman complains about having increasing heavy vaginal bleeding and pain with her menstrual periods. Two years ago, after workup for an abnormal Pap smear reported a low-grade squamous intraepithelial lesion (LSIL), she underwent cryotherapy for biopsy-confirmed cervical intraepithelial neoplasia grade I (CIN 1). Subsequent follow-up Pap smears have been negative. Her present pelvic examination is unremarkable except for a diffusely enlarged, globular, soft, tender uterus. Results of a qualitative urine -human chorionic gonadotropin (-hCG) test are negative. Which of the following is the most likely diagnosis?

35) A 14-year-old girl complains of irregular, unpredictable heavy menstrual bleeding. She denies pain or cramping. Her first menstrual period was at age 13, and they have always been irregular, but the bleeding seems to be getting heavier. She has no chronic health problems and states she has never been sexually active. She appears well developed and well nourished, with normal female secondary sexual characteristics. Inspection shows normal female external genitalia. Results of a qualitative urine human chorionic gonadotropin (-hCG) test are negative. Which of the following is the most likely diagnosis?

36) A 39-year-old multiparous woman complains of intermittent vaginal bleeding between normal menstrual periods that has been going on for the past 4 months. The bleeding is painless and occurs after sexual intercourse. She has had three cesarean sections, along with a tubal sterilization with her last delivery. She has a 30 pack-year history of cigarette smoking. She is currently in a monogamous sexual relationship but has had multiple sexual partners in the past. She has not been regular in her annual examinations. Her last Pap smear was 5 years ago. Which of the following is the most likely diagnosis?

37) A 6-year-old girl states that she has had vaginal bleeding for the past 3 days. She is brought to the office by her worried mother. The mother states that the child has no medical problems and is not on any medications. She denies headache or visual changes. General physical examination is consistent with a normal 6-year-old female without breast budding. External genitalia are unremarkable with no pubic hair. Which of the following is the most likely diagnosis?

38) A 63-year-old nulligravid woman comes to the outpatient office complaining about intermittent painless vaginal bleeding. Her last menstrual period was 10 years ago. She is not on hormone therapy. She has never used oral contraceptives. She has struggled with obesity all her life. Her last Pap smear was a year ago and was negative for dysplasia or malignancy. Her pelvic examination is unremarkable without vulvar, vaginal, or cervical lesions. Her uterus is small, mobile, and nontender. No adnexal masses are palpable. Which of the following is the most likely diagnosis?

39) A 21-year-old nulligravid woman complains that she has nonmenstrual vaginal bleeding and left-sided lower-abdominal pain. Her last menstrual period was 7 weeks ago. She is sexually active with multiple sexual partners. She uses barrier contraception irregularly and was treated with antibiotics 6 months ago for bilateral lower-abdominal pelvic pain. Her vital signs are stable. On pelvic examination, she has dark blood in the vagina with no active bleeding. Her uterus is slightly enlarged but nontender. She has left adnexal tenderness to palpation without an obvious mass. Which of the following is the most likely diagnosis?

40) A pregnant 22-year-old Taiwanese woman presents at 15 weeks’ gestation with vaginal bleeding and severe nausea and vomiting. She states she recently experienced vaginal passage of tissue that looked like grapes. Her uterine fundus is at her umbilicus and no fetal heart tones can be heard with a Doppler stethoscope. Ultrasonography of the uterus shows a “snow storm” image with no fetus or placenta. Which of the following is the most likely diagnosis?

41) A 65-year-old woman has an 8-year history of involuntary loss of urine: she leaks small amounts of urine when she coughs, sneezes, or laughs. In providing a history to her physician, she complains about feeling pelvic pressure, but denies feeling a burning sensation upon urinating or having an abnormally strong urinary urgency or frequency. She has no loss of urine at night; however, the symptoms occur frequently enough that she needs to wear a perineal pad. She underwent menopause 12 years ago. For treatment of hot flashes, she initially used oral estrogen hormone replacement along with 7 days of medroxyprogesterone acetate 1 week of every month. For the last 8 years, she has not used any hormone therapy. Speculum examination reveals an atrophic vagina and cervix without lesions. Bimanual examination reveals a small, symmetrical, midline, mobile, nontender uterus. There are no adnexal masses. With the Valsalva maneuver, there is protrusion of her anterior vaginal wall. Which one of the following is the most likely diagnosis for the physical finding?

42) A 21-year-old woman, primigravida, presents at 39 weeks’ gestation in active labor. She is 155 cm tall and weighs 75 kg. Her pregnancy weight gain has been 20 kg. On digital vaginal examination, the fetus is in cephalic presentation at –1 station. Her cervix is 5 cm dilated, 90% effaced, soft, midposition. Onset of regular uterine contractions was 8 hours ago, and she is now experiencing regular contractions every 3 minutes, lasting 45 seconds, which are firm to palpation. Clinical pelvimetry shows her pelvic dimensions as follows: pelvic sidewalls are straight, ischial spines are not prominent, pubic arch is wide, sacrum is hollow, and sacrosciatic notch is well rounded. Based on general bony architecture, the characteristics of this woman’s pelvis identify it as which one of the following common female bony shapes?

43) A 23-year-old woman, gravida 2, para 1, underwent first-trimester sonography at 10 weeks to rule out twins. A 6-cm, unilateral, fluid-filled, smoothwalled, unilocular pelvic mass was found. The mass is separate from the uterus and is essentially unchanged on serial sonograms. However, it is variable in location, being noted anterior, posterior, and lateral to the uterus. Which of the following is the most likely diagnosis?

44) A 34-year-old woman, gravida 1, para 0, at 18 weeks’ gestation with severe hyperemesis has a blood pressure of 150/95 mm Hg and 2 proteinuria. Pelvic examination reveals bilateral adnexal masses that are 8–10 cm in diameter and appear multiloculated on a sonogram. Which of the following is the most likely diagnosis?

45) An 18-year-old woman, gravida 1, now para 1, just delivered a 3,500 g (7 lb 12 oz) healthy male neonate without complications. At the beginning of this pregnancy, at 8 weeks’ gestation, she was noted to have a 5-cm right adnexal cystic mass that appeared as a simple, thin-walled, round, fluid-filled cyst structure. The mass spontaneously involuted and was no longer seen on sonogram at 16 weeks’ gestation. Which of the following is the most likely diagnosis?

46) A 29-year-old woman experienced her last menses 9 weeks ago. On her first prenatal visit, she is noted to have a 9–10 cm soft, smooth, symmetrical, midline pelvic mass. The mass is mobile and not tender to palpation. She has experienced morning nausea but no vomiting. Which of the following is the most likely diagnosis?

47) A mother brings her 5-year-old daughter to the family physician. The girl is of appropriate height and weight for age. The girl shows changes of early breast development and has had vaginal bleeding. These changes have occurred suddenly. Pelvic examination under sedation reveals a normal vagina, but a sonogram shows a 4 cm unilateral, solid pelvic mass. There is no family history of such events. Which of the following is the most likely diagnosis?

48) A 55-year-old postmenopausal woman shows evidence of temporal balding, clitoromegaly, and increased facial hair that began 6 months ago and had a rapid onset. She is noted to have a 5 cm unilateral, solid pelvic mass. Family history is negative for these findings. Which of the following is the most likely diagnosis?

49) A 28-year-old nulligravid woman is found on routine annual examination to have an asymptomatic, mobile, nontender, 6 cm unilateral pelvic mass. On sonogram, the mass is partially solid and partially cystic, with foci of calcifications. She is sexually active with her husband of 5 years. She has used combination oral contraceptives for the past 3 years. Which of the following is the most likely diagnosis?

50) A 32-year-old infertile, obese nulligravida complains of secondary dysmenorrhea as well as pain with intercourse and bowel movements. She is sexually active but has never used any contraceptive methods. Bimanual pelvic examination reveals a 7 cm right adnexal mass. On rectovaginal examination, she is found to have uterosacral ligament nodularity and a fixed retroverted uterus. Which of the following is the most likely diagnosis?

51) A 29-year-old G3P1011 with an IUP at 37 weeks' gestation presents to the emergency department because ofagush offluid from her vagina. The patient denies any other complaints. States that she was watching TV when shefelt the gush. The fluid appeared clear. Vital sign: BP, 110/80 mm Hg; P, 88 beats/min; R, 12 breaths/min; T, 98.6°F. Fetal movement: Present. Contractions: Absent. Vaginal bleeding: Absent. Leakage of fluid: Present. Physical Examination: CVS: Normal, Lungs: Normal, Abdomen: gravid, nontender, nondistended, +Bowel Sound; Extrimities: No edema bilaterally. What is the next step in the management of this patient?

52) An 18-year-old woman presents to the emergency departmentfor right lower quadrant abdominal pain. The pain started suddenly with a sharp, stabbing pain. The patient denies nausea, vomiting, diarrhea, and constipation. Her last menstrual period (LMP) was 6 weeks ago. Vital sign: BP, 115/75 mm Hg; P, 82 beats/min; R, 12 breaths/min; T, 98.6°F. Physical examination: Gen: Awake, alert, oriented x3, mild pain distress, CVS: Normal, Lungs: Clear bilaterally, Abd: Tender in right lower quadrant (RLQ), rebound tenderness present, nondistended, bowel sounds present. Which of the following is the next best step in the management of this patient?

53) A 31 -year-old G2P1001 with an IUP at 39 weeks' gestation present to the labor and delivery unitfor contractions. The patient states that her last pregnancy was delivered via C-section, but she wants to deliver this one vaginally. She states that she knows the risks and is willing to accept them. Vital sign: BP, 115/75 mm Hg; P, 82 beats/min; R, 12 breaths/min; T, 98.6°F. Contractions: Present, Fetal movement: Present, Vaginal bleeding: Absent, Leakage of fluid: Present. Physical examination: Gen: Awake, alert-oriented x3, mild pain distress, CVS: Normal, Lungs: Clear, Abd: Gravid, contraction present, Ext: 1+ edema bilaterally. Cervical examination: 7 cm, 100% effaced, -1 station. Fetal Heart Monitoring: Reassuring, good variability, + accelerations, no decelerations. Which of the following is a complication of vaginal birth after C-section (VBAC)?

54) The patient is a 25-year-old G1 P0 with an intrauterine pregnancy (IUP) at 24 weeks' gestation. She presents for her routine prenatal checkup. She has never had problems with blood pressure (BP). At her previous visit, her BP was 160/90 mm Hg. Now her vital sign: BP, 155/90 mm Hg; P, 85 beats/min; R, 12 breaths/min; T, 98F (37 C). She denies chest pain, denies shortness of breath, denies headache and blurry vision, denies abdominal pain and contractions, denies leakage of fluid, denies vaginal bleeding, fetal movement: present. Physical examination: cardiovascular: S1S2+ RRR no murmur, no rale, no gallop, lung: CTA bilaterally, extremities: 1+ edema, fundal height: 23 cm, fetal heart rate: 150s. What is the next step in the management of this patient?

55) A 32-year-old woman with a history of diabetes presents with an IUP at 5 weeks. She has been taking metformin, glyburide, and lisinopril. Her glucose has been well controlled on these medications. Vital sign: BP, 120/80 mm Hg; P, 75 beats/min; R, 12 breaths/min; T, 98°F (37 C). She denies leakage of fluid, denies contractions, denies fetal movement, denies vaginal bleeding, and denies abdominal pain. What is the next best step in the management?

56) A 28-year-old woman with no past medical history presents for her initial prenatal visit. Her last menstrual period (LMP) was 6 weeks ago. Vital sign: BP, 125/78 mmi P, 73 beats/mini R, 13 breaths/min, T: 98°F (37 C). She denies leakage of fluid, denies vaginal bleeding, denies fetal movement, and denies contractions, nausea and vomiting present. Labs: Complete blood count (CBC): white blood cells (WBCs); 8,000/ microL; hemoglobin (Hgb), 11.0 g/dL; hematocrit (Hct), 33.5%; platelets, 167,000/microL. CMP: Sodium, 128 mmol/ L; potassium, 4.5 mmol/L; chloride, 100 mmol/L; bicarbonate, 22 mmol/ L; blood urea nitrogen (BUN), 0.9 mg/dL; creatinine, 1 mg/dL; glucose, 97 mg/dL. Rubella IgG: positive. HIV: positive. CD4 count: 750. Viral load: 20,000 copies/mL. Hepatitis B sAg: Negative. HgbAlc: 5.6%. What is the next best step in the management of this patient?

57) A 32-year-old woman, gravida 1, para 0, with a history of infertility, underwent ovulation induction resulting in a twin pregnancy, now at 31 weeks’ gestation. An early obstetric sonogram at 7 weeks’ gestation showed dichorionic placentation. She has a positive group B –hemolytic streptococcus vaginal culture. Because of epigastric pain, vaginal bleeding, and uterine contractions, she is evaluated at the maternity unit. An obstetric sonogram shows twin A to be a female fetus in breech presentation and twin B to be a male fetus in transverse lie with the back down. The sonogram also shows a marginal anterior placenta previa. Her initial vital signs are as follows: temperature, 37.2C (99.0F); pulse, 95/min; respiration, 18/min; blood pressure, 165/115 mm Hg. Her urine dipstick test shows 2 glucose and 3 albumin. Which of the following is a contraindication to tocolysis in this case?

58) A 28-year-old primigravid woman comes to the outpatient prenatal clinic at 34 weeks’ gestation with a twin pregnancy. Her fundal height is 40 cm and the orientation of the fetuses in the uterus is cephalic–breech presentation. She was standing in the kitchen when she experienced a sudden gush of fluid that soaked her underwear and created a pool of fluid on the floor. Since then, she has had intermittent watery vaginal discharge for the past few days. She has had to wear a perineal pad for comfort. She denies dysuria or urinary burning but admits to urinary frequency. She is having occasional uterine contractions, up to three per hour. Which of the following is the most appropriate next step in the management of this patient?

59) A 24-year-old woman, gravida 4, para 1, abortus 2, is at 28 weeks’ gestation by poor dates. She admits to intravenous (IV) drug use and having sex for drugs. She is unsure who the father of this pregnancy is. She has recently undergone treatment for syphilis identified by a positive venereal disease research laboratory (VDRL) test result and confirmed by a positive fluorescent treponemal antibody (FTA) test. On her last prenatal visit, she underwent human immunodeficiency virus (HIV) testing by enzyme-linked immunosorbent assay (ELISA), which was found to be positive and was confirmed with a positive Western blot assay. She inquires as to the significance of this finding for herself, as well as her baby. Which of the following statements best summarizes what you will say about her medical conditions?

60) A 25-year-old woman comes to the outpatient office complaining of a pruritic, painful vaginal discharge. She is sexually active with two male sexual partners but finds intercourse very uncomfortable because of her vaginal symptoms. For the past 8 months, she has been using the estrogen–progestin contraceptive patch. She exercises regularly by walking 2 to 3 miles a day. She is following a low-carbohydrate diet and takes a multivitamin preparation. Findings of her general examination are unremarkable. Speculum examination of the vagina shows a foul-smelling greenish, frothy discharge. Vaginal pH, using Nitrazine paper, is 6.5. A wet mount of vaginal secretions in a saline suspension reveals a highly motile organism. Which of the following pharmacologic agents would be the most appropriate treatment?

61) An anxious 33-year-old woman, gravida 3, para 1, abortus 1, is seen for her first prenatal visit at 10 weeks’ gestation by dates. This was a planned pregnancy, and she discontinued the transdermal contraceptive patch 4 months ago. She is taking prenatal vitamins, including iron and folic acid. First trimester bleeding that progressed to hemorrhage complicated her first pregnancy, necessitating a suction dilatation and curettage at 8 weeks’ gestation. Her last pregnancy was uncomplicated prenatally. She went into spontaneous labor at 39 weeks’ gestation, progressing normally in labor with a reassuring electronic fetal heart rate monitor pattern. However, after an uncomplicated spontaneous vaginal delivery with neonatal Apgar scores of 8 and 9 at 1 and 5 minutes, respectively, her female neonate died on the second day of life from overwhelming group B -hemolytic streptococcal (GBS) infection. Which of the following statements best expresses what you will tell her about her current pregnancy?

62) Four hours ago, a 28-year-old woman, gravida 1, para 0, at 38 weeks’ gestation was admitted to the labor and delivery suite. On admission, she had regular uterine contractions occurring every 2–3 minutes, a dilation of 4 cm on cervical examination, effacement of 80%, and blood pressure of 115/75 mm Hg. The fetus is in longitudinal lie and cephalic presentation with an estimated weight of 3,500 g (7 lb 11 oz) by abdominal palpation. Her prenatal course was characterized by first-trimester bleeding that spontaneously resolved. Her blood pressure (BP) has gradually increased over the past 4 hours; it is now sustained at 150/95 mm Hg. Her patella deep tendon reflexes are brisk, but she has no clonus. A urine dipstick test shows 2 albumin. Administration of which of the following agents is indicated as the next step in management?

63) A 32-year-old woman who is 40 weeks pregnant comes to the maternity unit in active labor. She states that she has painful genital blisters and ulcers, which she has experienced intermittently in the past. Pelvic examination reveals exquisitely tender vesicles and ulcers on her labia and vagina consistent with an active genital herpes infection. She is advised by the obstetrician that she should undergo a primary cesarean section delivery because of the increased risk of fetal infection via passage through an infected birth canal. She is mentally competent and tells the obstetrician that she refuses to have a cesarean section because her mother died during a surgical procedure. Although the doctor explains the risks of a vaginal delivery, she still refuses. The obstetrician should do which of the following?

64) A 27-year-old primigravid woman presents for a prenatal visit at 32 weeks’ gestation. She complains of a severe headache and epigastric pain for 24 hours. The headache is not relieved by acetaminophen. The epigastric pain is unrelieved by antacids. Her blood pressure (BP) today is 165/115 mm Hg. A urine dipstick test shows 3+ proteinuria. Her blood pressure on her first prenatal visit at 12 weeks’ gestation was 120/70 mm Hg. She experienced severe nausea and vomiting during the first trimester, requiring antiemetic treatment, but her total pregnancy weight gain has been 22 pounds. She has taken thyroid replacement medication after undergoing iodine 131 (131I) treatment for Graves disease 5 years ago. Which of the following medications would be indicated in the treatment of this patient?

65) A 23-year-old woman with an 18-year history of insulin-dependent diabetes is brought to the emergency department by her date, who became alarmed by her acute mental confusion and sudden-onset bizarre behavior. He explains that they spent the day at the beach, where she had been very active, playing volley ball and swimming, and that they missed lunch but were on their way to eat dinner when this sudden change in behavior occurred. He states over and over again that they had not been using drugs or drinking alcohol. The triage nurse notes perspiration, increased salivation, restlessness, and tachycardia. Which of the following is the most appropriate next step in the management of this patient?

66) A 29-year-old G1P0 with an intrauterine pregnancy (IUP) at 37 weeks' gestation presents to the office for a routine prenatal visit. The patient states that she has a headache since this morning. She has no past medical history, no past surgical history, is taking no medications, and has no allergies. She denies visual disturbance, epigastric pain, nausea, and vomiting. Vital sign: BP, 150/90 mm Hg; P, 90 beats/min; R, beats/min; R, 16 breaths/min; T, 98.3°F (37.2 C). Fetal movement: Present. Contractions: Absent. Leakage of fluid: Absent. Vaginal bleeding: Absent. What is the next step in the management of this patient?

67) The patient continues to have a headache. She denies visual disturbances. Maternal Vital Sign: BP, 156/96 mm Hg; P, 89 beats/min Fetal Monitoring: Accelerations are present, good variability, no decelerations. Labs: CBC: White blood cells (WBCs), 6,300 /microL; hemoglobin (Hgb), 11.3 g/dL; hematocrit (Hct), 33.9%; platelets: 300,000/microL, CMP: Sodium, 127 mmol/L; potassium, 4. 7 mmol/L; chloride, 100 mmol/L; bicarbonate, 26 mmol/L; blood urea nitrogen (BUN), 10 mg/dL; creatinine, 0.9 mg/dL; glucose, 110 mg/dL, ALT: 22 IU/L, AST: 20 IU/L, Urinalysis: 2+ protein. What is the next step in the management of this patient?

68) A 29-year-old G2P1001 with an intrauterine pregnancy (IUP) at 8 weeks' gestation presents to the office for a routine prenatal examination. The patient states that with her first pregnancy, she was told that she had blood type 0 negative. She states that she read online that this could be a problem with the second pregnancy, and she is extremely concerned. Vital sign: BP, 115/75 mm Hg; P, 82 beats/min; R, 12 breaths/min; T, 98.6°F. Contractions: Absent. Vaginal bleeding: Absent. Leakage of fluid: Absent. Physical examination: CVS: Normal, Lungs: Normal, Abdomen: Nontender, nondistended, +Bowel Sound, Extremities: No edema. What is the next step in the management of this patient?

69) A 25-year-old Gl0 with an intrauterine pregnancy (IUP) at 38 weeks' gestation presents to the labor and delivery unit stating that she thinks she is in labor. She has had routine prenatal care. She states that she has generalized abdominal pain that comes and goes. Thepain has been going on for about 5 hours and is starting to become regular. She thinks it is contractions. Vital sign: BP, 115/75 mm Hg; P, 82 beats/min; R, 12 breaths/min; T, 98.6°F. Contractions: Present, Fetal movement: Present, Vaginal bleeding: Absent, Leakage of fluid: Absent. Physical examination: Gen: Awake, alert, oriented x3, mild pain distress, CVS: S1S2 + RRR no m/ r/ g, Lungs: CTA bilaterally, Abd: Gravid, Ext: 1+ edema bilaterally. What is the next step in the management of this patient?

70) A 34-year-old G2P1001 with an IUP at 38 weeks' gestation presents to labor and delivery for contractions. The patient states that she has had gestational diabetes that was diet controlled throughout her pregnancy. She states that she has had routine prenatal care. Vital sign: BP, 125/88 mm Hg; P, 95 beats/min; R, 12 breaths/min; T, 98.6°F. Contractions: Present, Fetal movement: Present. Physical examination: Gen: Awake, alert, oriented x3, mild pain distress, CVS: S1S2+ RRR no m/r/g, Vaginal bleeding: Absent, Leakage offluid: Present, Lungs: CTA bilaterally, Abd: Gravid, contractions present, Ext: 1+ edema bilaterally. Cervical Examination: 7 cm, 100% effaced, -1 station. Fetal Heart Monitoring: Reassuring, good variability, accelerations are present, no decelerations. What is the next step in the management of this patient?

71) A 27-year-old woman with an intrauterine pregnancy at 39 weeks' gestation presented in active labor. The patient becamefully dilated and delivered a baby boy 5 minutes ago. The patient then delivered the placenta without complication. There were no lacerations visualized ofthe cervix, vagina, or vulva. However, the patient is continuing to bleed. Vital sign: BP, 120/75 mm Hg; P, 95 beats/min; R, 12 breaths/min; T, 98.6°F. What is the next step in the management of this patient?

72) 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?

73) A 26-year-old woman G0P0 presents to the office for infertility. The patient states that she and her husband have been trying to conceive for almost 2 years without success. She menstruates regularly. Her cycles occur every 28 days with 5 or 6 days of bleeding. She does have some pain during menstruation but not more than usual. She has no medical, surgical, or sexually transmitted disease. The patient and her husband have sexual relations during ovulation on a daily basis. She has had multiple blood tests by her primary care provider (PCP), all of which are normal. BP, 120/80 mm Hg; P, 82 beats/min; R, 16 breaths/min; T, 97.8°F; body mass index (BMI), 24. Review of systems (ROS): Negative. Physical examination: Gen: Awake, alert, oriented x3, no acute distress, CVS: Normal, Lungs: Normal, Abd: Soft, nontender, nondistended, +bowel sounds, Pelvic exam: Within normal limits. Which of the following is most useful?

74) A 65-year-old woman with PMH of hypertension treated with lisinopril and hydrochlorothiazide (HCTZ) presents to the office for vaginal bleeding. The bleeding started last month. It was lighter than her menstruation used to be and lasted for 4 days. Vital sign: BP, 135/80 mm Hg; P, 76 beats/min; R, 18 breaths/min; T, 98.9°F. Review of system: No fever, chills, or weight loss, No chest pain or shortness of breath, No abdominal pain, nausea, vomiting, diarrhea, constipation, or distention. Physical examination: Gen: Awake, alert-oriented x3, no acute distress, CVS: S1S2 + RRR no m/r/g, Lungs: CTA bilaterally, Abd: Soft, nontender, nondistended, + bowel sounds, Ext: No edema, Pelvic: Cervix appears normal, no lacerations seen, bimanual examination findings within normal limits. What is the next step in the management of this patient?

75) A 14-year-old young woman with no PMH, no PSH presents to the office stating that she would like to begin birth control. She is sexually active with multiple male partners. Her last menstrual period (LMP) was 3 weeks ago. BP, 110/70 mm Hg; P, 82 beats/min; R, 16 breaths/min; T, 98.5°F. No fever, chills, abdominal pain, nausea, vomiting, diarrhea, constipation, chest-pain, shortness of breath, history of pulmonary embolism, or medical problems. Physical examination: Gen: Awake, alert, oriented x3, no acute distress, CVS: S1S2 + RRR no m/r/g, Lungs: CTA bilaterally, Abd: Soft, nontender, nondistended, + bowel sounds, Ext: no edema. Which of the following is the next step in the management of this patient?

76) A23-year-old woman with no PMH presents to the office for her annual gynecologic examination. She has never been pregnant. She has had five lifetime partners. She does not have vaginal discharge, vaginal pruritus, or dyspareunia. Her menstruation is regular every 28 days and lasts for 5 days. BP, 125/75 mm Hg; P, 78 beats/min; R, 16 breaths/min; T, 98.4°F. In addition to the Pap smear, what else is indicated?

77) 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?

78) A SO-year-old woman with no PMH presents f or a routine physical examination. The patient states that she has been pregnant three times. She has two children who were born fullterm and delivered vaginally. She had one miscarriage. She has been with her husband for the past 23 years. The patient started her menstruation at 15 years old and is currently going through perimenopause. Her LMP was 3 months ago. The patient states that she last had a Pap smear 2 years ago. All of her Pap smears have been normal. Vital sign: BP, 120/80 mm Hg; P, 80 beats/min; R, 17 breaths/min; T, 98.7 F. Review of system: Denies any complaints. Physical examination: Thyroid: Normal to palpation, Breast: Symmetric, nontender, no lesions felt, no nipple inversion, Cervix: Appears normal, no lesions seen. Which of the following is the next best step in the management of this patient?

79) A 52-year-old woman with a past medical history of hypertension presents for a lump in her breast. The patient noticed that her left breast was becoming slightly deformed and appears swollen on one side. The patient states that she first realized it when she was getting dressed about a month ago. She thought that it would go away on its own, but it seems to be growing. She is very concerned. BP, 136/82; P, 73 beats/min; R, 18 breaths/min; T, 98.6°F. Review of system: Denies weight loss, pain in the breast, nipple discharge, and erythema of the breast, Denies chest pain, shortness of breath, and abdominal pain. Physical examination: Gen: Awake, alert, oriented x3, no acute distress, Breasts: Asymmetric. Left breast slightly larger than right, with mass on left upper outer quadrant of breast. Thickening of skin in the same area. Palpation significant for a 2 in x 3 in mass in the left upper outer quadrant, nontender, nonmobile. The right breast is unremarkable. Which of the following the next step in the management of this patient?

80) A 32-year-old generally healthy woman presents to the office for a routine preemployment physical. She uses a vaginal ring for birth control. Her LMP was 2 weeks ago. She has been pregnant three times and has had two full-term births via normal spontaneous vaginal delivery. She had one spontaneous miscarriage at 10 weeks' gestation. She is only sexually active with her husband. She has a family history of breast cancer in her mother. Her mother had breast cancer at age 40 years and again at age 56 years. Her aunt also had breast cancer at an early age. Her last Pap smear, including human papillomavirus (HPV) was negative last year. BP, 120/80 mm Hg; P, 75 beats/min; R, 14 breaths/min; T, 98.4°F. Physical examination: Gen: Awake, alert, oriented x3, CVS: S1S2+ RRR no m/r/g, Lungs: Clear to auscultation bilaterally, Breast: No breast mass felt. What should be done as a part of the evaluation?

81) A 28-year-old woman presents to the office for her routine Pap smear. She has had eight lifetime partners but has recently gotten married. For the past 5 years, she has only been sexually active with her husband. All of her previous Pap smear results have been normal. She denies any history of STIs. She has never been pregnant, although she would like to become pregnant soon. She denies any vaginal discharge, abnormal vaginal bleeding, or dyspareunia. VS: BP, 120/80 mm Hg; P, 83 beats/min; R, 15 breaths/min; T, 98.3°F. Review: Entire ROS is negative. Physical examination: Pelvic examination was done. Pap smear completed. No cervical discharge, no cervical, Lesions present. Bimanual Exam: No cervical motion tenderness, no adnexal enlargement or tenderness, no uterine enlargement. What is the next step in the management of this patient?

82) A 32-year-old woman presents to the emergency department for left lower quadrant abdominal pain for thepast2 days. The patient states the pain is 8 of10 on the pain scale, non-radiating, and started off intermittent. The pain is now constant. She denies vomiting, diarrhea, and constipation but has nausea intermittently. Her last menstrual period was around 3 or 4 weeks ago. She has one sexual partner, and they have been trying to get pregnant. BP, 140/90 mm Hg; P, 90 beats/min; R, 15 breaths/min; T, 98.4°F. Review of system: Negative except for above. PE: Abd: Soft, tender in the left lower quadrant on palpation, + bowel sounds. Which of the following is the next step in the management of this patient?

83) A 34-year-old woman with no PMH presents to the office for intermittent left lower quadrant pain, nonradiating for the past 24 hours. She had her menstruation 1.5 weeks ago. She has no nausea, vomiting, diarrhea, or constipation. She denies dysuria, urinary urgency, and urinary frequency. BP, 122/84 mm Hg; P, 90; R, 13 breaths/min; T, 98.7°F. ROS: Denies fever and chills; AS per RPI. PE: Abd: soft, nondistended, left lower quadrant tenderness is present on superficial and deep palpation. The pain radiates toward the midline. Which of the following is the next step in the management of this patient?

84) A 45-year-old woman with no PMH presents to the office for an increase in abdominal fullness and bloating, worsening over the past 3 or 4 months. The patient states that she feels nauseous all the time, although has not had any vomiting. She states because of the constant nausea, she has not been eating as much. She has had a 10-lb weight loss in the last 4 months. BP, 110/70 mm Hg; P, 97; R, 18; T, 98.6°F. ROS: Denies fever and chills, Weight loss has occurred (10 lb in 4 months), Denies chest pain, shortness of breath, and abdominal pain, Nausea is present with no vomiting, No diarrhea or constipation. PE: Gen: Awake, alert, oriented x3, Abd: Soft, nontender, distended bowel sounds are present, shifting dullness to percussion is present, Pelvic: Cervix normal, no cervical motion tenderness, right adnexal enlargement is present. Which of the following is the next step in the management of this patient?