DES C_ParaClinic (2) Prepared : CHILLY

A 24-year-old Caucasian male undergoes pulmonary function testing. The following values are obtained: FEV 80% of predicted, FEV1/FVC 85%, FRC 110% of predicted. He has no current complaints except for occasional low back pain treated with naproxen. He smokes one pack per day and drinks a six-pack of beer each weekend. His ESR is 47 mm/hr. Which of the following best explains the pulmonary function test findings in this patient?

A 24-year-old Caucasian man is brought to the emergency room with acute asthma exacerbation. His current medications include inhaled fluticasone and salmeterol. The attack started 10 hours ago and did not respond to numerous albuterol inhalations and systemic steroids. His blood pressure is 120/70 mmHg and heart rate is 110/min. The patient is tachypneic and speaks with difficulty. Lung auscultation reveals decreased breath sounds, prolonged expiration, and bilateral wheezing. Pulse oximetry showed 86% at room air. ABG at room air are: pH 7.43, Po2 68 mmHg, PCO2 40mmHg. The chest x-ray demonstrates hyperinflated lungs. Which of the following findings indicates that the patient is getting worse?

A 24-year-old man woke up from sleep 1 hour ago with severe pain in his right testicle. He states that he is sexually active with multiple partners. On examination, the right scrotum is swollen, tender, and firm. You cannot elicit a cremasteric reflex. His BP is 145/75 mm Hg, HR is 103 beats per minute, RR is 14 breaths per minute, temperature is 98.9°F, and oxygen saturation is 99% on room air. Which of the following is the most appropriate next step in management?

A 24-year-old patient recently emigrated from the tropics. Four weeks ago she noted a small vulvar ulceration that spontaneously healed. Now there is painful inguinal adenopathy associated with malaise and fever. You are considering the diagnosis of lymphogranuloma venereum (LGV). The diagnosis can be established by which of the following?

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 white female is brought to the emergency department (ED) by her mother due to altered mental status. According to her mother, she suffered from viral gastroenteritis 4 days ago. Since then, she has been on oral fluids. Over the past 2 days, her condition had been deteriorating, but she kept refusing admission to the hospital. Her past history is not significant, except for excessive thirst, water intake and weight loss over the past two months. Her blood pressure is 100/56 mmHg, pulse is 120/min (regular and weak), temperature is 37.2°C (99°F), and respirations are 28/min (rapid and deep). Pulse oximetry is 94% on room air. She is arousable and moves all her extremities. Her mucous membranes are very dry. Her neck is supple. The chest is clear on auscultation. Which of the following is the most appropriate next step in management?

A 24-year-old woman comes to your office complaining of an 8-week history of amenorrhea. She is sexually active and uses OCPs for contraception. Her medical history is unremarkable. She does not have any particular complaints except moderate fatigue and a decline in mood. She denies headaches, visual disturbances, or any gastrointestinal symptoms. She denies cigarette smoking or any drug use, and drinks alcohol socially. Breast examination reveals a white, milky secretion upon expression of both nipples. A pelvic examination reveals a uterus of normal size. BMI is 28 kg/m2. Initial investigations reveal a negative serum beta-hCG level. According to these findings, which of the following is the most appropriate next step in the management of this patient?

A 24-year-old woman presents to the emergency department complaining of right lower quadrant pain and vaginal spotting. Her last menstrual period was 5 weeks ago. Her temperature is 37 C (98.6 F), blood pressure is 112/70 mm Hg, pulse is 74/min, and respirations are 14/min. The abdomen is soft and non-tender. Pelvic examination reveals scant blood in the vagina, a closed cervical os, no pelvic masses, and right pelvic tenderness. Her leukocyte count is 8000/mm3, hematocrit is 38%, and a platelet count is 250,000/mm3. Which of the following is the most appropriate step next in diagnosis?

A 24-year-old woman presents with nausea, vomiting, anorexia, and gross hematuria. She had a sore throat 2 weeks ago that resolved on its own. On examination, her blood pressure is 160/90 mm Hg, pulse 90/min, JVP is 7 cm, heart sounds are normal, there is 1+ pedal edema, and the lungs are clear. She has a renal biopsy. Which of the following electron microscopy findings on the renal biopsy is most likely in keeping with poststreptococcal GN?

A 24-year-old woman presents with new-onset right lower quadrant pain, and you palpate an enlarged, tender right adnexa. Which of the following sonographic characteristics of the cyst in this patient suggests the need for surgical exploration now instead of observation for one menstrual cycle?

A 24-year-old woman sustains multiple injuries in a car accident, including a pelvic fracture. She is hemodynamically stable. Initial assessment shows no vaginal or rectal injuries; however, when a Foley catheter is inserted, bloody urine is recovered. Which of the following would be the best way to evaluate her urologic injury?

A 24-year-old woman, G1 P1, comes to your office because she has been amenorrheic for two months. She has been taking low dose combined oral contraceptive pills (OCPs) for the past three months. She had withdrawal bleeding after the first month, but has had no bleeding over the past two months. Over the past few days, she has had nausea, vomiting and abdominal bloating. She does not use alcohol, tobacco, or drugs. Menarche occurred at the age of 14; menses have always been irregular. She is requesting a change in her contraception regimen because of these problems. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A 25-year-old female presents to her physician with a painful ulcerative lesion on her labia for the past 2 days. She also complains of dysuria. She admits to having sexual intercourse with multiple partners for the last 6 years. Tzanck preparations of one of her lesions reveal multi-nucleated giant cells. She is encouraged to undergo testing for HIV and other STDs. Which of the following is the most appropriate screening test for HIV infection?

A 25-year-old female presents to the emergency department with sudden-onset severe shortness of breath and wheezing. She has a history of asthma. On examination, she is unable to speak in full sentences and is using accessory muscles of respiration. She is intubated, mechanically ventilated and treated with continuous albuterol nebulization and intravenous methylprednisolone. Within six hours, her condition is improved. She is extubated and treated with hourly nebulizer treatments. The next morning, she complains of muscle weakness. On physical examination, she has difficulty lifting her arms over her head and mild hand tremors. Her vital signs are stable. What should be the immediate next step in her management?

A 25-year-old female presents to your office complaining of exertional dyspnea and fatigue. Her past medical history is insignificant. She does not smoke or consume alcohol. Her blood pressure is 110/70 mmHg and heart rate is 90/min. Physical examination reveals pale conjunctiva. The laboratory values are: ESR 15 mm/hr, Hemoglobin 7.5 g/dL, MCV 70 fl, MCHC 29%, Leukocyte count 7,000/cmm, Segmented Neutrophils 55%, Bands 3%, Eosinophils 3%, Basophils 0%, Lymphocytes 32%, Monocytes 7%. What is the best next step in the management of this patient?

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?

A 25-year-old male presents with progressive shortness of breath over the past 6 months. His past medical history is significant only for neonatal hepatitis that resolved spontaneously when he was 6 months of age. The man has never smoked. On lung auscultation today, there are decreased breath sounds over both lower lobes. Chest x-ray demonstrates emphysematous changes in the bilateral lower lobes. Routine blood work is normal. Which of the following analyses would be most helpful in establishing this patient's diagnosis?

A 25-year-old man is shot with a .22 caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, 5 cm below the groin crease. The exit wound is in the posterolateral aspect of the thigh, half way between the greater trochanter and the knee. He has palpable pulses in the dorsum of his foot and in the posterior tibial artery behind the malleolus. The popliteal pulse is reported normal by one examiner, but cannot be felt by another. There is no hematoma under the entrance wound, and blood is oozing from both wounds but not at an alarming rate. He is hemodynamically stable. Neurologic examination of the leg is normal. X-ray films show the femur to be intact. In addition to local wound care and the appropriate tetanus prophylaxis, which of the following is the most appropriate next step in management?

A 25-year-old nulligravid woman comes to the physician because of chronic pelvic and low sacral back pain for several months. The pain is usually worse premenstrually. She tried over the counter anti-inflammatory medications but had little relief. She has been in a monogamous relationship with her boyfriend for the past 4 years. She has no fever or abnormal vaginal discharge. Her temperature is 37.2 C (98.9 F), and blood pressure is 120/78 mm Hg. Physical examination shows tender posterior vaginal fornix and pain upon uterine motion. Complete blood count is normal. Pelvic ultrasonogram is normal. Urine pregnancy test is negative. Which of the following is most appropriate diagnostic test in her management?

A 25-year-old nulligravid woman comes to the physician because of constant pelvic and low sacral back pain for several months. The pain is usually worse premenstrually. She tried over the counter anti-inflammatory medications but had little relief. She has been in a monogamous relationship with her boyfriend for the past 4 years. She has no fever or abnormal vaginal discharge. Her temperature is 37.2 C (98.9 F), and blood pressure is 120/78 mm Hg. Physical examination shows tender posterior vaginal fornix and pain upon uterine motion. Complete blood count is normal. Pelvic ultrasonogram is normal. Which of the following is most appropriate diagnostic test in her management?

A 25-year-old postal worker presents with a pruritic, nonpainful skin lesion on the dorsum of his hand. It began like an insect bite but expanded over several days. On examination, the lesion has a black, necrotic center associated with severe local swelling. The patient does not appear to be systemically ill, and vital signs are normal. Which of the following is correct?

A 25-year-old who has been living in Washington, DC, presents with a diffuse vesicular rash over his face and trunk. He also has fever. He has no history of chickenpox and has not received the varicella vaccine. Which of the following information obtained from history and physical examination suggests that the patient has chickenpox and not smallpox?

A 25-year-old woman with end-stage renal disease is exploring the benefits of renal transplantation. Which of the following is an advantage of dialysis over renal transplantation?

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?

A 25-year-old woman, gravida 2 para 1, presents to your office at 20 weeks' gestation for a routine prenatal check-up. She is known to be 0 (-) while her husband is 0 (+). Her obstetric history is significant for intrapartum placental abruption, which did not require caesarian delivery. She received a standard dose of anti-0 immune globulin at 28 weeks of her first pregnancy and immediately postpartum. You decide to determine her anti-0 antibody titers, and they turn out to be 1:34. Which of the following is the most likely explanation of the positive antibody screen in this patient?

A 25-year-old woman, gravida 2 para 1, presents to your office at 20 weeks' gestation for a routine prenatal check-up. This pregnancy has been uncomplicated thus far. She is known to be D (-) while her husband is D (+). Her obstetric history is significant for intrapartum placental abruption, which did not require caesarian delivery. She received a standard dose of anti-D immune globulin at 28 weeks of her first pregnancy and immediately postpartum. You decide to determine her anti-D antibody titers, and they turn out to be 1:34. Which of the following is the most likely explanation of the positive antibody screen in this patient?

A 26-year-old Caucasian male comes to the physician because of severe productive cough for the past two months. He also complains of occasional blood in sputum, and dyspnea for the last three weeks. His past medical history is significant for otitis media, two episodes of pneumonia, and sinusitis. He and his wife were recently worked up for infertility. Physical examination shows crackles in the left upper lobe. Chest x-ray shows dilated and thickened airways and irregular peripheral opacities in the left upper lobe. Which of the following is the most appropriate test to make the diagnosis of his condition?

A 26-year-old G1P0 patient at 34 weeks gestation is being evaluated with Doppler ultrasound studies of the fetal umbilical arteries. The patient is a healthy smoker. Her fetus has shown evidence of intrauterine growth restriction (IUGR) on previous ultrasound examinations. The Doppler studies currently show that the systolic to diastolic ratio (S/D) in the umbilical arteries is much higher than it was on her last ultrasound 3 weeks ago and there is now reverse diastolic flow. Which of the following is correct information to share with the patient?

A 26-year-old man presents with a 1-week history of intermittent, crampy, lower abdominal pain accompanied by rectal urgency, bloody diarrhea, nausea and vomiting. His symptoms have become more severe over the past 24 hours. His past medical history is unremarkable. He denies any recent travel or antibiotic use. His temperature is 38.5°C (102.0°F), blood pressure is 120/80 mmHg, pulse is 95/min, and respirations are 15/min. Abdominal examination reveals distension and tenderness to palpation without rebound or guarding. The bowel sounds are decreased. Rectal examination shows marked rectal tenderness and mucus mixed with blood in the vault. An x-ray film of the abdomen shows distended colon filled with gas. Laboratory studies show: Hb 10.8 g/dl, WBC 19,600/cmm, Platelet count 459,000/cmm, ESR 54/hr. Which of the following is the most appropriate next step in management?

A 26-year-old nulligravid patient presents to her physician seeking preconceptional advice. She plans to conceive in about 1 year. Her past medical history is significant for chickenpox as a child. She had an appendectomy 2 years ago. She takes no medications and is allergic to penicillin. Her complete physical examination, including a pelvic examination, is unremarkable. Which of the following is the most appropriate next step in diagnosis to prevent morbidity in this patient's offspring?

A 26-year-old white female presents with worsening weakness of her right upper extremity, left lower extremity and ataxia. She also complains of unilateral eye pain and visual loss. The eye pain is worsened by ocular movements. On eye examination, there is a central visual field defect in her right eye. Fundoscopy is normal. Neurological examination shows spastic paraparesis in the right upper extremity and the left lower extremity. What is the most appropriate next step in this patient's management?

A 26-year-old woman presents for evaluation of infertility. She describes her menstrual cycles as irregular stating that they occur anywhere between 32 to 35 days. She has no galactorrhea. She eats a balanced diet and exercises regularly. She has no other medical problems. Her BMI is 22 Kg/m2. Physical examination is unremarkable. Which of the following is the most appropriate initial test to evaluate her infertility?

A 26-year-old woman, gravida 3, para 2, comes to the physician for the first time for a prenatal checkup. She changed her physician and in the interim has missed two prenatal checkups. She states that she is at 7months gestation. According to her prenatal records and an ultrasound performed at 16 weeks gestation, she is now at 30 weeks, but her fundal height is only 26 cm (10.2 inches). Fetal heart tones are heard by Doppler. Blood pressure is 140/90 mm Hg. You suspect fetal growth restriction (FGR) and order a repeat ultrasonogram. Which of the following is the single most useful parameter for predicting fetal weight by ultrasonogram in suspected FGR?

A 27 year-old African-American woman presents to the emergency room complaining of unilateral leg swelling, pleuritic chest pain and shortness of breath. She reports a rash on her face that worsens in the sun, two previous miscarriages, and complains of recent painful swelling in both knees. A CT angiogram confirms a pulmonary embolus. Which of the following is the most likely laboratory abnormality?

A 27-year old woman comes to the physician for evaluation of infertility. She and her 31-year-old husband have not been able to conceive after 12 months of unprotected and frequent intercourse. She has regular 28-day menstrual cycles and during the menstrual cycles she develops mild pelvic pain and bilateral breast tenderness. She has no pain during sexual intercourse. Her blood pressure is 128/76 mm Hg and pulse is 82/min. Physical examination is completely unremarkable. Which of the following could most likely be abnormal in this patient?

A 27-year-old Caucasian male is diagnosed with medullary thyroid carcinoma that is non-resectable. His past medical history is insignificant. He does not smoke or consume alcohol. His family history is significant for thyroid cancer and pheochromocytoma in his father. Which of the following tests could have been most effective in preventing this patient's non-resectable cancer?

A 27-year-old G2P1 at 29 weeks gestational age, who is being followed for Rh isoimmunization presents for her OB visit. The fundal height is noted to be 33 cm. An ultrasound reveals fetal ascites and a pericardial effusion. Which of the following can be another finding in fetal hydrops?

A 27-year-old healthy woman comes to the office for evaluation of infertility. She and her 31 -year-old husband have not been able to conceive after 12 months of unprotected and frequent intercourse. Her husband is healthy and takes no medications. He has a normal semen analysis. She has regular 28-day menstrual cycles. The patient has mid-cycle pelvic pain and an egg white like consistency to her discharge mid-cycle. She has no pain during sexual intercourse. The patient does report having been hospitalized with a pelvic infection in her late teens, during which time she had pain with intercourse, discharge, and fever. Her sister was diagnosed with polycystic ovarian disease. Her blood pressure is 128/76 mm Hg and pulse is 82/min. Physical examination shows no abnormalities. Which of the following is most likely to be abnormal in this patient?

A 27-year-old man complains of difficulty in walking. He noticed leg weakness several days ago, and now he is barely able to walk. He also complains of mild back pain and foot numbness. Two weeks ago, he had an upper respiratory tract infection. Physical examination reveals lower extremity muscle weakness, absent knee and ankle reflexes, and minimal sensory loss. Spinal MRI shows no abnormalities. Which of the following findings would you expect on CSF analysis in this patient? (Protein, WBC, count RBC, count Glucose)

A 27-year-old man complains of poor appetite, loss of interest in his daily activities, and impaired sleep. He has lost 10 pounds over the last two months. He says that he feels regretful about IV drug abuse in his past, but denies having suicidal or homicidal thoughts. He drinks alcohol occasionally but denies regular alcohol consumption or early morning drinking. He is sexually active with one partner and she uses oral contraceptives. On physical examination, his pulse is 76/min and his blood pressure is 110/70 mm Hg. His heart and lung exams are unremarkable and his abdomen is soft and non-tender. The liver span is 9 cm and the spleen is not palpable. He is fully oriented to person, place and time but performs poorly on memory tests. Which of the following is the best next step in managing this patient?

A 27-year-old man is seen in the ED for a leak around a surgical G-tube that was placed 2 weeks ago and has been used for enteral feeding for 1 week. Inspection reveals the tube is pulled out from the stoma, but is still in the cutaneous tissue. The abdomen is soft and nondistended and there are no signs of skin infection. Which of the following is the most appropriate next step in management?

A 27-year-old man presents with diarrhea. He returned 3 weeks ago from a trip to rural South America. Over the past few days, he has gradually developed lower abdominal pain and diarrhea. Now the symptoms are much worse with eight stools a day consisting mostly of mucus and blood. He is afebrile, the abdomen is tender in left lower quadrant, and the remaining examination is normal. His stool is mostly comprised of blood and mucus. Which of the following is the most appropriate initial diagnostic test?

A 27-year-old man was assaulted and stabbed on the left side of the chest between the areola and the sternum. He is hemodynamically unstable with jugular venous distention, distant heart sounds, and hypotension. Which of the following findings would be consistent with a diagnosis of hemodynamically significant cardiac tamponade?

A 27-year-old woman comes to the physician for preconception counseling. She takes no medication. Her menses are regular, are moderate in amount, and last 5-6 days. Her diet is well balanced. Her grandparents are from Greece. Her husband's family is also of Mediterranean ancestry. Her mother and sister have been diagnosed with anemia, but she does not know the types. The presence of thalassemia anemia in her family is suspected. Which of the following is the most appropriate initial screening test?

A 27-year-old woman complains of fatigue, low-grade fevers, anorexia, headaches and skin rash over the past several weeks. She also notes new exertional dyspnea and an unintentional 5-pound weight gain over the past two weeks. On physical examination, her blood pressure is 190/110 mmHg and her heart rate is 90/min. Which of the following is the most likely finding on this patient's urinary tests?

A 27-year-old woman presents to the office due to a significant amount of hair on her cheeks, chin and upper lips. This symptom developed over the past two months. Her last menstrual period was 12 weeks ago, but she did not seek medical help because her home pregnancy test was negative. Her medical history is unremarkable. She denies taking any medications other than oral contraceptive pills. Physical examination reveals acne on the forehead and cheeks; there is terminal hair on the upper lip, cheeks, chin, upper chest and lower abdomen. Examination of the genitals shows clitoromegaly. The abdominal exam is normal; the uterus is normal in size. Ultrasound reveals a normal uterus and ovaries, but there is a left adrenal mass. Which of the following measurements is most specific for this patient's condition?

A 27-year-old woman, gravida 2, para 1, at 12 weeks gestation comes to the physician because of a dark brown vaginal discharge. She had a mild brown vaginal discharge 3 weeks ago, which resolved without any intervention. She noticed similar discharge again two days ago. For the past two weeks, she has not had nausea or breast tenderness, which she used to have before. She does not use tobacco, alcohol or drugs. Her temperature is 37.0C (98.7F), blood pressure is 110/60 mmHg, pulse is 85/min and respirations are 15/min. Physical examination shows a soft uterus and a closed cervix. Fetal heart tones are not present. Which of the following is the most appropriate next step in management?

A 28-year-old Caucasian female presents to the emergency department (ED) appearing very anxious. She is accompanied by her boyfriend. She woke up this morning with severe weakness over the right side of her body. The weakness came on all of a sudden, but gradually resolved during the day. She denies any sensory symptoms. Her boyfriend reports that her speech was "weird, almost as if she was stuttering or struggling to get her words out." This too has resolved. The patient denies any other symptoms. The only other history of note is that she returned from a holiday in Italy 2 days ago. Vitals signs are unremarkable. The neurological examination is normal. Her chest x-ray is within normal limits. EKG shows normal sinus rhythm with a rate of 82/min. An urgent head CT scan is within normal limits. Which of the following investigations is most likely to reveal the underlying cause of this episode?

A 28-year-old G2, P 1woman in her 26th week of gestation comes to the office due to intermittent episodes of abdominal pain. She has been having these episodes for the past 4 days, and thinks that her fetus may be in distress. She points to her right flank when asked about the location of the pain, and says that it occasionally radiates to the groin area. She cannot identify any exacerbating or relieving factors. Her pregnancy has been uncomplicated so far. Her past medical history is significant for pelvic inflammatory disease. Her temperature is 37.5 C (99.5 F), blood pressure is 130/80 mm Hg, and pulse is 88/min. She is in considerable pain at the moment. Deep palpation of the right flank reveals tenderness. There is no CVA tenderness. Urinalysis shows: Specific gravity: 1.020, Blood: ++, Glucose: negative, Ketones: negative, Protein: negative, Leukocyte esterase: negative, Nitrites: negative. What is the best next step in the management of this patient?

A 28-year-old G3P2 woman at 32 weeks gestation comes to the physician because she has felt only 2 or 3 fetal movements in the past 12 hours. As in her previous pregnancies, she has gestational diabetes, which is under good control with diet and mild exercise. The patient does not use tobacco, alcohol, or illicit drugs. Vital signs are normal. Physical examination is unremarkable. Fetal heart tones are heard by Doppler. Which of the following is the most appropriate next step in management of this patient?

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?

A 28-year-old man presents with coughing up blood and sputum. He gives a history of recurrent pneumonias and a chronic cough productive of foul-smelling purulent sputum. He has no other past medical history and is a lifetime nonsmoker. On physical examination, there are no oral lesions, heart sounds are normal, and wet inspiratory crackles are heard at the lung bases posteriorly. He also has clubbing of his fingers, but there is no hepatosplenomegaly or any palpable lymph nodes. CXR show fibrosis and pulmonary infiltrates in the right lower lung. Which of the following is the most appropriate initial diagnostic test?

A 28-year-old nulligravid patient complains of bleeding between her periods and increasingly heavy menses. Over the past 9 months, she has had two dilation and curettages (D&Cs), which have failed to resolve her symptoms, and oral contraceptives and antiprostaglandins have not decreased the abnormal bleeding. Which of the following options is most appropriate at this time?

A 28-year-old primigravid woman at 8 weeks' gestation comes to the physician for her first prenatal visit. A home pregnancy test was positive. She has no complaints. She is concerned, however, because she is a carrier of the fragile X mutation. Her husband is also known to be a carrier. This is a highly desired pregnancy. She wants to know whether there is a way to determine whether the fetus is affected. Which of the following is the most appropriate next step in management?

A 28-year-old primigravid woman at term comes to the labor and delivery ward with a gush of fluid and regular contractions. Her prenatal course was remarkable for her being Rh negative and antibody negative. Her husband is Rh positive. Over the following 10 hours, she progresses in labor and delivers a 3600-g boy via a normal spontaneous vaginal delivery. The placenta does not deliver spontaneously, and a manual removal is required. To determine the correct amount of RhoGAM (anti-D immune globulin) that should be given, which of the following is the most appropriate laboratory test to send?

A 28-year-old primigravid woman comes to the physician for a follow-up prenatal visit. According to prenatal records, ultrasound at 16 weeks gestation showed an intrauterine gestation consistent with dates and showed no abnormalities. She is now at 40 weeks gestation. Examination shows a fundal height consistent with dates and the cervix is not favorable. Fetal heart tracing is reassuring. She wishes to continue the pregnancy for two more weeks rather than undergoing induction. She should be closely monitored for which of the following?

A 28-year-old white female presents to the office for the evaluation of goiter. She denies any recent change in appetite or weight, diarrhea, constipation, heat or cold intolerance, dyspnea and hoarseness. Her menses are normal and regular. Examination shows a symmetrically enlarged, non-tender, firm and rubbery thyroid gland. There is no lymphadenopathy. The rest of the physical examination is normal. Laboratory studies reveal an elevated serum TSH level with normal T4 and T3 levels. Serological testing for Hashimoto's thyroiditis is ordered. Which of the following are the most prevalent antibodies in patients with Hashimoto's thyroiditis?

A 28-year-old woman comes to the physician for routine physical examination and a Pap smear. She has had multiple sexual partners and uses barrier methods for contraception. She was treated for chlamydial cervicitis four months ago. She has no other medical problems. Pelvic examination is unremarkable and a Pap smear was performed. A week later the result came as "satisfactory for evaluation" and shows mild dysplasia (low grade intraepitheliallesion). Which of the following is the most appropriate next step in management?

A 28-year-old woman is admitted for delivery. She began experiencing regular, painful uterine contractions three hours ago and her water broke en route to the hospital. The cervix is 5 cm dilated and 80% effaced. The fetal presentation is vertex and the baby's head is at -1 station. After placing a fetal heart monitor and external tocometer, repetitive decreases in fetal heart rate are noted which begin at the same time as the contractions and end before the contractions have ceased. Which of the following is most likely responsible for the fetal heart pattern?

A 28-year-old woman presents 4 weeks after delivering her first child with a low-grade fever and pain in her right breast. She states that she has been breast feeding her newborn infant. Physical examination finds this breast to be tender, swollen, and erythematous. Microscopic examination of nipple smears from this woman would most likely reveal large numbers of which of the following types of cells?

A 28-year-old woman presents to your office with symptoms of a urinary tract infection. This is her second infection in 2 months. You treated the last infection with Bactrim DS for 3 days. Her symptoms never really improved. Now she has worsening lower abdominal discomfort, dysuria, and frequency. She has had no fever or flank pain. Physical examination shows only mild suprapubic tenderness. Which of the following is the best next step in the evaluation of this patient?

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?

A 28-year-old woman, gravida 3, para 2, at 28 weeks gestation comes to the physician because she has only felt 2-3 fetal movements in the past 12 hours. As in her previous pregnancies, she has gestational diabetes, which is under good control with diet and mild exercise. She does not use tobacco, alcohol or drugs. Vital signs are normal. Physical examination is unremarkable. Fetal heart tones are heard. Which of the following is the next most appropriate step in management?

A 29-year-old female is brought to the emergency department due to paraplegia, urinary incontinence and urgency. She denies any trauma. She has a history of trigeminal neuralgia. The neurological examination shows spasticity and hyperreflexia in the lower extremities, and impaired vibration and proprioception in her left forearm. Which of the following is the most likely finding in this patient's cerebrospinal fluid (CSF) examination?

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?

A 29-year-old man is brought to the hospital because he was found running around on the streets with no shoes on in the middle of winter, screaming to everyone that he was going to be elected president. Upon admission to the hospital, he was stabilized on olanzapine and lithium and then discharged home. Assuming the patient is maintained on the olanzapine and the lithium, which of the following tests should be performed at least once per year?

A 29-year-old woman comes to the physician for follow-up of a right breast lump. The patient first noticed the lump 4 months ago. It was aspirated at that time, and cytology was negative, but the cyst recurred about 1 month later. The cyst was re-aspirated 2 months ago and, again, the cytology was negative. The lump has recurred. Examination reveals a mass at 10 o'clock, approximately 4 cm from the areola. Ultrasound demonstrates a cystic lesion. Which of the following is the most appropriate next step in management?

A 29-year-old woman presents for her first prenatal visit. She is 10 weeks pregnant as determined by her last menstrual period. She does not have any medical problems and does not take any medications. She is devoutly religious and has been in a monogamous relationship with her husband since getting married 5 years ago. They live in a house built in 1983 where she works as a homemaker. Her husband is an accountant. She does not smoke cigarettes or drink alcohol. Her physical exam is within normal limits. Which of the following screening tests is indicated at this time?

A 29-year-old woman presents with chest pain and exertional dyspnea of 10days duration. Her medical history is significant for a normal spontaneous vaginal delivery three months ago, after which she has had frequent episodes of dark bloody vaginal discharge. The most recent bleeding episode was 6 days ago. The patient denies fever, chills, hemoptysis, orthopnea, or leg pain. She does not smoke cigarettes, drink alcohol, or use illicit drugs. Her temperature is 37.7°C (98.9°F), pulse is 80/min, blood pressure is 110/68 mmHg and respirations are 16/min. Examination shows clear lungs. Pelvic examination shows an enlarged uterus. Complete blood count and serum electrolytes are within normal limits. Chest radiographs reveal multiple bilateral infiltrates of various shapes. Which of the following investigations will be most helpful in establishing the diagnosis?

A 29-year-old woman presents with severe pain during menstruation (dysmenorrhea). During workup, an endometrial biopsy is obtained. The pathology report from this specimen makes the diagnosis of chronic endometritis. Based on this pathology report, which of the following was present in the biopsy sample of the endometrium?

A 3-day-old, full-term baby boy is brought into the emergency department because of feeding intolerance and bilious vomiting. X-rays films show multiple dilated loops of small bowel and a "ground glass" appearance in the lower abdomen. The mother has cystic fibrosis. Which of the following diagnostic tests would also have therapeutic value?

A 3-month old infant is brought to a pediatrician's office because of increased lethargy and irritability. The parents state that the child rolled off the couch and fell on the floor one day prior to presentation. His parents report that the child has been previously healthy and is up to date on his vaccinations. He has been meeting his development milestones. His fontanelles are full. While in office the patient develops a tonic-clonic seizure. Which of the following is the next appropriate step?

A 3-year-old African American boy is brought to the emergency department with sudden onset of difficulty walking. His mother reports that his right hand also seems "clumsy." The boy's past medical history is significant for a hospitalization one year ago for severe upper extremity pain and hand swelling. On physical examination, he has a blood pressure of 90/60 mmHg, heart rate of 120/min, temperature of 36.7°C (98°F), and respiratory rate of 22/min. Which of the following would be most helpful in diagnosing his condition?

A 3-year-old boy is admitted for seizure-like activity. He has been a healthy child and has been meeting all development milestones. His immunization schedule is up-to-date. Examination is notable for an erythematous throat and fever. His convulsions require IV administration of a benzodiazepine. Serum analysis reveals a normal white cell count with mild basophilic stippling. The lumbar puncture reveals elevated CSF pressure. Head CT scan is notable for cerebral edema. Which of the following is the next diagnostic step?

A 3-year-old boy is brought to the ER with a two-day history of decreased appetite, neck swelling, and irritability. He keeps his head rotated slightly to the right side. He resists passive flexion of the neck and rotation to the left side. Which of the following is the best next step in managing this patient?

A 3-year-old boy of African descent is brought to your office by his stepfather because of easy bruising. He says that the child bruises easily even without trauma. The child started playing games by himself recently. He has a past history of clavicular fracture, which the stepfather attributes to a fall down a set of stairs. The history of the biological father is unknown. On examination, there is a right knee effusion with decreased range of motion, and multiple soft tissue hematomas on the thigh. What is the most appropriate diagnostic step in management?

A 3-year-old child presents to your office for an evaluation of constipation. The mother notes that since birth, and despite frequent use of stool softeners, the child has only about one stool per week. He does not have fecal soiling or diarrhea. He was born at term and without pregnancy complications. The child stayed an extra day in the hospital at birth because he did not pass stool for 48 hours, but has not been in the hospital since. Initial evaluation of this child should include which of the following?

A 3-year-old girl is brought to the pediatrician with complaints of abdominal pain and fever. Her mother states that the fever started 2 days ago, with the highest temperature being 39.0 C (102.2 F). She has had no vomiting or diarrhea. The mother states that her daughter has been complaining of pain on urination. On examination, she is tender in her lower abdomen, and there is some right-sided costovertebral angle tenderness. A urinalysis confirms the suspicion of a urinary tract infection. Which of the following would be the most appropriate diagnostic procedure?

A 3-year-old girl with a ventricular septal defect (VSD) presents to the emergency department after a 15-minute focal seizure of her left arm and leg. A brief history reveals that the child has no known seizure disorder and has been having a low-grade fever at home for about 4 days. She also has been less active and has had poor appetite. On physical examination, her temperature is 40.2 C (104.3 F), and her pulse is 82/min. She is not responsive to her name, but she is responsive to painful stimuli with withdrawal of her extremities. Cardiac examination is significant for a grade 3 systolic murmur best heard at the left lower sternal border. Neurologic examination reveals anisocoria with a dilated right pupil. After stabilization, which of the following is the most appropriate next step in diagnosis?

A 30-hour-old infant has not passed meconium since birth. He was full term with a birth weight of 3856 g (8 lb 8 oz). The pregnancy was uncomplicated. The baby appears well with no respiratory distress. Slight abdominal distention is noted. Rectal examination reveals a slightly tight rectum and results in a greenish gush of stool. Which of the following tests will probably confirm the likely diagnosis?

A 30-year old woman has irregular menses. She reports that her last menstrual period (LMP) was 8 weeks ago. She has been experiencing vaginal spotting and left lower quadrant pain. She is afebrile. She has a normal size uterus and mild tenderness in the right lower quadrant with no rebound tenderness. A human chorionic gonadotropin (hCG) beta-subunit level of 1400 mIU/ml is reported in her records from an obstetrics visit 2 days ago. Which of the following is the appropriate management?

A 30-year-old black female has a 2-month history of non-productive cough and a painful skin eruption in the lower extremities. She denies fever or weight loss. Physical examination shows several non-tenders raised plaques around the nares and scattered similar plaques around the base of the neck. In the lower extremities she has several erythematous tender non-ulcerated nodules, measuring up to 4 cm in diameter. Chest x-ray reveals bilateral hilar adenopathy and a streaky interstitial density in the right upper lobe. What is the best way to establish a histological diagnosis?

A 30-year-old G1P0 with a twin gestation at 25 weeks presents to labor and delivery complaining of irregular uterine contractions and back pain. She reports an increase in the amount of her vaginal discharge, but denies any rupture of membranes. She reports that earlier in the day she had some very light vaginal bleeding, which has now resolved. On arrival to labor and delivery, she is placed on an external fetal monitor, which indicates uterine contractions every 2 to 4 minutes. She is afebrile and her vital signs are all normal. Her gravid uterus is non tender. The nurses call you to evaluate the patient. Which of the following is the most appropriate first step in the valuation of vaginal bleeding in this patient?

A 30-year-old male comes to the emergency department screaming, "Something blew into my right eye while I was drilling !' He complains of a foreign body sensation in the right eye, photophobia, and excessive lacrimation. Gross examination of the right eye with a penlight after the application of a topical anesthetic is insignificant. What is the best next step in the management of this patient?

A 30-year-old male with sickle cell anemia is admitted with cough, rusty sputum, and a single shaking chill. Physical examination reveals increased tactile fremitus and bronchial breath sounds in the left posterior chest. The patient is able to expectorate a purulent sample. Which of the following best describes the role of sputum Gram stain and culture?

A 30-year-old obese woman comes to the physician with a six-month history of oligomenorrhea. She has never had this problem before. She has no galactorrhea. She has gained significant weight over the past two years despite a regular exercise program. She has also experienced hair loss during this time. She has had regular Pap smears since the age of 21; none of which have shown any abnormalities. She takes no medications. She does not use tobacco, alcohol, or drugs. Her mother has a history of endometrial carcinoma and her grandmother had a history of ovarian carcinoma. Physical examination shows male pattern baldness. Abdominal and pelvic examination shows no abnormalities. A urine pregnancy test is negative. Serum prolactin level and thyroid function tests are normal. Which of the following is indicated in the initial workup of this patient?

A 30-year-old white female presents with an attack of common migraine. This is her fourth attack of migraine over the last 4 months. Her attacks previously responded well to aspirin and ibuprofen; however, her current headache is very severe and not relieved by NSAIDs. She has been trying to conceive for the past 2 months. Six years ago, she was treated with isoniazid due to a positive PPD test. Her father died at the age of 45 from an acute myocardial infarction. Before starting therapy with serotonin agonists (e.g., sumatriptan), which of the following tests should be performed in this patient?

A 30-year-old woman presents for a physical examination for work. She denies any medical problems or surgeries in the past. She has had no pregnancies. She is sexually active and has been using oral contraceptive pills for the past 6 years. She denies any allergies to medications. On examination, her weight is 62 kg, blood pressure 120/78 mm Hg, pulse 76 beats per minute, respiratory rate 15 breaths per minute, temperature 36.8C (98.4F). Her physical examination is normal. Laboratory evaluation is also done. Which direct effect of birth control pills could be noted in the laboratory results?

A 30-year-old woman presents with a 5-month history of episodic retrosternal pain that radiates to the interscapular region. The pain episodes typically last 15 minutes, and are precipitated by emotional stress and hot or cold food. Her relative gave her sublingual nitroglycerine tablets, which alleviated the pain. Her past medical history is unremarkable, and she does not take any other medications. There is no family history of coronary artery disease. Her vital signs are within normal limits. Physical examination shows no abnormalities. A lipid profile is within normal limits. An EKG shows a normal sinus rhythm. A stress test fails to reproduce the symptoms or to induce ST/T wave changes. Chest x-ray, upper GI endoscopy, and echocardiography show no abnormalities. Which of the following is the most appropriate next step in diagnosis?

A 30-year-old woman, gravida 3, para 2, at 26 weeks gestation comes to the physician because of a decrease in fetal movements. She has felt few fetal kicks the past 20 hours. Her prenatal course, prenatal tests and fetal growth have been normal. She has chronic hypertension and is now taking methyldopa and labetalol. Her previous pregnancies were uncomplicated and both delivered vaginally. She does not use tobacco, alcohol or drugs. Fetal heart tones are heard by Doppler. Non-stress test is reactive. Which of the following is the most appropriate next step in management?

A 3010-g (6.6-lb) boy was born to a 37-year-old primagravida by spontaneous vaginal delivery after an uncomplicated pregnancy. On examination he has cyanotic extremities and a significant right precordial heave, a single S2, and a harsh systolic ejection murmur along the sternal border. He also has a prominent squared nose and cleft palate. An echocardiogram is subsequently performed and demonstrates tetralogy of Fallot. Corrective surgery is performed without complications. At 2 months of age the infant is diagnosed with Pneumocystis jiroveci pneumonia, and at 3 months he is diagnosed with fungal septicemia. Additional work-up of this child should include which of the following tests?

A 31-year-old man is brought by helicopter to the trauma center after a motor vehicle accident in which he sustained massive lower extremity crush injury. The patient is alert and awake but in tremendous pain. His blood pressure is 140/80 mm Hg, and his pulse is 110/min. There is copious ongoing blood loss from the sites of injury. Urgent laboratory data will most likely show which of the following electrolyte abnormalities?

A 31-year-old woman presents to the emergency department complaining of shortness of breath. She denies associated chest pain or palpitations. She tells you that she recently returned from a trip to Thailand. She smokes one pack of cigarettes per day and drinks alcohol occasionally. She is married and uses oral contraceptives. She has no significant past medical history. On physical examination, her blood pressure is 110/70 mmHg and her heart rate is 120/min. A negative result on which of the following tests would best exclude pulmonary venous thromboembolism in this patient?

A 32-year-old Caucasian female presents to your office with persistent cough and shortness of breath. She has had three episodes of pneumonia over the last year. She had severe sinusitis one year ago, and an episode of bloody diarrhea that required hospitalization and IV antibiotic therapy six months ago. She does not smoke or consume alcohol. She denies any illicit drug use. She is currently not taking any medications. All her immunizations are up-to-date. Her blood pressure is 130/80 mmHg and heart rate is 90/min. Physical examination reveals fine crackles over the right lower lung lobe. No lower extremity edema is present. Neck palpation does not reveal any lymph node enlargement. The chest x-ray shows right lower lobe infiltrates and left upper lobe fibrosis. The ECG reveals non-specific ST segment and T wave changes. What is the best next step in the management of this patient?

A 32-year-old Caucasian primigravida presents to your office in her 30'" week of pregnancy. On review of systems, she complains of leg swelling and occasional heartburn. She denies abdominal pain or vaginal discharge. She eats a balanced diet and takes folic acid supplements. Her blood pressure is 165/100 mmHg and her heart rate is 90/min. Which of the following additional findings is most likely in this patient?

A 32-year-old female from South America presents with a 3-month history of progressive difficulty with swallowing for both liquids and solids. At night she has a bitter taste in her mouth. Over the past two months, she has had a 10 lb (4.54 kg) weight loss. She has not had any previous illnesses, and does not take any medication. Physical examination is unremarkable. A lateral x-ray film of the chest shows extreme dilatation of the esophagus with an air fluid level. Which of the following is the diagnostic test for this patient's condition?

A 32-year-old female is being evaluated for abnormal uterine bleeding. A urine pregnancy test is negative. Pelvic ultrasound reveals endometrial hyperplasia and a right-sided adnexal mass. In this patient, the adnexal mass is most likely to be a?

A 32-year-old female is brought to the clinic by her husband because he believes she is a malingerer and is "just being difficult." Sometimes, she appears confused and disoriented. Over the past year, she has complained of visual loss, eye pain and inability to do any household chores. Two months ago, she claimed to have lost control of her bladder. Interestingly, she is "her normal self" when it is time to go for summer trips. The wife insists that she does not understand what is happening to her, and adds that she occasionally loses the ability to move her right hand. The physical examination is basically normal. The patient appears, alert, oriented, and is in no distress. Which of the following is the most appropriate next step in management?

A 32-year-old male presents to your office with concern about progressive fatigue and lower extremity edema. He has experienced decreased exercise tolerance over the past few months, and occasionally awakens coughing at night. Past medical history is significant for sickle cell anemia and diabetes mellitus. He has had multiple admissions to the hospital secondary to vasoocclusive crises since the age of three. Physical examination reveals a displaced PMI, but is otherwise unremarkable. ECG shows a first degree AV block and low voltage. Chest x-ray shows an enlarged cardiac silhouette with clear lung fields. Which of the following would be the best initial diagnostic approach?

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?

A 32-year-old multiparous African-American woman comes for her initial prenatal visit at 14 weeks gestation. She complains of the recent appearance of facial hair and acne. The beta-HCG level is consistent with gestational age. Examination shows hirsutism. Ultrasonogram shows an intrauterine gestation consistent with dates and bilateral solid nodular masses in both ovaries. Which of the following is the most appropriate next step in management?

A 32-year-old woman comes to the emergency department complaining of sudden onset shortness of breath accompanied by a non-productive cough and left-sided chest discomfort that increases on inspiration. She denies subjective fever, coughing up blood, wheezing, palpitations, leg pain, and swelling of the lower extremities or any recent travel. Past medical history is significant for an appendectomy at age 15. Her medications include birth control pills and over- the-counter vitamins. She is a known carrier of sickle cell trait. Her father, age 65, has had diabetes for 20 years; mother, age 58, has coronary artery disease. She has never been pregnant, drinks alcohol socially and does not smoke. Her temperature is 99°F (38°C), blood pressure is 110/70 mmHg, pulse 130/min and respirations are 33/min. Pulse oximetry shows an oxygen saturation of 85% on 6 liters of oxygen. Her BMI is 30 kg/m2. She is alert and cooperative without cyanosis or jaundice. Her lungs are clear to auscultation. Her abdomen is soft, nondistended and non-tender. Which of the following is the best test to confirm this patient's diagnosis?

A 32-year-old woman consults with you for evaluation of an abnormal Pap smear done by a nurse practitioner at a family planning clinic. The Pap smear shows evidence of a high-grade squamous intraepithelial lesion (HGSIL). You perform colposcopy in the office. Your colposcopic impression is of acetowhite changes suggestive of human papilloma virus infection (HPV). Your biopsies show chronic cervicitis but no evidence of dysplasia. Which of the following is the most appropriate next step in the management of this patient?

A 33-year-old male was involved in a motor vehicle accident with numerous rib fractures. His course in the hospital was complicated by difficulty with deep breathing and later developed pneumonia. The chest x-ray later confirmed that the patient had developed a parapneumonic effusion. Which one of the following laboratory tests on the pleural fluid is currently thought to be most helpful in determining the need for chest tube placement in parapneumonic effusion?

A 33-year-old woman comes to the emergency department due to a 4-day history of left-sided flank pain, nausea, vomiting, fevers and chills. Her temperature is 39°C (102°F) and blood pressure is 100/60 mm Hg. Examination shows significant left costovertebral angle tenderness. Urinalysis shows positive nitrites, many WBC and bacteria. Laboratory studies show a WBC count of 17,000/cmm with 8% bands. Which of the following is the most appropriate next step in management?

A 33-year-old woman, gravida 1, para 0, comes for a routine prenatal visit, for the first time. According to her history, she is at 18-weeks gestation. Her family history is significant for Down syndrome on her maternal side. She does not use tobacco, alcohol or drugs. Vital signs are normal, and physical examination is unremarkable. Initial laboratory studies show a decreased maternal serum alpha-fetoprotein (MSAFP). Which of the following is the most appropriate next step in management?

A 33-year-old woman, gravida 3, para 3, comes to the physician for an annual examination. She has no complaints. Past medical history is significant for two episodes of Chlamydia and one episode of gonorrhea. Obstetric history is significant for three normal spontaneous vaginal deliveries with gestational diabetes during the last two pregnancies. She takes no medications. Family history is significant for paternal coronary artery disease. Physical examination is unremarkable. Which of the following interventions should this patient most likely have?

A 33-year-old woman, otherwise perfectly well, presents with recurrent episodes of hemoptysis. She has no fever, weight loss, cough, or sputum production. Her physical examination is entirely normal. Her CXR, biochemisty, CBC, and coagulation profile are also normal. Which of the following is the most appropriate initial diagnostic test?