Part5 (1246-1274) nana7

150) A 23-year-old man complains of progressive low back pain for the past several months. He has morning stiffness that lasts for one hour. He has no history of trauma to his back and denies any recent illness. He had an episode of pain, blurring, and photophobia of his right eye two years ago that required ophthalmology evaluation. His vital signs are within normal limits. Examination shows tenderness in both sacroiliac joints and reduced range of motion of the lower back. If measured, which of the following is most likely to be present in this patient?
HLA B 27 positivity
. Rheumatoid factor
Anti-cyclic citrullinated peptide (CCP) antibodies
Anti dsDNA antibodies
Glutamic acid decarboxylase antibodies
151) A 65-year-old man presents with right shoulder pain and weakness after falling on his outstretched hand. The pain is worse when he tries to position his arm above the shoulder level or when he pulls or pushes. He also complains of pain when he lies on the affected shoulder. He has a 40-pack-year history of cigarette smoking. His father died of multiple myeloma. His vital signs are within normal limits. Examination shows limitation of mid arc abduction and external rotation that does not improve after lidocaine injection. There is no swelling, redness or warmth of the joint. Radial pulse is normal. Muscle tone and bulk is within normal limits. Which of the following would be most helpful in confirming the patient's diagnosis?
. MRI of the shoulder
. X-ray shoulder
Chest-X ray
Chest-X ray
MRI of the cervical spine
152) A 49-year-old African American female complains of progressive exertional dyspnea. She also complains of swelling and pain in her finger joints over the last 6 months. She has been treated for severe heartburn with pantoprazole and for hypertension with lisinopril and hydrochlorothiazide. Her blood pressure is 145/100 mmHg and her heart rate is 80/min. Physical examination reveals prominent jugular venous distention. Her lungs are clear to auscultation, and no murmurs are present on cardiac auscultation. Her skin is thickened and discolored over the fingertips and interphalangeal joints. There is mild pitting ankle edema. Which of the following is most likely to be positive in this patient?
. Anti-topoisomerase-1 antibodies
Rheumatoid factor
Anti-neutrophil cytoplasmic antibodies
. Anti-smooth muscle antibodies
. Antimitochondrial antibodies
153) A 52-year-old woman presents with gradual-onset weakness in her leg muscles. She has noted difficulty climbing stairs and raising from a chair that has been worsening for the past few years. She initially related her symptoms to simply being "out of shape." She has no problem with chewing food. She has no pain in her muscles and has no skin rash. She takes metoprolol and hydrochlorothiazide for hypertension. She does not use tobacco, alcohol or drugs. Her vital signs are within normal limits. Examination reveals mild weakness of the thigh muscles in both legs. Deep tendon reflexes and sensory examination shows no abnormalities. Babinski sign is negative. Which of the following is most likely abnormal in this patient?
. Muscle biopsy
MRI of the spine
. Electroencephalogram
Temporal artery biopsy
Lumbar puncture
154) A 62-year-old Caucasian female complains of difficulty swallowing solid food. She needs to take sips of water during every meal to help with swallowing. Her past medical history is significant for hypertension controlled with metoprolol. She uses some over-the-counter eye drops for eye dryness. Her blood pressure is 140/90 mmHg and heart rate is 60/min. Physical examination reveals prominent dental caries. There are bilateral firm submandibular swellings present on neck palpation. Which of the following is the best test to confirm this patient's diagnosis?
Antibodies to Ro/SSA
. Antimitochondrial antibodies
. Barium swallow test
. CT scan of the neck
. Esophageal endoscopy with biopsy
155) A 60-year-old male presents to the emergency room with a two-week history of low back pain and low-grade fever. His past medical history is insignificant. He tried several over-the-counter pain medications with little success. His temperature is 38.3°C (101°F), blood pressure is 120/76 mmHg, pulse is 90/min, and respirations are 16/min. Physical examination reveals percussion tenderness over the lumbar vertebrae and local paravertebral muscular spasm. Neurological examination shows 2+ deep tendon reflexes and 5/5 muscle power. The straight-leg raising test is negative at 90 degrees. Laboratory values are: Hemoglobin 12.2 g/dL, Leukocyte count 10,700/cmm, Segmented Neutrophils 63%, Bands 4%, Eosinophils 3%, Basophils 0%, Lymphocytes 23%, Monocytes 6%, Platelets 400,000/cmm, ESR 75 mm/hr. What is the next step in the management of this patient?
MRI of the spine
. Plain radiograph
. Bone scan
Serum rheumatoid factor
. Physiotherapy
156) A 52-year-old man presents with 24 hours of pain and swelling of his right knee. He also reports having constipation, excessive urination, and fatigue for the past several months. He denies fevers, chills, and trauma to the knee. He does not use tobacco, alcohol or drugs. His temperature is 37.2°C (98.9°F), and blood pressure is 130/76 mmHg. Examination shows tenderness, erythema, and swelling of the right knee. His lab values are: Serum sodium 138 mEq/L, Serum potassium 4.0 mEq/L, Serum creatinine 1.1 mg/dl, Serum calcium 11.9 mg/dl, Serum phosphorous 1.9 mg/dl, Blood glucose 98 mg/dl. Which of the following would synovial fluid analysis from the knee most likely reveal?
Rhumboid shaped crystals with positive birefringence
Needle shaped crystals with negative birefringence
Coffin lid shaped crystals
Numerous polymorphs filled with gram positive cocci
Numerous lymphocytes and budding yeast
157) 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 sixpack of beer each weekend. His ESR is 47 mm/hr. Which of the following best explains the pulmonary function test findings in this patient?
. Chest wall motion restriction
Emphysema
. Small airway obstruction
. Pulmonary fibrosis
. Pulmonary vascular disease
158) A 58-year-old woman has had bilateral hip and knee pain for the past several months. The pain is worse with activity and better with rest. Recently she has noticed swelling of the right knee. She reports morning stiffness of about 10-15minutes duration. She denies fever or weight loss. Her past medical history is significant for hypertension, type 2 diabetes, gastroesophageal reflux disease, and obstructive sleep apnea. She takes hydrochlorothiazide, lisinopril, omeprazole, insulin and aspirin. She does not use tobacco, alcohol or drugs. Her temperature is 37.2°C (98.9°F), and blood pressure is 146/86 mmHg. Examination shows a mild effusion, tenderness, and decreased range of motion of the right knee. Synovial fluid analysis reveals the following: Cell count 1100/ml, Gram stain negative, Crystals absent. Plain films of her knee joint would most likely reveal?
. Narrowing of joint space and osteophyte formation
Punched out erosions with a rim of cortical bone
. Periarticular osteopenia and joint margin erosions
Normal joint space with soft tissue swelling
V
59) A 23-year-old white woman presents complaining of 6 months of progressive low back pain. She complains of morning stiffness that lasts one hour, and says her symptoms improve with physical activity. She denies rash, eye pain, urinary problems, and diarrhea. Her past medical history is significant only for an appendectomy at the age of 16 years. She has been taking birth control pills for the past two years. She is afebrile with normal weight and height. Examination reveals reduced forward flexion of the lumbar spine and tenderness over the sacroiliac joints. The remainder of the physical examination is normal. Which of the following is the most appropriate next step in the management of this patient?
. X-ray of the sacro-iliac joints
HlA-827 testing
ANA and rheumatoid factor levels
. Bone scan
MRI of the spine
 
aa160) A 33-year-old African-American woman presents with one week of painful skin lesions on her legs. She has no cough, shortness of breath or bowel symptoms, and denies any recent illness or travel. She has no other significant past medical history and does not take any medication. She smokes one pack of cigarettes and drinks one glass of wine daily. She denies a history of sexually transmitted diseases and has been married to a monogamous partner for the past eight years. Her mother was diagnosed with ovarian cancer at age 65. Her temperature is 37.2°C (98.9°F), and blood pressure is 126/76 mmHg. On examination, she has multiple tender pink to reddish nodules noted below the knee on the extensor surface, as shown below. Which of the following is the most appropriate next step in her management?
. Chest x-ray
. CT scan of the abdomen
. HIV testing
Rectal swab for culture
. Colonoscopy
161) A 60-year-old male presents to your office complaining of right-sided neck pain and numbness over the posterior surface of the forearm. He had several such episodes over the last two years that responded to NSAIDs and physical therapy. Physical examination reveals limited neck rotation and lateral bending. There is decreased pinprick sensation on the posterior aspect of the right forearm, but no muscle weakness is present. Triceps reflex is normal. Which of the following is the most likely finding on the neck radiography of this patient?
. Bony spurs
. Reversed lordotic curve
Vertebral body osteoporosis
. Osteolytic lesions
. Compression fracture
162) A 40-year-old school teacher comes to the physician's office complaining of joint pain. Her symptoms began 10 days ago and consist of pain in the metacarpophalangeal (MCP) joints, proximal interphalangeal (PIP) joints, wrists, knees and ankles, bilaterally. She describes joint stiffness lasting 10 to 15 minutes after a prolonged rest. She denies fever, malaise, weight loss and skin rash. Her past medical history is insignificant. She does not take any medications. On examination, there is no evidence of swelling, redness or tenderness of the involved joints. The remainder of the physical examination is unremarkable. Which of the following is most likely elevated in this patient?
Anti-B19 IgM antibody
. Rheumatoid factor
Anti-dsDNA .
. Erythrocyte sedimentation rate
Antinuclear antibodies
163) A 40-year-old woman complains of 7 weeks of pain and swelling in both wrists and knees. She has several months of fatigue. After a period of rest, resistance to movement is more striking. On examination, the metacarpophalangeal joints and wrists are warm and tender. There are no other joint abnormalities. There is no alopecia, photosensitivity, kidney disease, or rash. Which of the following is correct?
. The clinical picture suggests early rheumatoid arthritis, and a rheumatoid factor should be obtained
The prodrome of lethargy suggests chronic fatigue syndrome.
. Lack of systemic symptoms suggests osteoarthritis
. X-rays of the hand are likely to show joint space narrowing and erosion.
An aggressive search for occult malignancy is indicated.
164) A 70-year-old man complains of fever and pain in his left knee. Several days previously, he suffered an abrasion of his knee while working in his garage. The knee is red, warm, and swollen. An arthocentesis is performed, which shows 200,000 leukocytes/μL and a glucose of 20 mg/dL. No crystals are noted. Which of the following is the most important next step?
Gram stain and culture of joint fluid
. Urethral culture
Uric acid level
. Antinuclear antibody
Antineutrophil cytoplasmic antibody
165) A 60-year-old woman complains of dry mouth and a gritty sensation in her eyes. She states it is sometimes difficult to speak for more than a few minutes. There is no history of diabetes mellitus or neurologic disease. The patient is on no medications. On examination, the buccal mucosa appears dry and the salivary glands are enlarged bilaterally. Which of the following is the best next step in evaluation?
Schirmer test and measurement of autoantibodies
. Lip biopsy
. IgG antibody to mumps virus
. A therapeutic trial of prednisone for 1 month
Administration of a benzodiazepine
166) A 45-year-old woman has pain in her fingers on exposure to cold, arthralgias, and difficulty swallowing solid food. What is the best diagnostic test?
. Antinucleolar antibody
. Rheumatoid factor
ECG
. BUN and creatinine
. Reproduction of symptoms and findings by immersion of hands in cold water
167) A 65-year-old man develops the onset of severe knee pain over 24 hours. The knee is red, swollen, and tender. He has a history of diabetes mellitus and cardiomyopathy. An x-ray of the knee shows linear calcification. Definitive diagnosis is best made by which of the following?
Arthrocentesis and identification of positively birefringent rhomboid crystals
. Serum uric acid
. Serum calcium
. Rheumatoid factor
. ANA
 
bb168) Over the last six weeks a 45-year-old nurse has developed progressive difficulty getting out of chairs and climbing stairs. She can no longer get in and out of the bathtub. She has no muscle pain and takes no regular medications. She does not use alcohol and does not smoke cigarettes. On examination she has a purplish rash that involves both eyelids (see figure). There is weakness of the proximal leg muscles. What is the best next diagnostic test?
CPK
Vitamin B12 level
. Chest x-ray
. HLAB27
MRI scan of the lumbar spine
1) A 29-year-old Caucasian primigravida patient is 20 weeks pregnant with twins. She found out today on her routine ultrasound for fetal anatomy that she is carrying two boys. In this patient’s case, which of the following statements about twinning is true?
. If division of these twins occurred after formation of the embryonic disk, the twins will be conjoined
. The twins must be monozygotic since they are both males
She has a higher incidence of having monozygotic twins since she is Caucasian
If the ultrasound showed two separate placentas, the twins must be dizygotic
. Twinning causes no appreciable increase in maternal morbidity and mortality over singleton pregnancies
2) A 24-year-old primigravida with twins presents for routine ultrasonography at 20 weeks gestation. Based on the ultrasound findings, the patient is diagnosed with dizygotic twins. Which of the following is true regarding the membranes and placentas of dizygotic twins?
. They are dichorionic and diamniotic regardless of the sex of the twins
They are dichorionic and monoamniotic only if the fetuses are of the same sex
They are dichorionic and monoamniotic regardless of the sex of the fetuses
They are monochorionic and monoamniotic if they are conjoined twins
. They are monochorionic and diamniotic if they are of the same sex
3) After delivery of a term infant with Apgar scores of 2 at 1 minute and 7 at 5 minutes, you ask that umbilical cord blood be collected for pH. The umbilical arteries carry which of the following?
. Deoxygenated blood to the placenta
Oxygenated blood to the placenta
. Oxygenated blood from the placenta
Deoxygenated blood from the placenta
. Oxygenated blood from the placenta to mother
4) During the routine examination of the umbilical cord and placenta after a spontaneous vaginal delivery, you notice that the baby had only one umbilical artery. Which of the following is true regarding the finding of a single umbilical artery?
. It is an indicator of an increased incidence of congenital anomalies of the fetus
. It is a very common finding and is insignificant
. It is a rare finding in singleton pregnancies and is therefore not significant
It is equally common in newborns of diabetic and nondiabetic mothers
. It is present in 5% of all births
5) A 22-year-old G1P0 at 28 weeks gestation by LMP presents to labor and delivery complaining of decreased fetal movement. She has had no prenatal care. On the fetal monitor there are no contractions. The fetal heart rate is 150 beats per minute and reactive. There are no decelerations in the fetal heart tracing. An ultrasound is performed in the radiology department and shows a 28-week fetus with normal-appearing anatomy and size consistent with dates. The placenta is implanted on the posterior uterine wall and its margin is well away from the cervix. A succenturiate lobe of the placenta is seen implanted low on the anterior wall of the uterus. Doppler flow studies indicate a blood vessel is traversing the cervix connecting the two lobes. This patient is most at risk for which of the following?
. Fetal exsanguination after rupture of the membranes
. Premature rupture of the membranes
. Torsion of the umbilical cord caused by velamentous insertion of the umbilical cord
. Amniotic fluid embolism
. Placenta accrete
6) A 27-year-old woman has used oral contraceptives (OCs) without problems for 5 years. However, she just read an article about complications of OCs in a popular women’s magazine and asks you about the risks and hazards of taking OCs. You correctly tell her which of the following?
The risk of developing endometrial cancer is decreased
The risk of developing ovarian cancer is increased
The risk of developing pelvic inflammatory disease (PID) is increased
The risk of bearing a child with major congenital anomalies is increased if taken while pregnant
The risk of ectopic pregnancy is increased
7) In an amenorrheic patient who has had pituitary ablation for a craniopharyngioma, which of the following regimens is most likely to result in an ovulatory cycle? .
. Human menopausal or recombinant gonadotropin followed by human chorionic gonadotropin (hCG)
Clomiphene citrate
. Pulsatile infusion of GnRH
Continuous infusion of GnRH
Human menopausal or recombinant gonadotropin
8) A 35-year-old African American woman presents to a physician complaining of irregular menstrual periods. She had her first menses at age 15 and states that her periods come irregularly every 2 to 6 months. She has been in a monogamous relationship with her husband for 15 years; for 10 years they have been trying unsuccessfully to conceive. She gets yearly Pap smears, which have been normal. Her height is 5 feet 2 inches (157.5 cm), and her weight is 200 pounds (90.9 kg). Her temperature is 37 C (98.6 F), blood pressure is 118/78 mm Hg, pulse is 80/min, and respirations are 14/min. She has acne, as well as excess hair, on her face and between her breasts. Her abdomen is obese. Examination is otherwise within normal limits. This patient is at greatest risk for developing which of the following diseases?
Endometrial cancer
Cervical cancer
Lung cancer
Osteoporosis
Ovarian cancer
9) An ovarian mass removed from a 49-year-old female has yellow coloration of its cut surface. The pathologist describes it as a granulosa-theca cell tumor. Based on this pathology report, the tumor is most likely to secrete?
Estrogen
Human chorionic gonadotropin
. Alpha-fetoprotein
CA-125
. Cortisol
10) A 38-year-old Caucasian female presents to your office complaining of a small amount of vaginal discharge that appears following sexual intercourse. There is no associated abdominal pain or urinary symptoms. Her menstrual cycles occur with regular 28-day cycles; her last menstrual period was 2 weeks ago. She has never been pregnant. Menarche occurred at age 10, and she has been sexually active with 10 different partners over the last 20 years. She smokes two packs of cigarettes per day and consumes alcohol regularly. She admits that her diet is poor in vegetables and fruit. Her mother died of breast cancer at age 54, and her father, who is living, has hypertension. Cervical biopsy reveals cervical intraepithelial neoplasia III (CIN III). Which of the following is the strongest risk factor for this condition?
Multiple sexual partners
. Early menarche
. Smoking
. Alcohol consumption
Nulliparity
11) A 19-year-old woman comes to the physician because of irregular vaginal bleeding. She has asthma and has never had surgery. She takes albuterol for her asthma and has been taking the oral contraceptive pill for 2 years. She has no allergies to medications. On examination she is found to have a vaginal lesion, which is biopsied. The biopsy shows clear cell adenocarcinoma of the vagina. This patient's malignancy is most likely associated with which of the following types of exposure?
In utero dietbylstilbestrol (DES) exposure
Current albuterol use
Current oral contraceptive pill use
In utero aspirin exposure
In utero Coumadin exposure
12) A 60-year-old postmenopausal woman presents with the new onset of uterine bleeding. An endometrial biopsy is diagnosed as atypical hyperplasia. Which of the following histologic changes is most characteristic of this abnormality?
Crowding of endometrial glands with budding and epithelial atypia
. Lymphatic invasion by interlacing bundles of atypical spindle-shaped cells
. Menstrual-type endometrial glands with focal atypical cystic dilatation
Secretory-type endometrial glands with hyperplasia of atypical polygonal cells having clear cytoplasm
Stromal invasion by malignant glands with focal areas of atypical squamous differentiation
13) Prolonged unopposed estrogen stimulation in an adult woman increases the risk of development of endometrial hyperplasia and subsequent carcinoma. Which of the following is the most common histologic appearance for this type of cancer?
Adenocarcinoma
. Clear cell carcinoma
Small cell carcinoma
. Squamous cell carcinoma
. Transitional cell carcinoma
14) A 46-year-old woman undergoes an abdominal hysterectomy for a “fibroid” uterus. The surgeon requests a frozen section on the tumor, which is deferred because of the lesion’s degree of cellularity. Which of the following histologic criteria will be used by the pathologist to determine if this tumor is benign or malignant?
. Mitotic rate
. Cell pleomorphism
Cell necrosis
Nucleus-to-cytoplasm ratio
. Tumor size
15) A 25-year-old woman presents to your office complaining of a seven-week history of amenorrhea. She also states that she has had nausea and vomiting for five weeks. She is sexually active. Her medical and obstetrical histories are unremarkable. Serum hCG level is elevated. Which of the following is the most important direct role of hCG in pregnancy?
Maintenance of the corpus luteum
. Inhibition of uterine contractions
Induction of prolactin production by the pituitary
. Promotion and maintenance of implantation
. Induction of early embryonic division and differentiation
16) After reading an article titled: ''The Risk of Cancer in Patients with Diethylstilbestrol (DES) Exposed Mothers", a 23-year old female comes to your office with her mother for assessment of possible risks. Her mother had been given DES while pregnant. Which of the following cancers is this patient most at risk of developing?
. Adenocarcinoma of vagina
Vaginal squamous cell carcinoma
Cervical squamous cell carcinoma
. Adenocarcinoma of the endometrium
Adenocarcinoma of ovary
17) A 32-year-old woman who presents with menometrorrhagia is found to have a 4.0-cm mass within her left ovary. This mass is resected surgically and a histologic section reveals the tumor to be composed of small polygonal cells growing sheets and anastomosing cords. Rare Call-Exner bodies are present. The tumor cells are found to stain positively with an immunoperoxidase stain against inhibin. Which one of the following is most likely to be secreted by these tumor cells?
. Estrogen
. Acid phosphatase
α-Fetoprotein
. β-Human chorionic gonadotropin
. Testosterone
18) A 28-year-old nulliparous woman presents to your office complaining of fatigue, low mood, and amenorrhea. She says that it all started two months ago and progressively worsened. She is sexually active and uses condoms for contraception. Her medical history is unremarkable, and she denies taking any drugs or medications. Examination reveals dry skin, short eyebrows, a painless and enlarged thyroid gland, and galactorrhea. The uterus has a normal size, and the adnexae are not palpable. Initial investigations reveal the following: Serum pregnancy test: Negative; Free T4: 2.5 µg/dL (N= 5- 12); SerumTSH: 11.0 µU/ml (N= 0.5-5.0); Prolactin: 30 ng/ml (< 20 ng/ml); Antimicrosomal antibodies: Positive. Of the following, which represents the association between hypothyroidism and hyperprolactinemia in the above patient?
TRH stimulates prolactin production
TRH stimulates dopamine production
TSH inhibits dopamine production
. TSH stimulates dopamine production
Antimicrosomal antibodies stimulate dopamine production
19) A 39-year-old woman presents with increasing abdominal distention and pelvic pain. A CT scan finds a slight amount of fluid in the pleural cavity and also a 3.5cm tumor of the right ovary. The tumor is resected and histologic sections reveal the tumor to be composed of spindle-shaped cells. These cells did not stain with an oil red O special stain. Which of the following types of ovarian tumor is most likely to produce this constellation of findings?
Stromal tumor
. Epithelial tumor
. Germ cell tumor
. Surface tumor
Metastatic tumor
20) During the evaluation of secondary amenorrhea in a 24-year-old woman, hyperprolactinemia is diagnosed. Which of the following conditions could cause increased circulating prolactin concentration and amenorrhea in this patient?
. Stress
. Primary hyperthyroidism
Anorexia nervosa
Congenital adrenal hyperplasia
. Polycystic ovarian disease
21) A 36-year-old morbidly obese woman presents to your office for evaluation of irregular, heavy menses. An office endometrial biopsy shows complex hyperplasia of the endometrium without atypia. The hyperplasia is most likely related to the excess formation in the patient’s adipose tissue of which of the following hormones?
. Estrone
. Estriol
. Estradiol
Androstenedione
. Dehydroepiandrosterone
22) A 29-year-old woman, gravida 2, para 0, comes for a routine prenatal visit. According to her history, she is at 16-weeks gestation. She had a first trimester miscarriage during her previous pregnancy. She does not take any vitamin supplementation. Vital signs are stable and physical examination is unremarkable. Initial laboratory studies show increased maternal serum alpha-fetoprotein (MSAFP) levels. Which of the following is the most likely cause of the abnormal laboratory finding?
. Gestational age error
Neural tube defect
. Edward syndrome
Down syndrome
. Omphalocele
23) A 39-year-old patient is contemplating discontinuing birth control pills in order to conceive. She is concerned about her fertility at this age, and inquires about when she can anticipate resumption of normal menses. You counsel her that by 3 months after discontinuation of birth control pills, what proportion of patients will resume normal menses?
. 80%
99%
. 95%
. 50%
5%
24) A 32-year-old woman presents to your office to discuss contraception. She has recently stopped breast-feeding her 8-month-old son and wants to stop her progestin-only pill because her cycles are irregular on it. You recommend a combination pill to help regulate her cycle. You also mention that with estrogen added, the contraceptive efficacy is also higher. In combination birth control pills, which of the following is the primary contraceptive effect of the estrogenic component?
. Suppression of follicle-stimulating hormone (FSH) secretion
Conversion of ethinyl estradiol to mestranol
. Atrophy of the endometrium
Suppression of cervical mucus secretion
. Suppression of luteinizing hormone (LH) secretion
25) A 22-year-old woman presents to your office for her well-woman examination and contraception. She has no medical problems or prior surgeries. She does not smoke or drink. Her vital signs and physical examination are normal. You explain the risks and benefits of combination oral contraceptive pills to the patient. She wants to know how they will keep her from getting pregnant. Which of the following mechanisms best explains the contraceptive effect of birth control pills that contain both synthetic estrogen and progestin?
. Inhibition of ovulation
. Direct inhibition of oocyte maturation
. Production of uterine secretions that are toxic to developing embryos
Impairment of implantation hyperplastic changes of the endometrium
. Impairment of sperm transport caused by uterotubal obstruction
26) Five patients present for contraceptive counseling, each requesting that an IUD be inserted. Which of the following is a recognized contraindication to the insertion of an IUD?
Pelvic inflammatory disease
. Previous pregnancy with an IUD
Dysfunctional uterine bleeding
. Cervical conization
. Chorioamnionitis in previous pregnancy
27) A 30-year-old woman presents to your office for her well-woman examination and contraception. She has two prior vaginal deliveries without any complications. Her medical and surgical histories are negative. Her family history is significant for coronary heart disease in her father and breast cancer in her mother diagnosed at the age of 62 years. In addition to effective contraception, health benefits for women taking oral combination contraceptives include which of the following?
. Decreased incidence of benign breast disease
Decreased risk of lung cancer
. Decreased diastolic hypertension
. Decreased risk of cervical cancer
Decreased incidence of thromboembolism
28) A couple presents to your office to discuss permanent sterilization. They have three children and are sure they do not want any more. You discuss the risk and benefits of surgical sterilization. Which of the following statements is true regarding surgical sterilizations?
They can be considered effective immediately in females (bilateral tubal ligation)
. They cannot be performed immediately postpartum
. They have become the second most common method of contraception for white couples between 20 and 40 years of age in the United States
. They can be considered effective immediately in males (vasectomy)
. Tubal ligation should be performed in the secretory phase of the menstrual cycle
29) A 32-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the physician for a prenatal visit. She has no current complaints. Her past medical history is significant for hepatitis C infection, which she acquired through a needle stick injury at work as a nurse. She is hepatitis B and HIV negative. She takes no medications and has no allergies to medications. Her prenatal course has been uncomplicated. She wants to know whether she can have contact with the baby or breast-feed given her hepatitis C status. Which of the following is the correct response?
. There is no evidence that breast-feeding increases HCV transmission
There is strong evidence that breast-feeding increases HCV transmission
Complete isolation is not needed but breast-feeding is prohibited
. The patient should be completely isolated from the baby
. Casual contact with the baby is prohibited
30) The shortest distance between the sacral promontory and the symphysis pubis is called which of the following?
. Obstetric (OB) conjugate
. Interspinous diameter
. True conjugate
. Diagonal conjugate
. Biparietal diameter
31) A patient presents in labor at term. Clinical pelvimetry is performed. She has an oval-shaped pelvis with the anteroposterior diameter at the pelvic inlet greater than the transverse diameter. The baby is occiput posterior. The patient most likely has what kind of pelvis?
An anthropoid pelvis
A gynecoid pelvis
An android pelvis
. A platypelloid pelvis
. An androgenous pelvis
32) On pelvic examination of a patient in labor at 34 weeks, the patient is noted to be 6 cm dilated, completely effaced with the fetal nose and mouth palpable. The chin is pointing toward the maternal left hip. This is an example of which of the following?
. Mentum transverse position
Transverse lie
Occiput transverse position
. Brow presentation
. Vertex presentation
33) A 34-year-old primigravida develops severe postpartum bleeding requiring aggressive volume resuscitation and transfusion of 5 units of packed red blood cells. Her pregnancy was complicated by mild hypertension and trace proteinuria that was treated with low-dose methyldopa. Her mother suffered from premature menopause and severe osteoporosis. Seven days after giving birth, she has failed to lactate. Her urinalysis is insignificant and her blood pressure has ranged from 95 to110 mmHg systolic and 69 to 75 mmHg diastolic. Fundoscopy shows no retinal changes. Which of the following is most likely deficient in this patient?
. Prolactin
Inhibin
. Progesterone
. Aldosterone
. Oxytocin
34) A 28-year-old nulliparous woman is being evaluated for infertility. She has no other medical problems. Pelvic examination reveals abundant mucus and a clear cervical secretion, which when lifted vertically extends in a long thread; pH is 6.5. This visit took place at which of the following phases of the menstrual cycle?
. Ovulatory phase
Early follicular phase
. Mid luteal phase
. Late luteal phase
. The secretion is abnormal
35) A 32-year-old poorly controlled diabetic G2P1 is undergoing amniocentesis at 38 weeks for fetal lung maturity prior to having a repeat cesarean section. Which of the following laboratory tests results on the amniotic fluid would best indicate that the fetal lungs are mature?
. Phosphatidylglycerol is present
Phosphatidylglycerol is absent
. Lecithin/sphingomyelin ratio of 1:1
. Lecithin/sphingomyelin ratio of 1:1
. Lecithin/sphingomyelin ratio of 2.0:1
36) A wealthy executive donates five million dollars for the prevention of intrauterine growth restriction in the local county. Spending this money on which of the following programs would prevent the greatest number of cases of fetal growth restriction (FGR) in the population?
Smoking cessation
. Alcoholic anonymous
. Malnutrition prevention
. Hypertension control
. Infection control
37) Your patient is a healthy 28-year-old G2P1001 at 20 weeks gestational age. Two years ago, she vaginally delivered at term a healthy baby boy weighing 6 lb 8 oz. This pregnancy, she had a prepregnancy weight of 130 lb. She is 5ft 4 in tall. She now weighs 140 lb and is extremely nervous that she is gaining too much weight. She is worried that the baby will be too big and require her to have a cesarean section. What is the best counsel for this patient?
. During the pregnancy, she should consume an additional 300 kcal/day versus prepregnancy, and her weight gain so far is appropriate for her gestational age
. Her weight gain is excessive, and she needs to be referred for nutritional counseling to slow down her rate of weight gain
. Her weight gain is excessive, and you recommend that she undergo early glucola screening to rule out gestational diabetes
. She is gaining weight at a less than normal rate, and, with her history of a smallfor-gestational-age baby, she should supplement her diet with extra calories
. During the pregnancy she should consume an additional 600 kcal/day versus prepregnancy, and her weight gain is appropriate for her gestational age
38) A 28-year-old woman at 39 weeks gestation is admitted to the hospital. She has regular uterine contractions. Her blood pressure is 120/70mmHg, pulse is 80/min and respirations are 18/min. Fetal heart monitoring is placed and shows a baseline rate of 130 beats/min, without any associated abnormalities. Pelvic examination shows the cervix is 50% effaced and 3 cm dilated. Amniotomy is performed. Immediately after the rupture of membranes, the baseline fetal heart rate increases to 160 beats/min and then drops to 70 beats/min with repetitive late decelerations. There is severe acute vaginal bleeding. Repeat vital signs of the patient shows a blood pressure of 130/70mmHg, pulse of 80/min and respirations of 18/min. Which of the following is the most likely cause of the current condition?
Ruptured fetal umbilical vessel
. Premature separation of the placenta
Abnormal placental implantation
. Excessive amniotic fluid
. Tear in uterine musculature
39) A 62-year-old postmenopausal woman was found to have right adnexal enlargement on pelvic examination 2 weeks ago. Transabdominal and transvaginal ultrasounds revealed a 5-cm, unilocular, right ovarian mass with regular borders. There is no ascites. The patient went through menopause at age 52. She has had no postmenopausal spotting. There is no family history of ovarian or breast cancer. Her latest mammogram 2 months ago showed no abnormalities. Which of the following is the most appropriate course of action?
Cancer antigen 125 level
Combination chemotherapy
Needle aspiration for cytology
Repeated vaginal ultrasonography in 6-8 weeks
. Surgical removal
40) A 28-year-old nulliparous woman is being evaluated for infertility. She has no other medical problems. Pelvic examination reveals abundant mucous and a clear cervical secretion, which when lifted vertically extends in a long thread; pH is 6.5. This visit took place at which of the following phases of the menstrual cycle?
. Ovulatory phase
. Early follicular phase
Mid luteal phase
. Late luteal phase
The secretion is abnormal
41) A 21-year-old nulligravid woman comes to her physician to discuss birth control options. She became sexually active for the first time 2 weeks ago. She is currently using condoms for contraception. Her past medical history is significant for asthma, which has been inactive for 2 years. She takes no medications and has no allergies to medications. She has no family history of cancer. Her examination is within normal limits. After a discussion with the physician, she chooses to take the oral contraceptive pill (OCP). She stays on the pill for the next 6 years. She now has most significantly decreased her risk of developing which of the following malignancies?
Ovarian cancer
Breast cancer
Cervical cancer
Liver cancer
Lung cancer
42) A 33-year-old, gravida 3, para 3 woman comes to the physician because of amenorrhea of 9-month duration. She denies symptoms of any kind. She had a tubal ligation after the birth of her last child 2 years ago. She did not breast feed. Her menarche was at the age of 13 years, and her menses were regular until 18 months ago. At that time, her menses skipped every other month, and then they stopped. She currently takes no medication. She weighs 120.2 kg (264lb) and is 160 cm (5'3") tall. Initial physical examination shows no abnormalities except for morbid obesity. In the initial blood work, serum TSH and prolactin levels are within normal limits. Follow-up laboratory test show: FSH 20 mIU/mL (normal: 5-30 mIU/mL), LH 15 mIU/mL (normal: 5-20 mIU/mL). Which of the following is the most likely explanation for this patient's amenorrhea?
Anovulation
Post tubal ligation syndrome
Normal menopause
. Pituitary dysfunction
Premature ovarian failure (primary ovarian insufficiency)
43) An 18-year-old G2P1001 with the first day of her last menstrual period of May 7 presents for her first OB visit at 10 weeks. What is this patient’s estimated date of delivery?
. February 14 of the next year
. February 10 of the next year
December 10 of the same year
December 14 of the same year
December 21of the same year
44) A 45-year-old white female has undergone a right mastectomy for a node-negative, estrogen and progesterone receptor-positive tumor. She is scheduled to begin adjuvant therapy with tamoxifen. Her menstrual cycles are regular and her last menstrual period was 15 days ago. She has many concerns about tamoxifen therapy and would like to know its risks and benefits. Which of the following is she at risk for?
Endometrial cancer
Osteoporosis
. Vaginal candidiasis
. Ovarian cancer
Ischemic optic neuropathy
45) A 14-year-old girl s brought to the physician's office because of irregular menstrual periods. She had her menarche at age 13, and since then her periods have been irregular with the cycles varying from 3 to 6 weeks. She has no other symptoms. Physical examination is unremarkable. She has age appropriate secondary sexual characters. A urine pregnancy test is negative. Serum prolactin and thyroid stimulating hormone levels are normal. Administration of micronized oral progesterone results in withdrawal bleeding in 3 days. Which of the following most likely explains her irregular periods?
Insufficient gonadotropin secretion
Marked estrogen deficiency
Excess LH secretion
Marked androgen excess
. Uterine adhesions
46) A 26-year-old woman comes to the physician for follow-up after a recent spontaneous abortion at 14 weeks gestation. She had one other spontaneous first trimester abortion two years ago. She has no other medical problems and does not use tobacco, alcohol or drugs. Review of systems reveals photosensitivity and occasional hematuria. On examination, you observe a bilateral malar rash. What is the most likely pathophysiology for her abortions?
. Lupus anticoagulant
Vasospasm
Chromosomal abnormalities
. Disseminated intravascular coagulation
. Congenital heart block
47) A 27-year-old woman, gravida 2, para 1, at 20 weeks' gestation comes to the physician for a prenatal visit. She has no complaints. Her obstetric history is significant for a primary low transverse cesarean delivery because of a non-reassuring fetal tracing 3 years ago. She has no medical problems. She takes prenatal vitamins and has no known drug allergies. She is debating whether to have an elective repeat cesarean delivery or to attempt a vaginal birth after cesarean (VBAC). She wants to know her chances for a successful VBAC. Which of the following most accurately represents the patient's likelihood of having a successful vaginal delivery?
. 70%
0%
. 25%
. 50%
100%
48) A 29-year-old patient comes to the physician for an annual examination. She has normal menstrual periods every 30 days. She was 15 years old when she first began having intercourse. She uses condoms for contraception. Her past medical history is significant for multiple sclerosis. This condition has required her to use a wheelchair for the past 4 years, which makes pelvic examination somewhat difficult for her. She smokes one pack of cigarettes per day. Given her difficulty with the pelvic examination, she inquires as to how often she needs to have a Pap smear performed. Which of the following is the correct answer?
A Pap smear should be performed every year
A Pap smear should be performed every 3 years
A Pap smear should be performed every 5 years
A Pap smear should be performed only if there are symptoms
. A Pap smear is not necessary
49) A 33-year-old woman comes to the physician for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had no bleeding or abdominal pain. She has no medical problems and takes no medications. She has no family history of congenital anomalies. Her husband is 55 years old. He is in good health and also has no family history of birth defects. The patient is concerned that her husband's age may place their fetus at increased risk of a chromosomal anomaly. She wishes to know the paternal age above which amniocentesis or chorionic villus sampling should be considered. Which of the following is the correct response?
There is no age cut off for paternal risk
Above age 30
Above age 35
. Above age 40
. Above age 45
50) A 44-year-old woman, gravida 4, para 3, at 8 weeks' gestation comes to the physician for her first prenatal visit. She has mild nausea and vomiting but no other complaints. Her obstetric history is significant for three full-term, normal vaginal deliveries of normal infants. She has no medical or surgical history and takes no medications. Physical examination reveals an 8-week-sized uterus, but is otherwise unremarkable. She wishes to have chromosomal testing of the fetus and wants to have chorionic villus sampling performed, as she did with her last pregnancy. Compared with amniocentesis, chorionic villus sampling may place the patient at greater risk for which of the following?
. Fetal limb defects
. Fetal Down syndrome
Fetal neural tube defects
. Maternal sepsis
. Mid-second-trimester abortion
51) A maternal fetal medicine specialist is consulted and performs an in-depth sonogram on a 30-yearold G1 at 28 weeks with a twin gestation. The sonogram indicates that the fetuses are both male, and the placenta appears to be diamniotic and monochorionic. Twin B is noted to have oligohydramnios and to be much smaller than twin A. Which of the following would be a finding most likely associated with twin A?
Congestive heart failure
Anemia
. Hypovolemia
. Hypotension
Low amniotic fluid level
52) A 40-year-old G2P1001 presents to your office for a routine OB visit at 30 weeks gestational age. Her first pregnancy was delivered 10 years ago and was uncomplicated. She had a normal vaginal delivery at 40 weeks and the baby weighed 7 lb. During this present pregnancy, she has not had any complications, and she reports no significant medical history. She is a nonsmoker and has gained about 25 lb to date. Despite being of advanced maternal age, she declined any screening or diagnostic testing for Down syndrome. Her blood pressure range has been 100 to 120/60 to 70. During her examination, you note that her fundal height measures only 25 cm. Which of the following is a likely explanation for this patient’s decreased fundal height?
. Fetal growth restriction
. Multiple gestation
. Hydramnios
. The presence of fibroid tumors in the uterus
Large ovarian mass
53) A 38-year-old G4P3 at 33 weeks gestation is noted to have a fundal height of 29 cm on routine obstetrical visit. An ultrasound is performed by the maternal-fetal medicine specialist. The estimated fetal weight is determined to be in the fifth percentile for the estimated gestational age. The biparietal diameter and abdominal circumference are concordant in size. Which of the following is associated with symmetric growth restriction?
. Chromosome abnormalities
. Nutritional deficiencies
Hypertension
. Uteroplacental insufficiency
Gestational diabetes
54) A 37-year-old G4P2 presents to your office for new OB visit at 8 weeks. In a prior pregnancy, the fetus had multiple congenital anomalies consistent with trisomy 18, and the baby died shortly after birth. The mother is worried that the current pregnancy will end the same way, and she wants testing performed to see whether this baby is affected. Which of the following can be used for chromosome analysis of the fetus?
. Chorionic villus sampling
. Biophysical profile
. Fetal umbilical Doppler velocimetry
. Maternal serum screen
Nuchal translucency
55) A 21-year-old G0 woman presents for a well-woman examination. Menarche began at age 12 years, and her periods occur every 26–30 days and last 4–5 days. She has had two sexual partners since becoming sexually active last year. She uses condoms for contraception and denies a history of sexually transmitted disease. Her physical examination is within normal limits. She has never had a pelvic exam before, and asks why it is necessary for her to get a Pap smear. Which of the following statements about cervical cancer screening is true?
A patient whose cytology shows atypical squamous cells of undetermined significance and who is human papillomavirus negative should have repeat cytology in 12 months
A patient whose cytology shows high-grade squamous intraepithelial lesions should be tested for human papillomavirus status
Cervical cancer screening should be started only after a patient first reports sexual activity
Women >30 years old who have had three normal smears should be screened every 3years indefinitely
Cervical cancer screening should be started at the time of first reported sexual activity, but no later than age 21 years
56) During routine breast examination of a 28-year-old woman with no significant family or past medical history, a firm 2-cm mass is detected in the patient’s right breast. It is freely mobile and non-tender. Ultrasound reveals a solid, well-circumscribed mass, which is later found to be benign by biopsy. Which of the following statements is true?
This tumor may increase in size during pregnancy
There is an increased incidence of this tumor in Japanese women
There is an increased incidence of this tumor in women undergoing tamoxifen therapy
There is an increased risk of cancer in both breasts with this condition
There is no increased risk for this tumor in women with BRCA-1 mutations
57) Labor and vaginal delivery occur successfully in a 29-year-old woman after administration of oxytocin (Pitocin) for 9 hours. Spontaneous onset of labor at term is the result of which of the following?
Events that are currently uncertain
Cortisol production in the amniotic cavity
Prostaglandin release from the fetal membranes
Prolactin produced in the decidua
Fetal pituitary secretion of oxytocin from the neurohypophysis
58) A 28-year-old woman with 28-day menstrual cycle is attempting to conceive and is considering the use of a home ovulation predictor kit to time intercourse at ovulation. She asks you what day of her menstrual cycle her luteinizing hormone (LH) peak is most likely to occur. What should you tell her?
Day 14
Day 12
Day 18
Day 20
Day 27
59) An 11-year-old girl has her first menses. Both ovaries contain approximately how many oocytes?
500,000
7 million
1 million
50,000
5000
60) A healthy 29-year-old gravida 2 woman at 39 weeks has been in labor for 3 hours. She had a positive vaginal-anal culture for GBS at 37 weeks’ gestation. Which one of the following statements is correct?
Neonatal sepsis occurs in 1% of colonized mothers.
Asymptomatic rectovaginal colonization is present in 60% of pregnant women.
The transmission rate from mother to baby is approximately 25%.
A rectovaginal culture should have been obtained at the first prenatal visit.
Treatment with penicillin in labor is necessary only for heavy colonized mothers
61) A 17-year-old woman, gravida 1, para 0, at 38 weeks' gestation comes to the labor and delivery ward because of contractions. Her dating was determined by a 7-week ultrasound. Her prenatal course was complicated by gestational diabetes. Her past surgical history is significant for shoulder surgery. She takes insulin and prenatal vitamins. She has no known drug allergies. She smokes 3-4 cigarettes per day. She is initially found to be 4 cm dilated and is contracting every 2-3 minutes. She is admitted to the labor and delivery ward and, over the next 4 hours, progresses to full dilation. After pushing for 2 hours, she delivers the fetal head but has great difficulty delivering the fetal shoulders. Eventually, the fetus is delivered by the posterior arm. In the process of delivery of the newborn's humerus is fractured. Which of the following factors contributed the most to the difficult delivery of the fetus?
Gestational diabetes
Cigarette smoking
Gestational age
Maternal age
Maternal shoulder surgery
62) A 28-year-old nulliparous woman presents to your office complaining of fatigue, low mood, and amenorrhea. She says that it all started two months ago and progressively worsened. She is sexually active and uses condoms for contraception. Her medical history is unremarkable, and she denies taking any drugs or medications. Examination reveals dry skin, short eyebrows, a painless and enlarged thyroid gland, and galactorrhea. The uterus has a normal size, and the adnexae are not palpable. Initial investigations reveal the following: Serum pregnancy test: Negative, Free T4: 2.5 µg/dl (N= 5-12), Serum TSH: 11 .0 µU/ml (N= 0.5-5.0), Prolactin: 30 ng/ml (< 20 ng/ml). Antimicrosomal antibodies: Positive of the following, which represents the association between hypothyroidism and hyperprolactinemia in the above patient?
. TRH stimulates prolactin production
TRH stimulates dopamine production
. TSH inhibits dopamine production
TSH stimulates dopamine production
. Antimicrosomal antibodies inhibits dopamine production
63) A 51-year-old woman comes to your office for a routine health maintenance examination. She has no medical history but states that she has been having irregular menses and occasional hot flashes for the past eight months. Her husband has told her that she appears moody all the time. She has not had any surgeries in the past and currently takes no medications. She has a very stressful job and drinks two to three cups of coffee every morning. She does not smoke, but she does drink four to five twelve-ounce beers a day for the past 20 years to relieve her stress. She is a lacto-ovo vegetarian and walks two miles on a treadmill each day. Her temperature is 36.5C (97.7F), blood pressure is 120/70, heart rate is 84 beats/minute, and respirations are 12/minute. She is 5'4" and weighs 180 pounds (BMI is 30.9 kg/m2). Physical examination is unremarkable. You inform her that she is probably reaching menopause, and that she will be at an increased risk of developing osteoporosis. Which of the following is the most significant risk factor for the development of osteoporosis in this patient?
Excess alcohol use
Caffeine use
. Obesity
. Vegetarian diet
. Excess walking
64) A 25-year-old woman comes to the physician with abdominal bloating, headache, fatigue, weight gain, anxiety, and decreased libido. She experiences these symptoms intermittently in 7 to 10-day episodes. In retrospect, she is unable to identify any triggers for her symptoms. The patient has a history of postpartum depression but has no recent feelings of hopelessness or guilt Physical examination is normal. Complete blood count, serum chemistries, and thyroid-stimulating hormone levels are within normal limits. Which of the following is the most appropriate next step in management of this patient?
. Menstrual diary
Alprazolam
. Cognitive behavioral therapy
Fluoxetine
Gluten-free diet
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