2nd Para USMLE 100Q

A 23-year-old man presents to your office complaining of occasional headaches, muscle weakness and fatigue. He also describes periodic numbness of his extremities. The symptoms started 6 months ago and have gradually progressed. His past medical history is insignificant. He is not taking any medication. His blood pressure is 165/104 mmHg and heart rate is 80/min. His physical examination is within normal limits. Which of the following laboratory findings is the most specific for the patient's condition?

A 23-year-old primigravid woman at 9 weeks gestation presents to the emergency room because of generalized weakness and lightheadedness. For the past 4 weeks she has not been able to keep anything down and over the past week her nausea and vomiting have worsened. She has no fever, abdominal pain, diarrhea, headache, dysuria, polyuria, tremor, or heat intolerance. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2C (98.9 F); orthostatic vitals are as follows: BP 136/86 mm Hg and pulse 98/min supine, and 11 0/70 mm Hg and 115/min standing. Physical examination shows dry mucus membranes. The remainder of the examination is unremarkable. Laboratory studies show: Hematocrit: 50 %, Platelets: 200,000/mm3, Serum sodium: 130 mEq/L, Serum potassium: 2.8 mEq/L, Chloride: 86 mEq/L, Bicarbonate: 30 mEq/L, Blood urea nitrogen (BUN): 30mg/dl, Serum creatinine: 1.6 mg/dl, Blood glucose: 98 mg/dl. Which of the following is the most appropriate next step in management?

A 23-year-old primigravid woman comes to the physician because of vaginal bleeding. Her last menstrual period was 6 weeks ago. She has no other symptoms. Examination shows a 10-week sized uterus, but is otherwise unremarkable. Pelvic ultrasound reveals a snowstorm pattern consistent with a complete mole. Serum beta-hCG is markedly elevated over normal pregnant values. A chest x-ray film is negative. A dilation and evacuation is performed and the pathologic diagnosis is complete hydatidiform mole. Which of the following is the most appropriate next step in management?

A 23-year-old white man is brought to the emergency department (ED) by an ambulance due to an epileptic seizure. He fell on the sidewalk while going home from a pub, where he had two beers. A witness noted tonic-clonic movements of all four extremities for about one minute. This seizure was his first episode, and lasted 30 minutes. In the ED, he is in a state of partial confusion and disoriented to time, place and person. The physical examination does not reveal any focal neurologic pathology. His eye exam does not show any papilledema. His airway is secured, and his breathing is normal. CBC, serum electrolytes, EKG and chest x-ray are normal. Urine toxicology screen is ordered, and lorazepam is given. What is the most appropriate next step in the management of this patient?

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?

A 23-year-old woman calls her physician for the results of her Pap test. She has a history of Chlamydia. She has never had an abnormal Pap. She occasionally has unprotected intercourse. The physician informs her that the Pap was normal. The patient is relieved, but wants to know whether this result could be wrong. The physician explains that a Pap test detects abnormal cells in roughly 4 of every 5 women who have abnormal cervical cells. Which of the following represents the sensitivity of the Papanicolaou test?

A 23-year-old woman presents to the ED complaining of lower abdominal pain and vaginal spotting for 2 days. Her menstrual cycle is irregular. She has a history of ovarian cysts and is sexually active but always uses condoms. Her BP is 115/75 mm Hg, HR is 75 beats per minute, temperature is 98.9°F, and RR is 16 breaths per minute. Which of the following tests should be obtained next?

Chlamydia antigen test

β-Human chorionic gonadotropin (β-hCG)

Transvaginal ultrasound

Abdominal radiograph

Observe her abdominal pain, if it resolves discharge her with a diagnosis of menstruation

A 23-year-old woman presents to the ED in moderate pain in her left lower quadrant (LLQ). She states that the pain began suddenly and is associated with nausea and vomiting. She had a bout of diarrhea yesterday. This is the second time this month that she experienced pain in this location, however, never with this severity. Her BP is 120/75 mm Hg, HR is 101 beats per minute, temperature is 99.5°F, and RR is 18 breaths per minute. She has a tender LLQ on abdominal examination and a tender adnexa on pelvic examination. Which of the following is the most appropriate diagnostic test for the patient?

A 23-year-old woman presents with a rubbery, freely movable 2-cm mass in the upper outer quadrant of the left breast. Which of the following histologic features is most likely to be seen when examining a biopsy specimen from this mass?

Large numbers of neutrophils

Large numbers of plasma cells

Duct ectasia with inspissation of breast secretions

Necrotic fat surrounded by lipid-laden macrophages

A mixture of fibrous tissue and ducts

A 23-year-old woman presents with weight loss and chronic diarrhea. She appears unwell and cachectic. Routine laboratory tests reveal a low hemoglobin level and an increased international normalized ratio (INR) even though she is not taking any anticoagulants. The liver enzymes are normal, but the albumin and calcium levels are low, suggesting generalized malnutrition. Which of the following is the most appropriate initial diagnostic test for malabsorption?

A 23-year-old woman, gravida 1, para 0, at 25 weeks’ gestation comes to the physician because of right upper quadrant pain, nausea and vomiting, and malaise for the past 2 days. Her temperature is 37 C (98.6 F), blood pressure is 104/72 mm Hg, pulse is 92/min, and respirations are 16/min. Physical examination reveals right upper quadrant tenderness to palpation. The cervix is long, closed, and posterior. There is generalized edema. Laboratory values are as follows: Leukocyte count 10,500/mm3, Platelet count 62,000/mm3, Hematocrit: 26%, Sodium: 140 mEq/L, Chloride: 100 mEq/L, Potassium: 4.5 mEq/L, Bicarbonate: 26 mEq/L. A peripheral blood smear reveals hemolysis. Which of the following laboratory findings would be most likely in this patient?

A 24-month-old pale child is brought to the office by his mother, who says, "Doc, I think he is under some weird spell. He acts bizarre and always seems tired. He likes to eat wooden, painted toys." The child and her mother live in a relatively poor neighborhood. CBC reveals:WBC 8,600 /mm3, Hemoglobin 7.1 g/dl, Hematocrit 25%, Platelets 166,000 /mm3. His blood lead levels are elevated. Which of the following is most likely seen in this child's peripheral blood smear?

Megaloblastic anemia and basophilic stippling

Tear-drop RBCs and hypochromic, microcytic anemia

Loss of concavity of the RBC and basophilic stippling

Basophilic stippling and microcytic, hypochromic anemia

Normochromic, normocytic anemia and basophilic stippling

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?

Administer one dose of ceftriaxone and doxycycline for 10 days and have him follow-up with a urologist

Swab his urethra, send a culture for gonorrhea and Chlamydia, and treat if positive

Send a urinalysis and treat for a urinary tract infection (UTI) if positive

Treat the patient for epididymitis and have him return if symptoms persist

Order a statim (STAT) color Doppler ultrasound and urologic consultation

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?

Staining for Donovan bodies

The presence of serum antibodies to Chlamydia trachomatis

Positive Frei skin test

Culturing Haemophilus ducreyi

Culturing Calymmatobacterium granulomatis

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?

Fasting and random urine sugar

One time fasting blood sugar

75gram oral glucose tolerance test

One hour 50gram oral glucose tolerance test

Three hour 100gram oral glucose tolerance test

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 the physician because of a 24-hour history of right flank pain, burning micturition and high-grade fever with chills. Her temperature is 102°F (38.9°C), blood pressure is 90/60 mm Hg, pulse is 130/min, and respirations are 20/min. Physical examination shows costovertebral angle tenderness. Which of the following is the most likely urine dipstick finding in this patient?

Positive for nitrites and esterase

Positive for nitrites only

Positive for esterase only

Negative for both esterase and nitrites

Negative for esterase and positive nitrites

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?

Sonogram of the bladder

Intravenous pyelogram

Cystoscopy

Retrograde cystogram including post-void films

Retrograde cystogram including views of the ureters

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?

Discontinue OCP and recommend intrauterine contraceptive device

Measure serum FSH and LH

Measure serum beta-HCG

Advise her to stop taking oral contraceptives temporarily and advise condom use until symptoms resolve

Tell her this is normal with patients who have recently begun taking oral contraceptives, and that her symptoms will resolve eventually

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 the physician's office complaining of fatigue, joint pains, and frequent mouth ulcers over the past three months. She has no medical problems and does not take any medications. She does not use tobacco, alcohol or drugs. Her temperature is 37.5°C (99.5°F), blood pressure is 150/100 mmHg and pulse is 78/min. Examination shows erythema over the cheeks and nose. Labs reveal a serum creatinine of 2.8 mg/dl and her urinalysis shows 2+ protein and 20 RBC/HPF. Anti-double stranded antibodies (anti-dsDNA) are positive. Which of the following is the most appropriate next step in management of this patient?

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 female with blonde hair and fair complexion complains of a mole on her upper back. The lesion is 8 mm in diameter, darkly pigmented, and asymmetric, with an irregular border (see illustration below). Which of the following is the best next step in management?

Tell the patient to avoid sunlight

Follow the lesion for any evidence of growth

Obtain metastatic workup

Obtain full-thickness excisional biopsy

Obtain shave biopsy

A 25-year-old G2, PI at 28 weeks gestation is brought to the emergency department by her boyfriend, who found her lying on her bed in a pool of blood. She is very drowsy, but denies any pain or uterine contraction. Her temperature is 38°C (100.4°F) and respirations are 18/min. Physical examination is suggestive of a transverse lie. Inspection of the perineum reveals gross blood and active bleeding per vagina. Which of the following set of parameters would most likely be seen in this patient?

A 25-year-old G3P1011 presents to the ED with a 6-hour history of worsening lower abdominal pain, mostly in the RLQ. She also noticed some vaginal spotting this morning. She is nauseated, but did not vomit. Her last menstrual period was 2 months ago, but her cycles are irregular. She is sexually active and has a history of pelvic inflammatory disease. Her BP is 120/75 mm Hg, HR is 95 beats per minute, temperature is 99.2°F, and RR is 16 breaths per minute. Her abdomen is tender in the RLQ. Pelvic examination reveals right adnexal tenderness. Her WBC count is slightly elevated and her β-hCG is positive. After establishing IV access, which of the following is the most appropriate next step in management?

Call the OR to prepare for laparoscopy

Order an emergent CT scan of the abdomen

Perform a transvaginal ultrasound

Order a urinalysis

Swab her cervix and treat for gonorrhea and Chlamydia

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 male student presents with the chief complaint of rash. He denies headache, fever, or myalgia. A slightly pruritic maculopapular rash is noted over the abdomen, trunk, palms of the hands, and soles of the feet. Inguinal, occipital, and cervical lymphadenopathy is also noted. Hypertrophic, flat, wartlike lesions are noted around the anal area. Laboratory studies show the following: Hct: 40%, Hgb: 14 g/dL, WBC: 13,000/μL, Diff: 50% segmented neutrophils, 50% lymphocytes. Which of the following is the most useful laboratory test in this patient?

A 25-year-old man is shot with a .22 caliber revolver. The entrance wound is in the anteromedial aspect of his upper thigh, 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?

Discharge home

Digital exploration of the wounds in the emergency department

Hospitalization to observe for development of complications

Arteriogram

Formal surgical exploration of the area in the operating room

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?

The lesion is ecthyma gangrenosum, and blood cultures will be positive for Pseudomonas aeruginosa

A skin biopsy should be performed and Gram stain examined for gram-positive rods

The patient has been bitten by Loxosceles reclusa, the brown recluse spider

The patient has the bubo of plague

The patient has necrotizing fasciitis and needs immediate surgical debridement

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?

There are vesicular lesions on the palms and soles

Vesicular lesions are concentrated on the trunk

The rash is most prominent over the face

All lesions are at the same stage of development

The patient experienced high fever several days prior to the rash

A 25-year-old woman presents to your office for evaluation of primary infertility. She has regular periods every 28 days. She has done testing at home with an ovulation kit, which suggests she is ovulating. A hysterosalpingogram demonstrates patency of both fallopian tubes. A progesterone level drawn in the mid–luteal phase is lower than expected. A luteal phase defect is suspected to be the cause of this patient’s infertility. Which of the following studies performed in the second half of the menstrual cycle is helpful in making this diagnosis?

Serum estradiol levels

Urinary pregnanetriol levels

Endometrial biopsy

Serum follicle-stimulating hormone (FSH) levels

Serum luteinizing hormone (LH) levels

A 25-year-old woman who is “about 5 months” pregnant with her first child presents for the first time to an obstetrician. She has had no prenatal care. When asked about her medical history, she states she sometimes takes medicine for “depression,” and she produces a prescription bottle with lithium tablets in it. She is otherwise healthy and her pregnancy has been uncomplicated to date. The fundus of her uterus is 22 cm from the pubic symphysis, fetal movement is felt, and fetal heart tones are present at 130/min. Which of the following tests should be advised given the patient’s lithium ingestion?

Chorionic villus sampling

Fetal echocardiography

Fetal renal ultrasound

Maternal oral glucose tolerance test

Measurement of α-fetoprotein, β-human chorionic gonadotropin, and estriol levels

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?

Better patient survival

More cost-effective longterm

Improved quality of life

No need for lifelong immunosuppression

More cost-effective if the renal transplant functions for more than 2 years

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?

Lumpectomy and sentinel node biopsy

Lumpectomy and axillary dissection

Modified radical mastectomy

Radiation treatment to the affected breast

Systemic chemotherapy

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?

No prophylaxis early in this pregnancy

Too early administration of anti-0 immune globulin postpartum

Low dose of anti-D immune globulin at 28 weeks of her first pregnancy

Low dose of anti-D immune globulin postpartum

No prophylaxis between the pregnancies

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?

The Doppler studies indicate that the fetus is doing well

With advancing gestational age the S/D ratio is supposed to rise

These Doppler findings are normal in someone who smokes

Reverse diastolic flow is normal as a patient approaches full term

The Doppler studies are worrisome and indicate that the fetal status is deteriorating

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?

Annual physical examination

Frequent self-examination of the neck

Periodic serum calcium measurement

Periodic stimulated serum calcitonin measurement

DNA testing

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)

High, increased, normal, normal

High, increased, increased, low

High, increased, normal, low

High, normal, normal, normal

Normal, increased, increased, normal

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?

Insert a Foley catheter into the tract and aspirate. If gastric contents are aspirated the tube can be used for feeding

Insert a Foley catheter into the tract, instill water-soluble contrast, and obtain an abdominal radiograph prior to using for feeding

Remove the tube and admit the patient for observation

Remove the tube and immediately obtain a CT scan of the abdomen

Return to the OR for closure of gastrotomy and placement of a new tube

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?

More than a 10 mm Hg decrease in systolic blood pressure at the end of the expiratory phase of respiration

Decreased right atrial pressures on Swan-Ganz monitoring

Equalization of pressures across the 4 chambers on Swan-Ganz monitoring

Compression of the left ventricle on echocardiography

Overfilling of the right atrium

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?

Complete blood count in the patient

Hemoglobin electrophoresis testing in the patient

Hemoglobin electrophoresis testing in the patient and her husband

Iron level, total iron-binding capacity, and ferritin level in the patient

Solubility testing in the patient

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 is 7 months pregnant with her first child. Her pregnancy has been uncomplicated to date. She presents to the emergency department complaining of sudden-onset, right-sided chest pain that is exacerbated with deep breathing and shortness of breath, which began 1 hour ago. She denies leg pain and notes that her legs began swelling during the sixth month of her pregnancy but the swelling has not worsened. Her temperature is 37.9°C (100.3°F), blood pressure is 130/87 mm Hg, pulse is 107/min and regular, respiratory rate is 24/min, and oxygen saturation is 90% on room air, increasing to 98% with 4 L oxygen via nasal cannula. Physical examination is significant for crackles at the lower right lung field and a negative Homans’ sign bilaterally. X-ray of the chest appears normal. The D-dimer level is elevated. ECG shows sinus tachycardia, right-axis deviation, S wave in lead I, Q wave in lead III, and an inverted T wave in lead III. Which of the following is the most appropriate next step in diagnosis?

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 27-year-old, HIV-positive man comes to his physician with a two-day history of fever, profuse watery diarrhea, and abdominal cramps. He has been taking zidovudine, didanosine, and indinavir for the past eight months. His temperature is 37.9°C (100.2°F), pulse is 102/min, respirations are 14/min, and blood pressure is 105/70 mm Hg. He is started on fluid and electrolyte support. What is the most appropriate next step in the management of this patient?

Stop antiretroviral therapy and send stool for Clostridium difficile toxin assay

Colonoscopy with biopsy of the colonic mucosa

Stool examination for ova and parasites

Start empiric treatment for cytomegalovirus

Loperamide and lactose-free diet until diarrhea subsides

A 28-year-old African American woman presents with mild dyspnea on exertion. She reports no coughing, sputum production, or wheezing symptoms, but has noticed a red tender rash on her shins. Physical examination reveals hepatosplenomegaly, generalized lymphadenopathy, and tender erythematous nodules on her legs. CXR shows bilateral symmetric hilar adenopathy. Her pulmonary function tests reveal a mild restrictive pattern. Which of the following tests will most likely make a definitive diagnosis?

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 G1P0 woman at 12 weeks’ gestation presents for routine follow-up with her obstetrician. She complains of mild nausea and occasional vomiting, but otherwise is doing well and reports no other symptoms or complications. Her physical examination is unremarkable and fetal ultrasound is normal for gestational age. Laboratory tests show: Free triiodothyronine: 180 ng/dL, Free thyroxine: 2.2 ng/dL, Total thyroxine: 12 μg/dL, Thyroid-stimulating hormone: 0.1 μU/mL(normal: 0.4 – 4 μU/mL). Results of a thyroid-stimulating hormone receptor antibody test are negative. Which of the following best explains these findings?

Acute infectious thyroiditis

Graves’ disease

Hashimoto’s thyroiditis

High serum estrogen concentration

High serum β-human chorionic gonadotropin level

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 to the ED complaining of constant vague, diffuse epigastric pain. He describes having a poor appetite and feeling nauseated ever since eating sushi last night. His BP is 125/75 mm Hg, HR is 96 beats per minute, temperature is 100.5°F, and his RR is 16 breaths per minute. On examination, his abdomen is soft and moderately tender in the right lower quadrant (RLQ). Laboratory results reveal a WBC of 12,000/ μL. Urinalysis shows 1+ leukocyte esterase. The patient is convinced that this is food poisoning from the sushi and asks for some antacid. Which of the following is the most appropriate next step in management?

Order a plain radiograph to look for dilated bowel loops

Administer 40 cc of Maalox and observe for 1 hour

Send the patient for an abdominal ultrasound

Order an abdominal CT scan

Discharge the patient home with ciprofloxacin

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?

There is nothing to offer this couple

Offer testing of the parents

Offer MRI of the fetus

Offer 2nd trimester amniocentesis

Offer termination of the pregnancy

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?

Anti-thyroid peroxidase antibodies

Anti-smooth muscle antibodies

TSH-receptor blocking antibodies

Thyroid-stimulating immunoglobulins

Anti-mitochondrial antibodies

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?

Oligoclonal bands

Albumino-cytologic dissociation

Increased pressure

Increased cell count

Increased total protein concentrationIncreased total protein concentration

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

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?

Obtain a head computerized tomography scan

Perform a retinoscopic examination

Check serum levels of ammonia

Administer intravenous benzodiazepines

Perform a lumbar puncture

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?

{"name":"2nd Para USMLE 100Q", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"A 23-year-old man presents to your office complaining of occasional headaches, muscle weakness and fatigue. He also describes periodic numbness of his extremities. The symptoms started 6 months ago and have gradually progressed. His past medical history is insignificant. He is not taking any medication. His blood pressure is 165\/104 mmHg and heart rate is 80\/min. His physical examination is within normal limits. Which of the following laboratory findings is the most specific for the patient's condition?, A 23-year-old primigravid woman at 9 weeks gestation presents to the emergency room because of generalized weakness and lightheadedness. For the past 4 weeks she has not been able to keep anything down and over the past week her nausea and vomiting have worsened. She has no fever, abdominal pain, diarrhea, headache, dysuria, polyuria, tremor, or heat intolerance. She does not use tobacco, alcohol or illicit drugs. Her temperature is 37.2C (98.9 F); orthostatic vitals are as follows: BP 136\/86 mm Hg and pulse 98\/min supine, and 11 0\/70 mm Hg and 115\/min standing. Physical examination shows dry mucus membranes. The remainder of the examination is unremarkable. Laboratory studies show: Hematocrit: 50 %, Platelets: 200,000\/mm3, Serum sodium: 130 mEq\/L, Serum potassium: 2.8 mEq\/L, Chloride: 86 mEq\/L, Bicarbonate: 30 mEq\/L, Blood urea nitrogen (BUN): 30mg\/dl, Serum creatinine: 1.6 mg\/dl, Blood glucose: 98 mg\/dl. Which of the following is the most appropriate next step in management?, A 23-year-old primigravid woman comes to the physician because of vaginal bleeding. Her last menstrual period was 6 weeks ago. She has no other symptoms. Examination shows a 10-week sized uterus, but is otherwise unremarkable. Pelvic ultrasound reveals a snowstorm pattern consistent with a complete mole. Serum beta-hCG is markedly elevated over normal pregnant values. A chest x-ray film is negative. A dilation and evacuation is performed and the pathologic diagnosis is complete hydatidiform mole. Which of the following is the most appropriate next step in management?","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}