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* nbme-6
 #141310  
  tea - 11/25/06 16:47
 
  21. A 34-year-old primigravid woman at 24 weeks' gestation returns to the office to discuss results of a fasting serum glucose study and hemoglobin A1c obtained during a visit 2 weeks ago. Medical history is significant for infertility, oligomenorrhea, and hirsutism. She conceived 3 months after starting treatment with metformin; she discontinued metformin at 10 weeks' gestation. She currently takes only a prenatal multivitamin supplement. Her mother, a maternal aunt, and a paternal aunt have type 2 diabetes mellitus. The patient is 168 cm (5 ft 6 in) tall and weighs 118 kg (260 lb); BMI is 42 kg/m2. Vital signs are: temperature 37.0°C (98.6°F), pulse 82/min, respirations 15/min, and blood pressure 112/64 mm Hg. Fasting serum glucose concentration is 120 mg/dL and hemoglobin A1c is 7.5%. Which of the following is the most appropriate management?

A

) 1200-Calorie American Diabetes Association diet

B

) Glyburide therapy

C

) Insulin therapy

D

) Reinitiating metformin therapy

E

) Rosiglitazone therapy

22. A 28-year-old African-American woman comes to the office because of low back pain and decreased urine output. She is a semiprofessional basketball player and she is married. She had one pregnancy 12 years ago that was uncomplicated and resulted in vaginal delivery of a term female neonate. Medications include oral contraceptive pills and a corticosteroid inhaler for asthma. She is 182 cm (6 ft) tall and weighs 88 kg (195 lb). Physical examination is normal except for a palpable lower abdominal mass that extends to the umbilicus. Speculum examination discloses a 3-cm ulcerative lesion circumferentially around the external cervical os. Bimanual examination shows a firm, nodular, central pelvic mass filling the pelvis and extending cephalad to the umbilicus. Rectovaginal examination confirms these findings. Stool is negative for occult blood. Which of the following is the most appropriate recommendation?

A

) Arrange for laparoscopy

B

) Do a cervical biopsy

C

) Do an endometrial biopsy

D

) Increase Pap smear screening to every 3 months

E

) Obtain pelvic ultrasonography

The following vignette applies to the next 3 items.


A 61-year-old woman comes to the office because of a 3-month history of urinary incontinence. You have been providing care for her and her husband since they moved to your area 2 years ago. She has a history of diabetes mellitus that was first diagnosed 2 years ago and has been very well managed by diet alone. She currently takes lorazepam at night for sleep and calcium and vitamin D supplements to prevent osteoporosis. She has declined hormone replacement therapy in the past because of a concern about breast cancer. She denies dysuria or problems with incontinence after sneezing or laughing, but she says, "When I try to pass urine, there usually isn't much, but I have to go again a few minutes later. And then, at other times, I just lose control and wet myself. I recently saw a television program on this and I think I have stress incontinence." Vital signs are: temperature 36.9°C (98.4°F), pulse 64/min, respirations 16/min and blood pressure 158/72 mm Hg. She weighs 93 kg (205 lb) and is 163 cm (5 ft 4 in) tall. Physical examination is normal except for moderate vaginal mucosal atrophy. Urinalysis done in the office shows no signs of infection.

Item 1 of 3

23. Which of the following factors in this patient's history or physical examination suggests a diagnosis other than stress incontinence as the cause for this patient's symptoms?

A

) Absence of dysuria

B

) Diabetes mellitus

C

) Increased body mass index

D

) Pattern of urination

E

) Vaginal mucosal atrophy

Item 2 of 3

24. The most appropriate next step in management is to suggest which of the following?

A

) Increased fluid consumption at night

B

) Referral for bladder ultrasonography

C

) Replacement of lorazepam with diphenhydramine at night for sleep

D

) Scheduled voiding

E

) Use of a pessary

Item 3 of 3

25. The patient follows your suggestion. She returns to the office in 3 weeks and reports that she was recently incontinent while shopping with friends. She states, "I've never been so embarassed in my life! Frankly, I don't think I'm better off than when I saw you last time, and now I'm afraid to leave the house." Which of the following is the most appropriate response to the patient's comment?

A

) "Are you ready to use estrogen therapy now?"

B

) "Have you ever thought of using adult disposable diapers? They are very effective."

C

) "I understand your concern. Let's discuss this further and develop a plan."

D

) "I'm sorry to hear this. I'll refer you to a urologist right away."

E

) "These things happen. I'm sure you can understand you're growing older."


26. A 27-year-old woman comes to the office because she recently noted a copious vaginal discharge requiring showering or bathing two or three times daily. She states that despite bathing frequently, she never feels clean. She has had no other medical problems. Results of her last Pap smear 1 year ago were normal. She is not sexually active at this time and is taking no medications. She has never been pregnant. She works as a respiratory therapist at a local community hospital and recently broke up with a boyfriend of several months. Physical examination shows no abnormalities. Pelvic examination demonstrates no vaginal discharge, bleeding, or mucosal lesions. Uterus is normal-sized and nontender. Adnexa are palpable and there are no masses. In addition to obtaining cultures for gonorrhea and chlamydia, which of the following is the most appropriate next step?

A

) Determine serum estrogen concentration

B

) Order antibody studies for syphilis and HIV

C

) Prescribe an oral anti-trichomonal medication and antifungal cream

D

) Question the patient regarding the circumstances surrounding her recent break-up

E

) Tell the patient you will wait for the Pap smear results before prescribing anything for the discharge

27. A 77-year-old woman with breast cancer comes to the office because of a 2-week history of severe burning pain and weakness of her left arm. Two months ago, a bone scan obtained because of diffuse bony pain showed widespread metastases. The patient declined chemotherapy and asked for palliative care only. She received localized radiation therapy to left femur and right humerus for the most painful lesions. Her pain was well controlled with celecoxib and a long-acting morphine preparation until 2 weeks ago. Her only other medication is bisacodyl. The patient is alert and oriented. Vital signs are temperature 37.0°C (98.6°F), pulse 90/min, respirations 20/min, and blood pressure 110/70 mm Hg. She cannot extend her left arm above her head. There is weakness of wrist extension, flexion, and handgrip of the left upper extremity. Sensation to light touch and pinprick is decreased over the left arm. Stroking the left forearm with a cotton swab causes a painful sensation of electric shocks and heat. There are decreased biceps and brachioradialis reflexes on the left. Reflexes, strength, and sensation in the right upper extremity are normal. Neurologic examination of the lower extremities shows no abnormalities. Which of the following is the most appropriate next step in evaluation?

A

) CT scan of the head

B

) Electromyography and nerve conduction studies of the left upper extremity

C

) Measurement of serum B12 (cobalamin) concentration

D

) MRI of the cervical spine

E

) Radionuclide bone scan

28. A 32-year-old woman, gravida 3, para 2, who is at 38 weeks' gestation, is brought to the office by her coworker 15 minutes after the patient appeared to have had a seizure at work. The coworker says the patient was working at her computer when she suddenly fell to the floor, began shaking, and had incontinence of urine. She was unresponsive to voice until approximately 5 minutes after the episode. The patient has received routine prenatal care throughout her pregnancy. She has a history of mild, persistent asthma treated with corticosteroid inhalers. Vital signs on arrival are temperature 36.7°C (98.0°F), pulse 100/min, respirations 22/min, and blood pressure 160/110 mm Hg. The patient is alert but disoriented to time and place. She has no recollection of the episode. Physical examination shows bruising of her left arm and a bite on the lower lip. Which of the following is the most accurate statement regarding the risk of harm to the fetus?

A

) The fetus is at risk for developing intrauterine hypoxia

B

) The fetus will die unless it is delivered immediately

C

) The risk to the fetus depends on any coexisting respiratory condition

D

) The risk to the fetus is minimal because the seizure was short-lived

E

) The risk to the fetus will not be increased if the seizure does not recur

29. A 30-year-old African-American woman returns to the office for a second prenatal visit. She is 12 weeks pregnant and this is her first pregnancy. Results of laboratory studies that were ordered at her first visit show:


Blood

Hematocrit 28%

Hemoglobin 9.2 g/dL

Hemoglobin electrophoresis

Hemoglobin A1 64%

Hemoglobin S 32%

Hemoglobin A2 4%

Mean corpuscular hemoglobin (MCH) 26 pg/cell

Mean corpuscular hemoglobin concentration(MCHC) 32% Hb/cell

Mean corpuscular volume (MCV) 74 μm3


Which of the following is the most likely cause of her anemia?

A

) α-thalassemia trait

B

) β-thalassemia trait

C

) Iron deficiency

D

) Physiologic anemia of pregnancy

E

) Sickle cell trait

30. A 17-year-old girl brings her 4-day-old neonate to the health center 1 day after discharge from the hospital. She says, "I don't think my baby is getting enough milk. He wants to nurse every 2 hours and my nipples are sore and cracked. I feel miserable." The neonate was born via vaginal delivery without complications, following a normal pregnancy. His birth weight was 3317 g (7 lb 5 oz). Physical examination shows a vigorous, active neonate with a strong sucking reflex. He has a wet diaper on arrival and has had two stools since this morning. There is jaundice of the face. In order to support this new mother during this early stage of breast-feeding, which of the following is the most appropriate advice to the patient?

A

) Feed the neonate on only one breast at each feeding to ensure complete emptying of the breast

B

) Insert as much of the areola as possible into the neonate's mouth to improve latching

C

) Not feed the neonate more than every 3 hours to allow for better milk production

D

) Offer formula after each feeding to ensure that the neonate is getting enough milk

E

) Switch to formula for 5 days to assist with healing of her nipples
 
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* Re:nbme-6
#571251
  pk007 - 11/25/06 18:18
 
  21.a
22.b
23.d
24.d
25.c
26.d
27.d
28.b
29.c
30.b
 
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* Re:nbme-6
#571367
  tea - 11/25/06 20:36
 
  21c
22e
23d
24b
25c
26d
27d
28a
29e
30c
 
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* Re:nbme-6
#571822
  chirkut - 11/26/06 13:57
 
  21a
22e
23d
24b?
25c
26d
27d
28a
29e
30b
 
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* Re:nbme-6
#571847
  tea - 11/26/06 14:18
 
  21.GDM, abnormal fasting glucose and high HA1c, tx with insulin, if fasting is normal, but other three hours results abnormal, then diet and life style first.
30, ok, I don't know the skills of breast feeding, newborn q 4hr feeding? I think the new mom worries too much about not feeding the infant enough milk, even breast milk needs more often feeding than formula, but every two hours....? but you guys may be right.
 
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* Re:nbme-6
#571886
  captopril - 11/26/06 14:53
 
  y not
21:c
28:a
29:c
30:a
 
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* Re:nbme-6
#572507
  rich - 11/27/06 10:01
 
  21 C
22 B
23 D
24 C
25 C
26 D
27 D
28 B
29 C
30 B
 
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