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28.
A 23-year-old African American woman, gravida 3, para 2, comes to the office at 35 weeks' gestation for follow-up after having been treated in the emergency department 18 hours ago following a motor vehicle collision. At the time of the collision, the patient was not wearing a seatbelt and her chest and abdomen struck the dashboard. Obstetric ultrasonography and nonstress testing were obtained in the emergency department and disclosed no abnormalities. The patient had several superficial lacerations over her upper extremities that required suturing. Her prenatal course has been otherwise unremarkable. Her blood type is A, Rh-negative. The patient now reports light vaginal bleeding and decreased fetal movement. Vital signs are temperature 36.7°C (98.0°F), pulse 88/min, respirations 24/min, and blood pressure 100/68 mm Hg. Fetal heart tones are 140/min. Fundal height is 35 cm. Pelvic examination shows dark red blood at the cervical os. The cervix is long and closed. A repeat nonstress test is done and shows irregular painless contractions with repetitive late decelerations. At one point, three contractions are observed in a 10-minute interval. The office is located in a rural area, and while there are general surgeons 5 to 10 minutes away at the local hospital who do cesarean deliveries, the nearest obstetrician is 1 hour away. Which of the following is the most appropriate next step?

A) Order Kleihauer-Betke testing
B) Refer the patient to a surgeon for immediate cesarean delivery
C) Refer the patient to an obstetrician
D) Repeat nonstress testing in 24 hours
E) Repeat obstetric ultrasonography

Ans: B) Refer the patient to a surgeon for immediate cesarean delivery

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BLEEDING IN 3RD TRIMESTER

Placenta Previa

SUDDEN-ONSET PAINLESS BLEEDING occurs at rest or during activity without warning.
The case may include a history of TRAUMA, COITUS, OR PELVIC EXAMINATION before bleeding starts. Placenta previa occurs when the placenta is implanted in the lower uterine segment. As the lower uterine stretches, placental villi dislodge and painless vaginal bleeding results.

An scenario of intractable bleeding may require a C-section.


Fischer, Conrad (2012-09-22). Master the Boards: USMLE Step 3 (Kindle Locations 9581-9593).

29.
A 15-year-old girl comes to the office because of a 6-month history of episodes of sharp pain on either side of her lower abdomen that occur each month. The last episode occurred 18 days ago. A watery vaginal discharge usually accompanies the discomfort. She is concerned that the symptoms may be a sign of a tumor. Menarche occurred at age 13 years and the patient's menses were initially painless. Since that time, menstrual periods have occurred every 28 days; her last menstrual period was 4 days ago. For the past 6 months, she has had cramping pain associated with menstruation that has been relieved by nonsteroidal anti-inflammatory drugs. She is sexually active with two partners and uses nonlubricated condoms sometimes. Medical history is otherwise unremarkable and she takes no medications. She is 157 cm (5 ft 2 in) tall and weighs 63 kg (140 lb); BMI is 26 kg/m2. Physical examination shows normal development and no abnormalities. Pelvic examination discloses a normal-sized, anteverted uterus. There are no adnexal masses or tenderness. Which of the following is the most appropriate recommendation to the patient at this time?
A) Application of a heating pad to the abdomen
B) Danazol therapy
C) Hydrocodone-acetaminophen therapy
D) Nitrofurantoin therapy
E) Oral contraceptive therapy

q29)
Ans: E) Oral contraceptive therapy
nbme cert.

This pt had menstrual cramps but the pain has been controlled with NSAIDS. She is only 15y but she has 2 sexual partners, "not judging here" but hellooo! she definitely needs contraception, so E is the next good thing we can do for her

30.
A 23-year-old man with type 1 diabetes mellitus returns to the office for a routine follow-up examination. His diabetes mellitus is well controlled with insulin, and he regularly monitors his blood glucose concentration. He notes that his glucose concentrations have been normal during the past 2 months, except on one occasion, when his blood glucose decreased to 46 mg/dL. One hour prior to checking his glucose concentration on that occasion, he had consumed a peanut-butter and banana sandwich on white bread, a glass of milk, a chocolate-chip cookie, and two glasses of wine. He is 170 cm (5 ft 7 in) tall and weighs 61 kg (135 lb); BMI is 21 kg/m2. Vital signs are normal. The patient appears healthy and physical examination discloses no abnormalities. The patient asks, "Was there something in particular that I ate or drank the time my glucose level was low that caused it to be abnormal?" Which of the following is the most likely causal agent of the patient's episode of hypoglycemia?
A) The alcohol
B) The banana
C) The chocolate-chip cookie
D) The glass of milk
E) The two slices of white bread

q30)

Ans: A
nbme cert.

When we drink alcohol, the alcohol inhibits the liver’s ability to release glucose into the blood. This can be particularly dangerous for insulin dependent diabetics; the liver is not able to release enough glycogen to keep the glycemia from going too low under the influence of the insulin. The impairment of the liver by alcohol can last for several hours after drinking so it is important for the pt. to be aware of this.
A potentially dangerous situation can occur if the pt. that had alcohol goes to sleep without bearing that in mind. Many people with diabetes, particularly those insulin dependent can be at risk of severe Hypoglycemia overnight if they do not take additional carbohydrates before going to bed.

31.
A 47-year-old woman comes to the office for the first time because of night sweats and occasional vaginal itching with no discharge. She says that she missed her menstrual period 2 months ago and that her last period, approximately 9 days ago, was heavier in flow than usual. Medical history is remarkable for diabetes mellitus diagnosed by another physician 3 years ago. She has been taking sulfonylurea since that time. Her previous physician has since retired. Hemoglobin A1c obtained 2 months ago was 8.3%. Physical examination today is normal. Pelvic examination discloses slightly atrophic vaginal mucosa. Which of the following is the most likely cause for her recent symptoms?
A) Adverse effect of the sulfonylurea
B) Estrogen deficiency
C) Lymphoma
D) Pregnancy
E) Uncontrolled hyperglycemia


32.
A 58-year-old man comes to the office for a periodic health evaluation. He says, "During the past 3 to 4 months I have had to get up to urinate once or twice each night. I have to urinate more often during the day and my urine is slow. I think I have prostate trouble." He is married, has two grown children, and works at a greenhouse. He smokes about 10 cigarettes and drinks one to three bottles of beer daily. Physical examination discloses no abnormalities except for his prostate, which is moderately, symmetrically enlarged. Which of the following is the most appropriate initial diagnostic step?
A) Intravenous urography
B) Measurement of serum dihydrotestosterone concentration
C) Ultrasonography of the bladder
D) Ultrasonography of the prostate
E) Urinalysis

q31)

Ans: B) Estrogen deficiency
nbme cert.

This 47y old lady has vaginal itching and atrophic vagina, menses are spacing up, she is having symptoms of Estrogen deficiency, she is getting close to menopause.

q32)

E) Urinalysis
nbme cert.

Before we diagnose BPH we have to rule out other causes like UTI, Prostatitis. A urinalysis will guide us to differentiate other etiologies.

33.
A 72-year-old woman comes to the office because of increasing cough and shortness of breath for the past 3 days. She has had a left-sided frontal headache and some sweats, but she has not had fever. She has a history of allergic rhinitis, asthma, hypertension, and irritable bowel syndrome. Her medications include hydrochlorothiazide, albuterol by inhaler, and dietary fiber. Today, vital signs are temperature 37.2°C (99.0°F), pulse 88/min, respirations 20/min, and blood pressure 135/85 mm Hg. Physical examination discloses nasal congestion, mild tenderness over the left maxilla, and diffuse expiratory wheezes throughout the lungs. The remainder of the physical examination shows no abnormalities. Peak expiratory flow rate is 260 L/min; her baseline rate is approximately 400 L/min. In addition to amoxicillin, which of the following is the most appropriate pharmacotherapy?

A) Guaifenesin and ipratropium
B) Guaifenesin and loratadine
C) Guaifenesin and prednisone
D) Pseudoephedrine and loratadine
E) Pseudoephedrine and theophylline

Ans:
C) Guaifenesin and prednisone
nbme cert!

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Peak expiratory flow rate (PEFR) will change according to the severity of asthma:

Mild exacerbation............... PEFR > 70 % from expected
Moderate exacerbation ..... 40 to 70 %
Severe exacerbation ......... < 40 %

So, she is 260/400= 65% => Moderate exacerbation .... is this useful?... we'll see

First, we need to know how to manage asthma...
http://i42.photobucket.com/albums/e338/G...59fe6d.png

After giving Short Acting Beta Agonists; Inhaled Steroids come next... In the options I don't see "inhaled", but I checked around and found this...

"Both inhaled Beclomethasone and inhaled Betamethasone have advantages over po Prednisone in the Maintenance treatment of patients with asthma, but in the Management of Exacerbations, Systemic Corticosteroids will usually be needed as a supplement to inhaled therapy."

Nice huh?

Ok so final answer, we also give PO Steroids for Exacerbation of Asthma.

34.
A 60-year-old woman comes to the office for follow-up of abnormal blood tests recently obtained at an employee health screening. Medical history is significant for obesity, hypertension treated with captopril, and diabetes mellitus controlled by diet. In 1987 she received an emergency blood transfusion following a motor vehicle collision, from which she recovered uneventfully. She takes vitamins and nutritional supplements. Family history is significant for a paternal great-aunt with an iron-storage disease. On further history the patient says that for the past 6 months she has had fatigue, painful joints, and loss of her usually robust appetite. Physical examination is normal. Laboratory results obtained at the employee health screening show an increased serum liver chemistry profile to twice the normal range. Serum kidney function tests, complete blood count, and test of the stool for occult blood are normal. Which of the following is the most appropriate next diagnostic study?

A) Do thin-needle biopsy of the liver
B) Obtain abdominal ultrasound
C) Obtain double-stranded anti-DNA antibody titer
D) Obtain serum hepatitis C antibody titer
E) Recheck the serum liver chemistry profile in 6 weeks