08-12-2017, 10:06 AM
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
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