01-11-2012, 12:34 AM
32. A 54-year-old white man comes to the office because of increasingly severe nosebleeds for the past 10 days. He says initially his nosebleeds resolved spontaneously, but over the past week they have become more frequent and have had a heavier flow. He says his nose has been bleeding almost constantly for the past 48 hours. There is no history of trauma or previous nosebleeds. His only medication is quinidine, which was started 6 weeks ago for restless legs. Medical history is otherwise unremarkable and he takes no other medications. Vital signs are: temperature 36.5°C (97.7°F), pulse 75/min, respirations 18/min, and blood pressure 132/85 mm Hg. His nose is packed with tissue paper and he has blood stains on his shirt. Examination of the nose shows no active bleeding or nasal lesions, but there is dried blood on his nares. Petechiae are noted inside the oral cavity. Examination of the skin shows scattered ecchymoses over the lower extremities. The remainder of the physical examination is noncontributory. Results of laboratory studies show:
Serum Blood
ALT 32 U/L Hematocrit 37%
AST 43 U/L Hemoglobin 11.7 g/dL
WBC 6500/mm3
PTT 22 seconds
INR 1.0
Platelet count 32,500/mm3
Which of the following is the most appropriate initial management?
A
) Bone marrow biopsy
B
) Determination of bleeding time
C
) Discontinuation of quinidine
D
) Platelet transfusion
E
) Vasopressin therapy
35. A 17-year-old African-American girl comes to the health center because she wants contraception. She has been sexually active for the past 2 years. She has never taken oral contraceptive therapy. She says that her boyfriends use condoms some of the time. Past medical history is unremarkable. She takes no medication and has no allergies. She does not drink alcoholic beverages. She smokes one-half pack of cigarettes per day. Her last menstrual period, which was normal, was 3 weeks ago. She has had no vaginal symptoms. The patient is 165 cm (5 ft 5 in) tall and weighs 62 kg (137 lb). Pulse is 62/min and blood pressure is 106/64 mm Hg. Physical examination, including pelvic examination, is normal. Which of the following is the most appropriate recommendation for contraception in this patient?
A
) Combination oral contraceptive therapy
B
) Diaphragm
C
) Intrauterine device (IUD)
D
) Levonorgestrel
E
) Spermicidal jelly
Serum Blood
ALT 32 U/L Hematocrit 37%
AST 43 U/L Hemoglobin 11.7 g/dL
WBC 6500/mm3
PTT 22 seconds
INR 1.0
Platelet count 32,500/mm3
Which of the following is the most appropriate initial management?
A
) Bone marrow biopsy
B
) Determination of bleeding time
C
) Discontinuation of quinidine
D
) Platelet transfusion
E
) Vasopressin therapy
35. A 17-year-old African-American girl comes to the health center because she wants contraception. She has been sexually active for the past 2 years. She has never taken oral contraceptive therapy. She says that her boyfriends use condoms some of the time. Past medical history is unremarkable. She takes no medication and has no allergies. She does not drink alcoholic beverages. She smokes one-half pack of cigarettes per day. Her last menstrual period, which was normal, was 3 weeks ago. She has had no vaginal symptoms. The patient is 165 cm (5 ft 5 in) tall and weighs 62 kg (137 lb). Pulse is 62/min and blood pressure is 106/64 mm Hg. Physical examination, including pelvic examination, is normal. Which of the following is the most appropriate recommendation for contraception in this patient?
A
) Combination oral contraceptive therapy
B
) Diaphragm
C
) Intrauterine device (IUD)
D
) Levonorgestrel
E
) Spermicidal jelly