A 53-year-old woman comes to the office for a routine follow-up visit.  She has been experiencing menopausal symptoms for the past 2 years and started venlafaxine for worsening hot flashes 6 months ago.  She says, “I’m doing pretty well; that medication you gave me seems to have helped my hot flashes somewhat.  My sleep isn’t great, but it’s not that different from usual.  At least I’m not waking up 3 times a night anymore.”  Medical history is significant for hypertension and chronic insomnia.  Additional medication includes enalapril.  The patient drinks a glass of wine each day and does not use tobacco.  She works as a college professor and lives with her husband.  She exercises regularly and enjoys socializing with her friends when she has the opportunity.  When asked about her home life, she says her marriage is “fine,” although she wishes that she and her husband had more time for each other and were more intimate.  The patient says, “Actually, I am a little upset with my husband.  He comes home from work exhausted and just wants to watch television.  He doesn’t understand the changes I’m going through and isn’t interested in anything, including me!”

Item 1 of 2

Which of the following questions would be most helpful to address the patient’s concerns?

Item 2 of 2

The patient continues:  “I guess it shouldn’t matter to me as much anymore, but my sex life has been frustrating for the past 2 years.  My husband and I are never in the mood at the same time; when we are, well, let’s just say we’re not 18 anymore!  I wish our sex life was better, but sometimes I feel like giving up because it’s just not that pleasurable and can be painful.  It’s become easier not to try.”  Which of the following is the most likely explanation for this patient’s sexual dysfunction?

A 27-year-old woman comes to the office with a yearlong history of periodic irritability, anger, tension, and sleep disturbance.  The symptoms begin predictably a week before her menstrual period and resolve by day 2 of her menstrual cycle.  The patient has increased appetite, breast tenderness, and ankle swelling before her menstrual periods.  The symptoms are severe and impair her performance at work.  Menses are regular and occur every 29 days.  She has no intermenstrual bleeding or abnormal vaginal discharge.  The patient has been sexually active with 1 partner for the past 3 years.  She uses a copper-containing intrauterine device for contraception due to a history of migraines with aura.  The patient is prescribed fluoxetine at this visit.  Four months later, she returns to the office and says that her symptoms have not improved significantly and that she stopped taking the fluoxetine 6 weeks ago.

Item 1 of 2

Which of the following is the best next step in management of this patient?

Item 2 of 2

The patient returns 6 months later and says that she feels much better.  Her symptoms are less disabling, and she can work without significant discomfort.  She is concerned about the long-term prognosis and risk of future disorders that may be associated with her condition.  The patient is at increased risk for which of the following?

A 60-hour-old boy is evaluated in the newborn nursery prior to anticipated discharge.  He was born via vaginal delivery with vacuum assistance at 38 weeks gestation.  Prenatal maternal group B streptococcus screen was positive, for which the mother received antibiotics during labor and delivery.  Other prenatal laboratory studies were normal.  Maternal blood type is A+.  On day of life 1, the patient was noted to have a well-demarcated scalp swelling that has remained stable in size.  He is breastfed exclusively and has had 3 wet diapers in the last 24 hours.  Physical examination shows an alert and active boy with appropriate tone and a strong cry.  He has icteric sclerae, jaundice from the face to the lower abdomen, and a 2 x 3 cm scalp swelling over the right parietal area.  The remainder of the examination is unremarkable.  Laboratory results are as follows:

Phototherapy is initiated, and repeat total bilirubin 6 hours later is 17.1 mg/dL.  The father says, “We really want to take our baby home.  Can we supplement with formula and keep him by the window to get sunlight?”  Which of the following is the best next step in management of this patient?

A 24-year-old woman comes to the office for a routine prenatal visit at 32 weeks gestation.  Last week, she was evaluated for postcoital spotting.  The cervix was closed, and there was no evidence of preterm labor.  Nucleic acid amplification testing (NAAT) performed at that visit was positive for Chlamydia trachomatis.  Routine NAAT was negative for C trachomatis at the initial prenatal visit.  Today, the patient has no vaginal bleeding, leakage of fluid, or contractions.  Fetal movement is normal.  She has no chronic medical conditions or previous surgeries.  The patient does not use tobacco, alcohol, or illicit drugs.  She had 3 sexual partners prior to marriage.  She has been in a monogamous relationship with her husband for the last 2 years and is sexually active with him.  The patient swims at the local pool regularly but stopped after the episode of vaginal bleeding.  Blood pressure is 110/70 mm Hg and pulse is 72/min.  Fundal height is 32 cm.  Fetal heart rate is 140/min by Doppler ultrasound.  Urine dipstick is negative for glucose and protein.  The patient is concerned about the results and wonders how she acquired the infection during her pregnancy.

Item 1 of 2
Which of the following is the most appropriate statement to explain the results?

Item 2 of 2
If left untreated, this patient is at increased risk for which of the following pregnancy complications?

A 30-year-old woman, gravida 1 para 0, at 34 weeks gestation comes to the office for a prenatal visit.  The patient reports no abdominal pain, vaginal bleeding, or leakage of fluid.  Fetal movement is normal.  The patient has had urinary frequency throughout her pregnancy, but it has worsened over the past 4 days and is now associated with dysuria.  She has no fevers, chills, nausea, vomiting, back pain, or hematuria.  The pregnancy has been uncomplicated.  The patient has no history of chronic medical conditions and has had no previous surgeries.  She takes a daily prenatal vitamin.  The patient smokes half a pack of cigarettes a day but does not use alcohol or recreational drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 126/78 mm Hg, pulse is 76/min, and respirations are 18/min.  BMI is 28 kg/m².  Fetal heart rate is 140/min.  On physical examination, the uterus is nontender and fundal height is 34 cm.  Suprapubic tenderness is elicited with deep palpation.  There is no costovertebral angle tenderness.  Laboratory results are as follows:

Item 1 of 2

Which of the following is the most appropriate medication for this patient’s condition?

Item 2 of 2

The patient is prescribed an appropriate antibiotic, and a clean-catch urine sample is obtained and sent for culture.  The following day, she comes to the emergency department with fever, chills, nausea, and flank pain.  Temperature is 38.3 C (100.9 F), blood pressure is 110/70 mm Hg, pulse is 96/min, and respirations are 16/min.  Fetal heart rate tracing shows a baseline of 170/min, moderate variability, multiple accelerations, and no decelerations.  Tocometer shows no contractions.  The left costovertebral angle is tender to palpation.  Abdominal examination reveals a gravid, nontender uterus and no abdominal tenderness.  Digital cervical examination reveals the cervix to be closed, long, and posterior.  There is trace pedal edema over the bilateral lower extremities to the knees.  Which of the following is the best next step in management of this patient?

A 31-year-old woman, gravida 1 para 0, at 14 weeks gestation comes to the office to establish prenatal care.  She has had some nausea but no vomiting, abdominal pain, or vaginal bleeding.  The patient contracted HIV through intravenous heroin use.  She was diagnosed 3 years ago while hospitalized for drug rehabilitation.  The patient is on triple-combination antiretroviral therapy with no significant side effects.  She has no other chronic medical conditions and has had no previous surgeries.  In addition to her HIV medications, the patient takes a daily prenatal vitamin.  She does not use tobacco or alcohol and has not used illicit drugs since rehabilitation.  Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, and pulse is 65/min.  BMI is 24 kg/m².  Pelvic examination reveals a 14-week-sized nontender uterus with no adnexal masses.  Laboratory results are as follows:

Bedside ultrasound reveals a 14-week intrauterine pregnancy with a normal heart rate.

Item 1 of 2

Which of the following is the most appropriate recommendation for this patient?

Item 2 of 2

The patient is compliant with highly active antiretroviral therapy (HAART) throughout pregnancy.  She continues to abstain from tobacco, alcohol, and illicit drugs.  The patient has an uncomplicated delivery at 38 weeks gestation and indicates that she would like to breastfeed her child.  Which of the following is the most appropriate recommendation?

A 25-year-old woman, gravida 1 para 1, comes to the office for evaluation of fever and right breast pain.  The patient is 2 weeks postpartum after an uncomplicated pregnancy and vaginal delivery.  She has been breastfeeding every 2-3 hours; however, the infant has had difficulty with latching due to the mother’s inverted nipples.  Yesterday, the patient developed constant sharp pain in the side of her right breast as well as fever, chills, nausea, and body aches.  The pain is worsening, especially during breastfeeding.  She has been taking acetaminophen and ibuprofen with minimal relief.  The patient has no chronic medical conditions.  She is on maternity leave from her engineering job.  The patient has no drug allergies and is taking a daily prenatal vitamin.  Temperature is 38.9 C (102 F), blood pressure is 110/70 mm Hg, and pulse is 100/min.  Examination reveals the upper outer quadrant of the right breast to be erythematous, tender, and swollen but without fluctuance.  The left breast has no erythema or tenderness.

Item 1 of 3

Which of the following is the best next step in management of this patient?

Item 2 of 3

The patient had planned to breastfeed her infant exclusively for the first year of life but is now discouraged by the infection and the discomfort that occurs during latching.  Which of the following is the most appropriate advice for this patient?

Item 3 of 3

The patient returns to the office the next day with worsening symptoms.  She has a family history of breast cancer and is very concerned about the pain.  Temperature is 39.4 C (103 F), blood pressure is 100/70 mm Hg, and pulse is 114/min.  Examination shows persistent swelling and erythema in the upper outer quadrant of the right breast in addition to a palpable area of induration.  Which of the following is the best next step in management of this patient?

A 25-year-old healthy woman comes to the office due to 4 days of burning with urination and increased urinary frequency.  The patient has had no fevers, chills, or abnormal vaginal discharge.  She has tried to treat the symptoms with cranberry juice and increased fluid intake but has had no improvement.  The patient entered a new monogamous relationship 8 months ago, and she and her partner have intercourse 3 or 4 times a week.  Despite voiding immediately after intercourse and changing contraception from condoms with spermicide to a progestin-containing intrauterine device (IUD), she has had 3 urinary tract infections in the past 7 months.  The patient occasionally drinks alcohol but does not use tobacco or recreational drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, and pulse is 58/min.  BMI is 22 kg/m².  Abdominal examination shows suprapubic tenderness but no costovertebral angle tenderness.  Pelvic examination reveals a small, nontender uterus with no adnexal masses.  Speculum examination reveals a normal cervix with no abnormal discharge.  Urinalysis results are as follows:

A 1-week course of antibiotics is prescribed.  In addition to the course of antibiotics, which of the following is the best next step in management of this patient?

A 24-year-old woman, gravida 1 para 0, comes to the office at 12 weeks gestation for an initial prenatal visit.  She is feeling well and reports no nausea, cramping, or vaginal bleeding.  The patient has no chronic medical conditions and has had no previous surgeries.  She takes a prenatal vitamin daily.  Pap test and sexually transmitted infection screening last year were normal.  Family history is not significant.  She drank 1 or 2 alcoholic beverages a week prior to pregnancy, but does not use tobacco or illicit drugs.  The patient developed a skin rash and difficulty breathing after taking penicillin for streptococcal pharyngitis as a child.  Blood pressure is 110/60 mm Hg and pulse is 78/min.  BMI is 26 kg/m².  Bimanual examination is consistent with a 12-week-sized uterus.  Pelvic ultrasound reveals a singleton intrauterine pregnancy consistent with gestational age.  Fetal heart rate is 160/min.  Laboratory results from this visit are as follows:

Which of the following is the most appropriate treatment for this patient?

A 31-year-old woman is brought to the emergency department due to fever, chills, abdominal pain, and urinary frequency for the past 5 days.  She vomited twice today, and her symptoms have become progressively worse.  The patient reports increased malodorous vaginal discharge but no abnormal vaginal bleeding.  She has no associated dysuria, hematuria, diarrhea, constipation, or sick contacts.  The patient has no chronic medical conditions or previous surgeries.  Her last menstrual period was a week ago.  She is sexually active and uses oral contraceptives.  The patient has no known drug allergies.  Temperature is 38.9 C (102 F), blood pressure is 100/60 mm Hg, pulse is 110/min, and respirations are 18/min.  Physical examination shows a pale and diaphoretic woman.  The abdomen is soft, diffusely tender, and nondistended; no rebound tenderness or rigidity is present.  Bowel sounds are increased.  There is no splenomegaly, costovertebral angle tenderness, or tenderness to palpation of the lower back.  On pelvic examination, there is light yellow discharge at the external cervical os and tenderness on lateral movement of the cervix.  Laboratory results are as follows:

Urinalysis results are unremarkable.  Urine pregnancy test is negative.  Pelvic ultrasonography shows a small uterus with no adnexal masses.  Which of the following is the most appropriate next step in management of this patient?