A 32-year-old pregnant woman at 18 weeks gestation comes to the emergency department due to severe right-sided abdominal pain for 6 hours.  The patient rates the pain as 10 on a scale of 0-10.  The pain is crampy and paroxysmal and radiates to the labia.  When the pain occurs, she has associated nausea and vomiting.  The patient has no vaginal bleeding, fever, hematuria, or dysuria.  She underwent cesarean delivery with her first child 3 years ago.  The pregnancy thus far had been uncomplicated, and initial prenatal laboratory testing was normal.  On examination, the patient is unable to find a comfortable position.  Temperature is 36.7 C (98.1 F), blood pressure is 110/60 mm Hg, and pulse is 106/min.  BMI is 32 kg/m².  The abdomen is soft, nontender, and nondistended to palpation.  There is no costovertebral angle or suprapubic tenderness.  Pelvic examination shows an 18-week-sized uterus.  Laboratory results are as follows:

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

A 23-year-old primigravida comes to the clinic at 9 weeks gestation for prenatal counseling.  She reports a family history of hemophilia A and expresses concern about her child having hemophilia.  The patient and her husband have no history of abnormal bleeding.  A pedigree of the woman’s family is shown below; she is represented by II-8.

Which of the following best states the patient’s risk related to hemophilia?

A 38-year-old woman, gravida 3 para 3, comes to the office due to a 2-week history of dysuria and pain on deep penetration during sexual intercourse.  For the past few months, urine dribbling has occurred after she voids.  The patient has no fever, chills, hematuria, nocturia, or increased urinary frequency.  Medical history is notable for multiple urinary tract infections.  She has regular, monthly menses with 4 days of moderate bleeding.  The patient’s last pregnancy was 4 years ago, and all resulted in uncomplicated term vaginal deliveries.  Temperature is 36.7 C (98.1 F), blood pressure is 120/80 mm Hg, and pulse is 78/min.  The abdomen is soft and nontender, with no palpable masses.  There is no costovertebral angle tenderness.  Pelvic examination shows a tender area of fullness along the anterior vaginal wall.  The uterus is small, mobile, and nontender; there are no adnexal masses.  Laboratory results are as follows:

Item 1 of 2
Which of the following is the most likely diagnosis for this patient?

Item 2 of 2
Which of the following is the best next step in diagnosing this patient’s condition?

A 29-year-old woman, gravida 1 para 0, at 26 weeks gestation comes to the office for a routine prenatal visit.  She has had no contractions, vaginal bleeding, or leakage of fluid.  There is good fetal movement.  The patient has a history of polycystic ovary syndrome.  This pregnancy was conceived through ovulation induction but has otherwise been uncomplicated.  Results of prenatal laboratory testing from her initial visit at 8 weeks gestation include a hemoglobin A1c of 5.6%.  She has no other chronic medical conditions or previous surgeries.  The patient walks for 30-45 minutes 5 days a week.  She takes prenatal vitamins and a folate supplement daily.  Blood pressure is 130/80 mm Hg and pulse is 89/min.  BMI is 27 kg/m².  Fetal heart tones are 150/min.  Fundal height is 28 cm.  Laboratory results from today’s visit are as follows:

Item 1 of 2

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

Item 2 of 2

Appropriate evaluation of the patient is completed, and gestational diabetes mellitus is diagnosed.  She is instructed to start a diabetic diet and continue to exercise regularly, with an hour of brisk walking on most days.  The patient returns 2 weeks later for a routine prenatal visit and for evaluation of her glycemic control.  She reports compliance with diet and exercise and has been checking her fasting and postprandial blood glucose values daily.  Blood pressure is 136/70 mm Hg and pulse is 80/min.  Fetal heart tones are 140/min.  During the third week of the patient’s regimen, fasting blood glucose values are 110-130 mg/dL (normal: ≤95), and 2-hour postprandial glucose values are 138-168 mg/dL (normal: ≤120).  The physician recommends insulin initiation.  The patient states, “I really don’t like needles and don’t think I can give myself injections.”  Which of the following is the best response to this patient?

An 18-year-old woman comes to the office due to painful urination and urinary frequency.  The patient is sexually active with her boyfriend and has had painful intercourse the past 3 days.  She has no fever, chills, nausea, vomiting, or flank pain.  The patient uses condoms consistently for contraception, and her last menstrual period was 4 weeks ago.  She has no chronic medical conditions or surgeries and has no known drug allergies.  Temperature is 37.8 C (100 F), blood pressure is 110/70 mm Hg, pulse is 82/min, and respirations are 18/min.  Mild suprapubic tenderness is present on abdominal examination.  Pelvic examination shows clear, thin vaginal discharge with no cervical motion tenderness.  The remainder of the examination is normal.  Urinalysis shows positive leukocyte esterase, positive nitrites, and 10 red blood cells/hpf.  The physician considers prescribing a 1-week course of trimethoprim-sulfamethoxazole.

Item 1 of 2

Prior to initiating treatment, which of the following is the best next step in management of this patient?

Item 2 of 2

The pregnancy test result is positive.  Which of the following is the most appropriate treatment for this patient’s presenting symptoms?

A 35-year-old woman, gravida 2 para 1, at 20 weeks gestation comes to the office due to cholelithiasis found incidentally during a prenatal ultrasound.  She has no prior history of gallstones and has no abdominal pain, jaundice, or clay-colored stool.  She has no chronic medical conditions, and her only medication is a daily prenatal vitamin.  The patient stopped drinking alcohol after learning that she was pregnant and does not use tobacco or recreational drugs.  Her mother underwent cholecystectomy for acute cholecystitis at age 40.  Vital signs are within normal limits.  The patient is anicteric, and mucous membranes are moist and pink.  Examination reveals a gravid abdomen but no tenderness.  Laboratory results are as follows:

Ultrasonography of the right upper quadrant reveals a 1-cm gallstone without gallbladder distension, wall thickening, or pericholecystic fluid.  The intrahepatic biliary ducts and common bile duct are normal in size.  Which of the following is the most appropriate intervention for this patient’s gallstone?

A 26-year-old woman, gravida 1 para 0, comes to the office to initiate prenatal care.  The patient has had no nausea, abdominal pain, or vaginal bleeding since her last menstrual period 8 weeks ago.  She has no chronic medical conditions.  She had an appendectomy as a child but no other surgery.  The patient takes a daily prenatal vitamin and does not use tobacco, alcohol, or illicit drugs.  She is a vegetarian and emigrated from Southeast Asia 5 years ago.  Blood pressure is 110/75 mm Hg and pulse is 80/min.  BMI is 21 kg/m².  Pelvic examination reveals an 8-week-sized, nontender uterus and no adnexal masses or tenderness.  Laboratory results are as follows:

A transvaginal ultrasound reveals an 8-week intrauterine gestation with a normal heartbeat.  Which of the following is the most likely cause of this patient’s anemia?

A 32-year-old woman is brought to the emergency department after she was found confused on the street.  The patient is experiencing homelessness and lives in a shelter.  She has not received medical care in several years and has no known chronic medical conditions.  She has a history of intravenous drug use and smokes cigarettes.  Temperature is 37.2 C (99 F), blood pressure is 120/60 mm Hg, and pulse is 94/min.  BMI is 19 kg/m².  On examination, the patient is disoriented and mildly agitated.  The sclerae are icteric.  The mucous membranes are moist; there is poor oral hygiene and multiple dental caries.  Scattered petechial lesions are present on her extremities and trunk.  Heart and lung sounds are normal.  Abdominal examination reveals no tenderness, but the uterus is enlarged, corresponding to a 16-week gestation.  There is no focal weakness or sensory loss.  Laboratory results are as follows:

Urine pregnancy test is positive.  Which of the following is the most likely cause of this patient’s current condition?

A 34-year-old woman, gravida 2 para 1, at 32 weeks gestation comes to the office for routine prenatal care.  The patient reports no contractions, vaginal bleeding, or leakage of fluid.  Fetal movement is normal.  The patient reports a dark rash on her face that she first noticed 2 weeks ago.  She has applied an over-the-counter moisturizer to the rash daily for the last week but has not noticed any improvement.  The patient has no chronic medical conditions and no previous surgeries.  She takes a daily prenatal vitamin and does not use tobacco, alcohol, or illicit drugs.  The patient has no known drug allergies.  She works as an accountant and enjoys gardening on the weekends.  Blood pressure is 120/80 mm Hg and pulse is 65/min.  The fetal heart rate is 140/min by Doppler ultrasound.  Fundal height is 32 cm.  Skin examination is shown in the image below.  The remainder of the physical examination is unremarkable.

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