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* nbme-10
 #141507  
  tea - 11/26/06 16:03
 
  25. A 25-year-old woman returns to the office because of intermenstrual spotting since beginning oral contraceptive therapy 6 months ago. This is her first attempt at oral contraceptive therapy; she and her partner primarily used condoms for contraception in the past. Before this current therapy her menstrual periods had always been regular. Which of the following is the most appropriate management?

A

) Advise her to take two pills daily until the bleeding stops

B

) Discontinue the oral contraceptive therapy and have her resume use of condoms for birth control

C

) Reassure her that the bleeding problem will resolve in a few months

D

) Switch the current oral contraceptive pill to one containing a higher estrogen dose

E

) Switch to a progestin-only oral contraceptive pill

The following vignette applies to the next 2 items.


A 17-year-old girl is brought to the health center by her mother because the girl has had only two menstrual periods in the past 8 months. She had regular menstrual periods from menarche at age 14 years until 18 months ago. For the past 18 months she has been training as a long-distance runner.

Item 1 of 2

26. The underlying mechanism of her menstrual dysfunction is best defined by an abnormality in which of the following serum concentrations?

A

) Androstenedione

B

) Creatine kinase

C

) Luteinizing hormone

D

) Testosterone

E

) Thyroid-stimulating hormone (TSH)

Item 2 of 2

27. Which of the following is the most likely cause of the menstrual irregularity?

A

) High-carbohydrate diet

B

) Increased basal body temperature

C

) Increased muscle mass

D

) Loss of body fat

E

) Repeated volume depletion


28. A 23-year-old white nulligravid woman returns to the office for follow-up of a 2-year history of primary infertility. Menstrual periods occur at regular 28-day intervals. She has a history of chronic pelvic pain. Analysis of her husband's semen shows a sperm count of 40 million with 65% motility and normal morphology. Diagnostic laparoscopy with hydrotubation shows normal pelvic anatomy, with no evidence of endometriosis or pelvic adhesions. Both fallopian tubes spill methylene blue dye. The patient's basal body temperatures recorded during the past month are shown. Which of the following is the most likely cause of the patient's inability to conceive?

A

) Anovulation

B

) Male factor infertility

C

) Old pelvic inflammatory disease

D

) Polycystic ovary syndrome

E

) No cause can be identified at this time

29. In the course of routine prenatal care at the health center, a 30-year-old Hispanic woman is found to have gestational diabetes. This is her first pregnancy and she is at 20 weeks' gestation. She should be counseled that adequate prenatal care, including regular determination of blood glucose concentrations and adherence to a controlled dietary regimen, may reduce the possibility of which of the following?

A

) The fetus developing macrosomia

B

) Her developing essential hypertension

C

) Her developing type 1 diabetes mellitus in the future

D

) Intrauterine growth restriction

E

) Premature delivery

30. A 20-year-old woman returns to the office for the results of her prenatal laboratory studies. By date of her last menstrual period she is 14 weeks pregnant with her second child. Her first pregnancy, which you followed, resulted in an uncomplicated vaginal delivery approximately 11 months ago. Her prenatal serology screening for syphilis is positive with a titer of 1:126, and a fluorescent treponemal antibody absorption (FTA-ABS) test is positive. The patient denies having lesions consistent with syphilis, and her current physical examination shows no lesions. Serology during her first pregnancy was negative. At this time, which of the following is the most appropriate management?

A

) Do an amniocentesis to obtain fluid for darkfield evaluation

B

) Follow the treatment regimen recommended for primary or secondary syphilis

C

) Postpone treatment until the patient is at least 20 weeks pregnant

D

) Schedule a lumbar puncture before instituting treatment

E

) Withhold treatment until further studies rule out a biologic false-positive

31. A 34-year-old man comes to the office with his wife and daughter because he has had some dusky lesions on his shoulder for the past 2 months. He says that two have become larger during the past week. He and his wife have recently adopted an 18-month-old girl from the Ukraine who has a similar rash. He is an environmental scientist and his work requires him to travel overseas and work outdoors. He is concerned about the possibility of skin cancer. Vital signs are normal. Physical examination shows a cluster of six discrete papular lesions on his left shoulder that are slightly tender. These lesions have a central depression containing some pus-like material. There is no axillary or cervical adenopathy. His rash is shown. Which of the following is the most appropriate management for the patient?

A

) Acyclovir

B

) Scabicidal cream

C

) Topical corticosteroid cream

D

) Topical fluconazole

E

) Topical liquid nitrogen

32. A 25-year-old Latino man comes to the health center for a periodic health evaluation. He tells you that he has attended a day-treatment program for his schizophrenia, paranoid type, since his discharge from the hospital 1 year ago. The patient's most recent psychiatrist is moving away and he now wants you to refill his medications. He takes haloperidol, benztropine and valproic acid. He says, "The voices aren't telling me to harm myself anymore. And I know now that my food is not poisoned." The patient is 183 cm (6 ft) tall and weighs 86 kg (190 lb). Vital signs are: temperature 37.0°C (98.6°F), pulse 72/min, respirations 14/min and blood pressure 130/86 mm Hg. Physical examination is significant for darting and protruding movements of the tongue and some facial grimacing. Which of the following is the most appropriate change in pharmacotherapy?

A

) Prescribe vitamin A

B

) Increase the dose of benztropine

C

) Increase the dose of haloperidol

D

) Replace haloperidol with risperidone

E

) Replace valproic acid with lithium

33. A third-year medical student returns to the student health service for the third time because he thinks he has ulcerative colitis. After a thorough history and physical examination, he is told that no organic disease is present. Despite that reassurance, the student continues to test his stool for blood and continues to believe that his physicians have missed the correct diagnosis. This behavior is most characteristic of which of the following?

A

) Conversion disorder

B

) Depersonalization

C

) Hypochondriasis

D

) Munchausen syndrome

E

) Somatization disorder

34. A 10-year-old Asian-American boy is brought to the office for a sports physical examination. He has been healthy except for a few episodes of otitis media as an infant. He has had no shortness of breath, syncope or chest pain in the past. Growth has been normal. Vital signs are: temperature 36.6°C (97.8°F), pulse 80/min, respirations 16/min, and blood pressure 110/76 mm Hg. Cardiac examination discloses an early systolic click at the apex, a midsystolic ejection murmur at the right upper sternal border and a thrill in the suprasternal notch. The remainder of the physical examination is normal. The patient is referred to the cardiologist and the diagnosis of aortic stenosis is confirmed by echocardiogram. Close follow-up and graded exercise testing are recommended. The patient is at increased risk for which of the following?

A

) Atrial arrhythmias

B

) Complete heart block

C

) Coronary artery disease

D

) Pulmonary hypertension

E

) Sudden death

35. A 12-year-old Haitian boy is brought to the health center for the first time by his mother and maternal grandmother. The mother states, "There was a voodoo curse placed on my family and now my son is having problems because of that." She reports that for the past 6 months he has been talking back to his teachers, has been suspended from school for skipping class, and has been defiant with all adults. He is failing two subjects in school and will need to attend summer classes. His medical history is significant for an allergy to sulfa drugs, a positive PPD skin test for which he was treated prophylactically at age 10 years, and encopresis that resolved. He currently takes no medications. The patient is 163 cm (5 ft 4 in) tall and weighs 49 kg (108 lb). Vital signs are: temperature 37.0°C (98.6°F), pulse 80/min, respirations 18/min and blood pressure 90/50 mm Hg. Which of the following is the most appropriate opening statement to the mother?

A

) "Do you think your son may be taking drugs?"

B

) "I suggest you consult a voodoo priest for help with this problem."

C

) "Tell me more about the voodoo and its effect on your son's behavior."

D

) "There is no such thing as voodoo."

E

) "Voodoo does not cause children to have bad behavior."

36. You are invited to a council meeting of Native-Americans to discuss a heptavalent pneumococcal polysaccharide-protein conjugate vaccine (Prevnar7) for use in the community's children, many of whom are younger than age 12 months. All of the infants and children in the community are up-to-date on standard recommended vaccinations. The council spokesperson says, "We are skeptical about the safety of giving our sons and daughters yet another vaccine." Which of the following is the most compelling reason to recommend vaccination of all infants younger than 12 months of age?

A

) Administration of the vaccine will decrease the incidence of invasive pneumococcal disease among the children in the community

B

) Administration of the vaccine will decrease the likelihood of secondary pneumonia during respiratory syncytial virus (RSV) season

C

) Administration of the vaccine will significantly decrease the severity of acute otitis media and prevent hearing loss

D

) Native-American children make ineffective antibodies when the 23-valent pneumococcal vaccine alone is administered to them

E

) The peak incidence of pneumococcal disease occurs in children younger than 12 months of age
 
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* Re:nbme-10
#572179
  tea - 11/26/06 20:49
 
  25d
26c
27d
28a
29a
30d
31e?
32d
33c
34e
35c
36a
 
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* Re:nbme-10
#572221
  pk007 - 11/26/06 22:15
 
  25c
26c
27b
28e
29e
30b
31c
32d
33c
34e
35c
36a
 
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* Re:nbme-10
#572234
  hani - 11/26/06 22:40
 
  25c
26c
27d
28e
29a
30b
31d
32d
33e
34c
35a
 
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* Re:nbme-10
#572301
  benign1998 - 11/26/06 23:42
 
  25c
26c
27d
28e
29a
30b
31d????
32d
33c
34e
35c
36a
35c
 
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* Re:nbme-10
#572352
  benign1998 - 11/27/06 00:55
 
  36a  
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* Re:nbme-10
#572533
  tea - 11/27/06 10:40
 
  agree with q25c, I got confused with break through bleeding due to OCP, thank you so much guys.

q30, high RPR or VDRL >1:32 (+) FTA-ABS, asymptomatic, need to do LP, key: asymtpmatic with very high VDRL, she also needs to be tested for HIV as well.

asymptomatic laten without active infection, PRP should fall to 1:1 or 1:16.(that is why she was negative in first preg screening-I think, not 100% sure), now it looks like she is having recurrent of active disease with asymptomatic. see "medscape"

also see LP criteria : neuro/ophthalmic sign and symptoms, Tx failure, or VDRL of 1:32 or greater. Step 3 first aid p135

q31, can anyone tell what kind of skin lesions are those? thanks
 
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* Re:nbme-10
#572579
  prav - 11/27/06 11:50
 
  Is that skin lesion - viral/umbilicated molluscum  
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