| * NBME-BLOCK-3....Please post your answer, if u can?
||1. A 60-year-old white woman comes to the office because of a 6- to 12-month history of weakness. She initially noted the weakness in her right hand, and it has now become generalized and is associated with muscle cramps. She is not taking any medications. Past medical history is unremarkable. On physical examination there is marked muscle wasting of the hands and arms bilaterally (left greater than right). There is less muscle wasting in the legs. Sensation to touch remains intact. Muscle fasciculation of the arms and hands is noted and deep tendon reflexes are decreased. Speech and mentation are intact. Which of the following studies is most likely to be abnormal in this patient?
A) Edrophonium chloride test
C) Serum protein electrophoresis
D) Urine lead levels
E) Urine mercury levels
2. A 23-year-old primigravid woman comes to the office to begin prenatal care. She and her husband had been having unprotected sexual intercourse for 8 months prior to becoming pregnant. The patient is excited about the pregnancy. She is at 10 weeks' gestation based on the date of her last menstrual period. Medical history is significant for a 6-year history of intermittent left-sided seizures that began following a motor vehicle accident during high school. The patient has taken valproic acid therapy for the past 4 years with good control of the seizures. Vital signs today are temperature 36.7°C (98.0°F), pulse 80/min, respirations 20/min, and blood pressure 110/60 mm Hg. Which of the following is the most appropriate modification to the patient's pharmacotherapy?
A) Discontinue the valproic acid until after pregnancy
B) Switch the valproic acid to diazepam
C) Switch the valproic acid to phenobarbital
D) Switch the valproic acid to phenytoin
E) No modification is indicated
3. A 32-year-old secretary comes to the office for a periodic health evaluation and Pap smear. She says, "I've been doing fine except that for the past 2 months my right hand sometimes has been tingling and feels numb, especially at night. I'm always dropping things, too." She takes oral contraceptive pills and thyroid replacement medication for hypothyroidism. She is right-hand dominant. She has no history of acute trauma. On physical examination, she has numbness and tingling in the thumb and first two digits of her right hand after 15 seconds of a wrist flexion test. The remainder of the examination is normal. Which of the following studies is most likely to establish a diagnosis?
A) Cervical spine x-ray films
B) MRI of the brain
C) Nerve conduction studies
D) Serum thyroid-stimulating hormone (TSH) concentration
E) X-ray film of the right hand and wrist
4. A 48-year-old Iranian American man comes to the office because of chronic dry cough, weight loss and intermittent temperatures to 38.3°C (101.0°F) for the past 2 months. He has lost 3.5 kg (8 lb) during this time. Today vital signs are: temperature 38.3°C (100.9°F), pulse 90/min, respirations 18/min and blood pressure 120/78 mm Hg. Auscultation of the lungs discloses fine crackles throughout the lung fields. The remainder of the physical examination is normal. Chest x-ray film is shown. Therapy with isoniazid, rifampin, pyrazinamide and ethambutol is begun. Your office staff ask you whether they should be evaluated for exposure to tuberculosis. Which of the following is the most appropriate next step?
A) Do nothing for office staff because the patient is unlikely to be infectious
B) Monitor the staff during the next few weeks for development of cough or fever, and base further treatment on this information
C) Obtain chest x-ray films in 4 weeks of each staff member who came into contact with the patient
D) Place a 5-TU PPD skin test in 4 weeks on each staff member who came into contact with the patient
E) Prescribe prophylactic isoniazid therapy to all office staff
5. A 67-year-old man comes to the office for an initial visit. He says his daughter, who is a patient in your practice, "made me come" because of a lesion in his mouth under his tongue. He is a farmer from the South who is visiting his daughter, and he is not concerned about the lesion. He says, "It has been present for a couple of months, and although I can feel it with the tip of my tongue and it is slightly sore, it doesn't give me any trouble." He has always been healthy and takes no medication. He drinks alcohol in small amounts on weekends, and he uses tobacco in a variety of forms. On physical examination, a 2H2-cm, raised, roughened gray lesion on the oral mucosa of the left side of the floor of the mouth is noted extending to the base of the tongue. You decide the lesion is highly suggestive of a malignancy and that a biopsy should be obtained. Based on the patient's history and incidence of lesions in this location, the lesion is most likely which of the following?
B) Basal cell carcinoma
E) Squamous cell carcinoma
6. A 52-year-old African-American man returns to the health center for a follow-up visit 1 week after he was discharged from the hospital after being diagnosed with acute pneumonia. Discharge medications included inhaled bronchodilators, oral antibiotics and a tapering course of oral corticosteroids. The antibiotic and corticosteroid therapies were completed yesterday. He has no previous hospital admissions for respiratory disease. He has a nonproductive, chronic, daily cough. He smoked one to two packs of cigarettes per day since age 13 years, but he has not smoked since admission to the hospital. Vital signs today are: temperature 36.8°C (98.2°F), pulse 92/min, respirations 10/min and blood pressure 120/80 mm Hg. On physical examination he appears well. There are markedly diminished, but clear, breath sounds with no wheezing or rhonchi; there is a prolonged expiratory phase. There is no digital clubbing. Which of the following is the most likeley diagnosis?
C) Chronic bronchitis
E) Pulmonary fibrosis
The following vignette applies to the next 3 items.
Age: 53 years
Sociodemographic information: African-American high school teacher, married, no tobacco use, history of heavy alcohol use but not for the past 10 years
Medical history: Hypertension; peptic ulcer disease 15 years ago; pneumonia-related hospitalization 15 years ago; no known drug allergies
Family history: Mother died of renal failure due to diabetes and hypertension at age 69 years; father died of heart failure and hypertension; two sisters have hypertension
Current medications/drug information: One aspirin tablet daily
Height: 185 cm (6 ft 1 in)
Weight: 87 kg (192 lb)
Temperature 36.8°C (98.2°F) Respirations 16/min
Pulse 88/min, regular Blood pressure 150/95 mm Hg
Physical examination: Blood pressure is equal in both arms, fundi show arteriolar narrowing; remainder of physical examination is normal
Laboratory studies: Electrocardiogram shows normal sinus rhythm and left ventricular hypertrophy
The patient whose chart is shown comes to the office for the first time because he has been transferred to your managed care organization. He had been taking a blood pressure medication but explains that he ran out of it 8 months ago. He did not make an appointment until now because, he says, "I just never got to it." His wife persuaded him to seek care now. He tells you that he requested his previous records be sent to you but they have not arrived.
Item 1 of 3
7. Which of the following is the most appropriate pharmacotherapy for this patient?
tem 2 of 3
8. The patient returns to the office in 1 week for a follow-up visit. He says he has a cold with cough, nasal congenstion and a scratchy throat. Blood pressure in now 140/85 mm Hg. On physical examination lungs are clear and there is no peripheral edema. Regarding over-the-counter medications for this patient's cold, he should be cautioned to avoid which of the following?
Item 3 of 3
9. Regarding his blood pressure, which of the following is the most appropriate management?
A) Add a second antihypertensive medication to the regimen
B) Add potassium chloride supplements to the medication
C) Change the antihypertensive medication
D) Continue with the current regimen
E) Increase the dose of the prescribed medication
10. A family of two adults and two school-aged children comes to the office because each family member has had intermittent nausea and diarrhea during the past 4 to 6 weeks. They are at increased risk for giardiasis if which of the following is true?
A) A close family friend has AIDS
B) Their water supply is a shallow well
C) They frequently consume uncooked vegetables
D) They recently adopted a new pet dog
E) They recently returned from a trip to Mexico
11. A 61-year-old Dutch businessman comes to the office to discuss the results of screening flexible sigmoidoscopy done 1 week ago. He has hypertension and hypercholesterolemia, for which he takes hydrochlorothiazide and pravastatin. His grandmother died of colon cancer, but no other family members have had colon cancer or polyps. During the sigmoidoscopy, the colon was well visualized to 60 cm and a 1-cm polyp was removed. On pathologic examination, the polyp was found to be adenomatous. Which of the following is the most appropriate diagnostic study at this time?
B) Determination of serum α-fetoprotein concentration
C) Determination of serum carcinoembryonic antigen concentration
D) Double-contrast lower gastrointestinal barium study
E) No further study is indicated
12. A 52-year-old woman is brought to the office by her husband for evaluation of increasing tearfulness, restlessness, difficulty sleeping and weight loss for 1 month. During the visit, the patient appears restless and upset. She acknowledges her husband's account of her symptoms, but she does not volunteer any additional information. They have been married for 15 years and have a good relationship. Both the patient and her husband are teachers and they have a healthy 13-year-old son. She was previously healthy. Physical examination today is normal. The most appropriate initial management of her symptoms is to do which of the following?
A) Prescribe haloperidol
B) Prescribe lithium
C) Prescribe lorazepam
D) Prescribe sertraline
E) Refer them for couples therapy
13. A 14-year-old white girl is brought to the health center by her mother. The mother is in tears and states, "My daughter has been suspended from school for cursing at a teacher in class. Last night she came home 2 hours after her curfew. When I confronted her she yelled at me and pushed me into the wall. I don't know what is wrong with her." The girl states, "There is nothing wrong with me. I just want to be with my friends and do what I want. I don't feel I need a curfew. I didn't do anything wrong at school. The teacher mouthed off at me. She should have been suspended instead of me." The girl has been your patient since age 10 years when the family moved from another state. She has a history of allergies to mold and dust for which she uses loratadine as needed. She takes no other medications. Her menses began at age 12 years. Vital signs now are: temperature 37.0°C (98.6°F), pulse 90/min, respirations 12/min and blood pressure 106/60 mm Hg. Physical examination is normal. Which of the following is the most appropriate opening question to the patient when you are speaking alone with her?
A) "Are you using drugs or alcohol?"
B) "How do you want your parents to react to your violating their rules?"
C) "What seems to be bothering you the most?"
D) "Why aren't you showing your parents any respect?"
E) "Why did you push your mother?"
14. A 7-year-old white boy is brought to the health center by his mother because of stomach pain for the past 3 months. The mother says that the pain typically comes on soon after waking and is not relieved by antacids. She says his symptoms never occur late in the day, but only in the mornings. There has been no vomiting, diarrhea or weight loss. The child has been generally healthy and is up-to-date with vaccinations. He lives with both parents. His height and weight are at the 75th percentile. Physical examination, including developmental assessment, is normal. Specific additional history should be obtained regarding which of the following?
A) Days of the week in which the patient is most symptomatic
B) Family history of milk allergy
C) Quantity of food intake
D) Recent travel history
E) The source of water at home
15. A 49-year-old man, who is accompanied by his son, comes to the office for the first time for follow-up of mild depression. He recently moved to the area and he tells you that his previous physician initiated fluoxetine therapy 4 weeks ago. He has a history of stage I malignant melanoma, which was treated with wide, local excision 2 years ago. He mentions that he was adopted as a young child and his family history is unknown. The patient is friendly and engaging, seems to be full of energy and calls you by your first name. He reports that he has been unusually productive at work recently and is able to "get by" on 1 to 2 hours of sleep nightly. His son says, "Dad isn't acting like himself. He talks about weird things and he's become religious in a creepy way." On physical examination the patient is well developed and well nourished. Vital signs are: temperature 37.0°C (98.6°F), pulse 95/min, respirations 14/min and blood pressure 135/90 mm Hg. There is a mild, nonpainful increase in tactile sensory acuity. He says, "My skin is really sensitive." The remainder of the physical examination, including neurologic examination, is normal. Which of the following is the most likely precipitant of this episode?
A) Family conflict
C) Recurrence of melanoma in his central nervous system
E) Unknown; this cannot be determined
16. A 62-year-old man returns to the office to discuss findings of x-ray films of the lumbosacral spine obtained 2 months ago following an office visit for evaluation of chronic low back pain. Physical examination at that time was normal. He was instructed to take aspirin as needed for pain and to await notification from the office regarding when he should return to discuss the x-ray films. The office staff failed to schedule a return visit for the patient; today's visit was scheduled by the patient. The patient says, "I've been extremely anxious about the potential results of the x-ray film, and I'm angry that nobody from the office called me to schedule a follow-up visit." The radiologist's report accompanying the x-ray film notes the presence of a lytic lesion at the L1 vertebra consistent with metastatic cancer and the recommendation that a CT scan be obtained. In addition to apologizing to the patient for neglecting to contact him to schedule follow-up, which of the following is the most appropriate approach to informing the patient of the x-ray film findings?
A) Inform him of the findings and emphasize that the responsibility to schedule a follow-up appointment was his
B) Inform him of the findings and emphasize the need for further evaluation
C) Inform him of the findings and tell him that the radiologist is as much to blame for not informing him of the urgency of his condition
D) Inform him that the findings are nonspecific and that further studies are needed to identify a diagnosis
E) Tell him that the radiologist's report is likely overstated and that additional x-ray films will need to be obtained
17. A 21-year-old woman who is a varsity basketball player comes to the student health center because of left knee pain for the past month. She says the pain has progressively worsened and has not been relieved with ibuprofen. The pain occurs when she descends stairs or is in class for long periods. She says, "My knee pops a lot." Physical examination today shows knee crepitus, and weakness and atrophy of the vastus medialis muscle. Which of the following is the most appropriate treatment at this time?
A) Anterior cruciate ligament reconstruction
B) Arthroscopic meniscectomy
C) Immobilization of the knee
D) Nonweight-bearing on crutches for 2 weeks
E) Quadriceps-strengthening exercises
18. A 39-year-old African-American woman is brought to the health center at 7:00 PM by her children because of weakness and numbness in her right leg. She also says, "I have an odd feeling in my left leg." The symptoms started several days ago and gradually have increased. She also experienced low back pain about 10 days ago, which responded until recently to oral morphine and ibuprofen prescribed by her primary care physician, whom she could not reach tonight. She has had no problems with bowel or bladder function. She was treated 4 months ago with mastectomy, chemotherapy and radiation therapy for infiltrating ductal carcinoma of the left breast. Neurologic examination today discloses weakness of all muscle groups in the right leg and thigh, with normal strength in the left leg. There is marked decrease in sensation to pinprick and temperature up to the area of the inguinal ligament on the right, and decreased perception of position and vibration sense in the left lower extremity. The patellar and Achilles reflexes are hyperactive on the right and those on the left are normal. Rectal sphincter tone is normal. Diagnostic studies show metastatic disease to L2 with minimum invasion of the spinal canal. Which of the following is the most appropriate method to control her pain?
B) Dorsal rhizotomy
C) Long-acting oral morphine therapy
D) Radiation therapy
E) Surgical decompression
19. A 55-year-old man comes to the office because of a 1-month history of right knee pain. He reports no recent trauma to his knee but says that he has recently increased his weekly running distance from 12 miles to 30 miles. On physical examination he has aching knee pain with squatting. The rest of the physical examination is normal. Which of the following factors in the patient's history , if present, would indicate the patellofemoral joint as the source of the pain?
A) Associated thigh pain
B) Buckling of the knee
C) Increased pain with stair climbing
D) Locking of the knee
E) Prominent knee swelling
20. A 24-year-old professional gardener comes to the office because of a generalized, maculopapular, itchy rash that developed a few days ago. The itching is keeping him awake at night. Three weeks ago he began treatment for a seizure disorder with 400 mg of phenytoin, daily. Physical examination now shows a generalized maculopapular rash with excoriations. The most appropriate management at this time is discontinuation of the drug and addition of which of the following?
A) Oral hydroxyzine
B) Oral prednisone
C) Topical betamethasone
D) Topical emollients
E) Topical hydrocortisone
21. A 58-year-old white man comes to the office because of a mass in his neck for the past 2 months. He says, "My voice is bad and sometimes I can't catch my breath." He is a construction worker and has a long history of alcohol abuse and cigarette smoking. Vital signs are normal. Physical examination shows a large mass in the floor of the mouth, extending to the tonsillar fossa. A 4H5-cm mass is noted in the right anterior triangle of the neck. The greatest immediate risk to the patient is which of the following?
A) Airway obstruction
22. A 15-year-old girl comes to the office because of a 2-day history of an itchy rash on her right ankle. The rash occurred 1 day after she took a school field trip to a local park while wearing a new pair of sandals. She has moderate to severe asthma, for which she takes zafirlukast, salmeterol, and albuterol by metered-dose inhaler as needed. She has been tapering off oral prednisone for the past 2 months. Vital signs are temperature 37.5°C (99.5°F), pulse 86/min, respirations 16/min, and blood pressure 125/80 mm Hg. Auscultation of the lungs discloses mild, diffuse expiratory wheezing. Her right ankle is shown. Which of the following is the most likely diagnosis?
A) Chigger infestation
B) Contact dermatitis
C) Herpes zoster
D) Poison ivy dermatitis
The following vignette applies to the next 2 items.
A 29-year-old truck driver comes to the health center for advice regarding his serum cholesterol concentration, which was determined recently at a shopping mall health fair. He had the test at the request of his wife, who is pregnant with their first child. The test result read "high," with advice to see a physician. The patient has a family history of premature coronary artery disease. Two uncles had myocardial infarctions (MI), one at age 41 years and the other at age 45 years. His father died of an MI at age 47 years. He tells you that his 34-year-old brother takes "some type of cholesterol pill." The patient has no significant medical history. He denies smoking cigarettes but admits to drinking a few beers in the evenings at home. Two to three times per week he meets his friends at a local tavern before driving home. He is currently taking no medications, and his physical examination is normal except for mild obesity. A fasting serum lipid profile was done 2 days ago at the suggestion of the nurse who took his history by phone. Results are available today and show:
Item 1 of 2
23. To evaluate his risk for cardiac disease, in addition to his serum lipid concentrations it is appropriate to obtain which of the following serum laboratory studies?
A) Angiotensin II concentration
B) Apolipoprotein B concentration
C) Endothelin concentration
D) Homocysteine concentration
E) Lipoprotein lipase concentration
Item 2 of 2
24. With respect to his alcohol intake, it is most appropriate to do which of the following?
A) Determine if his uncles and father drank and whether it affected their lipid levels
B) Encourage him to continue drinking in moderation given his lipid analysis
C) Investigate the risk of his drinking while driving his truck
D) Recommend that he switch from beer to red wine
E) Recommend that he switch to a low-calorie beer
25. A 50-year-old African-American woman returns to the office for follow-up of diabetes mellitus, which has been treated with diet; extended-release glipizide, 10 mg daily; and metformin, 500 mg twice a day. She says, "I do the best I can adhering to my diet." She tests her blood glucose concentration daily. For the past month her fasting blood glucose concentrations have averaged 170 mg/dL. Hemoglobin A1c 1 week ago was 8.4%. The patient is 167.5 cm (5 ft 6 in) tall and weighs 86 kg (190 lb). Which of the following is the most appropriate change in therapy?
A) Add chlorpropamide
B) Add insulin
C) Increase the metformin dosage
D) Stop the glipizide and metformin and start insulin
E) No change is indicated
26. A 36-year-old African-American woman with hypertension comes to the office because of a 3-day history of intermittent, painless, gross hematuria. Symptoms started spontaneously, and she has not had fever, chills, flank pain or dysuria. Her only medication is hydrochlorothiazide. Vital signs are: temperature 37.0°C (98.6°F), pulse 72/min and blood pressure 128/84 mm Hg. Physical examination is normal; there is no costovertebral angle tenderness. Laboratory studies show:
RBCs too numerous to count
No WBCs, bacteria or casts
Partial thromboplastin time
Which of the following is the most appropriate next step?
B) Determination of protein excretion in a 24-hour urine sample
C) Initiation of antibiotic therapy
D) Renal biopsy
E) Transvaginal ultrasonography of the uterus
The following vignette applies to the next 2 items.
A 15-year-old girl is brought to the office for the first time by her mother, who has been your patient for many years. The mother is concerned because her daughter, who had menarche at age 11 years, has not had a period in the past 6 months. Both mother and daughter have kept a record of the girl's periods. The first three periods were irregularly spaced and not painful. Subsequent periods were regularly spaced and were accompanied by severe cramping on the first day. The cramping subsided 1 year ago. The mother insists that you interview her and her daughter together. She says that her daughter is not sexually active. She tells you that her daughter gets straight A grades and that she is very active in sports. The girl is also a cheerleader and is taking a night course for college credit at the local community college through the school's gifted child program. The mother tells you that her daughter has a good appetite for healthy food and does not eat junk food. She asks you what is causing her daughter's amenorrhea.
Item 1 of 2
27. Which of the following is the most appropriate initial response?
A) "In young women, missing a few periods is not unusual, and we should wait a while longer before becoming concerned."
B) "It is a well-known fact that the most likely cause of amenorrhea in young women is pregnancy. How can you be certain she has not been sexually active?"
C) "Many things can cause missed periods. After I examine your daughter, I may be able to provide more insight into the problem."
D) "Over-involvement in some athletic activities can cause menstrual periods to cease."
E) "Your daughter is involved in a lot of activities and may be under stress. That can certainly be a factor in causing cessation of periods."
Item 2 of 2
28. After responding to the mother's question, you ask the mother to wait outside while you speak privately with the girl and do a physical examination. No additional information is obtained. Vital signs are: temperature 37.0°C (98.6°F), pulse 110/min and blood pressure 90/50 mm Hg. Height is 165 cm (5ft 5 in) and weight is 49 kg (105 lb). Physical examination shows some eroding of the enamel on the girl's rear teeth. Sexual maturation is complete. Abdomen is soft and nontender. Which of the following is the most likely diagnosis?
A) Athletic amenorrhea
E) Stress-induced amenorrhea
29. A 39-year-old white homemaker comes to the office because of abnormal vaginal bleeding. You provide routine medical care for her and her family. She says her menstrual periods always have been regular and that her last normal regular period was about 10 weeks ago. She has had spotting for 1 week. She tells you that she and her husband use "withdrawal" as their birth control method. Urine pregnancy test is positive. Vital signs now are: temperature 37.4°C (99.3°F), pulse 88/min and blood pressure 110/72 mm Hg. Pelvic examination discloses a small amount of blood in the vagina. Cervix is closed. Uterus is soft, nontender and anteverted. Adnexae are nontender. Additional history reveals that she had a first trimester elective abortion at age 20 years and she has genital herpes that recurs about twice each year. Her husband is age 40 years and has Crohn disease. Her children are ages 7 and 9 years. The 7-year-old was born by cesarean delivery at 32 weeks' gestation after placental abruption. This couple's greatest risk factor for miscarriage is which of the following?
A) History of abruptio placenta
B) History of genital herpes
C) History of premature delivery
D) Maternal age
E) Paternal history of auto-immune disease
30. A 30-year-old woman who is 28 weeks pregnant with her first child comes to the office for a routine prenatal visit. She has been a strict vegetarian for many years. At each prenatal visit she has insisted that she is eating well. However, she has gained only 0.9 kg (2 lb) since her initial prepregnancy weight of 54 kg (120 lb); she is 165 cm (5 ft 5 in) tall. She says that she has been taking her prenatal vitamins and iron as instructed. She has a regular exercise routine but has decreased this activity significantly during the past 4 weeks because, she says, "I've been too tired." Pulse is 90/min and blood pressure is 110/60 mm Hg. Physical examination shows a reddened, malar rash. Laboratory studies at this visit show:
Hemoglobin 7.5 g/dL
MCV 105 μm3
Platelet count 89,000/mm3
Which of the following is most appropriate to prescribe orally at this time?
A) Corticosteroid therapy
B) Vitamin Bl2 (cyanocobalamin) supplementation
C) Folate supplementation
D) Iron supplementation
E) Vitamin E (tocopherol) supplementation
31. A 36-year-old African-American woman with hypertension comes to the office because of a 3-day history of dysuria, hematuria, and urinary frequency and urgency. Symptoms started the day after she returned from a weekend visit with her boyfriend in another city. She has no prior history of urinary tract infections and she denies fever, chills, flank pain, nausea or vomiting. Her only medication is hydrochlorothiazide. Vital signs at today's visit are: temperature 37.6°C (99.6°F), pulse 90/min and blood pressure 126/84 mm Hg. Physical examination is normal. Laboratory studies show:
Which of the following is the most appropriate next step?
A) Increase oral intake of fluids and order a urine culture
B) Order cystoscopy
C) Order intravenous urography
D) Repeat the urinalysis in 3 to 4 days
E) Start antibiotic therapy
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:
ALT 32 U/L Hematocrit 37%
AST 43 U/L Hemoglobin 11.7 g/dL
PTT 22 seconds
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
33. At an annual company examination, a 40-year-old man has an elevated mean corpuscular volume. Hemoglobin concentration is normal. This finding is most suggestive of which of the following?
A) Alcohol abuse
C) Hepatitis B infection
E) Vitamin B6 (pyridoxine) deficiency
34. A 15-year-old white girl is brought to the health center by her mother for a periodic health evaluation and refill of tetracycline for acne. Upon entering the examination room, the patient's mother asks to speak alone with you. In private, she says, "My daughter has been like a different person for the past 4 months. She used to be on the honor roll and is now failing school. She received detention six times for truancy and for talking back to teachers. She argues with her brother and me over everything. She quit the tennis team and doesn't see any of her friends." The mother can think of no explanation for these changes. When you interview the patient alone, she becomes angry and says, "Mom should mind her own business and stop talking about me behind my back." She denies use of drugs or alcohol. She tells you, "I don't want to go out of the house because my acne makes me feel ugly. Plus, I've put on ten pounds." Today she weighs 54 kg (120 lb); she is 165 cm (5 ft 5 in) tall. Which of the following is the most appropriate advice to the mother?
A) Her daughter is just going through a normal adolescent phase
B) Her daughter would benefit from a diet program
C) Her daughter would benefit from a trial of antidepressant medication
D) She should use a behavior-modification program to control her daughter
E) No advice is indicated because it would violate patient confidentiality
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
C) Intrauterine device (IUD)
E) Spermicidal jelly
36. A 20-year-old white woman comes to the office because of increasing fatigue for the past 3 weeks. She is 24 weeks pregnant with her first pregnancy. She says she has noted increased difficulty maintaining her usual pace in the local factory where she works packing boxes. Prior to pregnancy, she had no health problems and was considered an above-average worker. Other than the fatigue and an occasional backache, she has had an uneventful pregnancy. Results of initial prenatal laboratory studies were normal, and she has attended all of her prenatal office appointments. Complete blood count is obtained at this visit and a peripheral blood smear, also obtained during this visit, is shown. At this time, the most likely explanation for the patient's fatigue is that she has which of the following?
A) Iron-deficiency anemia
B) Vitamin B12 (cyanocobalamin) deficiency
C) Folate deficiency
E) Physiologic anemia of pregnancy