Office Management PROLOG 1-10

1. A 25-year-old woman, gravida 3, para 2, comes in for a routine prenatal visit. Seasonal influenza vaccines have just been released. She is concerned about the risks she has heard about in the media, and wants to avoid any adverse consequences for her and the fetus. In order to maximize the benefit and minimize the risk for the mother and baby, the best recommendation for timing of this intramuscular vaccination is

2. A 24-year-old nulligravid woman is taking carbamazepine for epilepsy. She currently uses con doms, but would prefer a more effective contraceptive. She tells you that she does not plan on becoming pregnant for several years. You counsel her that, given her use of carbamazepine, the most effective contraceptive for her would be

3. A 68-year-old postmenopausal woman comes to your office for a health maintenance visit. She is asymptomatic, but asks about hormone therapy (HT) and her risk of ischemic heart disease. She has never had any gynecologic surgery. The Women’s Health Initiative (WHI) evaluated the health effects of HT in asymptomatic women. You advise her that the study found that the effect of HT on ischemic heart disease for patients such as her was

4. A 61-year-old woman with limited ambulation and a history of cerebrovascular accident 5 years ago comes to your office with diarrhea. She has a history of depression and is on multiple medica- tions: venlafaxine hydrochloride, clopidogrel bisulfate, nifidepine, and hydrochlorothiazide. She was hospitalized for pyelonephritis, during which time she was treated with intravenous ceftriax- one sodium. Since discharge from the hospital, she tells you that she has had diarrhea for several months and has experienced a loss in weight of 8 kg in that time, although she has a good appetite and eats a balanced diet. On examination, she is afebrile, her blood pressure is 137/78 mm Hg, and her heart rate is 73 beats per minute. Laboratory test results show that her electrolytes, creatinine, complete blood count, and albumin are normal. A stool sample is cultured and revealsClostridium difficile toxin. The best initial treatment option for her C difficile-associated diarrhea is

5. A 38-year-old woman, gravida 2, para 2, comes to your clinic with impaired glucose tolerance, diagnosed on her postpartum 75-g 2-hour glucose tolerance test, with a fasting value of 90 mg/dL and a 2-hour value of 150 mg/dL. She has gestational diabetes mellitus diagnosed during her recent pregnancy, for which she was placed on insulin, and she has several family members who have type 2 diabetes mellitus. Her body mass index (weight in kilograms divided by height in meters squared [kg/m2]) (BMI) is 36, her waist circumference is 107 cm (42 in.), and her blood pressure is 120/76 mm Hg. The most appropriate treatment for this patient is

6. A 45-year-old woman returns for follow-up after being diagnosed with symptomatic Graves dis- ease 9 months ago. She was treated with methimazole. Her thyroid-stimulating hormone (TSH) and thyroxine (T4) values are now within normal limits and she is asymptomatic. She stopped taking methimazole 1 week before her visit and would like to discontinue the use of medication if possible. You advise her that the best next step in management is

7. A 53-year-old nulliparous woman visits your office for her well-woman examination. She has been postmenopausal for the past 4 years and has had well-controlled hypertension for the past 10 years. Her family history is significant for a sister with stage III colon cancer diagnosed at age 59 years during her first colonoscopy. At age 51 years, she received a negative screening colonoscopy, but she remains concerned about her risk of colon cancer. She asks about further screening. You tell her that the recommended screening strategy at this time would be

8. A 32-year-old woman, gravida 2, para 2, comes to your clinic 5 days post elective repeat cesarean delivery with bloody discharge from her wound. Her postoperative course in the hospital was unre- markable. On physical examination, her oral temperature was 37°C (98.6°F) and removal of the surgical staples from the incision revealed a hematoma. The rectus fascia was noted to be intact and no skin erythema or purulent material was noted in the wound. The hematoma was drained and the wound was packed with saline-soaked gauze. Wet to dry dressings were continued at home twice a day. The patient returned to the office 3 days later and the wound was noted to have granulation tissue without evidence of infection. The best next step in management is

A 37-year-old woman, gravida 2, para 0, comes to you for evaluation for recurrent miscarriage after experiencing two consecutive first-trimester losses. She was managed expectantly with her first loss but required dilation and curettage with the second loss. Overall she is in good health, is of normal weight, and has no medical problems. She takes no medications. Her husband has fathered no children. Hysterosalpingography reveals normal intrauterine architecture. Thyroid-stimulating hormone (TSH) and fasting glucose levels are within normal limits and the test result for antiphos- pholipid antibodies (anticardiolipin antibody and lupus anticoagulant tests) is negative. The most appropriate next step in her workup is

10. A 29-year-old woman, gravida 2, para 1, comes to your office at 31 weeks of gestation with decreased fetal movement for 2 days. Intrauterine fetal demise is diagnosed and she is admitted for induction of labor. You order diagnostic testing to identify the cause of the stillbirth. The best tissue to obtain for fetal karyotype analysis is