Office Prolog 21-30

21. A 53-year-old postmenopausal woman presents for discussion of her stress urinary incontinence (SUI). Although she has had minor episodes of SUI in the past, it has become a significant problem over the past 3 months because of the development of a chronic cough. She now has to wear a pad all the time, and has cut back on her activities. She was seen in the emergency room 1 month ago and had a negative chest X-ray but the cough has not improved or gone away. She is healthy except for hypertension, which is well controlled on an angiotensin-converting enzyme (ACE) inhibitor. She does not smoke. She would like to avoid surgery, but cannot tolerate the coughing and leak- ing. Your review of systems is otherwise negative and the physical examination, including a lung examination, is unchanged from her previous visits. You recommend that she begin treatment with

22. A 25-year-old nulligravid woman is seen for an annual screening visit. You find that she has a vulvar lesion which requires biopsy. While you are preparing to do the biopsy, your office admin- istrator informs you not to do the biopsy today because the patient’s insurance company will not provide payment for an office procedure and a screening examination at the same visit. The patient would like to have the biopsy done now. Your most appropriate action is to

23. A 32-year-old primigravid woman at 16 weeks of gestation was prescribed nitrofurantoin for asymptomatic bacteriuria. You tell her that in addition to possible progression to cystitis and pyelo- nephritis, another pregnancy complication associated with untreated asymptomatic bacteriuria is

24. A 27-year-old woman, gravida 2, para 1, visits your office at 6 weeks of gestation. She experienced severe postpartum depression in her prior pregnancy. She was on medication for depression for 5 years after the birth of her first child, but discontinued use before the start of the current preg- nancy. She is experiencing symptoms of decreased appetite, weight loss, and feelings of excessive guilt, similar to her prior depressive symptoms. You consider prescribing sertraline hydrochloride, a selective serotonin reuptake inhibitor (SSRI). The most common adverse effect to the fetus or neonate from use of an SSRI is

25. A 38-year-old woman comes to your office for health maintenance. She is 1.65 m (65 in.) tall and weighs 79.4 kg (175 lb) for a body mass index (weight in kilograms divided by height in meters squared [kg/m2]) (BMI) of 29.1. She states that she weighed 61 kg (135 lb) before the birth of her three children. She has a negative medical history and negative review of systems. The patient has asked you for medication to assist her in losing weight. She also seeks your advice regarding the best methods for weight loss and healthy nutrition. The best weight loss management plan to recommend to this patient is

26. A 24-year-old nulligravid woman comes to your office for help with fertility preservation. Stage III Hodgkin lymphoma was recently diagnosed and she is scheduled to undergo intensive che- motherapy and abdominal radiation treatment that is likely to render her sterile. She is currently single and not in a serious romantic relationship, but wants to retain her childbearing potential. The reproductive endocrinologist has recommended ovarian cryopreservation followed by depot leup- rolide acetate to suppress ovarian function before induction chemotherapy. Her insurance company is denying reimbursement for these services. The most appropriate next step with this patient is to

27. Shingles was diagnosed in a 66-year-old white woman 9 months ago. She subsequently developed postherpetic neuralgia and was started on amitriptyline hydrochloride and achieved resolution of the pain over the past 6 months. She is now weaning herself off the medication, but is concerned that she might have a reoccurrence of neuralgia in the future. The best choice for prevention of new episodes of shingles and postherpetic neuralgia is

28. A 23-year-old woman at 16 weeks of gestation comes to your clinic with a “spider bite” on her mons pubis. She states the lesion has worsened over the past week and has become increasingly painful. She shaves her mons, most recently 2 weeks ago. She works with small children at a day care center. On examination, you note a 2-cm fluctuant mass on the mons that is draining a small amount of purulent discharge, along with 4 cm of surrounding erythema and induration. The best antibiotic choice for treatment of her abscess is

29. A 14-year-old adolescent girl comes to your office for evaluation of depression. Her depression started after the death of her grandmother 8 months ago. She began therapy 6 months ago with no improvement in symptoms. She has not made a suicide attempt, but has anhedonia, increased fatigue, and declining school performance. In addition to continued cognitive behavioral therapy, the most appropriate medication for this adolescent is

30. A 29-year-old nurse at 10 weeks of gestation comes to your office for consultation after her annual intermediate strength purified protein derivative (PPD) skin test result was reported as positive. A prior PPD skin test result had been negative 18 months ago. The patient reports no current health problems and does not have any cough or weight loss. She has experienced some nausea and fatigue since becoming pregnant. A chest X-ray performed with shielding was negative. The most appropriate medication for this patient is