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Total questions: 3
Worksheet time: 5mins
A 34-year-old woman at 30 weeks of gestation presents to the emergency department for upper abdominal pain
and vomiting for two days. She denies fever and vaginal bleeding. She has a history of gallstones and is
concerned they are causing her problems. Vital signs show BP 164/108, HR 90, RR 16, T 37.6℃ and O2
saturation 98% on room air. She has a gravid uterus with epigastric and right upper quadrant tenderness.
Laboratory work shows WBC 12.5 x 109/L WBC/µL, hemoglobin of 8.2 g/dL, and platelets 80 x 109/L.
Sodium is 142 mEq/L, potassium is 4.0 mEq/L, chloride is 99 mEq/L, and creatinine is 2.0 mg/dL. Aspartate
aminotransferase is 330 units/L, alanine aminotransferase is 400 units/L, total bilirubin is 1.6 mg/dL, and lipase
is 356 units/L. Urinalysis shows 2+ proteinuria with 15 RBC/hpf. Right upper quadrant abdominal sonography
demonstrates gallstones without a thickened gallbladder wall and no pericholecystic fluid. What is the most
appropriate management of this patient?
Begin treatment with magnesium sulfate and consult obstetrics for induction of labor
Begin treatment with magnesium sulfate and dexamethasone and admit to the labor and delivery ward
for expectant management
Begin treatment with oral labetalol and facilitate outpatient evaluation with her obstetrician in the morning
Consult surgery for cholecystectomy
A 35-year-old woman comes to the emergency department due to vaginal spotting. The patient's last menstrual period was 6 weeks
ago. She is HIV positive and nonadherent to her antiretroviral treatment; she has had 2 ectopic pregnancies. Vital signs are stable.
Pelvic examination reveals a right adnexal mass. Hemoglobin is 8 g/dL and platelet count is 60,000/mm3. B-hCG is 6215 IU/L. Pelvic
ultrasound shows a thin endometrial stripe and a 4.5 cm complex adnexal mass, with no pelvic free fluid.
Which of the following is the best next step in management of this patient?
laparoscopy
methotrexate
misoprostol
repeat B-hcg in 48h
suction curettage
A 40-year-old woman, gravida 1 para 0, comes to the office for an initial prenatal visit after a positive home pregnancy test. She has
had no abdominal pain or vaginal bleeding. She has a long history of infertility and has tried to conceive for the last 5 years. The
patient is at 6 weeks gestation based on her last menstrual period. Vital signs are normal. Ultrasound reveals an ovoid gestational
sac, without a yolk sac or fetal pole. No adnexal masses are seen. Serum B-hCG level is 2,000 IU/L. Serum ß-hCG level repeated
48 hours later is 1,800 IU/L.
Which of the following is the most likely diagnosis?
complete hydatiform mole
missed abortion
pseudocyesis
twin intrauterine pregnancy
