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56. A 22-year-old woman at 32 weeks’ gestation comes to the office for a prenatal visit. Vital signs are within normal limits.
Fundal height and fetal heart tones are also normal. At the end of the examination, the patient tells the physician that her
friend is a certified lay midwife and has recently convinced her to have a home birth. The patient asks the physician if
he would be the backup for the midwife in case of an emergency. Which of the following is the most appropriate initial
response by the physician?
(A) “I’m sorry, but I would no longer be able to be your doctor if you pursue a home birth.”
(B) “I would like to meet with your friend before I decide.”
(C) “If there’s a problem, I could still act as your doctor if you arrive at the hospital in labor.”
(D) “Let’s set up an appointment next week to discuss your birth plan in detail.”
(E) “Perhaps your midwife could act as your birth coach instead.”
57. A 36-year-old woman with hypertension comes to the office because she thinks she may be “going through early
menopause.” She has not had a menstrual period since her most recent office visit 6 months ago. During this time, she
also has been “gaining weight around the middle” despite increased exercise; she has had a 6.3-kg (14-lb) weight gain.
She has no other history of major medical illness. Her only medication is lisinopril. She does not smoke, drink alcohol,
or use illicit drugs. She is 168 cm (5 ft 6 in) tall and weighs 107 kg (236 lb); BMI is 38 kg/m
2
. Vital signs are within
normal limits. Examination shows a uterus consistent in size with a 24-week gestation. Pelvic ultrasonography shows
oligohydramnios and a fetus with a misshapen cranium, pericardial effusion, small bladder, and echogenic bowel. The
most likely cause of the fetal abnormalities in this patient’s pregnancy is interference with which of the following?
(A) Fetal lung/epithelial differentiation
(B) Fetal lung/surfactant development
(C) Fetal renal hemodynamics
(D) Maternal placental perfusion
(E) Maternal prostaglandin synthesis
58. A 67-year-old man comes to the office because he is concerned about memory loss. He says he sometimes forgets the
names of acquaintances he sees while he is out shopping. He also has occasional word-finding difficulty and forgets to
buy some items when he goes shopping unless he makes a list. He lives alone and is able to manage his finances, cook,
and shop without help. He works part-time as an accountant. He has gastroesophageal reflux disease and hypertension.
Current medications are hydrochlorothiazide and omeprazole. Vital signs are within normal limits. Physical and
neurologic examinations show no abnormalities. On mental status examination, he is fully oriented. His speech is
normal, and thoughts are organized. His mood is euthymic, and he has a full range of affect. His concentration is intact,
and he is able to perform calculations quickly and accurately. He can name objects accurately and follow written and
verbal commands. He recalls three of four objects after 5 minutes. Which of the following is the most appropriate
physician response to this patient’s concern?
(A) “I am concerned about your memory loss. Let’s discuss how to further evaluate your memory.”
(B) “There's no need to worry right now, but let's meet again in 6 months.”
(C) “Unfortunately, your memory loss will likely increase significantly during the next 5 years; let’s discuss some
ways to plan for the future.”
(D) “Your episodes of forgetfulness are likely just ‘Senior Moments,’ but we should obtain in-depth laboratory test
results and an MRI to be certain.”
(E) “Your examination findings indicate that your memory loss is likely consistent with the normal aging process.”