[MCQs] The Quizzes about Acute Complaints - Part 1 (20 test)

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Acute Complaints-1

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Question 1

You are evaluating a 36-year-old man in your office with the chief complaint of abdominal Which of the following characteristics of the pain, if present, would lead you toward an emergent evaluation?

A	The pain is located in the right lower quadrant
B	The pain began suddenly
C	The pain is described as a “gnawing” sensation
D	The pain is worse after eating
E	The pain is associated with emesis

Question 1 Explanation:

The first priority when evaluating abdominal pain is to determine whether the pain is acute or chronic. Sudden and/or severe onset of pain should lead the clinician toward an emergent evaluation. Right lower quadrant pain is suspicious for an acute appendicitis, but by itself is not specific enough to warrant an emergent workup. A “gnawing” sensation is often described with ulcer disease, while pain that worsens after eating is associated with many conditions—pancreatitis, gallbladder disease, or even reflux. In the absence of hemodynamic instability, those causes are less likely to warrant emergent workup. Emesis with pain is not enough, by itself, to warrant emergent workup.

Question 2

A 42-year-old woman presents to your office complaining of abdomi- nal She describes upper abdominal pain that radiates to her scapula. For which of the following is this description classic?

A	Acute appendicitis
B	Pancreatitis
C	Gallbladder disease
D	Esophageal spasm
E	Gastroesophageal reflux disease

Question 2 Explanation:

The location and radiation of pain is often helpful in determining the cause of abdominal pain. Pain from an acute appendicitis usually starts in the periumbilical region before moving to the right lower quadrant. Pancreatitis generally settles in the mid-epigastric region with radiation to the back. Gallbladder pain is typically in the epigastric or right upper quadrant and radiates to the scapula. Esophageal spasm is often referred higher in the chest. GERD is midepigastric and generally does not radiate.

Question 3

An 80-year-old man presents with mild, crampy, bilateral lower quad- rant pain, decreased appetite, and low-grade fever for about 48 Which of the following is most likely?

A	Small bowel obstruction
B	Appendicitis
C	Constipation
D	Irritable bowel syndrome
E	Pancreatitis

Question 3 Explanation:

Advanced age can change the presentation and perception of abdominal pain. In fact, studies estimate that there is a 10–20% reduction in the perceived intensity of the pain per decade after age 60. Only 22% of elderly patients with appendicitis present with classic symptoms, making the diagnosis more difficult. Therefore, a high index of suspicion is necessary. Small bowel obstruction and constipation may cause bilateral lower quadrant pain and decreased appetite, but fever indicates something different. IBS is chronic and generally not associated with fever. Pancreatitis is associated with food intolerance but the associated pain is usually in the epigastric region.

Question 4

While performing an abdominal examination on a 42-year-old woman in your office, she suddenly stops inspiratory effort during deep palpation of the right upper Which of the following problems is this most suggestive of?

A	Hepatitis
B	Gallstones
C	Cholecystitis
D	Pancreatitis
E	Right-sided renal calculi

Question 4 Explanation:

The specific site of tenderness is classic for many sources of abdominal pain. Sudden cessation of Copyright © 2008 by The McGraw-Hill Companies, Inc. Click here for terms of use.Acute Complaints Answers 143 inspiratory effort during deep palpation of the right upper quadrant is called “Murphy’s sign” and is suggestive of acute cholecystitis. Hepatitis and gallstones may cause right upper quadrant tenderness, but generally do not elicit Murphy’s sign. Pain caused by pancreatitis often radiates to the back. Pain from renal calculi often radiates to the shoulder.

Question 5

You are evaluating a 64-year-old man with abdominal Your differ- ential diagnosis includes diverticulitis, perforated diverticuli, and appendici- tis. What imaging study would be most helpful to establish the diagnosis?

A	Abdominal radiograph
B	Ultrasound of the abdomen and pelvis
C	Computed tomography (CT) scan of the abdomen and pelvis
D	Magnetic resonance imaging (MRI) of the abdomen and pelvis
E	Colonoscopy

Question 5 Explanation:

A CT scan of the abdomen and pelvis with and without contrast is usually the most helpful imaging study to confirm a diagnosis, or if not, to dictate the need for additional testing. CT provides adequate visualization of many causes of abdominal pain including an abdominal aortic aneurysm, diverticulitis, pancreatitis, appendicitis, and obstruction. It is better than a plain film of the abdomen to see free air. Spiral CT scan is comparable to an intravenous pyelogram (IVP) to evaluate stones. Ultrasound is best for biliary pathology. An MRI is useful for some things including pancreatic cancer, but often is not better than a CT scan. A colonoscopy should not be done in the setting of acute diverticulitis or perforation.

Question 6

A 67-year-old presents to your office with a complaint of gnawing abdominal pain in the epigastrum and a sensation of She has a 50-pack-year history of tobacco use, and notes that her stool has become darker within the last 2 weeks. Which of the following is the most likely cause of her illness?

A	Helicobacter pylori infection
B	Nonsteroidal anti-inflammatory drug (NSAID) abuse
C	Alcoholism
D	Gallstones
E	Gastroparesis

Question 6 Explanation:

The patient describes the classic presentation for peptic ulcer disease. Infection with Helicobacter pylori is the leading cause of peptic ulcer disease, with the use of NSAIDs the second most common cause. Alcoholism and gallstones can cause pancreatitis, but that presents differently. Gastroparesis may cause dyspepsia, but is a less likely cause for ulcer disease.

Question 7

A 26-year-old man presents with 3 months of He also com- plains of regurgitation, belching, and occasional dry cough. His symptoms are worse when he is lying down. He denies melena, weight loss, or dys- phagia. What is the appropriate next step, if you suspect gastroesophageal reflux disease (GERD) in this patient?

A	Treat with H2 receptor antagonists, a proton pump inhibitor or a prokinetic agent and evaluate the response
B	Obtain a barium swallow
C	Obtain a CT scan of the abdomen with oral and IV contrast
D	Obtain an ultrasound of the abdomen
E	Perform an esophagogastroduodenoscopy (EGD)

Question 7 Explanation:

Reflux can be appropriately diagnosed by medical history and by evaluating the response to treatment. Those who respond are likely to have the diagnosis. Upper endoscopy fails to reveal GERD in 24–50% of the patients who have been found to have GERD by a pH probe. EGD should be performed if bleeding, weight loss, or dysphagia is present, especially in an elderly patient. The other tests have not been shown to be sensitive or specific enough to replace response to treatment as a diagnostic tool.

Question 8

A 44-year-old woman is admitted to the hospital for acute right upper quadrant pain for 4 hours consistent with biliary colic, fever, and a positive Murphy’s She has a history of asymptomatic gallstones, identified incidentally several years ago. Her laboratory evaluation is as follows:

WBC: 17.5 K/uL (H) with a left shift Aspartate aminotransferase AST: 88 U/L (H)

Alanine aminotransferase (ALT): 110 U/L (H) Alkaline Phosphatase: 330 U/L (H)

Bilirubin (total): 3.2 mg/dL (H)

What would the next test of choice be?

A	Ultrasound of the abdomen
B	CT scan of the abdomen
C	MRI of the abdomen
D	Endoscopic retrograde cholangiopancreatography (ERCP)
E	Cholescintigraphy (HIDA or PISIDA)

Question 8 Explanation:

ERCP is the gold standard for diagnosis and treatment of choledocholithiasis, and is usually performed in the setting of an acute cholecystitis with increased liver enzymes, amylase or lipase. Ultrasound shows stones, but is less sensitive for choledocholithiasis or for complications (abscess, perforation, and pancreatitis). CT or MRI is better for those. HIDA can be used, and a negative one rules out144 Family Medicine cholecystitis, but in the setting of increased liver enzymes, an ERCP is a better choice.

Question 9

You have diagnosed a patient with acute What is the most common cause of this condition?

A	Gallstones
B	Alcohol abuse
C	Iatrogenic
D	Idiopathic
E	Hyperlipidemia

Question 9 Explanation:

Gallstones cause about 50% of cases of pancreatitis. Alcohol causes about 30%. Ten to thirty percent are idiopathic. Less common causes include iatrogenic (for instance, after an ERCP), or hyperlipidemia.

Question 10

You are concerned about panreatitis in a 44-year-old woman with acute Which of the following laboratory tests is most specific for pancreatitis?

A	White blood cell count
B	Amylase
C	Lipase
D	AST
E	ALT

Question 10 Explanation:

Amylase is sensitive, but not specific. Lipase is also sensitive, but more specific, as virtually all lipase is pancreatic in origin. If it is more than three times normal, it is very sensitive and specific. White blood cell count, glucose, and transaminases can be elevated, but are better used to assess prognosis, not make the diagnosis.

Question 11

You are seeing a 53-year-old man who was hospitalized for His admission laboratory studies include a white blood cell count of 18,000/mm3, glucose of 153 mg/dL, lactate dehydrogenase of 254 IU/L, and AST of 165 U/L. According to Ranson’s criteria, which of these factors sug- gest a poor prognosis in this patient?

A	Age
B	White blood cell count
C	Glucose
D	LDH
E	AST

Question 11 Explanation:

Ranson’s criteria assess the severity and prognosis of pancreatitis. On admission, 5 criteria are considered. It is a poor prognostic sign if the age is more than 55, white blood cell is greater than 16,000, glucose is greater than 200, LDH is greater than 350, and AST is greater than 250. Six other criteria reflect the development of complications and include a decrease in hematocrit greater than 10 mg/dL, a BUN increase greater than 5 mg/dL, calcium less than 8 mg/dL, PaO2 less than 60 mmHg, base deficit greater than 4 mEq/L and a fluid sequestration greater than 6 L. These are assessed during the first 48 hours of admission.

Question 12

A 22-year-old Caucasian female college student complains of diffuse lower abdominal pain. It has been present for approximately 5 months and gets better with defecating. The onset is associated with more frequent and loose bowel movements (three to five times per day). Sometimes the diarrhea is watery with mucus, but she denies blood or bloating. There has been no weight loss, and no nighttime symptoms. What is the most likely diagnosis?

A	Ulcerative colitis
B	Irritable bowel syndrome
C	Crohn’s disease
D	Lactose intolerance
E	Diverticulitis

Question 12 Explanation:

The Rome consensus committee for irritable bowel syndrome developed diagnostic criteria for IBS. These criteria include: • Symptoms for at least 12 weeks (not necessarily consecutive) in 12 months • Characterized by two of the following symptoms: • Relief with defecation • Onset associated with a change in stool frequency • Onset associated with a change in stool appearance Crohn’s disease and ulcerative colitis are inflammatory bowel diseases. Ulcerative colitis is likely to have perirectal pain with bloody diarrhea. Crohn’s disease is likely to have right lower quadrant pain with weight loss. Lactose intolerance and diverticulitis are less likely to present this way

Question 13

A 65-year-old man presents to you complaining of abdominal pain. His pain is associated with anorexia, bloating, nausea and He is afebrile and denies fever. On examination, his abdomen appears distended, and he has absent bowel sounds. Abdominal percussion produces tym- pani. What would his abdominal x-ray likely show?

A	A fecalith in the right lower quadrant
B	Free intraperitoneal air
C	Stool throughout the colon
D	Proximally dilated loops of bowel
E	Stones in the right upper quadrant

Question 13 Explanation:

The patient is presenting with symptoms consistent with obstruction. In this case, abdominal radiographsAcute Complaints Answers 145 are crucial in the decision making process, and to rule in/rule out a surgical abdomen. A fecalith is a hard stony mass of feces that can obstruct the appendix or a diverticuli. Without a fever or other evidence of appendicitis, that would be a less likely finding. In a perforation, x-ray would show free intraperitoneal air, but this patient’s presentation is more consistent with obstruction. Stool may be seen on an abdominal film, but constipation would not likely present with the symptoms listed above. Gallstones are less likely to be seen on plain film.

Question 14

You are caring for a 26-year-old generally healthy She is sex- ually active and currently in a monogamous relationship. You recently completed her annual examination. Her Pap smear reports “atypical squa- mous cells of undetermined significance.” Human papillomavirus testing was negative. Which of the following is the most appropriate next step?

A	Repeat the Pap smear immediately
B	Treat the patient with metronidazole and repeat the Pap smear when the course of antibiotics is finished
C	Repeat the Pap smear in 4–6 months
D	Repeat the Pap smear in 1 year
E	Perform colposcopy

Question 14 Explanation:

Many types of cervical and vaginal abnormalities can be detected using the Pap smear. When the results are reported as “atypical squamous cells of undetermined significance” (ASCUS), the physician may repeat the test in 4–6 months and in 1 year, perform HPV testing on the sample, or proceed to colposcopy. If the HPV testing is negative, the patient is at low risk for cancer, and the Pap test can be repeated in 1 year, especially if the patient is monogamous.

Question 15

You are caring for a 24-year-old generally healthy She is sex- ually active and currently in a monogamous relationship, using oral con- traceptives. You recently completed her annual examination. Her Pap smear reports “atypical squamous cells of undetermined significance.” Human papillomavirus testing was positive. Which of the following is the most appropriate next step?

A	Repeat the Pap smear immediately
B	Repeat the Pap smear in 4–6 months
C	Repeat the Pap smear in 1 year
D	Perform colposcopy
E	Treat the patient with imiquimod (Aldara) and repeat the Pap smear after the treatment is complete

Question 15 Explanation:

When the results of a Pap smear are reported as ASCUS, and HPV testing on the sample is positive, the physician should proceed to colposcopy. Colposcopy involves cervical examination under stereoscopic magnification and includes biopsy of abnormal appearing areas, and is the definitive test for assessing Pap smear abnormalities. Imiquimod (Aldara) is an immune modulator and can treat warts, but is not indicated in this case.

Question 16

You are caring for a 40-year-old obese woman with mild hyperten- She is sexually active with her husband of 16 years, and had a tubal ligation after her son was born 5 years ago. One year ago, her Pap smear reported “atypical squamous cells of undetermined significance.” Human papillomavirus testing at your institution was unavailable. You repeated the Pap smear at 4 months and 8 months after the initial sample was taken. Both of those samples were normal. Which of the following is the most appropriate next step?

A	Repeat the Pap smear immediately
B	Repeat the Pap smear in 4–6 months
C	Repeat the Pap smear in 1 year
D	Perform colposcopy
E	Treat the patient with fluconazole (Diflucan) and repeat the Pap smear after the treatment is complete

Question 16 Explanation:

When the results of a Pap smear are reported as ASCUS, and HPV testing is unavailable, the physician may choose to perform colopscopy or repeat the Pap smear in 4–6 months. If the physician chooses to repeat the Pap smear, the results should be carefully followed. If the results are reported as ASCUS or higher, a colposcopy should be performed. If the repeat is normal, the Pap should be repeated again in 4–6 months. If the repeat Pap smear is again negative, the frequency of testing can return to normal.

Question 17

You are caring for a 28-year-old generally healthy She is cur- rently not sexually active, but has had multiple partners in the past. You recently completed her annual examination. Her Pap smear reports “atypical squamous cells of undetermined significance, favor low-grade squamous intraepithelial lesion.” Which of the following is the most appropriate next step?

A	Repeat the Pap smear immediately
B	Repeat the Pap smear in 4–6 months
C	Repeat the Pap smear in 1 year
D	Perform colposcopy
E	Perform endometrial biopsy

Question 17 Explanation:

When the results of a Pap smear are reported as ASCUS, favoring low-grade intraepithelial lesion (LSIL), the physician should proceed to colposcopy. Colposcopy involves cervical examination under stereoscopic magnification and includes biopsy of abnormal appearing areas, and is the definitive test for assessing Pap smear146 Family Medicine abnormalities. If the biopsies confirm the diagnosis, definitive treatment is needed.

Question 18

You are caring for a 34-year-old generally healthy She is sex- ually active and currently in a monogamous relationship with her husband, using oral contraceptives. You recently completed her annual examination. Her Pap smear reports “atypical glandular cells,” but does not specify if those cells are endocervical or endometrial in origin. She has not had any abnormal vaginal bleeding. Which of the following is the most appropriate next step?

A	Repeat the Pap smear immediately
B	Repeat the Pap smear in 4–6 months
C	Repeat the Pap smear in 1 year
D	Perform colposcopy
E	Perform endometrial biopsy

Question 18 Explanation:

When the results of a Pap smear are reported as “atypical glandular cells,” the physician should proceed to colposcopy. Colposcopy involves endocervical sampling, and will help to further identify the glandular cell abnormality noted on the Pap smear.

Question 19

You are caring for a 46-year-old generally healthy She is sex- ually active with her husband only. You recently completed her annual examination. Her Pap smear reports “atypical glandular cells” and are reported to be of endometrial origin. She does not report any abnormal vaginal bleeding. Which of the following is the most appropriate next step?

A	Repeat the Pap smear immediately
B	Repeat the Pap smear in 4–6 months
C	Repeat the Pap smear in 1 year
D	Perform colposcopy
E	Perform endometrial biopsy

Question 19 Explanation:

When the results of a Pap smear are reported as AGC, and are reported to be of endometrial origin, endometrial biopsy is necessary to rule out endometrial cancer. This is true even if the patient does not report abnormal vaginal bleeding.

Question 20

A 21-year-old woman is being evaluated for Further history reveals weakness, exercise intolerance and a craving for chewing ice that has occurred over the last few weeks. Laboratory analysis reveals a hemo- globin of 8.7 g/dL. What is the likely cause of her anemia?

A	Lead
B	Iron deficiency
C	Chronic disease
D	Vitamin B-12 deficiency
E	Folic acid deficiency

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II. Preview all questions below

1.You are evaluating a 36-year-old man in your office with the chief complaint of abdominal Which of the following characteristics of the pain, if present, would lead you toward an emergent evaluation?

The pain is located in the right lower quadrant
The pain began suddenly
The pain is described as a “gnawing” sensation
The pain is worse after eating
The pain is associated with emesis

2. A 42-year-old woman presents to your office complaining of abdomi- nal She describes upper abdominal pain that radiates to her scapula. For which of the following is this description classic?

Acute appendicitis
Pancreatitis
Gallbladder disease
Esophageal spasm
Gastroesophageal reflux disease

3. An 80-year-old man presents with mild, crampy, bilateral lower quad- rant pain, decreased appetite, and low-grade fever for about 48 Which of the following is most likely?

Small bowel obstruction
Appendicitis
Constipation
Irritable bowel syndrome
Pancreatitis

4. While performing an abdominal examination on a 42-year-old woman in your office, she suddenly stops inspiratory effort during deep palpation of the right upper Which of the following problems is this most suggestive of?

Hepatitis
Gallstones
Cholecystitis
Pancreatitis
Right-sided renal calculi

5. You are evaluating a 64-year-old man with abdominal Your differ- ential diagnosis includes diverticulitis, perforated diverticuli, and appendici- tis. What imaging study would be most helpful to establish the diagnosis?

Abdominal radiograph
Ultrasound of the abdomen and pelvis
Computed tomography (CT) scan of the abdomen and pelvis
Magnetic resonance imaging (MRI) of the abdomen and pelvis
Colonoscopy

6. A 67-year-old presents to your office with a complaint of gnawing abdominal pain in the epigastrum and a sensation of She has a 50-pack-year history of tobacco use, and notes that her stool has become darker within the last 2 weeks. Which of the following is the most likely cause of her illness?

Helicobacter pylori infection
Nonsteroidal anti-inflammatory drug (NSAID) abuse
Alcoholism
Gallstones
Gastroparesis

7. A 26-year-old man presents with 3 months of He also com- plains of regurgitation, belching, and occasional dry cough. His symptoms are worse when he is lying down. He denies melena, weight loss, or dys- phagia. What is the appropriate next step, if you suspect gastroesophageal reflux disease (GERD) in this patient?

Treat with H2 receptor antagonists, a proton pump inhibitor or a prokinetic agent and evaluate the response
Obtain a barium swallow
Obtain a CT scan of the abdomen with oral and IV contrast
Obtain an ultrasound of the abdomen
Perform an esophagogastroduodenoscopy (EGD)

8. A 44-year-old woman is admitted to the hospital for acute right upper quadrant pain for 4 hours consistent with biliary colic, fever, and a positive Murphy’s She has a history of asymptomatic gallstones, identified incidentally several years ago. Her laboratory evaluation is as follows:

WBC: 17.5 K/uL (H) with a left shift

Aspartate aminotransferase AST: 88 U/L (H)

Alanine aminotransferase (ALT): 110 U/L (H)

Alkaline Phosphatase: 330 U/L (H)

Bilirubin (total): 3.2 mg/dL (H)

What would the next test of choice be?

Ultrasound of the abdomen
CT scan of the abdomen
MRI of the abdomen
Endoscopic retrograde cholangiopancreatography (ERCP)
Cholescintigraphy (HIDA or PISIDA)

9. You have diagnosed a patient with acute What is the most common cause of this condition?

Gallstones
Alcohol abuse
Iatrogenic
Idiopathic
Hyperlipidemia

10. You are concerned about panreatitis in a 44-year-old woman with acute Which of the following laboratory tests is most specific for pancreatitis?

White blood cell count
Amylase
Lipase
AST
ALT

11. You are seeing a 53-year-old man who was hospitalized for His admission laboratory studies include a white blood cell count of 18,000/mm3, glucose of 153 mg/dL, lactate dehydrogenase of 254 IU/L, and AST of 165 U/L. According to Ranson’s criteria, which of these factors sug- gest a poor prognosis in this patient?

Age
White blood cell count
Glucose
LDH
AST

12. A 22-year-old Caucasian female college student complains of diffuse lower abdominal It has been present for approximately 5 months and gets better with defecating. The onset is associated with more frequent and loose bowel movements (three to five times per day). Sometimes the diarrhea is watery with mucus, but she denies blood or bloating. There has been no weight loss, and no nighttime symptoms. What is the most likely diagnosis?

Ulcerative colitis
Irritable bowel syndrome
Crohn’s disease
Lactose intolerance
Diverticulitis

13. A 65-year-old man presents to you complaining of abdominal pain. His pain is associated with anorexia, bloating, nausea and He is afebrile and denies fever. On examination, his abdomen appears distended, and he has absent bowel sounds. Abdominal percussion produces tym- pani. What would his abdominal x-ray likely show?

A fecalith in the right lower quadrant
Free intraperitoneal air
Stool throughout the colon
Proximally dilated loops of bowel
Stones in the right upper quadrant

14. You are caring for a 26-year-old generally healthy She is sex- ually active and currently in a monogamous relationship. You recently completed her annual examination. Her Pap smear reports “atypical squa- mous cells of undetermined significance.” Human papillomavirus testing was negative. Which of the following is the most appropriate next step?

Repeat the Pap smear immediately
Treat the patient with metronidazole and repeat the Pap smear when the course of antibiotics is finished
Repeat the Pap smear in 4–6 months
Repeat the Pap smear in 1 year
Perform colposcopy

15. You are caring for a 24-year-old generally healthy She is sex- ually active and currently in a monogamous relationship, using oral con- traceptives. You recently completed her annual examination. Her Pap smear reports “atypical squamous cells of undetermined significance.” Human papillomavirus testing was positive. Which of the following is the most appropriate next step?

Repeat the Pap smear immediately
Repeat the Pap smear in 4–6 months
Repeat the Pap smear in 1 year
Perform colposcopy
Treat the patient with imiquimod (Aldara) and repeat the Pap smear after the treatment is complete

16. You are caring for a 40-year-old obese woman with mild hyperten- She is sexually active with her husband of 16 years, and had a tubal ligation after her son was born 5 years ago. One year ago, her Pap smear reported “atypical squamous cells of undetermined significance.” Human papillomavirus testing at your institution was unavailable. You repeated the Pap smear at 4 months and 8 months after the initial sample was taken. Both of those samples were normal. Which of the following is the most appropriate next step?

Repeat the Pap smear immediately
Repeat the Pap smear in 4–6 months
Repeat the Pap smear in 1 year
Perform colposcopy
Treat the patient with fluconazole (Diflucan) and repeat the Pap smear after the treatment is complete

17. You are caring for a 28-year-old generally healthy She is cur- rently not sexually active, but has had multiple partners in the past. You recently completed her annual examination. Her Pap smear reports “atypical squamous cells of undetermined significance, favor low-grade squamous intraepithelial lesion.” Which of the following is the most appropriate next step?

Repeat the Pap smear immediately
Repeat the Pap smear in 4–6 months
Repeat the Pap smear in 1 year
Perform colposcopy
Perform endometrial biopsy

18. You are caring for a 34-year-old generally healthy She is sex- ually active and currently in a monogamous relationship with her husband, using oral contraceptives. You recently completed her annual examination. Her Pap smear reports “atypical glandular cells,” but does not specify if those cells are endocervical or endometrial in origin. She has not had any abnormal vaginal bleeding. Which of the following is the most appropriate next step?

Repeat the Pap smear immediately
Repeat the Pap smear in 4–6 months
Repeat the Pap smear in 1 year
Perform colposcopy
Perform endometrial biopsy

19. You are caring for a 46-year-old generally healthy She is sex- ually active with her husband only. You recently completed her annual examination. Her Pap smear reports “atypical glandular cells” and are reported to be of endometrial origin. She does not report any abnormal vaginal bleeding. Which of the following is the most appropriate next step?

Repeat the Pap smear immediately
Repeat the Pap smear in 4–6 months
Repeat the Pap smear in 1 year
Perform colposcopy
Perform endometrial biopsy

20. A 21-year-old woman is being evaluated for Further history reveals weakness, exercise intolerance and a craving for chewing ice that has occurred over the last few weeks. Laboratory analysis reveals a hemo- globin of 8.7 g/dL. What is the likely cause of her anemia?

Lead
Iron deficiency
Chronic disease
Vitamin B-12 deficiency
Folic acid deficiency

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