A 6-month-old infant is brought to the urgent care center for unstoppable crying for the last 3 days. The mother states that the child cannot be consoled with formula or pacifier. She lives with her boyfriend and works at a local warehouse. Her boyfriend takes care of the baby during her work hours. On physical examination, the infant has left thigh swelling and tenderness. The mother denies any trauma or injury. The infant also has left-sided scalp swelling and several small bruises on the trunk, back and buttocks. There is a punched out wound on the back of the size 1 cm by 1 cm in size. There is a bruise in the shape of a spatula on the left buttock. Mother reports that she has not witnessed any falls or injuries that could have caused these injuries. Radiographs of the left thigh reveal a transverse femur fracture. Which of the following is the next best stop in management?

A 6 year-old girl is brought to the emergency room by her mother for evaluation of abdominal pain. For the last three days, the child has been reporting severe abdominal pain. No fever, no constipation, no nausea, no vomiting – just abdominal pain. She describes different hospitalizations and different invasive tests in a detached, unperturbed tone. Dr.Johnson at Mount Sinai Hospital recommended citalopram, Dr.Giriraj at Lakeview Hospital and Dr.Ahmed at Little Angels Hospital recommended surgery and Dr.Ambrose at Bluesky Hospital recommended CT guided biopsy. As you go over the medical records of the child, you notice that the child had multiple admissions for severe abdominal pain over the last two years with no identifiable diagnosis during any hospitalization, despite going through lots of blood, urine and imaging investigations. She becomes tearful as she recounts experiences of abuse when she was a child. In her childhood, she had similar problems like her daughter but eventually she grew out of them. She reports that her husband rarely spends time with her except for things related to her daughter, and if ‘he pays little more concern for her and her daughter, things like this would not happen’. As you proceed with the physical examination, the mother sticks to her child and prompts the child with directed questions, ‘Isn’t the belly pain so bad, sweetie?’. The child nods her head in agreement as the mother raises her voice. But when the mother walks away to attend to other things, the child makes a smiley face. You started to wonder what might be the underlying cause of this disorder but eventually realized the condition of the child. What is the next best step in the management of this individual and her child?

A 28-year-old woman presents to the clinic seeking contraception. She is in a stable relationship, has regular menstrual cycles, and has no plans for pregnancy in the near future. Her medical history is significant for mild acne and occasional menstrual cramps but is otherwise unremarkable. She is a non-smoker with no history of hypertension, migraines, or clotting disorders. After discussing various options, she opts for a combination oral contraceptive pill (COC) for its dual benefits of contraception and potential improvement of her acne and dysmenorrhea. Her current medications include rifampin, griseofulvin, phenytoin, and St.John’s Wort. Which of her current medications reduce the efficacy of combination oral contraceptives?

A 35-year-old woman with a history of deep vein thrombosis (DVT) presents for follow-up while taking warfarin for anticoagulation therapy. During the visit, she mentions recently starting combination oral contraceptives (COCs) for contraception and menstrual cycle regulation. Her other medications include butabarbital, prednisone, phenylbutazone, and amiodarone. On further discussion, it is noted that she was not aware of the potential interactions between warfarin and her current medications. You decide to counsel her on how her medications later warfarin requirement. Regarding the interactions between her current medications and warfarin dosing, which of the following is true?

A 33-year-old woman with a history of deep vein thrombosis (DVT) presents for follow-up while taking warfarin for anticoagulation therapy. During the visit, she mentions recently starting combination oral contraceptives (COCs) for contraception and menstrual cycle regulation. Her other medications include allopurinol, cimetidine, erythromycin and glipizide. On further discussion, it is noted that she was not aware of the potential interactions between warfarin and her current medications. You decide to counsel her on how her medications alter warfarin requirements. Which of the following medications lead to decreased anticoagulant effect of warfarin? 

A 65-year-old postmenopausal woman presents to the clinic with a 3-month history of a gradually enlarging, firm nodule at her umbilicus. She reports mild abdominal discomfort and unintentional weight loss of 8 kilograms over the past six months. The nodule has become tender over the last few weeks, and she has noticed occasional serosanguinous discharge. She denies nausea, vomiting, or changes in bowel or urinary habits. Her medical history is unremarkable, and she has no significant family history of cancer. On physical examination, there is a 2 cm firm, irregular, non-reducible nodule at the umbilicus with overlying erythema and a small amount of discharge. Abdominal palpation reveals mild diffuse tenderness but no palpable masses. No ascites is detected on percussion. Laboratory investigations show an elevated CA-125 level of 580 U/mL (normal <35 U/mL), while other routine blood tests, including a complete blood count and liver function tests, are within normal limits. A CT scan of the abdomen and pelvis reveals a 10 cm complex ovarian mass on the left side with irregular margins and solid components. There is evidence of peritoneal carcinomatosis with omental thickening, and the umbilical nodule appears consistent with metastatic spread. Fine-needle aspiration cytology (FNAC) of the umbilical nodule confirms adenocarcinoma, likely of ovarian origin. What is the appropriate management for this patient with a Sister Mary Joseph nodule associated with advanced ovarian cancer?

A 58-year-old postmenopausal woman presents to the clinic with a 3-month history of a gradually enlarging, firm nodule at her umbilicus. She reports mild abdominal discomfort and unintentional weight loss of 10 kilograms over the past six months. The nodule has become tender over the last few weeks, and she has noticed occasional serosanguinous discharge. She denies nausea, vomiting, or changes in bowel or urinary habits. Her medical history is unremarkable, and she has no significant family history of cancer. On physical examination, there is a 2 cm firm, irregular, non-reducible nodule at the umbilicus with overlying erythema and a small amount of discharge. Abdominal palpation reveals mild diffuse tenderness but no palpable masses. No ascites is detected on percussion. The presence of a nodule at her umbilicus made you wonder whether this is a Sister Mary Joseph nodule. Which of the following malignancies is most commonly associated with Sister Mary Joseph nodules?