Question of the Week # 448 and 449

Q448  ) A 78 year old man presents to emergency room with severe pain in his right lower extremity. Pain began after he stumbled and fell on a sidewalk. He does not report pain anywhere else and did not lose consciousness. No tingling or numbness in either extremity. He reports inability to bear weight because it is extremely painful. His past medical history is significant for coronary artery disease and hypertension. He does report about 8lbs weight-loss in the past 1 month.  On examination, he is afebrile. There is tenderness in the right thigh area. Laboratory investigations reveal Hemoglobin 10.5gm%, Platelet count 110k/ul, Calcium at 10.4 mg/dl ( N = 9.0 to 10.5 mg/dl) , Serum creatinine 2.0 mg/dl, Total protein 4.5 gm/dl, Albumin 2.0gm/dl and Ferritin 200 ng/ml.  Liver function tests including Alkaline phosphatase are within normal limits. Whole body bone scan is negative for any lesions. Serum protein electrophoresis is normal with out any monoclonal spike.

An x-ray of the femur is shown  below :

bone

448) Which of the following is most helpful in diagnosing this condition?

A) Colonoscopy

B) DEXA scan

C) 24 hour urine electrophoresis

D) Vitamin D level

E) Parathyroid hormone level

 

449) Which of the following is likely to explain the patient’s findings?

A) Metastatic colon cancer

B) Multiple Myeloma

C) Osteoporosis

D) Secondary Hyperparathyroidism

E) Metastatic Prostate cancer

Question of the Week # 447

447) A 54 year old caucasian man is seen in your office for initial visit examination. He recently moved from Texas to your town and would like to establish care with you. He has no significant past medical problems except for Gastro-Esophageal Reflux Disease for twenty years. He previously suffered hearburn symptoms that were controlled with over the counter ranitidine . Later, his symptoms became refractory and he was started on omeprazole by his previous physician. He currently takes 20 mg of Omeprazole and is very happy that he has been asymptomatic for the past 1 year.  He has had colonoscopy 2 years ago and this was normal. His father died of Colon cancer at the age of 70. He does not smoke.

Which of the following is the most appropriate action at this time ?

A) Instruct him to continue Omeprazole and follow up in 1 year.

B) Refer to gastroenterology for Upper Endoscopy

C) 24 hour Esophageal pH monitoring

D) Stool Guaic test and Flexible Sigmoidoscopy

E) Stool test for H.Pylori antigen

Question of the Week # 446

446) A 64 year old woman presents to your office with productive cough and fever for the past three days. About two months ago, she was admitted for pneumonia. Past medical history is significant for Rheumatoid arthritis. Her medications include hydroxychloroquine and prednisone. Previously, she was treated with Azathiprine for about 6 years.

On examination, temperature is 101F, blood pressure 120/80 and heart rate of 106/min.  Chest examination reveals decreased breath sounds at left lower lobe. No hepatomegaly, spleen tip is palpable. Chest X-Ray reveals left lower lobe consolidation  Labs reveal WBC 1000/µl with differential count showing neutrophils of 30% and Hemoglobin 9.9 gm%

Which of the following is the most likely explanation for the patient’s presentation?

A) Hypogammaglobulinemia from Rheumatoid arthritis

B) Marrow suppression by Hydroxychloroquine

C) Marrow toxicity by Azathiprine

D) Myeloproliferative disorder

E) Felty Syndrome

Question of the Week # 445

445) A 45 year old african-american man presents to the emergency room with altered mental status. His past medical history is significant for skin nodules. One of the nodule was recently biopsied and it revealed non-caseating granuloma. On examination, his oral mucosae are dry.  Blood pressure is 90/60 . Skin examination  reveals multiple scattered skin nodules about 1 to 2cm in diameter. Chest X-ray reveals bilateral hilar adenopathy.   Laboratory Studies reveal

WBC 5400/µl

HGB: 11.8 gm%,

Platelets : 300k/µl

Calcium 14.2gm%

Creatinine 3.2mg%

Phosphorous 2.2mg%

He is started on agressive intravenous hydration. In addition to the above  measures, you should also proceed with  intervention directed to towards which of the following at this time ?

A) Reducing serum phosphorous

B) Reducing serum parathyroid hormone

C) Reducing Blood Calcitrol level

D) Promoting loop diuresis

E) Direct removal of calcium by Hemodialysis

Question of the week # 444

444) A 25 year old woman is seen by you today due to an abnormal blood count. Three weeks ago, she volunteered for blood donation and a complete blood count that was drawn at that time showed abnormal values. She has regular menstrual periods with normal flow. Her last menstrual period was one week ago.  Her previous blood count was done several years ago and she is unaware of being told they were abnormal. A complete blood count is as follows :

WBC 550/µl

HGB: 12.1 gm%

MCV 84 fl

Platelets : 800k/µl ( Normal 140k to 340k/ul)

Differential count : Neutrophils : 64% Lymphocytes 30% Monocytes 4%

Which of the following is the most important next step?

A) Obtain Bone Marrow Biopsy

B) Order Transferrin Saturation

C) Obtain Jak-2 Mutation Analysis

D) Obtain Arterial Blood Gases

E) Start her on Aspirin

Question of the Week # 443

443 ) A 38 year old man is evaluated in your office for a chronic rash on his elbows. He reports this has been worsening over the last 6 months and is intensely itchy. He lost about 8lbs weight in the past 6 months. Review of systems is normal except for 4 to 5 episodes of loose stools every day. Laboratory investigations reveal moderate microcytic anemia. On examination, he is afebrile. There is a vesicular rash on the extensor aspects of his bilateral elbows as shown below:

elbows

Which of the following is most helpful in diagnosing this condition?

A) Fecal occult blood testing and Sigmoidoscopy

B) Anti-nuclear antibodies

C) Anti-Endomysial antibodies

D) Small bowel follow through

E) Anti-Sacharomyces Cerviseae antibodies ( ASCA)

Question of the Week # 442

442 ) A 14 month old toddler is brought to your out-patient clinic by her concerned mother regarding a rash that appeared recently in her ano-genital region. The rash has appeared 3 weeks ago and is persistent. Mother says she tried to use local Zinc Oxide  cream but it did not help. There is no history of fever. No vaginal discharge. She is otherwise healthy and reaching all her milestones appropriately. On examination, she is afebrile. There are several papules seen in the ano-genital area as shown below.

IMAGE 3 KIDS

Which of the following is the most appropriate next step?

A) Screen for Child Sexual Abuse

B) Local steroid application

C) Reassure that the rash will resolve in few months

D) Refrain the child from Day-care to prevent transmission

E) Local antibiotic application

Follow

Get every new post delivered to your Inbox.

Join 107,229 other followers

%d bloggers like this: