119) A 60-year-old woman presents to the Emergency Room with massive hemetemesis. The onset is acute. She denies any alcohol use or  any antecedent nausea, vomiting or retching. On physical examination, the patient is found to be hypotensive with a blood pressure of 80/40. The patient is started on Intravenos fluids and proton pump inhibitors. Prothrombin time and liver function tests are with in normal limits. Hemoglobin is low at 7gm/dl and the patient is now being transfused with 2 units of packed red cells. An immediate Endoscopy is scheduled which revealed bleeding gastric varices but no esophageal varices. Local vasocontrictor therapy and band ligation could not restrain the bleeding. Ultrasound and CT scan of abdomen revealed enlarged spleen, an engorged splenic artery and an intraluminal filling defect in the Splenic Vein as shown in the picture below 

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115) A 44-year-old HIV-infected man with a CD4 count of 280cell/mm³ presents to your office for regular follow up. His viral load is undetectable. His HIV medications include tenofovir, lamivudine and Ritonavir for the past one year.  On examination, he has features of lipodystrophy. A fasting lipid panel reveals Total cholesterol 270 mg%,  LDL cholesterol 200mg%, Triglycerides 150mg% and HDL 40mg%.  He is advised to start low fat diet and exercise. The most important next step in controlling this patient’s hyperlipidemia.

A) Add Niacin

B) Add Simvastatin

C) Add Pravastatin

D) Add Lovastatin

E) Hold HAART therapy until lipids normalize

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114) A 44-year-old HIV-infected man with a CD4 count of 280cell/mm³ presents to your office with complaints of fatigue, body aches, leg cramps and muscle pain. His viral load is undetectable. His HIV medications include tenofovir, lamivudine and Ritonavir for the past one year.  The patient was recently seen in the office for lipodystrophy and hyperlipidemia. His LDL cholesterol was 190 during last visit and hence, he was started on Simvastatin about 2 weeks ago. On  physical examination, he is afebrile and he has diffuse muscle tenderness. Laboratory studies show a serum creatinine of 3.2 mg/dL ( his baseline = 1.0 mg/dl), serum urea nitrogen = 55 mg/dL , total bilirubin 0.8gm/dl,  aspartate aminotransferase (AST) level of 632 U/L and alanine aminotransferase (ALT) level of  140 U/L . Urinalysis was positive for blood on dipstick. Urine microscopy shows no red cells or white cell casts. The most likely reason behind the etiology of this patient’s renal failure :

A) Polymyositis

B) HIV associated Nephropathy

C) Tenofovir induced Nephrotoxicity

D) Interaction between Ritonavir and Simvastatin

E) HIV myopathy

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113) A 44-year-old HIV-infected man with a CD4 count of 280cell/mm³ presents to your office with complaints of fatigue, body aches, leg cramps and muscle pain. His viral load is undetectable. His medications include tenofovir, lamivudine and Ritonavir.  The patient was recently seen in the office for lipodystrophy and hyperlipidemia. His LDL cholesterol was 190 during last visit and hence, he was started on Simvastatin about 2 weeks ago. On  physical examination, he is afebrile and he has diffuse muscle tenderness. Laboratory studies show a serum creatinine of 3.2 mg/dL ( his baseline = 1.0 mg/dl), serum urea nitrogen = 55 mg/dL , total bilirubin 0.8gm/dl,  aspartate aminotransferase (AST) level of 632 U/L and alanine aminotransferase (ALT) level of  140 U/L . Urinalysis was positive for blood on dipstick. Urine microscopy shows no red cells or white cell casts. The most useful test in determining the etiology of the liver enzyme elevations in this patient:

A) Ultrasound Abdomen

B) Serum Creatinine Phosphokinase

C) Gamma glutamyl transferase (GGTP)

D) CT abdomen with contrast

E) Hepatitis C antibodies

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A 30-year-old HIV-infected man presents to your office for evaluation regarding starting of Anti-retroviral therapy. The patient’s most recent CD4 count was 460 cells/mm³ and HIV RNA level of 20,000 copies/ml. He has  a history of Intravenos drug abuse. The patient was also noted to have elevated liver enzymes twice the upper limit of normal.  During the work-up for his liver abnormalities, his Hepatitis C is negative but Hepatitis B surface antigen returns positive consistent with hepatitis B active infection.  He has no HIV-related symptoms and has not had any AIDS-defining illnesses. The patient requests that he be started on Highly Active Anti-Retrovial therapy (HAART). Which of the following is the most appropriate indication for starting HAART in a HIV infected patient?

A) CD4 count of less than 500

B) HIV viral load greater than 50,000

C) Initiation of treatment for Hepatitis B co-infection

D) Renal Insufficiency with out proteinuria

E) All Reproductive age group HIV + women

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110.    A 45 year old HIV positive patient has been receiving Highly active anti-retroviral therapy. Her medications include Lamivudine, Zidovudine, Indinavir and Ritonavir. His most recent HIV viral load was undetectable and Absolute CD4 count was 400/µl .  Eight weeks after initiation of therapy, the patient comes to the emergency department complaining of  nausea, burning urination, frequency and severe flank pain. One week prior to this visit, the patient visited the ER for burning urination and was treated with Trimethoprim/Sulfamethaxozole. Urine cultures from last visit are negative. Laboratory investigations reveal a serum creatinine of 2.2. A urinalysis is negative for protein, nitrite and leucoesterase with out any bacteriuria. Urine microscopy reveals numerous WBCs and some starburst crystals. A non-contrast abdominal CT scan reveals mild right hydronephrosis without any evidence of stones. Patient is given adequate pain medications. The most likely etiology of this patient’s renal insufficiency :
a)    Acute Pyelonephritis
b)    Acute Bacterial Cystitis
c)    Indinavir Nephropathy
d)    Allergic Interstitial Nephritis
e)    HIV nephropathy

111. Most important next step in managing this patient’s renal failure :

A) IV hydration and Intravenos Ceftriaxone

B) IV hydration and Discontinue Indinavir for three days

C) IV hydration and Enalapril

D) Arrange for Hemodialysis

E) Discontinue Indinavir and refer for Lithotripsy

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109) A 35 year old HIV positive male patient comes to your office with complaint of anorexia, nausea and vomiting and abdominal pain. His anti-retroviral medications include Stavudine and Didanosine. On physical examination, his temperature is 100F. His abdomen is tender in the epigastric area.  Laboratory results reveal WBC count of 20k/µl, Serum amylase 500 IU/L ( N =  25 to 160 U/L) , Lipase 590 units/liter (Normal = 25 to 300U/L), AST  120 IU/L, ALT 200 IU/L, Total bilirubin 3.6gm% and  Alkaline phosphatase 200IU/L . Ultrasound reveal gallstones with no cystic duct obstruction and no evidence of cholecystitis and a  common bile duct diameter of 1.5cm. The most important step that will help improve the patient’s acute pancreatitis is :

a)    Intravenos Imipinem/ Cilastatin
b)    Endoscopic Retrograde Cholangiopancreatography ( ERCP)
c)    Stop Didanosine
d)    Stop Stavudine
e)    Exploratory Laporotomy

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108) A 34 year old man with history of schizophrenia and hypertension presents to your office with complaints of sore throat and low grade fever. He has mild cough. He denies any sick contacts. On examination, the patient has a temperature of 100F. Throat examination reveals mild erythema with no exudate. There is no cervical lymphadenopathy. His medications include Metoprolol and Clozapine. The most important step in managing this patient :

A) Influenza Rapid Antigen Test

B) Throat Lozenges

C) Obtain Complete Blood Count

D) Oral Azithromycin

E) Discontinue Clozapine

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107)  A 24-years old man with history of Hepatitis C is brought to the ER with history of attempted suicide by cutting his veins with a knife. His family members spotted him while trying to cut his wrist and could save him. He was immediately admitted to psychiatric ward of the hospital. On examination, his vitals are stable. The patient appeared very depressed. The wrist was bandaged and there is no significant bleeding. The patient has a history of depression for the past three years which was adequately controlled on Fluoxetine. Laboratory investigations revealed  ALT: 95 IU/ml , AST: 65 IU/ml, , Hemoglobin: 15.2 gr/dl, Platelet count: 345000/ml, WBC count: 6500/ml. Approximately 4 weeks ago, the patient was diagnosed with HCV infection  after screening due to intravenous drug addiction history. At that time, HCV – RT PCR was positive, HIV ab  and Hepatitis B Surface antigen were negative. The patient was started on Interferon and ribavirin for Hepatitis – C infection. The patient denied any recent drug use. He has been compliant with his Fluoxetine. He reports  increased suicidal thoughts over the past few days. The most important next step in controlling this patient’s depression :

A) Electroconvulsive therapy

B) Discontinue Fluoxetine

C) Start Cyproheptadine

D) Discontinue Interferon

E) Start Clozapine to reduce suicidal tendency

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105) A 46 year old man is seen in your office for complaints of severe fatigue over the last one week. The patient was diagnosed with chronic Hepatitis – C infection 2 weeks ago for which he was started on Interferon and Ribavirin. On examination, his vitals are stable and he is afebrile. Conjunctivae are notable for pallor.  Abdominal examination is benign except for mild splenomegaly.

Laboratory investigations :

WBC count of 3,ooo/µl

Hemoglobin of 5.8gm%

Platelet count of 60k/µl.

Total protein 6.8gm%

Albumin 3.2gm%

Total Bilirubin 3.2gm%

Direct bilirubin 0.8gm%

SGPT 52 U/L

SGOT 66 U/L

Alkaline Phosphatase 110U/L

Haptoglobin < 5.8

Reticulocyte count of 6.0%

Lactic Dehydrogenase 1200 IU/L

Serum creatinine 1.0

Peripheral blood smear reveals reduced platelets, polychromasia and anisocytosis. His laboratory tests 4 weeks ago were normal except for mild elevations in his liver enzymes.  The immediate next step in managing this patient is :

A) Parvo virus B19 antibodies

B) Endoscopy

C) Plasmapheresis

D) Stop Ribavrin

E) Intravenos Methylprednisolone

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105) A 66 year old man presents to your office with complaints of productive cough and low grade fever for past two days. He denies any sick contacts. On physical examination, his temperature is 100F, breath sounds are reduced in left lower lobe. A chest x-ray reveals left lower lobe infiltrate. Laboratory investigations reveal WBC count of 12,ooo/µl with 80% neutrophils. Sputum gram stain and cultures are sent for. Blood cultures have been obtained and are pending.  He received a Flu vaccine about one month ago but never received a pneumococcal vaccine. The next important step in managing this patient:

A) Oral Azithromycin

B) Oral Levofloxacin

C) Admit the patient

D) Swallowing evaluation

E) PPD skin test

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104) A 65 year old man presents to your office with increasing abdominal distension and bilateral leg swelling. He is accompanied by his daughter. He reports his symptoms started 3 months ago and progressively worsening. He smokes about one pack cigarettes per day and drinks one pint vodka every day. His last drink was 1 day ago. On examination, he is afebrile and he has abdominal distension and ascites with out any tenderness on palpation. Lab studies show  WBC 8k/µl, Hemoglobin of 10.2 gm%, Platelets 90k/µl, Total protein of 6.4, Albumin 2.2, SGOT 300, SGPT 130, Total Bilirubin 4.2 , Direct Bilirubin 3.3, Prothrombin time of 19 seconds and Creatinine 2.2. Ultrasound reveals cirrhosis of the liver and splenomegaly. The daughter asks  you if her father can be considered for Liver transplantation. The most common indication for liver transplantation in the United States :

A) Alcoholic Liver Disease

B)Chronic  Hepatitis B

C) Acute Liver Failure

D) Hepatitis C

E) Primary Biliary Cirrhosis

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102) A 65 year old man presents to your office with increasing abdominal distension and bilateral leg swelling. He reports his symptoms started 3 months ago and progressively worsening. He smokes about one pack cigarettes per day and drinks one pint vodka every day. His last drink was 1 day ago. On examination, he is afebrile and he has abdominal distension and ascites with out any tenderness on palpation. Lab studies show  WBC 8k/µl, Hemoglobin of 10.2 gm%, Platelets 90k/µl, Total protein of 6.4, Albumin 2.2, SGOT 300, SGPT 130, Total Bilirubin 4.2 , Direct Bilirubin 3.3, Prothrombin time of 19 seconds and Creatinine 2.2. The patient undergoes diagnostic paracentesis which reveals a total protein of  1.4, albumin of 0.6, WBC count of 400 with polymorphonuclear neutrophils of 100cells/ml. Bacterial cultures are pending. The most important step in managing this patient is :

A) Intravenos Ceftriaxone

B) Intravenos Corticosteroids

C) Intravenos Albumin Infusion

D) Trans-jugular Intrahepatic Porto-systemic Shunt (TIPS)

E) Arrange for Liver Tranplant

F) Furosemide and Spironolactone

103) The most important factor that should be considered in determining the etiology of this patient’s Ascites:

A) Fluid WBC

B) Fluid  Albumin

C) Fluid Total protein

D) Serum – Ascites- Albumin – Gradient

E) Serum Albumin and Prothrombin time

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Q98) A 68 year old man with history of DM type II, Hypertension and severe osteoarthritis presents to your office with complaints of chest pain on exertion for past 3 months. He denies any pain now.  His only medications are Glyburide, Metprolol, Enalapril and Metformin. An EKG is obtained in the office and it reveals non-specific ST segment changes.  While undergoing the test, the patient develops severe chest pain and headache. EKG monitor reveals  > 2mm ST depressions in the anterior leads. The technician immediately terminates the dipyridamole infusion. After 2 minutes of cessation of infusion, the patient continues to have chest pain. His blood pressure is 88/68 mm hg. The next step in managing this patient :

A) Order Cardiac enzymes

B) Start Heparin infusion

C) Administer Intravenos Aminophylline

D) Reassure the patient that symptoms will improve in few minutes

E) Urgent Cardiac Catheterization

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Q97) A 68 year old man with history of DM type II, Hypertension and severe osteoarthritis presents to your office with complaints of chest pain on exertion for past 3 months. He denies any pain now.  He smokes about one pack cigarettes per day. His only medications are Glyburide, Metprolol, Enalapril and Metformin. An EKG is obtained in the office and it reveals non-specific ST segment changes.  The patient is scheduled for Dipyridamole stress test .  The patient should be advised regarding which of the following:

A) Avoid Aspirin or NSAID for 24 hours prior to testing

B) Stop Metprolol 24 hours prior to tesing

C) Avoid Coffee or Caffeine for 24 hours prior to testing

D) Avoid smoking for one week prior to testing

E) Start inhaled Albuterol two days prior to testing

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Q96) A 65 year old man with history of DM type II presents to your office with complaints of chest pain that he has been having lately. He denies any pain now. He says his chest pain is more left sided and about 5/10 in intensity and it appears after walking about 2 blocks. The pain disappears after resting for a while. He has been having these chest pain episodes for the past 3 months.  He also reports severe crampy leg pain that occurs in his both legs which is also relieved by rest. He denies any shortness of breath. He has smoked about 1 pack per day for the past 40 years. He denies any cough.  His only medications are Glyburide and Metformin. An EKG is obtained in the office and it reveals non-specific ST segment changes. Next important step in managing this patient:

A) CT angiogram of Chest

B) Exercise Treadmill Stress test

C) Obtain Cardiac Enzymes

D) Dipyridamole Stress test

E) Start Calcium Channel Blocker

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Q95). A 62 year old man with history of  DM Type II and Coronary Artery Disease presents to the Emergency room with right leg pain and swelling.   The pain and swelling started 2 days ago and has been increasing. He denies any fever, chest pain or shortness of breath. He was recently admitted to the hospital 10 days ago for Non ST elevation Myocardial infarction. The patient was treated at that time with medical management that included Heparin, Clopidogrel, Aspirin and Beta blockers. The patient was discharged with instructions to continue aspirin, clopidogrel and metoprolol. At the time of discharge. his labs were all with in normal limits. He says he has an appointment with his cardiologist’s office next week for further work-up. He denies any bleeding. Physical examination reveals ankle tenderness and mild swelling of the right lower extremity up until his mid thigh. Laboratory investigations reveal a WBC of 5100, HGB 14.2 and a platelet count of 40k/µl ( N = 160 to 400k/µl. Prothrombin time and partial thromboplastin time with in normal limits. A venos doppler reveals a common femoral to popliteal DVT in his right lower extremity. Next step in managing this patient ?

A) Start Low Molecular Weight Heparin

B) Start Warfarin

C) Place Inferior Vena Cava Filter due to bleeding risk

D) Start Lepirudin

E) Platelet Transfusion

Which of the following is most likely to establish the diagnosis in this patient?

A) Lupus Anticoagulant Profile

B) Anti Platelet Factor 4/ Heparin antibodies

C) Factor V leiden mutation

D) Prothrombin gene mutation

E) Peripheral Blood Smear

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A 62 year old man presents with right leg pain and swelling.   The pain and swelling started 2 days ago and has been increasing. He denies any fever, chest pain or shortness of breath. He has no significant past medical history. There is no family history of clots. His last visit to a doctor’s office was 30 years ago. He denies any weightloss or dyspepsia or melena or rectal bleeding. Physical examination reveals ankle tenderness and mild swelling of the right lower extremity up until his mid thigh. Laboratory investigations reveal normal complete blood count with prothrombin time and partial thromboplastin time with in normal limits. A venos doppler reveals a common femoral to popliteal DVT in his right lower extremity. The patient is started on Low Molecular Weight heparin. The next important step in evaluating the hypercoaguilabilty in this patient?

A) Protein C level

B) Protein S level

C) Anti thrombin III level

D) Screening Colonoscopy

E) CT scan of the abdomen and Pelvis.

F) Heparin Induced Platelet Antibodies

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Q92) 67 year old african american man presents to your office for regular check up. He has no significant past medical history. He underwent a screening colonoscopy 5 years ago that was normal . He underwent a PSA testing 3 months ago and it was 2.5. The  patient denies any complaints. He denies any fatigue or recent weight changes. He denies alcohol use or smoking. He does not use any medications at home. Physical examination is normal.  Routine  laboratory investigations reveal a WBC count of 4200/µl, Hemoglobin of 9.6gm% , Mean Corpuscular Volume of 106, Reticulocyte count of 1%  and Platelet count of 152,000/µl. Peripheral smear reveal macrocytosis and hyposegmented neutrophils.  B12 level 540 pmol/L, TSH 2.0 ( N = 0.3 – 4.2) miU/L and Folic acid level is with in normal limits. Lactic Dehydrogenase is 170 *( normal). Haptoglobin is 220( normal). Most likely etiology of this patient’s anemia?

A) Iron deficiency

B) Subclinical Vitamin B12 Deficiency

C) Subclinical Hypothyroidism

D) Hemolytic Anemia

E) Myelodysplatic Syndrome

Q93) The next best step in obtaining the diagnosis :

A) Serum Ferritin

B) Methylmalonic Acid Level

C) Free T4 and T3 level

D) G6PD level

E) Bone marrow biopsy

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Q90) A 57 year old hispanic woman is admitted to the hospital with right leg cellulitis. The patient is started on intravenos antibiotics. She is afebrile. Physical examination reveals erythema and tenderness in right lower extremity. Venos Doppler is negative for DVT. Her past medical history is significant for chronic alcoholism and liver cirrhosis. Laboratory investigations reveal a WBC count of 1700/µl with absolute neutrophil count of 800, Hemoglobin of 10.2gm% and Platelet count of 52,000/µl. Peripheral smear reveal reduced platelets and no evidence of any abnormal cells. B12 and folic acid level as well as Iron studies are with in normal limits. Blood cultures are negative at Day 1.  HIV serology, Hepatitis B and Hepatitis C are negative. Antinuclear antibodies are negative. Reticulocyte count is 4% and Lactic Dehydrogenase is 170 *( normal). Haptoglobin is 220( normal). A hematology evaluation is obtained and a bone marrow biopsy performed to evaluate her pancytopenia. BM biopsy reveals hypercellualar bone marrow with no dysplatic features. The most important next step in evaluating this patient’s pancytopenia?

A) CT scan of the abdomen

B) Parvo virus B19 Antibodies

C) CT scan of the chest to rule out Thymoma

D) Methyl malonic acid level

E) Flow cytometry for CD58 and CD59

Q91) Most likely cause of this patient’s Pancytopenia?

A) Hypersplenism

B) Parvovirus B19

C) Aplastic Anemia

D) Sub clinical Vitamin B12 deficiency

E) Acute Leukemia

F) Paroxysmal Nocturnal Hemoglobinuria

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Q87) A 42 year old african-american man is admitted to hospital with acute seizures. Seizures were appropriately controlled in the ER and the patient currently, in post-ictal confusion. He is unable to give further history. However, a review of the old records reveal that the patient has history significant of Chronic HIV infection. He also has a history of IV drug use. As per his sister, the patient has been compliant with Highly active anti-retroviral therapy and prophylactic medications for Pneumocystis jiroveci and Mycobacterium Avium Complex for the past one year. His recent CD4 count 1 month ago was 45. On physical examination, he is afebrile with a blood pressure of 120/60.  He is confused. Reflexes are intact. Electrolytes and CBC are with in normal limits. Urine drug screen is negative. A non-contrast CT scan did not not reveal any bleed. A CT scan with IV contrast reveals a 4 cm ring – enhancing lesion in left cerberal hemisphere. A  subsequent MRI brain confirmed the findings on the CT. There is no mass effect. Next step in approaching this patient ?

A. Stereotactic Brain Biopsy

B. Start emperic Toxoplasma therapy.

C. Obtain Toxoplasma Serology ( IgM and IgG)

D. PCR for Papova Virus JC

E. Emperic therapy for CNS tuberculosis.

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Q86) A patient had a closed fist injury at a bar while trying to punch his friend who he later learnt was HIV positive. The patient tells you that there was only an abrasion on his hand and all he noted on his hand was his friend’s saliva. He is very concerned. What is your next step?

A. Give HIV prophylaxis with HAART
B. Clean and debride the wound and reassure that no need for prophylaxis
C. Call surgical consult
D. Close the wound with sutures
E. Check for HIV antibody

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Q70) A 40-year-old man presents to your office for regular follow up. He has history of  hypertension  for which he has been on Hydrochlorthiazide and Lisinopril. Lately, his blood pressure has not been well controlled and this has been documented both in the office and outside during several visits. The patient says he has had increasing fatigue and irritability over the last few months and has difficulty concentrating at work. He  thinks his boss has never been supportive and he attributes his irritability to this. He has smoked 2 packs of cigarettes per day for the past 15 years. On physical examination he is a obese male with a neck circumference of 18cm. He has a ruddy complexion. His vitals reveal a HR of 90 and a BP of 152/92.  Reminder of the physical exam is normal. EKG reveal changes consistent with long standing hypertension. A CBC, electrolyes and creatinine are normal. Which of the following is the most important investigation that can identify the cause of  his uncontrolled hypertension?

( A ) Ambulatory blood pressure monitoring

( B ) Pulmonary function studies

( C ) Polysomnography

( D ) Arterial blood gases

(E)  Urine drug screen

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Q69) You are treating an 18-year-old white male college freshman for allergic rhinitis. It is September and he tells you that he has severe symptoms every autumn, which impair his academic performance. He has a strongly positive family history of atopic dermatitis. Which one of the following is the most appropriate management?

a) Intranasal decongestants

b) Intranasal glucocorticoids

c) Intranasal cromolym sodium

d) Intranasal antihistamine

e) RAST testing

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Q67) A 44 year old woman presents to your office with pain and swelling of the small joints in his hands and wrists. The symptoms have been progressing over the past 4 months. She denies any fever or weightloss. She reports stiffness in his both hands that occurs every morning and lasts for 2 hours. On examination, she has symmetrical involvement of both the wrists and two of her left proximal interphalangeal joints. The involved joints are swollen and tender. Laboratory tests shows normal ESR, negative rheumatoid factor, and a negative anti-CCP antibody. X-ray of the wrist and hands reveal mild joint space narrowing with only very small peripheral erosions. The most appropriate next step in management :

A. Prednisone
B. Start NSAID and follow-up in one month.
C. Start NSAID and Methotrexate
D. Start Infliximab
E. Start NSAID and Hydroxychloroquine

Q68) The patient in the above question is started on appropriate therapy. He returns to your clinic in 1 month for regular follow up and his disease is well controlled with near complete remission. The most important next step in follow up of this patient :

A. DEXA scan in 1 year
B. PPD placement
C. Check hepatitis B serology
D. Ophthalmology referral at 3 months
E. Liver function tests

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A 24 year old woman presents to the Emergency Room with complaints of  left sided weakness and slurred speech. The patient has history of Systemic Lupus Erythematosus. Her SLE was diagnosed 2 years ago when she had malar rash and abnormal blood counts. She reports that she has not received any treatment for it since her physician felt this was not needed at that time. She denies any history of kidney involvement. She denies any joint pains or rash. Physical examination revealed left hemiparesis consistent with cerebrovascular accident. A CT of the head reveals right parietal infarct with out any bleed. An EKG is obtained and is normal.  Anti-cardiolipin antibody is +ve which was also positive 1 year ago as per her old records . The patient is started on adequate therapy and follows up in your office 1 month later. Which of the following interventions is most appropriate to prevent recurrent stroke in her case?

a)        Aspirin  for life

b)       Warfarin for 1 year

c)        Warfarin for 6 months

d)       Warfarin for life

e)        Hydroxychloroquine

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A middle aged man presents with a history of foot pain on walking for a few weeks. The patient has a history of long standing diabetes mellitus for more than 15 years. He has been on Metformin and Glyburide combination. His HGBA1C that was obtained 3 months ago revealed inadequate control  at 9%. He reports pain and swelling in his right foot for about one month.  On examination the foot is swollen & tender to touch. Neurlogical examination reveals loss of vibratory sensation and position sensation in bilateral feet. There is also impaired light touch until the level of knees bilaterally. Joint motion at the level of ankle is within normal limits. Complete blood count , creatinine and ESR are with in normal limits. Most likely working diagnosis for his right foot pain  is :

a)      Chronic  Gout

b)       Septic arthritis

c)        Peripheral Neuropathy

d)       Charcot arthropathy

e)       Reflex Sympathetic Dystrophy

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Q58) A 30 year old man comes to your office with complaints of pain in both the wrists and in the hands for the past two months. The pain is particularly worse in the nights and awakens him from sleep. It radiates to the forearms from the wrists.  Occassionally, the pain is associated with abnormal sensations in both hands.  He denies any pain or paresthesiae at this time. Upon further questioning, he also reports some mild stiffness & very mild pain in the neck in the past two weeks. Physical Examination is normal. The most appropriate initial investigation is:

A. Nerve conduction studies

B. Plain X-ray of the wrist

C. Plain X-ray of the cervical spine

D. Rheumatoid factor

E. MRI cervical spine

Q59) The most likely underlying etiology of this patient’s clinical features is :

A. Spinal cord compression

B. Brachial plexopathy

C. Rheumatoid arthritis

D. Hypothyroidism

E. Cervical Spondylosis

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A 4-month-old girl is brought by her concerned mother  because the child has been inconsolably crying for 6 hours. The child is breast fed and has been doing well. There is no vomiting, diarrhea, constipation, or increased gas. The mother has not changed her diet and the infant is on no medications. There has been no fever. On physical examination the child is active and screaming. There is no fever.  The physical examination is normal except that there is redness and swelling affecting the left  third toe with indentation proximal to the redness. It is tender to touch. There was no history of similar problems.  The picture is shown below:

The most likely working diagnosis:

A. Trauma

B. Herpetic whitlow

C. Hairy tourniquet syndrome

D. Acute paronychia

E. Ingrown toe nail

F. Acute Gout

The most appropriate next step in management :

A. Joint aspiration

B. X-ray of the foot

C. Inspect the toe for hair strangulation

D. Incision and drainage

E. Topical acyclovir

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A 75 year old woman was diagnosed with Stage II breast cancer one year ago. The patient received chemotherapy, underwent modified radical mastectomy and radiation. . The cancer was ER+, PR+ and Her2-neu negative. The patient has been receiving Tamoxifen for the past few months. She reports that she has been experiencing vaginal spotting and intermittent mild vaginal bleeding over the past few months. She has also been experiencing intermittent hot flashes after starting Tamoxifen therapy. On physical examination, her vitals are with in normal limits. Pelvic examination does not reveal any gross pathology. Next step in managing this patient:
A. Stop Tamoxifen
B. Start oral progesterone
C. Obtain endometrial biopsy
D. Do a hysterosalpingogram
E. Recommend Hysterectomy with bilateral oophorectomy

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A 50 year old woman with history of coronary artery disease and hypertension presents to your office for regular health check up. The patient is compliant with her medications which include aspirin, atorvastatin and enalapril. Her blood pressure is 110/70. Laboratory investigations including CBC and comprehensive metabolic panel are with in normal limits. A fasting lipid panel that was performed one week ago reveal an LDL cholesterol of 65, HDL of 50 and Triglycerides of 150. You discuss the results with her and you inform her that the goals of therapy are being adequately met. She seemed happy to know about the results but tells you that lately, her mood has been slightly low. There are good days but she tends to have frequent bad days as well. She enjoys surfing as she used to before. She has no weightloss and her appetite is good. She denies any suicidal ideations. She asks you if there is any medication that would benefit her heart and also, help her mood. The next best step in managing this patient is :

A. Start escitalopram
B. Start clozapine
C. Refer to psychiatrist
D. Start Omega 3 Fatty Acids
E. Start St.John’s Wort

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A 45 year old woman presents to your clinic with history of intermittent epistaxis. Of late, this has become more frequent. The patient has a history of atrial fibrillation for which she has been taking aspirin as recommended by her cardiologist. She has no other past medical history. The patient also takes over the counter medications such as Vitamin b-complex which she thinks keeps her from getting tired. She says she also takes about 4 grams of Omega 3 fatty acids to keep “her heart healthy” and Ginkgo biloba to slow the “ageing of her brain”. Her laboratory tests reveal normal complete blood count. Prothrombin time and partial thromboplastin time are with in normal limits. Which of the following is your next step in managing this patient’s recurrent epistaxis?

A. Advise her to discontinue omega 3 fatty acids.
B. Discontinue Aspirin
C. Advise her to stop both Omega 3 fatty acids and Ginkgo biloba
D. Advise her to stop Ginkgo biloba
E. Advise her to stop Vitamin B-complex

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A 55 year old man was recently found to have a 2.0 cm thyroid nodule on palpation during his annual physical. An ultrasound revealed no suspicious features of malignancy. TSH  and free T4 levels were normal. Patient denies any history of neck irradiation, pain, dysphagia or hemoptysis. There is no history of cancer in his family.  The next best step in evaluation of the nodule :

A. Suppressive therapy with levothyroxine

B. FNAC

C. Lobectomy with isthmectomy

D. Observation

E. Radio iodine therapy

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1. A 55-year-old man presented for a regular follow-up to your office 2 weeks ago at which time a palpable nodule of 1.7 cm was noted in the left thyroid lobe. He denies a history of head and neck irradiation, hoarseness, pain, dysphagia, or hemoptysis. His physical exam is otherwise normal, with no lab abnormalities. Most appropriate next step in management?

A. Ultrasound of thyroid

B. TSH level

C. Fine Needle Aspiration ( FNAC)

D. Observation

E. Suppressive therapy with levothyroxine

2. The patient in Q1. subsequently, underwent an FNAC which revealed Papillary Carcinoma of thyroid. Staging work-up revealed no evidence of distant metastases and a neck CT scan does not reveal any lymphadenopathy. The most appropriate management of his thyroid cancer involves:

A. Radio iodine therapy ( RAI)

B. Partial thyroidectomy

C. Total thyroidectomy

D. Life long levothyroxine + Total Thyroidectomy + RAI therapy

E. Total Thyroidectomy + Life long levothyroxine

F. Partial thyroidectomy + life long levothyroxine

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Most of the highyield CCS cases will be demonstrated with individual one on one practice in our monthly interactive CCS Workshops. Slots are limited and you  may register at http://shop.ccsworkshop.com

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A 24 y/o athlete presents to your office with complaints of reddish discoloration of urine. He claims that he has been exercising and running vigorously for the past two days. He is very determined to lose the extra weight that he has put up in the recent months and has been fasting in the nights for the past one week. His past medical history is significant for two abdominal surgeries which included laparotomy and appendicectomy in the past for intermittent severe abdominal pain. The patient does not smoke but does occassional consumes alcohol in binges. He did involve in one such alcohol binge last night. Physical examination is benign except for decreased power and reflexes in bilateral lower extremities. There is no rash. His urine specimen was grossly red in color. Urine dipstick was negative for protein, blood, leucoesterase and nitrite. Urine microscopy did not reveal any RBCs, WBCs or Casts. Serum creatinine and complete blood count are with in normal limits. A Creatinine Phosphokinase ( CPK) level has been ordered but is not yet available. The most likely cause of this patient’s grossly red urine is :

A) Rhabdomyolysis
B) Paroxysmal Nocturnal Hemoglobinuria
C) Acute Intermittent Porphyria
D) Await CPK level for correct diagnosis
E) Glomerulonephritis

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A 55 y/o woman with history of well controlled DM Type II presents for her regular follow-up visit. She has no new complaints. She has been well controlled on Metformin alone with a hemoglobin A1c of 6.5. The patient is afebrile with a B.P 96/72, HR 88, RR 16. Physical examination is benign except for decreased sensation in her bilateral lower extremities consistent with diabetic neuropathy and bilater lower extremity edema. Her last urinary microalbumin about one year ago was negative. A repeat dipstick test now is positive for protein and blood but negative for leucoesterase and nitrite. Subsequent urine microscopy reveals 4 dysmorphic RBCs/HPF and red cell casts. Labs reveal elevated serum creatinine at 1.4 as opposed to her baseline creatinine of 0.8 6 months ago. The next important step in approaching this patient’s Renal Insufficiency is:

A) Obtain CPK level
B) 24 hour urine for microalbumin
C) Start ACE inhibitor
D) Repeat urinalysis in 3 months
E) Referral to Nephrologist and Renal biopsy
F) Start emperic antibiotic therapy for UTI

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A 65 y/o man with history of chronic smoking and COPD presents for follow up visit in your office after being discharged from the hospital about three weeks ago. The patient was admitted and treated in the hospital for community acquired pneumonia and COPD exacerbation. During his hospital stay he was noted to have microscopic hematuria on routine urinalysis. The patient denies any symptoms now. His COPD is well controlled on tiotropium inhaler. His allergies include Isoniazid and Penicillin. Past medical history is significant for a positive PPD test ( latent tuberculosis) for which he has been on treatment with Rifampin for past three months. Physical examination is benign. Labarotory investigations reveal a normal CBC and serum creatinine. Dipstick is positive for blood. A repeat urinalysis during this visit reveals persistent microscopic hematuria with 3 RBCs/HPF. A urine cytology has been sent. The next appropriate step in evaluating this patient’s hematuria is:

A) Repeat urinalysis in 3 months
B) Urine cultures
C) Intravenos pyelogram
D) CT urogram and Cystoscopy
E) Stop Rifampin

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•A 46-year-old fisherman and Vietnam veteran presented with a recurrent rash on his arms and legs and a painful, swollen area on his left leg of several days’ duration. The rash had been a problem for about two years and was treated with several courses of antibiotics for cellulitis. The patient reported that for the past two years his skin had been prone to blister and tear with minor trauma and that at times his urine appeared to be dark reddish in color. On examination, he had a slight fever and an area of cellulitis on his left leg. His face was erythematous. On his hands, arms, and legs were vesicles and small bullae, some crusted lesions, and hypopigmented and hyperpigmented macules. What is the most important next step in diagnosis?

A. ANA

B. Rheumatoid factor

C. Skin biopsy

D. Hepatitis C serology

E. Hepatitis B serology

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