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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