Question of the Week # 216

216 )  A 75 year old woman with past medical history of hypertension and diabetes is evaluated in your office for 20 lb weight loss. She reports decreased appetite and depressed mood for the past 6 months. Her history is significant for chronic smoking 1 pack per day for last 50 years. She lives alone and does all her daily activities by herself.  She has no known cardiac problems. She denies shortness of breath or cough. On examination, scleral icterus is noted. Lab studies show total bilirubin elevated at 10gm% with predominantly direct component. A subsequent CT of the abdomen shows a heterogeneous mass of about 4cm in diameter. A triphasic CT with pancreatic protocol shows invasion of the portal vein and encasement of superior mesenteric artery by the mass. There are no distant metastases. A chest X-Ray is normal. CA 19-9 level 1400U/ml.  Which of the following is the most appropriate next  step ?

A) Hospice Evaluation

B) Surgical resection

C) Fine needle aspiration biopsy

D) Chemotherapy

E) Radiation therapy

Question of the Week # 215

215 )  A 65 year old woman with past medical history of chronic smoking is evaluated in the office for painless jaundice. She has noticed yellow coloring of her skin about 3 weeks ago and it has been progressively increasing. She denies abdominal pain, fever or altered bowel movements. On examination, she has profoundly icteric sclerae. Lab studies show total bilirubin elevated at 5gm% with predominantly direct component. A subsequent CT of the abdomen shows a heterogeneous mass of about 4cm in diameter. A triphasic CT with pancreatic protocol shows no involvement of portal vein or superior mesenteric artery. No lymphadenopathy is evident. CA 19-9 level 400u/ML. Which of the following is the most appropriate next step?

A) Fine needle aspiration biopsy

B) Surgical resection

C) Radiation therapy

D) Chemotherapy

E) Hospice evaluation

 

Question of the Week # 214

214 )  A 58 year old woman presents to the office because  her friend noticed that she looked yellow and asked her to seek medical attention. Lately, her urine has turned dark yellow but she thought it was because of reduced fluid intake. She has lost 10lb weight in the last 3 months. She denies any abdominal pain, nausea or vomiting. She denies any fever. She smoked about 2 packs per day for the past 30 years. She quit smoking 1 month ago. Physical examination reveals profound scleral icterus. Laboratory investigations reveal a Hemoglobin 10gm%, MCV 88, Total Bilirubin 17gm% , Direct bilirubin 13gm%, AST 120U/L, ALT 110U/L and ALP 600U/L. A CT scan of the abdomen does not show any mass in the pancreas. Ultrasound of the abdomen reveals common bile duct diameter of 12mm. Which of the following is the most appropriate next step in management?

A) CA 19-9 level

B) Endoscopic Retrograde Cholangiopancreatography

C) CT guided biopsy of Pancreatic Head

D) Percutaneous Biliary Stent

E) Haptoglobin level

Question of the Week # 213

213 )  A 38 year old woman with manic depressive illness is evaluated in the emergency department for slurred speech and severe fatigue of one day duration. She also has nausea and vomiting since morning. She denies any recent fever. She has been on Lithium Carbonate for the past 3 months and her level was therapeutic 1 month ago. She is a very compliant patient and denies overdosing herself with lithium. Her past medical history is significant for hypertension for which she was started on combination of  Hydrochlorthiazide and Enalapril one week ago. She does report “salt craving” for past few days and has been taking excessive amount dietary salt though she is aware that it is not good for blood pressure. Physical examination reveals coarse tremors and fasciculations. Laboratory investigations reveal slightly increased serum creatinine at 1.2mg%. Her  baseline creatinine is 1.0mg%.  Today, the Lithium level is 3.0 mmol/L. Which of the following is responsible for acute lithium toxicity in this patient?

A) Acute renal failure

B) Drug interaction

C) Increased absorption

D) Excess Salt intake

E) Intentional overdose

Question of the Week # 212

212 )  A 40 year old man is brought by his sister to the Emergency room for a change in his mental status. The patient appears slightly confused but as per his sister, he reported weakness and blurred vision yesterday. She also noticed that his gait has been abnormal and un-coordinated for the past one day. She reports that he was diagnosed with a psychiatric disorder few months ago and was started on a medication 4 months ago. He seems to be compliant with his medications but  has not followed up with his psychiatrist for the past 3 months. His Past Medical History is unremarkable except for the mental illness. Physical examination reveals a slightly confused male. Neck examination shows mild but diffuse enlargement of thyroid with out any nodules. Nystagmus and exaggerated reflexes are noted.  The drug that is most likely responsible for this patient’s presentation?

A) Fluoxetine

B) Venlafaxine

C) Lithium

D) Amitryptyline

E) Escitalopram

Question of the Week # 211

211 )  A 42 year old woman in otherwise good health presents to the Emergency room for severe headache. She has history of migraines in the past for which she uses sumatriptan at the onset of Headache and usually, she has relief. Though this is not the worst headache of her life, she says that it is very severe and is upset that the headache did not resolve even after injecting herself  with a triptan. She denies any fever.  Her physical and neurological examination is benign. There is no neck stiffness.  A computed tomography (CT) scan of the head is obtained, which did not reveal any abnormalities. A subsequent  lumbar puncture reveals bloody fluid. The specimen was transported to the lab for further evaluation. It was processed in the laboratory 12 hours later and the report indicates “Xanthochromia” Which of the following most likely explains  the CSF findings?

A) Status migranosus

B) Meningitis

C) Sub-arachnoid Hemorrhage

D) Sentinel bleed

E) Delay in CSF processing

Question of the Week # 210

210 )  A 42 year old woman in otherwise good health presents to the Emergency room for sudden onset of severe headache 2 hour ago. She has no previous history of headache or migraine . Upon arrival in the ER, she described her headache as “10 out of 10” in severity. She thinks this is the worst headache of her life. She denies any fever or visual problems or drug abuse.  Her physical and neurological examination is benign. There is no neck stiffness at this time.  A computed tomography (CT) scan of the head is obtained, which did not reveal any abnormalities. A subsequent  lumbar puncture reveals bloody fluid which shows decreasing red color in subsequent collection tubes. The last collection tube shows red fluid but much decreased color as opposed to the first collection tube. Which of the following is the most appropriate management decision?

A) Repeat Lumbar Puncture at a different site

B) Immediate CSF centrifugation

C) Neurosurgery evaluation

D) Re-assurance and analgesic therapy

E) Subcutaneous Sumatriptan

Question of the Week # 209

209)  A 35 Year old woman presents for evaluation of recurrent headaches for the past few months.  Lately, she has been waking up with a headache almost daily though it tends to improve in the latter half of the day. She is frustrated as she can not even get some sleep during the attack since lying down makes her feel worse . She has associated nausea. She has transient attacks of light flashes  that resolve spontaneously. Her menstrual history is unremarkable. On physical examination, she has no neurological deficits. Funduscopic examination shown below:

Which of the following information, if elicited in the patient history, would increase the clinical suspicion of the diagnosis?

A)     Constipation

B)      Family History

C)      Recent weight gain

D)      Galactorrhea

E)      Urinary incontinence

Question of the Week # 208

208)  A 31 Year old woman with suspected diagnosis of Idiopathic intracranial hypertension underwent a lumbar puncture. An MRI of the brain that was obtained prior to lumbar puncture did not reveal any structural abnormalities or mass effect. Laboratory investigations including coagulation parameters were normal. About 12 hours after the procedure, she complains of moderate to severe headache. Headache is mainly in the occipital region which increases while sitting up and improves on lying flat. She has two episodes of vomiting in the last one hour. She also complains of dizziness and ringing sensation in her ears.  Physical examination does not reveal any papilledema or focal neurological deficits. Most appropriate next step in managing this patient?

A)     Blood cultures

B)      MRI of the Lumbar Spine

C)      Non-Contrast CT scan of brain

D)     Observation

E)      Acetazolamide

Question of the Week # 207

207)  A 30 year old  pregnant woman with 32 week gestation presents with severe itching that is present through out the day and  interferes with her sleep at night. The itching is more on palms and soles. She had a similar problem during her previous pregnancy. She denies any history of eczema or liver disease in the past. Physical examination reveals excoriations on the skin. There are no papules, wheals or plaques. There is no scleral icterus. Laboratory investigations reveal an elevated Asparate aminotransferase ( AST) 140u/l , Alanine Aminotransferase (ALT) 150u/l, alkaline phosphatase at 280U/L ( Normal 40 to 120U/L) and Total bilirubin 2.2mg%. Complete blood count is with in normal limits. Hepatitis profile is negative. Which of the following is the most common complication associated with this entity:

A) Hepatic Failure

B) Fetal Prematurity

C) Renal Failure

D) Disseminated Intravascular Coagulation

E) Severe Post-Partum Hemorrhage

Question of the Week # 206

206)  A 30 year old  pregnant woman with 32 week gestation presents with severe itching that is present through out the day and  interferes with her sleep at night. The itching is more on palms and soles. She had a similar problem during her previous pregnancy. She denies any history of eczema or liver disease in the past. Physical examination reveals excoriations on the skin. There are no papules, wheals or plaques. There is no scleral icterus. Laboratory investigations reveal an elevated Asparate aminotransferase ( AST) 140u/l , Alanine Aminotransferase (ALT) 150u/l, alkaline phosphatase at 280U/L ( Normal 40 to 120U/L) and Total bilirubin 2.2mg%. Complete blood count is with in normal limits. Hepatitis profile is negative. The most appropriate next step in managing this patient?

A) Serum Bile Acid level

B) Liver Biopsy

C) Ursodeoxycholic acid

D) Immediate delivery

E) Long-chain 3-hydroxyacyl CoA dehydrogenase (LCHAD) mutation testing

Question of the Week # 205

205) A 27 year old woman, primigravida at 35 week gestation is evaluated in your office for extreme itching associated with rash. The rash and itching first started on her abdomen but now spread to her buttocks and legs as well. She denies similar complaints in any of her family members. On physical examination, an eruption consisting of small erythematous wheals is noted mostly in the abdominal striae with sparing of the peri-umbilical skin. Some rash is also noted on her lower extremities.  There is no involvement of palms and soles. A picture of her abdomen is shown below:

Most likely diagnosis:

A)           Scabies

B)            Pemphigoid Gestationis

C)            Intahepatic Cholestasis of Pregnancy (ICP)

D)            Pruritic Urticarial Papules of Pregnancy (PUPP)

E)            Pruritic folliculitis of Pregnancy

Question of the Week # 204

204) A 16 year old boy presents for pre-participation examination prior to athletic training in his college campus. He denies any history of dizziness or palpitations or shortness of breath upon exertion. He denies any syncopal episodes.  His father died of cardiac arrest during a marathon at the age of 32 years. Physical examination reveals a systolic murmur that increases with valsalva maneuver.  Electrocardiogram reveals changes consistent with left ventricular hypertrophy. An echocardiogram reveals asymmetric septal hypertrophy and Systolic Anterior Motion (SAM) of the Anterior Mitral Leaflet. Which of the following is an indication for Implantable Cardioverter-Defibrillator in this patient?

A) Left Ventricular Thickness of 22mm

B) Increase in blood pressure upon exercise

C) His age

D) Systolic Anterior Motion of Mitral leaflet

E) Decrease in blood pressure during exercise

 

Question of the Week # 203

203) A 16 year old boy presents for pre-participation examination prior to athletic training in his college campus. He denies any history of dizziness or palpitations or shortness of breath upon exertion. He denies any syncopal episodes. He denies any family history of Sudden Cardiac Death.  Physical examination reveals a systolic murmur that increases with valsalva maneuver.  Electrocardiogram reveals changes consistent with lEft ventricular hypertrophy. An echocardiogram reveals asymmetric septal hypertrophy and Systolic Anterior Motion (SAM) of the Anterior Mitral Leaflet. The findings are discussed with patient and he intends to participate in athletics because he does not have any symptoms. Which of the following is the most appropriate next step?

A) Clear the patient for athletic training

B) Start Beta Blocker Therapy

C) Exercise Stress Test

D) Cardiac catheterization

E) Implantable Cardioverter-Defibrillator

Question of the Week # 202

202) A 36 year old male athlete is rushed to the Emergency Room after he collapsed during a soccer game.  In the Emergency Room, he is found to be in cardiac arrest  and cardio-pulmonary resuscitation is begun as per ACLS protocol. There is no history of trauma during the game. As per his brother, the patient does not have any history of hypertension or diabetes or known cardiac disease.There is no family history of sudden cardiac death.  Which of the following is the most common cause of sudden cardiac death in athletes with a clinical profile similar to this patient?

A) Aortic dissection

B) Idiopathic

C) Coronary artery disease

D) Hypertrophic Obstructive Cardiomyopathy

E) Valvular Heart Disease

Question of the Week # 201

201) A 16 year old male athlete is rushed to the Emergency Room after he collapsed during a basket ball match.  In the Emergency Room, he is found to be in cardiac arrest  and cardio-pulmonary resuscitation is begun as per ACLS protocol. A electrocardiogram reveals ventricular fibrillation which is successfully defibrillated with 200 joules. The patient is currently awake but confused. His mother is present at the bed-side and denies any family history of sudden cardiac death. Which of the following is the most common cause of sudden death in young athletes?

A) Aortic dissection

B) Long QT syndrome

C) Blunt trauma to the chest

D) Hypertrophic Obstructive Cardiomyopathy

E) Mitral valve prolapse

Question of the Week # 200

200)  A 26 year old pregnant woman is evaluated in the emergency Room for severe weakness and dehydration from persistent vomiting. She is a primigravida at 9 weeks gestation. She reports that her nausea and vomiting started at 5 weeks of pregnancy and have progressively become worse. She denies any abdominal pain or vaginal bleeding. She denies any headache. Her bowel movements are normal. Her past medical history is unremarkable. Her pre-pregnancy weight was 60lbs but now she weighs about 55lbs. Physical examination reveals dry oral mucosa. Laboratory tests reveal Serum sodium 140 meq/l, potassium 3.2meq/L, Chloride 102meq/l, Bicarbonate 34meq/L. hematocrit of 52 (normal = 36 to 46%).  Urine reveals ketonuria. The most appropriate next step in investigating this patient:

A)     Hemoglobin A1C level

B)      Serum Uric acid

C)      Urine for total protein

D)     Ultrasound Pelvis

E)      Plain X-Ray abdomen

Question of the Week # 199

199)  A 32 year old pregnant woman with 32 week gestation is evaluated in your office during a regular follow up visit. She denies any abdominal pain or vomiting or vaginal bleeding or headache.  She denies any headache or pruritis. She feels healthy and is hoping for a normal delivery. Physical examination is consistent with 32 week gestation. Extremities do not reveal any edema. Laboratory investigations reveal a mild anemia at 12.0gm%. Rest of the lab results are normal except for elevated alkaline phosphatase at 280U/L ( Normal 40 to 120U/L) . The patient is very concerned. Most appropriate next step in managing this patient?

A) Ultrasound of the liver and gall bladder

B) Immediate Delivery

C) Ursodeoxycholic acid

D) Reassurance

E) Obtain Peripheral Smear

Question of the Week # 198

198)  A 26 year old pregnant woman is evaluated in the emergency Room for severe weakness and dehydration from persistent vomiting. She is a primigravida at 9 weeks gestation. She reports that her nausea and vomiting started at 5 weeks of pregnancy and have progressively become worse. She denies any abdominal pain or vaginal bleeding. She denies any headache. Her bowel movements are normal. Her past medical history is unremarkable. Her pre-pregnancy weight was 60lbs but now she weighs about 55lbs. Physical examination reveals dry oral mucosa. Laboratory tests reveal Serum sodium 140 meq/l, potassium 3.2meq/L, Chloride 102meq/l, Bicarbonate 34meq/L. hematocrit of 52 (normal = 36 to 46%); Total bilirubin of 2mg/dl; ALT of 160U/L and AST of 140U/L. Urine is positive for ketones. Ultrasound reveals normal fetus appropriate for 9 week gestation. Which of the following explains her jaundice and elevated liver function tests:

A) Acute pancreatitis

B) Acute Fatty Liver of pregnancy

C) Cholestatis of Pregnancy

D) Hyperemesis Gravidarum

E) HELLP Syndrome

Question of the Week # 197

197)  A 26 year old pregnant woman is evaluated in the emergency Room for severe weakness and dehydration from persistent vomiting. She is a primigravida at 9 weeks gestation. She reports that her nausea and vomiting started at 5 weeks of pregnancy and have progressively become worse. She denies any abdominal pain or vaginal bleeding. She denies any headache. Her bowel movements are normal. Her past medical history is unremarkable. Her pre-pregnancy weight was 60lbs but now she weighs about 55lbs. Physical examination reveals dry oral mucosa. Laboratory tests reveal hematocrit of  52 ( normal = 36 to 46%) ; Total bilirubin of 2mg/dl; ALT of 160U/L and AST of 140U/L . Urine is positive for ketones. Ultrasound reveals normal fetus appropriate for 9 week gestation. The most likely diagnosis:

A) Diabetic Ketoacidosis

B) Acute Pancreatitis

C) Hyperemesis Gravidarum

D) Cholestasis of Pregnancy

E) Morning Sickness

Question of the Week # 196

196)  A 72 year old obese woman is evaluated during a follow up visit for Diabetes Mellitus Type II. She had been started on Insulin therapy 5 years ago after several months of oral hypoglycemic drug therapy that failed to improve her glycemic control. Her insulin regimen includes 40 units of Insulin Glargine at bed time and 10 units of Regular insulin 30 minutes before each meal.  She has been maintained on this regimen for the past 2 years. She had two recent hypoglycemic episodes for which she was treated in the Emergency Room. She now reports that she had been taking only 5 units of Regular insulin before meals but her post-prandial glucometer reading has usually, been on the lower side of the normal range. At this rate of decreased insulin use, she believes she will be cured of diabetes by the end of the year. She denies any recent weight changes. She denies any depression or drug overdose. Physical examination is consistent with diabetic neuropathy in bilateral lower extremities.  The most appropriate next step in managing this patient:

A)     Urine Sulfonyl Urea screen

B)      C-peptide level

C)      Renal Function Tests

D)     Stop Insulin therapy

E)      Switch to Regular insulin to Lispro

Question of the Week # 195

195)  A 3 year old male child is brought to emergency room by his concerned mother because of history of fever for the past 5 days. The patient also has developed a red rash on his extremities.  On physical examination, temperature is 102F. The tongue is very inflamed and has red, enlarged papillae. Posterior pharynx is erythematous without any exudate.  There is a palpable cervical lymph node of 1.8cm on the right side of the neck. There is conjunctival erythema bilaterally. Erythema is noted on palms and soles. and skin appears to be peeling off around the nails. Laboratory investigations reveal a WBC count of 15,000/µl, platelet count of 550000 per μl and an ESR of 50mm/hr. Which of the following therapeutic interventions are most helpful in preventing the complications associated with this condition?

a)      Penicillin

b)      Corticosteroids

c)       Aspirin

d)      Intravenous Immunoglobulin

e)      Clindamycin

Question of the Week # 194

194)  A 3 year old male child is brought to emergency room by his concerned mother because of history of fever for the past 5 days. The patient also has developed a red rash on his extremities.  On physical examination, temperature is 102F. The tongue is very inflamed and has red, enlarged papillae. Posterior pharynx is erythematous without any exudate.  There is a palpable cervical lymph node of 1.8cm on the right side of the neck. There is conjunctival erythema bilaterally. Erythema is noted on palms and soles. and skin appears to be peeling off around the nails. Laboratory investigations reveal a WBC count of 15,000/µl, platelet count of 550000 per μl and an ESR of 50mm/hr. Which of the following is the complication that is most likely to develop if this condition is not treated early in the course?

A) Toxic Shock Syndrome
B) Acute Glomerulonephritis
C) Coronary artery aneurysm
D) Carditis
E) Aortic regurgitation

Question of the Week # 193

193)  A 22 year old woman is evaluated in the office for recurrent attacks of colicky abdominal pain that resolve spontaneously. During the episodes, the pain lasts about 8 to 10 hours and resolves spontaneously. Several clinical examinations, laboratory investigations and imaging studies in the past have failed to reveal any clear etiology. She also reports recurrent swelling of her hands and feet, the last episode being 2 weeks ago. Physical examination is benign. A complete blood count and comprehensive metabolic panel are with in normal limits. Which of the following is most helpful in confirming the suspected diagnosis?

a)      Urinary Porphobilinogen

b)      Radio Allergosorbent Test ( RAST)

c)       Anti-nuclear antibodies

d)      C1-Inhibitor

e)      24 hour delta-aminolevulinic acid

Question of the Week # 192

192) A 26-year-old man is evaluated for a history of recurrent headaches and palpitations for the past one month. At this time, he has no headache or palpitations. He denies any chest pain, dizziness or shortness of breath. His past history is unremarkable except for fleshy nodules over his trunk that have been present since adolescence and have been increasing in number. On physical examination, heart rate is 102/min; blood pressure is 168/100 (Lying) and 138/90 ( Standing). Skin examination reveals freckling in the inguinal region and several fleshy tumors on his back as shown in the picture:

An Electrocardiogram reveals Sinus Tachycardia. The most appropriate next step in management of this patient?

a. Biopsy of the tumors
b. Plasma Metanephrines
c. CT Scan of the abdomen
d. Intravenous fluids
e. 24-Hour holter monitoring

Question of the Week # 191

191)  A 68-year-old man with history of chronic obstructive pulmonary disease presents with increasing shortness of breath and increasing sputum production over the past 5 days.  The patient also has history of atrial fibrillation for which he is on beta blocker and aspirin. Physical examination reveals a fever of 102°F, scattered wheezes and reduced breath sounds at the right lung base.  He is awake and oriented to place, person and time. EKG shows atrial fibrillation that is rate controlled. Chest X-ray reveals a new right sided pleural effusion. A diagnostic thoracentesis is planned. Which of the following is a contraindication for thoracentesis in this patient?

a. Fever > 101F

b. A new right sided effusion

c. Severe left lung disease

d. Atrial Fibrillation

e. Age

Question of the Week # 190

190) A 45 year old man presents to your office for follow up of his dyslipidemia that was diagnosed 6 month. His lipid panel at that time was consistent with high Total cholesterol , Low HDL and high triglyceride levels. He was instructed on dietary modification. He presents for a follow up visit today and reports that he had been strictly compliant with reduced fat diet. His social history is significant for smoking 1 pack per day for the past 25 years . He reports drinking about 1 pint vodka per day for past 10 years. He read on an online magazine  that drinking alcohol would boost his “Good” cholesterol. At this time, a repeat fasting lipid profile reveals:

Total Cholesterol : 250mg%

HDL cholesterol : 35mg%

Triglycerides: 500mg%

The most important step at this time to address his lipid abnormalities:

A) Niacin

B) Gemfibrozil

C) Fenofibrate

D) Alcohol cessation

E) Smoking cessation

Question of the Week # 189

189) A 38 year old woman presents for follow up visit of right leg weakness. Her history is significant for episodes of diplopia and right sided weakness that recurred thrice in the last 3 months. These presentations were also associated with concomitant urinary incontinence and ataxia. Her most recent hospitalization for such an episode was three weeks ago. She was discharged after her symptoms improved upon using intravenous steroids. An MRI brain taken during the initial episode revealed multiple white matter lesions in the peri-ventricular area. Today, she feels well except for minimal weakness in her right leg. Most appropriate drug that should be administered to this patient to reduce the frequency and severity of these recurrences?

A) Methyl dopa

B) Interferon Beta

C) Methyl Prednisolone

D) Interferon Alpha

E) Intravenos Immunoglobulin ( IVIG)

Question of the Week # 188

188) A 24 year old woman is evaluated for a history of chronic anemia. Her history is significant for anemia for the past 7 years. She has been treated with oral iron supplements in the past with out any response. She denies any  gastrointestinal bleeding. Her menstrual cycle is 3 days in duration and her menses have been scant for the past 5 years. There is no family history of anemia or bleeding disorder or cancer. Physical examination is unremarkable. Laboratory investigations reveal :

Hemoglobin : 10.6gm%

MCV: 68fl ( normal 80 to 100)

WBC : 8.8K/μl

Platelets: 230k/μl

Red Cell Distribution Width : 12.8% ( 10.2 to 14.5%)

Reticulocyte count : 6% ( normal 0.5% to 1.5%)

Which of the following are most helpful in diagnosing this patient’s anemia?

A) Serum ferritin

B) Bone marrow biopsy

C) Direct Coombs’ test

D) Hemoglobin Electrophoresis

E)  Anti-endomysial antibodies

Question of the Week # 187

187) A 34 year old obese man presents with complaints of cough of 3 months’ duration. His cough is non-productive and occurs daily. It is worse in the night. He also reports a need to clear his throat constantly. He denies any nasal congestion. He denies smoking or alcohol. He also reports a chronic history of heart burn for which he uses over the counter antacids intermittently. He works as a nurse in a health care facility. He denies any fever or night sweats or weightloss. On examination, throat is normal in appearance with out any exudate or eythema. Lungs are clear to auscultation. A Chest X-ray is normal. The most appropriate initial diagnostic step in evaluating his cough is :

A) Tuberculin skin test

B) Methacholine challenge

C) Albuterol trial

D) Omeprazole trial

E) 24 Hour esophageal  pH monitoring

Question of the Week # 186

186) A 65 year old woman is evaluated in your office for lower extremity swelling and weakness. She has difficulty speaking for the past 3 months. Her past medical history is significant for renal insufficiency and hypertension that was diagnosed 6 months ago. A TSH level that was obtained 3 weeks ago was normal. She smokes cigarettes, about 1 pack per day for the past 35 years. Her medications include Lisinopril and Hydrochlorthiazide. On physical examination, her heart rate and rhythm are regular. Lungs are clear to auscultation. She has gross edema of the lower extremities. There is no extremity weakness. Head and neck examination reveals findings as shown below:

Most appropriate next step in management of this patient:

A) Stop Lisinopril

B) Start Levothyroxine

C) Intubation

D) Abdominal fat pad biopsy

E) Serum immunoelectrophoresis

Question of the Week # 185

185) A 65 year old woman is evaluated in your office for lower extremity swelling and weakness. She reports difficulty speaking for the past three months. Her past medical history is significant for renal insufficiency and hypertension that was diagnosed 6 months ago. A TSH level that was obtained 3 weeks ago was normal. She smokes cigarettes, about 1 pack per day for the past 35 years. Her medications include Lisinopril and Hydrochlorthiazide. On physical examination, her heart rate and rhythm are regular. Lungs are clear to auscultation. She has gross edema of the lower extremities. There is no extremity weakness. Head and neck examination reveals findings as shown below:

Which of the following is most likely to be abnormal in this patient?

A) Free thyroxine

B) Serum immunoelectrophoresis

C) Rheumatoid factor

D) ACE Level

E) Bradykinin level

Question of the Week # 184

Q184)  A 10 year old boy is evaluated in the emergency room after he tripped over and fell during a basketball game. There is no history of loss of consciousness. He denies any injury except  some pain in the occipital area of the skull.  He also reports chronic fatigue. A routine skull x-ray is obtained for evaluation and is shown below:

Which of the following is most likely to be associated with these incidental skull x-ray findings ?

A) Monoclonal gammopathy

B) Pituitary tumor

C) Hemolysis

D) Paget disease

E) Glioma

Question of the Week # 183

183) A 65 year old woman  presents  with a white plaque on her vulva. It is associated with occasional itching. She has no other hypo-pigmented lesions on her body.  She denies any post-coital bleeding. Physical examination reveals a white colored plaque on the vulva. The lesion is atrophic, thin with a crinkled surface and is well-demarcated. There is atrophy of the labia minora. Most appropriate next step in managing this patient?

A) Topical Corticosteroids

B) Fluconazole

C) Vulvar Biopsy

D) HPV testing

E) Topical Testosterone

Question of the Week # 182

Q182) A 65 year old woman  presents  with a white plaque on her vulva. She has no other hypo-pigmented lesions on her body.  She reports history of repeated itching in the area for past several years. She has seen by her gynecologist in the past. Repeated evaluation did not reveal any infection or candidiasis. She says the lesion has not changed in appearance but the itching bothers her. She denies any vaginal bleeding.  Physical examination reveals a raised white colored plaque on the vulva. There are excoriations adjacent to and overlying the lesion. Most likely diagnosis:

A) Lichen Sclerosus

B) Lichen Simplex Chronicus

C) Lichen planus

D) Vulvar Cancer

E) Vitiligo

Question of the Week # 181

181) A 35 year-old man with history of ulcerative colitis is seen in your office for nodular, tender skin lesions on both of his anterior legs. He was diagnosed with ulcerative colitis about 6 months ago when he first presented with severe bloody diarrhea. He was initially managed with steroids and is now, being maintained on Mesalamine. A colonoscopy at the time of diagnosis revealed pancolitis. He has no diarrhea now. There is no evidence of weight-loss.  Physical examination reveals tender erythematous lesions on the  anterior aspect of his bilateral lower extremities. Laboratory investigations reveal leucocytosis and elevated C-reactive protein. Which of the following is a poor prognostic factor in Inflammatory Bowel Disease?

A) Proctitis

B) Erythema nodosum

C) Albumin of 4.1 gm/dl

D) Lymphocytosis

E) Elevated ANCA (anti-neutrophilic cytoplasmic antibodies) level.

Question of the Week # 180

Q180) A 35 year old woman presents with a 3-week history of nodular lesions on her lower legs. She states that he had similar lesions that appeared few years ago and spontaneously resolved . She denies any recent infection except for an upper respiratory infection for which he was treated with antibiotics 2 weeks ago. She is currently not on any medications. He denies any weightloss or diarrhea or constipation. She has no cough or night sweats. Physical examination revealed erythematous nodular swellings on the anterior lower legs. The lesions are tender to palpation.

 

 

 

The most common etiology of these lesions world-wide:

A) Tuberculosis

B) Inflammatory bowel disease

C) Sarcoidosis

D) Diabetes Mellitus

E) Streptococcal infection

F) Herpes Simplex Virus

Question of the Week # 179

Q179) A 48  Year old woman is evaluated in your office for a skin eruption that appeared three days ago. Her past medical history is significant for Rheumatoid arthritis for which she uses Methotrexate. She recently had increasing joint pain and she was placed on ibuprofen which takes about three times daily. Her joint pain is well controlled now.  She is now concerned about the skin eruption that is predominantly distributed on her arms, hands and feet. The eruption is painless.  On examination, there is no joint swelling or tenderness, range of motion in the joints is normal. Skin examination reveals the lesions as shown in the image below.

The most appropriate management option for this patient:

A)     Observation

B)      Stop Ibuprofen

C)      Start Acyclovir

D)      Intra-lesional corticosteroids

E)      Anti-citrullinated pep-tide levels

Question of the Week # 178

Q177) A 55-year-old white woman is seen in your office for a 6-month  history of slowly enlarging lesions on both lower extremities. She is otherwise healthy. The lesions are painless. She denies any trauma to these areas. Her past medical history is significant for diabetes mellitus diagnosed 2 years ago and rheumatoid arthritis. Her medications include Metformin, Enalapril and Methotrexate. On skin examination, she has  2 cm yellow, smooth, firm centrally depressed plaques involving the thighs and knees. Image is shown below

 

 

 

 

 

 

 

 

The most likely underlying etiology :

A) Drug-induced

B) Rheumatoid arthritis

C) Diabetes Mellitus

D) Malignancy

E) Sarcoidosis

Question of the Week # 177

Q177) A 52 Year old obese man is evaluated in your office during a routine annual visit.  He denies any fatigue or recent weight changes. He has normal appetite and physically active. He had a colonoscopy 1 year ago that was normal. On physical examination, he is obese with a BMI of  34. Skin examination reveals the findings shown in the image below :

 

 

 

 

 

 

 

 

 

Which of the following is most likely to be seen in this patient?

A) Diabetes Mellitus, Type I

B) Gastric cancer

C) Increased Insulin levels

D) Hyperthyroidism

E) Addison’s disease

Question of the Week # 176

Q176) A 48 Year old woman is evaluated in your office for a skin eruption that appeared few days ago. She has a history of Non-Hodgkin’s lymphoma that was treated 2 years ago and is in remission. A PET ( positron emission tomography) scan that was performed 3months ago did not reveal any evidence of recurrent disease. She also reports recurrent episodes of genital herpetic lesions which  resolve spontaneously. Her most recent genital herpetic eruption was 4 weeks ago and it was self-limited. At this time, she is concerned about a skin eruption that is predominantly distributed on her arms, hands and feet.  On examination, there is no peripheral lymphadenopathy. Genital examination is normal with out any vesicles or papules. Skin examination reveals the lesions as shown in the image below.

 

 

 

 

 

 

 

 

 

The most appropriate management option for this patient:

A)     Observation

B)      Repeat PET/CT scan

C)      Start Acyclovir

D)     Biopsy of the lesion

E)      Start antihistamine

Question of the Week # 175

Q175) A 28 Year old man is evaluated in your office during a pre-employment health check-up . His history is notable for severe hypertension for which he was started on beta blocker a year ago. He says he stopped the medication 6 months ago because it interfered with his sexual activity. On examination his blood pressure is 172/94. Cardiovascular examination revealed a systolic murmur that radiates to the back and associated with ejection click. Brachio-femoral delay in pulses is noted. The patient is agreeable to restart antihypertensive therapy. The most appropriate management option for this patient:

A)     Cardiac catheterization with Stenting

B)      Percutaneous coronary intervention

C)      Surgery

D)     Medical management of Hypertension

E)      Aortic valvulotomy

Question of the Week # 174

174) A 52 year old African-american woman is seen in the office during a regular follow-up visit. Her history is significant for diabetes mellitus and hypertension. She has been suffering from cough over the past two weeks.  She feels that there is a tickle at the back of the throat which leads to paroxysms of coughing. Her medications include Aspirin, Glipizide, atorvastatin, enalapril and Hydrochlorthiazide.  Enalapril was started 3 weeks ago at a low dose of 5mg/day. On examination, blood pressure is 132/90 mm Hg seated and standing.  Her physical examination is normal.  Laboratory values reveal a serum creatinine concentration of 1.8mg/dl. Her baseline creatinine  1 month ago was 1.5mg%. Which of the following is not an indication to stop ACE inhibitor?

A)     Swelling of the lips and tongue

B)      20% increase in serum creatinine

C)      Intractable severe cough

D)     Serum potassium of 6.5mmol/L

E)      Hypovolemia with shock

Question of the Week # 173

173) A 52 year old African-american woman is seen in the office during a regular follow-up visit. Her history is significant for diabetes mellitus and hypertension. Her medications include Aspirin, Glipizide, atorvastatin and losartan. She states that she stopped taking diuretic because it increased her frequency of urination that it interfered with her active lifestyle.

On examination, blood pressure is 152/94 mm Hg seated and standing.  Her physical examination is normal.  Laboratory values reveal microalbuminuria  of 250mg/24hours and a serum creatinine concentration of 1.3mg/dl. Based on the findings above, her blood pressure medications should be optimized to achieve which of the following targets?

A)     < 140/90

B)      < 135/85

C)      <130/80

D)     <120/70

E)      <130/90

Archer USMLE Step 3 CCS Workshop – June 2011

Archer live Online CCS Workshop– Live Webinar- June 2011

Archer Live Online USMLE Step3 CCS Workshops from http://www.CcsWorkshop.com

Archer is the only live CCS Workshop in which experienced Internal Medicine board certified physicians will teach you live how to apply unique high-yield CCS strategies to score the most in the CCS Component.

Archer online live step 3 reviews aims to bring USMLE step 3 courses on your desktop, at your doorstep! These highly successful live USMLE Step3 online reviews are an extension of our very popular and successful ” Dr.Red’s online ccs workshop, which has reached more than Twelve thousand step3 takers in less than 2 years and has resulted in 98% pass rate. Archer Reviews have achieved a high success rate even with examinees with multiple attempts by our unique approach. These online reviews are done live and in a webinar format. You can stay at home and listen to lectures live and like in a virtual classroom, you can raise your hand and your question will be immediately answered by the instructor. This is a live online classroom which reduces the pain of flying several miles to attend live reviews. These are the only one in the market that offer successful step 3 lectures in this unique, live format. Archer’s most successful endeavor has been Dr.Red’s CCS Workshop which has helped hundreds of examinees to pass easily by excelling on CCS component.

Archer’s next CCS online workshop for the month of June 2011 will be on Sunday 06/12/2011 at 10 AM EST.

If you are interested in registering for this course, you can pay for the course on the website at http://www.shop.ccsworkshop.com. Upon payment of the registration fee, your registration request will be automatically approved and an approval e-mail will be sent to you. This approval notice will have a button “Join Webinar” in it. Clicking this button on the day of the workshop will open up the live workshop on your desktop

To participate in the workshop, you will need a computer with internet access. For the audio, you can use either your computer’s microphone or a telephone. You will use the phone for the voice and log in to the conference call while you watch the power-point slides and the CCS demonstration on your desktop via. our unique net meeting software. You can also just opt to use your computer’s microphone in which case you do not need a telephone. Then you will get to practice a case while we watch and analyze your approach and correct it.

CCS Workshop Includes :

1. Lecture on CCS Strategies
2. Live demonstration of CCS cases
3. Common mistakes committed by the examinees and preventing them
4. Tips to score extremely high on CCS
5. Follow-ups of office and ER cases
6. Efficient use of time, doing more stuff without advancing the clock
7. Avoiding invasive tests
8. Basic set of orders for emergency cases
9. The 5-minute screen – adding/ disconinuing the orders that can matter
10. Obtaing consults and their appropriateness
11. Differential diagnosis for common ER and office presentations and easy tips to get the most out of few orders.
12. Working on efficiency
13. Live practice of 15 to 20 CCS cases by the attendees in the workshop
14. A these in addition to –> 20 minutes of supervised practice of one CCS case by each attendee who volunteers to practice. About 15 to 20 Highyield CCS cases will be practiced. During this time, you will be thoroughly analyzed, corrected and given instantaneous feedback by our experienced faculty

The total course fee is $97 .Slots are limited at 35.
If you are interested in the course, you visit Archer’s online store directly to pay : http://www.shop.ccsworkshop.com

If you have further questions, please directly contact support@ccsworkshop.com

Archer’s other courses include very informative topic reviews and the high-yield rapid review – please check our website. Next 3-Day Step 3 Rapid Review is in August -2011. Archer theory reviews are now available as streaming videos so that you can start accessing them from the beginning of your step 3 preperation and fine tune your conceptual understanding.

Question of the Week # 172

172)  A 44 year old obese woman presents with complaints of abdominal pain in the right upper quadrant that started 4 hours ago and is persistent. She has mild nausea. On physical examination, there is tenderness in right upper quadrant which increases with deep breath. Her liver function tests are normal; WBC count is 24,000/µl with neutrophilic predominance. Amylase and Lipase are with in normal limits. An ultrasound of the gall bladder reveals gall stones but there is no pericholecystic fluid or any other sonographic evidence of acute cholecystitis. Sonographic murphy’s sign is absent. The most appropriate next step in managing this patient:

A)     Percutaneous Cholecystostomy

B)      Laparoscopic Cholecystectomy

C)      HIDA scan

D)     Endoscopic Retrograde Cholangiopancreatography (ERCP)

E)     Magnetic Resonance CholangiOpancreatography ( MRCP)

 

Question of the Week # 171

171)  A 54 year old woman presents with complaints of abdominal pain in the right upper quadrant that started 4 hours ago and is persistent. She denies any fever, nausea or vomiting.

On physical examination, there is mild tenderness in right upper quadrant. Her liver function tests reveal an AST (SGOT) 160U/L ( N= 5 to 40U/L) , ALT (SGPT) 240U/L( N= 8 to 55U/L)  , Alkaline phosphatase 110 U/L ( 40 TO 130U/L) , Total Bilirubin 1.2mg%.  An ultrasound of the gall bladder does not reveal any gall stones or pericholecystic fluid and shows a common bile duct diameter of 9mm (normal 6mm). The most appropriate next step in managing this patient:

A)     Hepatitis Serology

B)      Laparoscopic Cholecystectomy

C)      HIDA scan

D)     Endoscopic Retrograde Cholangiopancreatography (ERCP)

E)      Magnetic Resonance CholangiOpancreatography ( MRCP)

Question of the Week # 170

170) A 41 year old woman is evaluated in the office for 20lb weight loss over the last three months. She has a history of Hodgkin’s disease involving mediastinal and cervical lymph nodes and was treated with chemotherapy and Involved field radiation therapy at the age of 12.  She is born in the USA and never traveled outside United States. Her recent tuberculin skin test was 2mm about 1 month ago. Recent mammogram was normal. She denies any night sweats or pruritus. She reports chronic cough over the last 6 months associated with intermittent mild hemoptysis. On physical examination, there is no peripheral lymphadenopathy. A Chest X-ray is shown below:

 

 

 

 

 

 

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

A)     Tuberculosis

B)      Long term sequel of Hodgkin’s therapy

C)      Recurrent Hodgkin’s disease

D)     Radiation fibrosis

E)      Radiation Pneumonitis

Question of the Week # 169

169) A 77 year old woman is brought by her son for evaluation in your office for excessive forgetfulness.  Her son discovered that the patient has become increasingly forgetful over the last two years. She has difficulty managing her finances. She lives alone, drives her own car and prepares her own meals. As per son, several recent new dents were noted on her mother’s car. She is dressed well and is comfortable. Visual acuity on examination is 20/100 in both eyes and is partially corrected with glasses. She also has a fixed visual field deficit that is persistent for past one year due to a cerebrovascular accident. Rest of the physical including sensory and motor functions are grossly normal. She scores 25/30 on Mini-Mental Status examination.

The most appropriate recommendation regarding her driving at this time:

A)           Limit driving to day-time only

B)            Unrestricted driving

C)            Complete cessation of driving

D)           On-Road performance based driving test

E)            Adaptive devices for safe driving

Question of the Week # 168

168) A 70 year old woman with history of Hypertension, Diabetes mellitus, severe osteoarthritis and Macular degeneration is seen during a follow-up visit. He was seen a month ago in your office for evaluation of his driving capacity. At that time, he was noted to have significant impairment of vision and motor skills. His visual impairment persisted despite corrective glasses. He also uses cane to walk and has persistent deficits of left sided weakness and hemi spatial inattention secondary to a stroke 8 months ago. He was subsequently referred to driving rehabilitation specialist and was deemed unsafe to drive. During his visit 2 weeks ago, he has been counseled and was instructed to stop driving. While talking him about his transportation, he tells you that he drove himself to the clinic today.

Your most appropriate response at this time:

a) “When do you think it’s an appropriate time for a person to stop driving?”

b)  Let’s talk about some of your concerns regarding retiring from driving

c) I am wondering, is there someone whom you trust, and who would tell you when they thought it was unsafe for you to continue driving?

d) “You are a threat to others while driving on the road”

e) “I have a duty to protect you and so, I will have to report you to DMV”

f) “Let me refer you to Driving Rehabilitation so that they can help you with adaptive devices”

Question of the Week # 167

167)  A 77 year old woman is brought by her son for evaluation in your office for excessive forgetfulness.  Her son discovered that the patient has become increasingly forgetful over the last two years. She has difficulty managing her finances. She lives alone, drives her own car and prepares her own meals. As per her son, several recent new dents were noted on her mother’s car. She is dressed well and is comfortable. Visual acuity on examination is 20/40 in both eyes. She has seen her ophthalmologist recently and was prescribed corrective glasses which correct her vision to normal. She is compliant with using her glasses during driving. Rest of the physical including sensory and motor functions are grossly normal. She scores 25/30 on Mini-Mental Status examination.

The most appropriate recommendation regarding her driving at this time:

A)     Limit driving to day-time only

B)      Unrestricted driving

C)      Complete cessation of driving

D)     Referral to Driving Rehabilitation Service

E)     Start therapy for Alzheimer’s

Question of the Week # 166

166) A 42 year old woman with history of lupus nephritis presents with complaints of pain in her right thigh. Pain increases on walking and standing. Her kidney disease is under control on Prednisone maintenance for past one year. She denies any recent trauma. On physical examination, she is noted to have a right sided limp on walking. Her Hip X-ray is shown below:

The most likely etiology for the condition shown above:

A)           Renal insufficiency

B)            Secondary Hyperparathyroidism

C)            Systemic Lupus Erythematosus

D)           Vitamin D deficiency

E)            Prednisone therapy

Question of the Week # 165

165) A 42 year old woman with history of lupus nephritis presents with complaints of pain in her right thigh. Pain increases on walking and standing. Her kidney disease is under control on Prednisone maintenance for past one year. She denies any recent trauma. On physical examination, she is noted to have a right sided limp on walking. Her Hip X-ray is shown below:

 

 

 

 

 

 

 

 

The most likely diagnosis is:

A)     Osteosarcoma

B)      Osteonecrosis

C)      Lupus arthritis

D)     Osteoarthritis

E)      Osteoporosis

Question of the Week # 164

164) A 64 year old man is seen in the Emergency room for sharp sub sternal chest pain that started few hours ago. The pain increases on coughing and deep breathing. His history is significant for Acute Myocardial Infarction about 6 weeks ago. At that time, he was treated with percutaneous coronary intervention and stent placement. On physical examination, temperature is 100F, Heart rate 88/min, and Blood pressure 110/70 mm Hg. Pulsus paradoxus is 8mm Hg and lungs are clear to auscultation. A chest X-ray reveals enlargement of cardiac shadow. The most appropriate treatment for this patient’s presentation:

A) Pericardiocentesis

B) Oral Ibuprofen

C) Oral Prednisone

D) Metoprolol

E) Cardiac catheterization to evaluate stent re-occlusion

Question of the Week # 163

163) A 62 year old man with past medical history significant for Congestive Heart Failure presents with progressively increasing shortness of breath over the past 2 months. He denies any chest pain on exertion or at rest. He was recently started on furosemide for management of peripheral edema and is compliant with low salt diet. An Echocardiogram obtained 3 months ago revealed an Ejection Fraction of 32% (Normal = above 55%) at which time he was started on Enalapril. On physical examination, there is trace ankle edema. There are no lung crackles on auscultation. Rest of the examination is normal. An EKG reveal changes of left ventricular hypertrophy with normal QRS duration. The most important intervention at this time that would most improve his survival is

A) Start Losartan

B) Start Carvedilol

C) Start Isosorbide and Hydralazine

D) Add Digoxin

E) Biventricular Pacing

Question of the Week # 162

162) A 42 year old man is evaluated in your office for pain in his left hand. He has a chronic history of biciptal tendinopathy in his left upper extremity and Gastro-esophageal Reflux disease. He denies any history of recent trauma. He reports sudden onset of pain in his left hand that is associated with burning sensation. On physical examination, the left hand is swollen, pal, cool and tender to touch. Radial and ulnar pulses are intact. The image of his hands is shown below:

 

 

 

 

 

 

 

The cornerstone of the treatment modalities in this condition:

A)  Encouraging normal use of the limb

B)  Immobilization in plaster cast

C) Surgical decompression

D) Arterial Bypass surgery

E)     Prevention of exposure to cold temperatures

Question of the Week # 161

161) A 42 year old man is evaluated in your office for pain in his left hand. He has a chronic history of biciptal tendinopathy in his left upper extremity and Gastro-esophageal Reflux disease. He denies any history of recent trauma. He reports sudden onset of pain in his left hand that is associated with burning sensation. On physical examination, the left hand is swollen, pal, cool and tender to touch. Radial and ulnar pulses are intact. The image of his hands is shown below:

 

 

 

 

 

 

Most likely diagnosis of this patient’s presentation

A)     Scleroderma

B)      Raynaud’s phenomenon

C)      Complex regional pain syndrome

D)     Acute arterial occlusion

E)      Carpal Tunnel Syndrome

F)      Compartment Syndrome

Question of the Week # 159, 160

159) A 65 year old man with history of Diabetes Mellitus Type II and Hypertension is evaluated for a one month history of numbness in bilateral hands and feet. He has been feeling excessively tired lately. His medications include Glyburide, Metformin and Enalapril for the past 5 years. Physical examination reveals loss of position sensation in bilateral lower extremities.  He reports good control of blood pressure and Diabetes. His recent HgBA1C was 6.0% 1 month ago. His laboratory tests reveal a Hemoglobin of 9.0gm%; WBC of 8.0k/µl, MCV of 103 and Platelets of 200k/µl. Once the diagnosis is confirmed, the most important therapeutic step in addressing this patient’s presentation:

A) Stop Metformin

B) Switch to insulin

C) Vitamin b12 and Calcium supplementation

D) Start Gabapentin

E) Start Thyroid Supplements

160) In Question above, the most likely underlying cause of this patient’s presentation:

A) Diabetes related complications

B) Chronic Metformin Use

C) Poor Glycemic Control

D) Myelodysplastic Syndrome

E) Hypothyroidism 

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