Question of the Week # 242

242) A 64 year old man is evaluated in the clinic for moderately severe pain in his both legs for the past 6 months. He describes the pain that occurs upon standing and worse on walking. The pain is worse walking downhill and slightly less while walking uphill. He reports that the pain interferes with his activities and he has to sit for about 30 minutes each time to obtain relief from the pain.  His history is significant for diabetes mellitus and chronic smoking about 1 pack per day for the past 45 years. On examination, he is afebrile and heart sounds are regular. Dorsalis pedis artery pulses are diminished bilaterally. Neurological examination is normal. Which of the following is the most appropriate next step in evaluating his pain?

A)     Clopidogrel

B)      Angiography

C)      MRI lumbar spine

D)     Ankle Brachial Index

E)     Supervised Exercise

Question of the Week # 241

241) A 44 year old man is evaluated in the clinic for moderately severe pain in his bilateral lower extremities for the past 6 months. He describes pain that occurs at rest and is increased on walking. The pain is worse in winters. His history is significant for chronic smoking about 2 packs per day for the past 25 years. He denies any history of thrombosis. On examination, he is afebrile and heart sounds are regular. Distal lower extremities are tender to touch. An ulcer measuring 2cm is noted on the left great toe. Posterior tibial and dorsalis pedis artery pulses are diminished. There is erythema and tenderness along the course of great saphenous vein. Laboratory investigations including complete blood count, chemistry panel and anti-nuclear antibodies are with in normal limits. Which of the following is most helpful in distinguishing this disorder from other vaso-occlusive diseases?

A)     Raynaud phenomenon

B)     Superficial Phlebitis

C)      Digital ulcers

D)     Young age

E)     Diminished arterial pulses

Question of the Week # 240

240) A 55 year old woman is evaluated in the emergency room for acute development of double vision and droopy right eyelid. She also reports pain in her right eye. She denies any fever.  She has no significant past medical history. On physical examination, she is afebrile and her blood pressure 132/88 mm Hg. Head and neck examination reveals ptosis of the right eyelid. Pupillary light reflex is lost. She can not adduct her right eye past the midline. The right eye is deviated downwards and laterally as shown in the picture below. There is no sensory loss on her face and the function of her other facial muscles are intact. Power is normal in all her extremities and deep tendon reflexes are intact.

The  most appropriate next step in management?

A)     Temporal artery biopsy

B)     Obtain Erythrocyte Sedimentation Rate

C)     Observation

D)     Magenetic Resonance Angiography (MRA)

E)     Ptosis Surgery

Question of the Week # 239

239) A 64 year old woman is evaluated in the emergency room for acute development of double vision and droopy left eyelid. She denies any fever or headache.  Her past medical history is significant for diabetes mellitus and hypertension. On physical examination, she is afebrile and her blood pressure 132/88 mm Hg. Head and neck examination reveals ptosis of the left eyelid. Pupillary light reflex is intact . She can not adduct her left eye past the midline. The left eye is deviated downwards and laterally as shown in the picture below. There is no sensory loss on her face and the function of her other facial muscles are intact. Power is normal in all her extremities and deep tendon reflexes are intact.

Which of the following is the most likely eventual outcome of her condition?

A)     Sub-arachnoid hemorrhage

B)     Spontaneous resolution

C)     Cerebellar ataxia

D)     Persistent visual deficits

E)     Aneurysmal Rupture

Question of the Week # 238

238) A 64 year old woman is evaluated in the emergency room for acute development of double vision and droopy left eyelid. She denies any fever or headache.  Her past medical history is significant for diabetes mellitus and hypertension. On physical examination, she is afebrile and her blood pressure 132/88 mm Hg. Head and neck examination reveals ptosis of the left eyelid. Pupillary light reflex is intact . She can not adduct her left eye past the midline. The left eye is deviated downwards and laterally as shown in the picture below. There is no sensory loss on her face and the function of her other facial muscles are intact. Power is normal in all her extremities and deep tendon reflexes are intact.

 

Which of the following is the most likely cause of her symptoms?

A)     Ophthalmoplegic migraine

B)     Diabetic Mono-neuropathy

C)     Posterior communicating artery aneurysm

D)     Weber syndrome

E)     Lateral medullary syndrome

Question of the Week # 237

237 )  A 25-year old primi-para is evaluated for soreness in her breasts. She just started breast feeding her three day old male infant. She also reports low grade fever over the past few hours. On examination, her temperature is 99.2F. Her breasts are hard and swollen. They are warm to touch. She has pain on movement of the breast. Which of the following is the most appropriate recommendation?

A) Hand expression of milk between feedings

B) Use of  ”Breast Pump”

C) Correction of improper “Latch on”

D) Re-assurance

E) Breast massage

Question of the Week # 236

236)  A 25-year woman presents to your office with complaints of soreness in her right nipple. She had a uneventful delivery 10 days ago. She has been breast feeding for the past ten days. She had some nipple soreness initially however, it resolved after five days. The soreness returned on the eighth day and is persistent since then . The pain is present through out the nursing episode. On examination, she is afebrile. Her right breast is full. There is no erythema or tenderness. Which of the following is the most appropriate recommendation to the patient?

A) Hand expression of milk between feedings

B) Use of  “Breast Pump”

C) Correction of improper “Latch on”

D) Re-assurance

E) Breast massage

Question of the Week # 235

235)  A 25-year woman presents to your office with complaints of soreness in her right nipple. She had a uneventful delivery 10 days ago. She has been breast feeding for the past ten days. She had some nipple soreness initially however, it resolved after five days. The soreness returned on the eighth day and is persistent since then . The pain is present through out the nursing episode. On examination, she is afebrile. Her right breast is full. There is no erythema or tenderness. Which of the following is the most likely cause of her clinical presentation?

A) Poor positioning of infant while feeding

B) Prolonged suckling

C) Inadequate feeding

D) Infection

E)  “Normal” Nipple Sensitivity

 

Question of the Week # 234

234 )  A 25-year old primi-para is evaluated for soreness in her breasts. She just started breast feeding her three day old male infant. She also reports low grade fever over the past few hours. On examination, her temperature is 99.2F. Her breasts are hard and swollen. They are warm to touch. She has pain on movement of the breast. Which of the following is the most likely cause of her clinical presentation?

A) Poor positioning of infant while feeding

B) Prolonged suckling

C) Inadequate feeding

D) Infection

E) Plugged ducts

Question of the Week # 233

233 )  A 36 year old man is evaluated in the emergency room for nausea, vomiting and diarrhea. He also reports fever of one day duration. He denies any rash. He has had 4 to 5 watery bowel movements in the last 24 hours. The diarrhea started 3 days ago and is progressively worse. He feels extremely weak.  His last sexual activity was 6 months ago and he always uses condoms. He denies any fever or  using any recent medications. He works in tourism industry and returned from a business trip to Mexico one week ago.  On examination, temperature is 101F, blood pressure 90/50 mm hg, his oral mucosa are dry. Abdominal examination is benign. The patient has been adequately hydrated and feels better now though, he continues to have diarrhea. Which of the following is the most appropriate next step in management?

A) Observation

B) Rifaximin

C) Amoxicillin

D) Trimethoprim-Sulfamethoxazole

E) Metronidazole

Question of the Week # 232

232 )  A 32 year old man is evaluated in the clinic for an intensely itchy rash on his feet.  He denies any fever or  using any recent medications. He just returned yesterday from a pleasure trip to Philippines. While on vacation , he spent his time visiting historical sites, rivers and beaches. He does not swim but enjoys walking in the water near shore. On examination, there  are multiple papules on the plantar and dorsal aspect of the feet bilaterally. There are no vesicles or pustules. The skin above the level of calves is not involved. Which of the following is the most likely diagnosis?

A) Hot tub folliculitis

B) Vibrio Vulnificus

C) Cutaneous Larva Migrans

D) Swimmer’s itch

E) Strongyloidiasis

Question of the Week # 231

231) A 62 year old woman was admitted to the hospital two days ago for complicated acute pyelonephritis. She was initially started on piperacillin-tazobactam. On day 2 of hospital stay, urinary cultures are positive for ampicillin resistant enterococci. The patient is started on Vancomycin . While receiving her first dose of vancomycin, she develops flushing, redness and itching over her upper body. On physical examination, her temperature is 101F, HR 120/min and blood pressure is 120/70 mm hg.  There is  erythema on her chest. An intravenous cannula is in place on her left arm. There is no erythema or tenderness at the cannula site. Which of the following is the most appropriate next step in management?

A)     Diphenhydramine

B)     Stop Vancomycin and switch to Linezolid

C)     Change the IV cannula

D)     Methylprednisolone

E)     Stop Vancomycin and restart at slower rate

Question of the Week # 230

230) A 72-year-old white man with history of type 2 diabetes mellitus and hypertension is evaluated in your office during a follow up visit. He was discharged 3 days ago from the hospital after undergoing diagnostic cardiac catheterization for an abnormal exercise stress test. Femoral sheath was removed three days ago. He denies any chest pain or shortness of breath.  On physical examination, he is afebrile, HR 120/min and blood pressure is 120/70 mm hg.  There is a new palpable mass in the right groin and systolic bruit is heard at the catheter insertion site. Dorsalis pedis and posterior tibial pulses are intact. Which of the following is the most likely diagnosis?

A)     Arterio-venos fistula

B)     Local Hematoma

C)      Femoral artery true aneurysm

D)     Hematoma in continuity with arterial lumen

E)     Femoral artery thrombosis

Question of the Week # 229

229 )  A 70-year-old white man with history of poorly controlled type 2 diabetes mellitus and hypertension is evaluated in the emergency room for severe pain in the right thigh. The patient has a coronary artery disease for which he underwent cardiac catheterization with percutaneous coronary intervention 2 days ago. He denies any chest pain or shortness of breath.  On physical examination, temperature is 99.2F, HR 120/min and blood pressure is 80/40 mm Hg.  There is erythema at the site of  cardiac catheterization in the femoral area. Laboratory studies reveal a creatinine of 4.2mg% as opposed to his baseline creatinine of 1.8mg% one week ago. Which of the following is the most likely diagnosis?

A)  Toxic shock syndrome

B)  Atheroembolism

C)  Contrast Nephropathy

D) Ruptured femoral artery pseudo-aneurysm

E)  Retroperitoneal bleeding

Question of the Week # 228

228 )  A 70-year-old white man  with type 2 diabetes mellitus and hypertension is evaluated in the emergency room for lacy purplish discoloration of the lower extremities that developed few hours ago. He reports diffuse bodyaches and low grade fever. He denies chest pain or shortness of breath. His past medical history is significant for coronary artery disease for which he underwent cardiac catheterization with percutaneous coronary intervention one week ago.  He has a history of chronic atrial fibrillation for which he is on 5mg coumadin daily. His most recent INR has been therapeutic at 2.5. Physical examination reveals lacy purplish pattern on bilateral lower extremities shown in the image below.

The site of cardiac catheterization in the femoral area is clean and healing with out any tenderness or erythema. Neurological examination is normal. Laboratory studies reveal a creatinine of 4.2mg% as opposed to his baseline creatinine of 1.8mg% one week ago. Hemoglobin and platelet count are within normal limits. WBC count is 12.6k/µl with neutrophils 70%, bands of 2% , eosinophils 18% and lymphocytes 10%. Which of the following is the most likely diagnosis?

A)  Toxic shock syndrome

B)  Atheroembolism

C)  Contrast Nephropathy

D)  Anti-Phospholipid antibody syndrome

E)  Cryoglobulinemia

Question of the Week # 227

227 )  A 32 year old man is evaluated in the clinic for intensely itchy rash . The rash appeared suddenly on his trunk 24 hours ago  and has spread to his extremities. He denies any fever or  using any recent medications. His travel history is significant for a trip to Colarado 3 days ago where he stayed with his friend in a hotel room. He enjoyed camping in the mountains and spent his evenings in the hotel building’s swimming pool. On examination, there  are multiple red papules all over his body and extremities but not on the head and the neck. Some of the papules are tender. Which of the following is the most appropriate next step in management?

A) Doxycycline

B) Lyme Serology

C) Ciprofloxacin

D) Reassurance

E) Amoxicillin-Clavulunate

Question of the Week # 226

226 )  A 2 year old male child is brought by his pregnant mother for evaluation of a rash all over his body. The rash developed 48 hours ago and is associated with fever. She also has a 12 year old daughter at home who is being treated for acute lymphoid leukemia. On examination, the patient has rash in different stages including papules, pustules and vesicles. You suspect chickenpox. The mother denies any history of chickenpox in the past. Which of the following is the most appropriate recommendation?

A)     Varicella vaccine to the male child

B)      Varicella vaccine to the mother

C)      Varicella Zoster immunoglobulin to mother and the daughter

D)     Varicella vaccine to mother and VZIG to the daughter

E)      Varicella vaccine to the mother and the daughter

Question of the Week # 225

225 ) A 40 year-old man presents to office for routine follow-up visit. His past medical history is significant for hypertension for which he is on Hydrochlorthiazide. He denies any chest pain, palpitatations, shortness of breath or syncope. He is a journalist by occupation. A routine EKG  is obtained and is shown below:

Which of the following is the most appropriate managment of this patient?

A) Beta-blocker

B) Catheter ablation

C) Diltiazem

D) Observation

E) Electrophysiological studies

 

Question of the Week # 224

224 ) A 38 year old man presents to the emergency room with complaints of palpitations that started 5 hours ago and are persistent. He denies having similar episodes in the past. He has no fever or shortness of breath or chest pain. His past medical history is unremarkable and he is not on any medications. On examination, blood pressure is 110/60 mmHg, heart rate  130/min, RR 20/min  and temperature 98.6 F.   Cardiovascular examination reveals irregularly, irregular heart rate at 140beats/min.  An Electrocardiogram now is shown below :

An EKG that was done during a pre-employment health check-up upon patient’s own request two months ago is shown below:

The most appropriate next step in managing this patient:

A) Defibrillation

B) Intravenous metoprolol

C) Intravenous Diltiazem

D) Intravenous Procainamide

E) Synchronized Cardioversion

Question of the Week # 223

223 ) A 38 year old obese African American man presented to the emergency department with headache, blurred vision and weakness.  His past medical history was unremarkable. He smoked about 1 pack per day for 20 years.  On examination, this patient’s blood pressure was 210/140 mmHg, heart rate 98/min, RR 20/min  and temperature 98.6 F.  He is alert, awake and oriented. Physical examination is unremarkable. There are neurological deficits. Laboratory investigations showed Hemoglobin 8.2 g/dl, White cell count 10k/µl, Platelets 97000/µl, Sodium 140meq/L, Potassium 4.0meq/L, Bicarbonate 24meq/L,  BUN 34 and Creatinine 3.2mg% . Further investigations included a Lactic dehydrogenase which was elevated at 900U/L and a reticulocyte count of 7.0% . A periphreral smear is shown below :

The most appropriate next step in managing this patient:

A) Fresh frozen plasma

B) Intravenous Labetalol

C) Plasmapheresis

D) Intravenous Nitroprusside

E) Hemodialysis

Question of the Week # 222

222 )  A 70-year-old white man  with type 2 diabetes mellitus, hypertension, coronary artery disease, chronic kidney disease and severe chronic obstructive pulmonary disease is admitted with increasing shortness of breath. The patient lives by himself and he has not been very compliant with his medications. On examination, he is awake and oriented, blood pressure is 230/140 . Funduscopic examination reveals papilledema.  Chest exam reveals bilateral crepitations. Neurological examination is normal. An electrocardiogram reveals non specific ST segment changes. A chest x-ray shows bilateral pulmonary edema. Pulse oximetry reveals a saturation of 89% on room air. The patient is started on oxygen by nasal cannula. Laboratory studies reveal a creatinine of 4.2mg% as opposed to his baseline creatinine of 2.2mg%. Which of the following is the most appropriate next step in management?

A)  Non-contrast CT Scan, head

B)  Intravenous Sodium nitroprusside

C)  Intravenous Labetalol

D)  Fenoldapam

E)  Cardiac catheterization.

Question of the Week # 221

221 )  A 73-year-old white man with type 2 diabetes mellitus, hypertension, coronary artery disease is admitted with increasing shortness of breath and lower-extremity edema. A brain natriuretic peptide level is 1000 pg/ml. His medications include glyburide, aspirin, atorvastatin and enalapril. He is allergic to sulfonamides. On physical examination, he has bilateral crepitations more in the right chest. Extremity examination reveals 3+ edema bilaterally. An electrocardiogram reveals changes consistent with left venricular hypertrophy but no evidence of acute ischemia. Cardiac enzymes are negative. A chest x-ray reveals bilateral pulmonary edema. Pulse oximetry reveals a saturation of 89% on room air. The patient is started on oxygen by nasal cannula. Which of the following is the most appropriate next step in management?

A) Intubation

B) Intravenous Furosemide

C) Bilevel Positive Airway pressure (BIPAP)

D) Intravenous Ethacrynic acid

E) Cardiac catheterization.

Question of the Week # 220

220 )  A 32 year old woman presents to the office for evaluation of dysuria, frequency and urgency. She has had two episodes of urinary tract infection in the last 4 months. Her previous episodes were managed with 3 day course of trimethoprim-sulfamethoxazole.  She has been using cranberry juice but has not experienced any improvement in recurrences. At this time, she denies any flank pain or fever.  She is sexually active with one partner and uses diaphragms with spermicide for contraception. Physical examination is normal except for mild supra-pubic tenderness. There is no costo-vertebral angle tenderness. Urinalysis  reveals pyuria and 3+ leukoesterase. There are no WBC casts. Which of the following is the most appropriate recommendation to avoid recurrent urinary tract infections in this patient?

A) Post-coital voiding

B) Post-Coital Trimethoprim-sulfamethoxazole

C) Avoid vaginal spermicides

D) CT scan abdomen

E) Daily Trimethoprim-Sulfamethoxazole

Question of the Week # 219

219 )  A 32 year old woman presents to the office for evaluation of recurrent urinary tract infections. She has had two episodes of cystitis in the last 4 months. In the past she was managed with 3 day course of trimethoprim-sulfamethoxazole. Now, she presents with burning micturition, urgency and frequency. She denies flank pain or fever.  She uses diaphragms with spermicide for contraception. She is sexually active with one partner and her last sexual intercourse was 5 months ago since her partner is away on a business tour. Physical examination is normal except for mild supra-pubic tenderness. Which of the following is the most appropriate recommendation to avoid recurrent urinary tract infections in this patient?

A) Post-coital voiding

B) Post-Coital Trimethoprim-sulfamethoxazole

C) Avoid vaginal spermicides

D) CT urogram and Cystoscopy

E) Daily Trimethoprim-Sulfamethoxazole

Question of the Week # 218

218 )  A 36 year old woman presents to the office for a routine follow up visit. Her past medical history is significant for recurrent urinary tract infections which are unrelated to sexual intercourse. She was initially managed on intermittent self-treatment with Trimethoprim-Sulfamethoxazole. However, in view of frequent episodes of UTI she was started on continuous Trimthoprim prophylaxis one week ago. She denies any fever or abdominal pain. She has not had dysuria or frequency or urgency over the last 5 days. Physical examination is normal. Laboratory investigations reveal a WBC count of 6.3k/µl with normal differential, Sodium 140meq/l, Potassium 4.0meq/l, Blood urea nitrogen 10mg% and Creatinine 1.4mg% . Her labs obtained 1 month ago show Blood urea nitrogen of 12mg% and creatinine of 0.7mg%. The most likely explanation for her increased creatinine?

A) Allergic Interstitial Nephritis

B) Acute Tubular Necrosis

C) Pyelonephritis

D) Decreased tubular secretion

E) Papillary necrosis

Question of the Week # 217

217 )  A 36 year old woman presents to the office complaining of burning urination, urgency and frequency. She denies fever or abdominal pain. She is sexually active with one partner for the past 1 month and her partner always uses condoms.  Her past medical history is significant for peri-partum cardiomyopathy 2 years ago which spontaneously resolved. She recalls that she was treated with furosemide for her peripheral edema at that time however, the drug had to be stopped due to a severe rash. On physical examination, she is afebrile. There is mild supra-pubic tenderness with out any costo-vertebral angle tenderness. Urinalysis reveals bacteriuria and several white blood cells with out any casts. Which of the following is the most appropriate next  step in managing this patient?

A) Admit for Intravenous antibiotics

B) Trimethoprim-Sulfamethoxazole

C) Piperacillin-Tazobactam

D) Moxifloxacin

E) Trimethoprim

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