2011 in review

The WordPress.com stats helper monkeys prepared a 2011 annual report for this blog.

Here’s an excerpt:

The Louvre Museum has 8.5 million visitors per year. This blog was viewed about 100,000 times in 2011. If it were an exhibit at the Louvre Museum, it would take about 4 days for that many people to see it.

Click here to see the complete report.

Question of the week # 296

296) A 6 month old Asian infant  is brought by his concerned aunt for evaluation of dark blue areas on the child’s buttocks. She says she was called to baby-sit the infant since his mother found a new job 2 days ago. She noted the rash and became suspicious that the child may have been abused. The mother arrives in Emergency room an hour later and reports that the rash has been present since birth. The mother is divorced and lives alone with the child. On examination, there are bluish-green patches on bilateral buttocks and on the lower back. They are irregular in shape and  margins are indistinct. There is no swelling or tenderness. An image of the skin findings is shown below:

Which of the following is the most appropriate next step ?

A) Order Skeletal Survey

B) Reassure that rash may fade away in few years

C) Contact Child Protection services

D) Obtain Coagulation parameters

E) Obtain Platelet count

Question of the week # 295

295) A 10 year old boy is brought to your office for evaluation of rash in bilateral axillae and groin for the past 2 months. He denies any itching or any other skin rashes.  However, he reports that the area has become progressively rough to touch. He is otherwise, healthy. On examination, there are  reddish brown patches in bilateral axillae and groin. There is maceration and scaling in the web spaces between the toes of bilateral feet. Rest of the examination is normal. A KOH mount is obtained and is negative. Wood’s lamp examination reveals coral red fluorescence. A picture of  the rash is shown below:

Which of the following is the most appropriate next step ?

A) Topical corticosteroid

B) Topical Selenium Sulfide

C) Oral erythromycin

D) Topical Clotrimazole

E) Oral Metronidazole

Question of the week # 294

294) A 71 year old woman presents to the emergency room with complaints of bright red bleeding per rectum. She denies any abdominal pain, nausea or vomiting. She has a history of paroxysmal atrial fibrillation. Her medications include aspirin and beta blocker. About 10 days ago, she had a screening colonoscopy. She had a 3cm polyp in the sigmoid colon which was removed at that time.  She reports that she did not experience any bleeding immediately after polyp removal and is concerned about this episode that occured so many days after the procedure. On physical examination she is afebrile . Abdominal examination is benign. Rectal examination reveals bright red blood and no palpable hemorrhoids. Patient is anxious about her diagnosis.  Which of the following is the most appropriate statement?

A) ” Your bleeding is mostly secondary to ischemic colitis”

B) ” Bleeding can occur up to two weeks after polypectomy”.

C) ” Your bleeding is related to Aspirin use”.

D)  ” We will have to repeat colonoscopy to confirm that a cancer has not been missed”

E) ” You will need diagnostic laporoscopy to evaluate the cause”

Question of the week # 293

293) A 70 year old man is evaluated in the emergency room for abdominal pain , fever, nausea and vomiting that began 8 hours after he underwent a screening colonoscopy. The pain is severe and is mostly in the left lower quadrant of the abdomen. He reports that his colonoscopy procedure was uneventful except that he had a 2cm sessile polyp which was removed during the procedure. He denies any rectal bleeding. On examination, temperature is 102 F, blood pressure 100/60 mmHg, pulse 120, respiratory rate 28/min. Abdominal examination reveals severe tenderness,  guarding and rigidity in the left lower quadrant. Laboratory investigations show:

WBC 28k/µl with left shift

Hemoglobin 13.5 g/dL

Mean cell volume (MCV)  84  fL

Platelet count 310k/µl

Which of the following is most important next step in management?

A) Obtain urgent surgical consult

B) Rectal tube placement

C) Serum amylase level

D) Supportive care alone

E) Barium enema

Question of the week # 292

292) A 66 year old man is evaluated in the emergency room for abdominal pain and fever. The patient underwent a screening colonoscopy in the outpatient Gastroenterology clinic 8 hours ago and had a 3cm sessile polyp removed. He complains of moderate pain in left lower quadrant that started one hour ago. He denies nausea or vomiting or rectal bleeding. On examination, temperature is 100.8F, blood pressure 140/90 mmHg, pulse 102, respiratory rate 20 bpm. Abdominal examination reveals tenderness and guarding in the left lower quadrant. There is no rigidity or rebound tenderness. His laboratory investigations including complete blood count and comprehensive metabolic panel are within normal limits. Which of the following is the most appropriate next step in managing this patient?

A) Exploratory Laporotomy

B) Rectal tube placement

C) Flexible sigmoidoscopy

D) CT Scan of the Abdomen

E) Conservative management

Question of the week # 291

291) A 66 year old man with past medical history of hypertension and  type-2 diabetes mellitus is evaluated in your office during a regular follow up visit for his diabetes. During this visit, he reports problem getting and maintaining an erection.  On the times that he does have an erection, they are very soft.  He says this problem began approximately 10 months ago and has slowly worsened but he was too embarrassed to disclose this during his previous visits. He still has a strong sexual desire and this problem has caused strain in his current relationship.  He is physically very active walking two to three miles per day. His medications include glipizide and hydrocholrthiazide. He says his home blood sugars have been “perfect”. A Hemoglobin A1C 2 weeks ago was 6.0gm% .  He currently does not smoke after having quit smoking 15 years ago. Physical examination shows blood pressure 140/90 mmHg, pulse 86, respiratory rate 20 bpm. Genitilia and testicles are normal in size . Peripheral pulses are normal. Rest of the physical examination is normal. Which of the following is the most appropriate next step in managing this patient?

A) Obtain Serum Total Testosterone

B) Obtain Nocturnal Penile Tumescence

C) Start Sildenafil

D) Prescribe Vacuum assisted erection device

E) Switch Hydrochlorthiazide to ACE inhibitor

 

Question of the week # 290

290) A 72 year old man with history of Diabetes Mellitus and peripheral vascular disease is evaluated in your office for impotence. He denies any premature ejaculation and states that he can not even attain an erection. Further studies confirm erectlie dysfunction secondary to organic causes. The patient denies any history of angina in the past. His medications include Aspirin, Clopidogrel, Glargine insulin and Lispro. His most recent HGBA1C was 6.5%. You offer him sildenafil for erectlie dysfunction. He is now concerned about the possible side effects. Which of the following is the most common side effect of sildenafil?

A) Headache

B) Nasal congestion

C) Diarrhea

D) Blurred vision

E) Flu like symptoms

Question of the week # 289

289) A 32 year old male athlete is evaluated in the office for bilateral breast enlargement. He is a state champion in running and is scheduled to participate in the national level running championship in few weeks. He is very concerned about his appearance.   He denies using any illicit drugs or exogenous androgens or aromatase inhibitors  is seen in the office during a routine follow up visit.  His past medical history is unremarkable. Physical examination reveals gynecomastia bilaterally. His laboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 18.5 g/dL ( Normal = 13.0 to 16.5 gm%),

Mean cell volume (MCV)  84  fL

Platelet count 310k/µl

Which of the following is most useful in establishing the diagnosis?

A) Erythropoetin level

B) Urine Drug Screen

C) Serum Total Testosterone

D) Urine Testosterone/ Epitestosterone ratio

E) Serum Free Testosterone

Question of the week # 288

288) A 38 year old caucasian man  is seen in the office during a routine follow up visit.  His past medical history is significant for testicular non-seminomatous germ cell tumor diagnosed 9 months ago and was treated with radical orchiectomy of left testicle and chemotherapy.  He completed chemotherapy 6 months ago and achieved a complete response. His tumor markers and imaging studies 3 months after completion of therapy were normal. He complains of decreased sexual drive and energy.  He denies smoking tobacco or alcohol. He  uses Marijuana on a daily basis but quit 2 months ago. His family history is unremarkable.  Physical examination shows absent left testicle. Rest of the physical is normal. Serum alpha-fetoprotein is normal. Beta HCG is elevated at 15U/L ( Normal < 5 U/L) . A chest X-ray , CT scan of the abdomen and pelvis are normal.  His routine laboratory investigations including complete blood count are within normal limits. Which of the following is most likely reason for his elevated Beta-HCG?

A) Recurrent tumor

B) Marijuana Use

C) Hypogonadism

D) Chemotherapy effect

E) Hyperthyroidism

Question of the week # 287

287) A 38 year old caucasian man  is seen in the office due to decreased libido and energy. His past medical history is significant for testicular cancer diagnosed 1 year ago and was treated with radical orchiectomy of left testicle and chemotherapy. He denies smoking tobacco but admits using Marijuana on a daily basis for the past few months. His family history is unremarkable.  Physical examination  reveals gynecomastia and absent left testicle. Body mass index is 24.  His routine laboratory investigations including complete blood count are within normal limits. Serum total testosterone level is reduced and Serum LH concentration is elevated. The patient is started on Testosterone replacement therapy with a testosterone skin gel. Which of the following is the most appropriate step in follow up care of  this patient after starting testosterone therapy?

A) Digital Rectal exam and Serum PSA level at one year

B) Hematocrit at 6 months and then, every year

C) DEXA scan at one year

D) Serum Testosterone level at 6 months

E) Serum LH at one month.

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