Question of the Week # 335

335) A 75 year old hispanic man presents with right upper quadrant abdominal pain for past two weeks. He reports that the pain is excruciating and sharp when he takes a deep breath. He denies any recent trauma or fever or night sweats or cough. He reports lack of appetite and 30 lbs weight loss in the past 3 months. He immigrated to United States from Mexico about 15 years ago. He has no significant medical problems and has never been to a doctor in the past 25 years. A chest x-ray does not reveal any significant abnormalities. An ultrasound of the abdomen shows normal appearing gall bladder with gall stones but no evidence of cholecystitis. Common bile duct is within normal limits. Murphy’s sign is negative. Laboratory investigations reveal:

Total Protein : 7.5gm%

Albumin : 4.0gm%

Total bilirubin : 0.4 mg% ( N = 0.3 to 1.0 mg%)

AST : 30U/L (  N= 5 to 40U/L

ALT : 28 U/L (  N= 8  to 55U/L)

Alkaline Phosphastase ( ALP) : 750 U/L (  N= 4 to 130U/L)

GGTP : 40U/L (  N= 3 to 60U/L)

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

A) Laparoscopic Cholecystectomy

B) HIDA scan

C) Bone Scan and Prostate Specific Antigen

D) Quantiferon Gold Test

E) MRI of the Pancreas


Question of the Week # 334

334) A 50 year old male nurse is evaluated in your office for a recently discovered lung nodule. About 1 month ago, he had whole body CT scans because he read over the internet that these can be helpful in early detection of cancer. A high resolution CT scan of chest revealed a 7 mm nodule with very smooth edges. The margins are well-defined and there is no calcification. The patient has never smoked in his life and he has no family history of cancer. He has no other risk factors for lung cancer.  He denies any night sweats, weightloss or chronic cough. His recent Tuberculin skin test was negative. Laboratory investigations including complete blood count and comprehensive metabolic panel are within normal limits.

Which of the following is the most appropriate management option?

A) Obtain a Positron Emission Tomography scan ( PET/CT scan)

B) No further follow-up

C) CT guided biopsy of the nodule

D) Follow-up CT scan at 6-12 months and then at 2 years if no change

E) Refer to Cardiothoracic surgery for Wedge Resection

Question of the Week # 333

333) A 75 year old woman with past medical history of  Type 2 Diabetes mellitus, Hypertension and Ischemic stroke presents to your office for a new patient visit. She has been under the care of another primary care physician who has retired from practice so the patient has decided to establish care with you. She has left sided residual weakness from her old cerebrovascular accident. She has no other complaints. She requests you for a refill of warfarin which she has been taking for three years . This drug was prescribed by her former physician for “stroke prevention” . Her recent echcardiogram shows an ejection fraction of 60% and a recent cardiovascular stress test was negative for ischemia. Her other medications include Metformin, Glyburide and enalapril.  Her laboratory investigations including complete blood count are normal and her  INR is 1.5. Which of the following is the most appropriate  management?

A) Increase warfarin to achieve a target INR of 2.0 to 3.0

B) Discontinue Warfarin and start Aspirin/Dipyridamole combination

C) Continue low-dose Warfarin with target INR 1.5 to 2.0

D) Add Aspirin to her current regimen

E) Add Clopidogrel to her current regimen

Question of the Week # 332

332) A 22 year old ballet dancer is evaluated in your office during a routine annual physical examination. She does not have any complaints except for excessive fear of gaining weight. She reports that her mother thinks she has lost a lot of weight in the past two years however, she personally believes she is excessively fat and seeks help to lose more weight. Her menstrual cycles are irregular occurring, once every three to four months. On examination, she is very thin and has a dry, scaly skin. Her Body Mass Index is 15.0. She is afebrile, heart rate is 54/min and blood pressure 86/54 mm Hg. Complete blood count shows mild anemia. Urine pregnancy test is negative. Which of the following findings are consistent with her diagnosis?

A) Metabolic Acidosis

B) Parotid swelling

C) Hyperkalemia

D) Low serum cortisol

E) Increased Pulmonary vital capacity

Question of the Week # 331

331) A 16 year old girl is evaluated in the office for mild to moderate pain in her left ankle.  She reports that she heard a pop sound followed by the pain when she was about to walk briskly on her way to college. She is unable to walk normally and cannot lift up on to her toes while weight bearing. Her past medical history is significant for recurrent episodes of urinary tract infections. On examination, she is afebrile. There is no bruising or swelling in her left foot. There is tenderness at the back of her left foot about 2 cm above the posterior calcaneus.  Squeezing of the left calf muscle fails to result in passive plantar flexion at the ankle.  Which of the following element if obtained from the patient’s history would help in determining the cause of her presentation?

A) Eating habits

B) Menstrual History

C) Sexual History

D) Recent antibiotic use

E) Family history of Muscular Dystrophy

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