Question of the week # 444

444) A 25 year old woman is seen by you today due to an abnormal blood count. Three weeks ago, she volunteered for blood donation and a complete blood count that was drawn at that time showed abnormal values. She has regular menstrual periods with normal flow. Her last menstrual period was one week ago.  Her previous blood count was done several years ago and she is unaware of being told they were abnormal. A complete blood count is as follows :

WBC 5.5k/µl

HGB: 12.1 gm%

MCV 84 fl

Platelets : 800k/µl ( Normal 140k to 340k/ul)

Differential count : Neutrophils : 64% Lymphocytes 30% Monocytes 4%

Which of the following is the most important next step?

A) Obtain Bone Marrow Biopsy

B) Order Transferrin Saturation

C) Obtain Jak-2 Mutation Analysis

D) Obtain Arterial Blood Gases

E) Start her on Aspirin

Question of the Week # 443

443 ) A 38 year old man is evaluated in your office for a chronic rash on his elbows. He reports this has been worsening over the last 6 months and is intensely itchy. He lost about 8lbs weight in the past 6 months. Review of systems is normal except for 4 to 5 episodes of loose stools every day. Laboratory investigations reveal moderate microcytic anemia. On examination, he is afebrile. There is a vesicular rash on the extensor aspects of his bilateral elbows as shown below:

elbows

Which of the following is most helpful in diagnosing this condition?

A) Fecal occult blood testing and Sigmoidoscopy

B) Anti-nuclear antibodies

C) Anti-Endomysial antibodies

D) Small bowel follow through

E) Anti-Sacharomyces Cerviseae antibodies ( ASCA)

Question of the Week # 442

442 ) A 14 month old toddler is brought to your out-patient clinic by her concerned mother regarding a rash that appeared recently in her ano-genital region. The rash has appeared 3 weeks ago and is persistent. Mother says she tried to use local Zinc Oxide  cream but it did not help. There is no history of fever. No vaginal discharge. She is otherwise healthy and reaching all her milestones appropriately. On examination, she is afebrile. There are several papules seen in the ano-genital area as shown below.

IMAGE 3 KIDS

Which of the following is the most appropriate next step?

A) Screen for Child Sexual Abuse

B) Local steroid application

C) Reassure that the rash will resolve in few months

D) Refrain the child from Day-care to prevent transmission

E) Local antibiotic application

Question of the Week # 441

441) A 3 week old male infant is evaluated for a rash in your clinic . Mother appears concerned and she reports rash has appeared all of a sudden over his cheeks, in the genital areas and on certain areas of trunk. The baby is entirely on formula feeds. No history of fever. The mother is healthy and none of the family members are sick at home. The baby was born by an uncomplicated vaginal delivery. On examination, he is afebrile.  There are numerous white papules on his face around the nose, cheeks and in the genital areas. A picture of the rash is shown below:

IMAGE 2 KIDS

Which of the following is the most likely diagnosis?

A) Miliaria

B) Molluscum Contagiosum

C) Erythema Toxicum

D) Milia

E) Staphylococcal Pyoderma

Question of the Week # 437 to 440

Q437) A 65 year old man with HTN presents to your office for evaluation of right leg pain that increases on walking about one block. The pain seems to disappear when he sits and takes rest for about 10 minutes. He is concerned because it is interfering with his exercise activity that his cardiologist has recommended him. His medications include hydrochlorthiazide and enalapril. The patient has a history of heavy smoking but he quit 2 years ago. Physical exam was normal except for diminished dorsalis pedis pulses bilaterally. An arterial doppler is performed and ankle brachial index obtained which is 0.70 . The next best step in the management of his leg pain?

A) Start Cilostozol
B) Start Pentoxyfilline
C) Supervised exercise therapy
D) Recommend unsupervised exercise for 30 minutes everyday.
E) Add clopidogrel.
F) Obtain Magnetic Resonance Angiography.
G) Arterial bypass surgery

438) For the patient in Q437, which of the following is most effective in reducing the combined risk of ischemic stroke, myocardial infarction, or vascular death ?
A) Aspirin
B) Clopidogrel
C) Cilostozol
D) Pentoxifilline
E) Abciximab

439) The patient was appropriately treated and a follow up visit was scheduled one month later. The patients symptoms have moderately improved. During this visit, his fasting lipid panel revealed an LDL of 126mg%, HgbA1c of 5.5 and a blood pressure of 128/82. Next important step:
A) Advise dietary modification to treat his high LDL cholesterol
B) Start Atorvastatin and Dietary changes
C) Start Metformin
D) Start Metoprolol

440) Three months after he was diagnosed with Peripheral arterial disease, the patient suffered a massive myocardial infarction and hospitalized. He underwent Coronary artery bypass grafting and his symptoms are now well controlled. While in the hospital, the patient was started on Aspirin and Clopidogrel. He was continued on Hydrochlorthiazide and Enalapril. His Ejection fraction after the MI was 35%. One month after discharge, during a regular follow up with his cardiologist, he was started on metoprolol. Two weeks after this the patient comes back to your office with worsening leg pain on walking. On physical examination, the legs are normal in color with diminished dorsalis pedis pulses bilaterally.
Next best step in management:

A) Stop metoprolol
B) Change metoprolol to carvedilol
C) Start Cilostozol
D) Obtain angiogram and schedule arterial bypass surgery

Question of the Week # 436

436) A 24 year old woman returns to your office to discuss breast biopsy results. One week ago, she was evaluated your office for a palpable lump in her left breast of one week duration. She reported significant pain associated with this lump and it was also associated with pale yellow colored nipple discharge. She is physically very active and enjoys playing soccer. She does not smoke or drink. She has no other problems except for mild ankle sprain that she sustained during an  inter-collegiate match two weeks ago. Physical examination was positive for a tender left breast lump in the outer quadrant . She underwent ultrasound guided core needle biopsy . Image from pathology slides is shown below:

breast

Which of the following is the most appropriate recommendation for this patient?

A) Refer her for lumpectomy

B) Genetic testing for BRCA1/BRCA2

C) Reassurance and repeat in 6 months

D) Counsel regarding increased risk of subsequent breast cancer in this condition

E) Start Tamoxifen

Question of the Week # 435

435) A 29 year old woman is seen in your office for fatigue and exertional shortness of breath of 2 week duration. Past medical history is significant for hospitalization for splenic vein thrombosis 1 year ago. She received heparin 1 year ago and therafter, coumadin for 6 months. She is off anticoagulation now. Physical examination is unremarkable. Laboratory Studies reveal

WBC 2400/µl

HGB: 6.8 gm%

MCV 84 fl

Platelets : 80k/µl

Reticulocyte count 4.5%

Haptoglobin : Undetectable

Lactic Dehydrogenase (LDH) 800U/L

Direct Coombs Test : Negative

Which of the following is the best step in diagnosing this condition?

A) Hemoglobin Electrophoresis

B) Flow cytometry

C) Osmotic Fragility Test

D) Urine Hemosiderin

E) Heparin Antibody Testing

Question of the Week # 434

434) A 44 year old woman is evaluated in your office for one month history of worsening fatigue. She also reports tingling and numbness in bilateral lower extremities. Her past medical history is significant for morbid obesity for which she underwent gastric bypass surgery four years ago. She has lost about 80lbs weight since her surgery. Her medications include oral ferrous sulfate, folic acid and vitamin b-complex. Physical examination reveals absent ankle jerks. Laboratory Studies reveal WBC 5400/µl HGB: 9.8 gm%, MCV 74 fl, Platelets : 300k/µl, Serum ferritin 280ng/ml, Transferrin saturation 26% . A bone marrow aspirate smear is shown below :

Archer USMLE

Which of the following is the most likely cause of patient’s presentation?

A) Iron deficiency

B) Copper deficiency

C) Vitamin B12 deficiency

D) Zinc deficiency

E) Pure red cell aplasia

Question of the Week # 433

433) A 27 year old woman with no significant past medical history presents to your office after she sustained an accidental cut from a clean, new kitchen knife. She has no significant family history. She does not smoke or drink. She enjoys hanging out in beaches over the weekends and sun tanning. She however, noticed that she tans very quickly when compared to her friends. She received Tetanus immunization as a child and her last tetanus booster was 1 year ago. She also reports she recently visited her gynecologist office at which time some routine labs were done. She has the copies of her lab reports with her which reveal:
WBC : 10k/µl

HGB: 15gm%

Platelets : 300k/µl

Iron : 150 mcg/dL

TIBC: 200 mcg/dl

Transferrin saturation : 75%

Serum Ferritin : 220 ( N= 12 to 200 ng/ml)

Further investigations revealed homozygos state for C282Y mutation. On examination, her skin is golden tan in color. She has a  1cm cut on her palm which is clean. The wound is cleaned with soap and water.

Which of the following is the most appropriate management?

A) Instruct her to increase Vitamin C intake to promote wound healing

B) Administer Tetanus Immunoglobulin

C) Administer Tetanus Toxoid

D) Instruct her to avoid contact with sea water until the wound is healed

E) Instruct her to increase Red Meat Intake

 

 

Question of the Week # 432

432) A 62-year-old man presents with painless, progressive enlargement in the left side of his neck over the past 3 months. He denies any fever, night sweats or chills. He denies any pain, dysphagia, cough, hemoptysis, chestpain, shortness of breath, history of trauma or dental infection. His past medical history is significant for  100 pack-year history of smoking and daily alcohol abuse. On examination, he is afebrile. He has a large 5 cm , hard, non-tender and matted lymphadenopathy on the left lateral aspect of his neck . He has no other lymph node enlargement. No rash. Reminder of the exam including oral cavity examination is normal. There are no obvious tongue, pharyngeal or tonsillar lesions.  HIV and VDRL are negative. A CT scan of the chest, abdomen and pelvis does not reveal any lymphadenopathy or obvious mass lesions. Which of the following is the most appropriate next step in management?

A) Open biopsy of the neck mass

B) Pan-endoscopy

C)  Fine Needle Aspiration Cytology ( FNAC)

D) Test for HPV ( Human Papilloma Virus) and EBV ( Ebstein Barr Virus)

E) Prescribe antibiotic therapy and re-evaluate in 4 weeks

Question of the Week # 431

431) A 25 year old G2P1L1 at 32 weeks gestation presents with right leg swelling and pain progressively increasing over the past two days. Her previous pregnancy was uneventful except for uncomplicated C-section and she has a 2 year old healthy male child. Past medical history is negative for any significant health issues. There is no family history of clots or cancer.  Physical examination is consistent with 32 week gestation. Right lower extremity is swollen about 3cm more in calf-circumference when compared to the left. There is tenderness in right calf. A Doppler ultrasound reveals thrombosis in superficial femoral vein. Factor V leiden mutation, Lupus anticoagulant, anti-cardioloipin antibodies, prothrombin gene mutation are negative. Anti-thombin III is within normal limits. She is scheduled for C-section in 6 weeks. Which of the following is the most appropriate Statement concerning her management?

A)     Since this is not deep vein thrombosis, start her on LMWH ( Low Molecular Weight Heparin) at prophylactic doses

B)      Start warfarin and continue for total 6 months

C)      Start LMWH, discontinue 2 days prior to C-section, start unfractionated heparin followed by discontinuation 4 hrs prior to C-section and then start LMWH 12 hrs after surgery followed by Warfarin for 6 months.

D)     Start LMWH, discontinue 2 days prior to C-section, start unfractionated heparin followed by discontinuation 4 hrs prior to C-section and then start LMWH 12 hrs after surgery followed by Warfarin for 6 weeks post-partum

E)      Start LMWH now through delivery followed by warfarin for 6 months post-partum.

Question of the Week # 430

430 ) A 70  year-old man is evaluated in your office for fatigue and unsteady gait. His symptoms started 2 months and progressively increasing. He also reports numbness and paresthesias in his bilateral lower extremities. His other issues include ill-fitting dentures for which he used dental adhesives for past 2 years. His past medical history is also significant for gastric bypass surgery approximately 8 years ago for recurrent peptic ulcer disease. He receives Vitamin B12 Subcutaneously every 3 to 6 months. On presentation, he is confined to a wheelchair. Neurological examination revealed markedly decreased vibratory sensation and proprioception in the lower extremities bilaterally. Both pin-prick and light touch sensations were moderately reduced below the knees. Muscle power, bulk, tone, and reflexes were normal. Rest of his physical examination is normal. Laboratory investigations reveal hemoglobin = 8.5 g/dL, MCV= 74 fL, MCHC = 33.6gm/dl, leukopenia with a WBC =1.9k/µl and absolute neutrophil count = 475 cells/µL. His platelet count, iron studies, folate and syphilis serologies were within normal limits.  Vitamin B12 was 900pg/ml ( N = 180 to 400pg/ml) . Serum Zinc level is  600µg/dl  ( Normal is 70-150 µg/dl).

Which of the following is most appropriate at this time?

A) Check Methyl Malonic Acid Level

B) Start Penicillamine

C)  Bone Marrow Biopsy

D) CT scan of the Head

E) Discontinue dental adhesives and check Copper levels

Interpreting Mixing Studies – Hematology Highyield Concept I

Approaching Prolonged PTT and understanding Mixing Studies : 

 

ARCHER HEMATOLOGY REVIEW

Question :  On a mixing study, the PTT corrects initially but gets prolonged again after incubation for 2 hours. What is this condition?

This description of mixing studies is consistent with presence of a temperature- and time-dependent anti-VIII inhibitor. It just means that the inhibitor is a warm reacting IgG antibody that requires one or two hour’s incubation at 37°C to be detected. If the PTT corrects initially but prolongs again after incubation (meaning if thePTT is at least 15% longer than the normal reagent plasma’s incubated PTT ) –> anti-VIII should be suspected. This can be confirmed by obtaining a Factor VIII level which will be low in case of presence of inhibitor. Further coinfirmation of Factor VIII inhibitor can be obtained by Bethesda Titer. In such cases, you should also carefully review patient’s prior bleeding history – because patients with significant inhibitor will have prior bleeding history. 

 

Discussion : 

 

All about Mixing Studies :  

 Mixing studies involve mixing patient’s plasma with equal amount of normal plasma. If the PTT immediately corrects ( that is if mixture yields within 10% of normal value) – it indicates Factor Deficiency ( example : VIII, IX, XI, XII) . If the PTT does not correct – it means an inhibitor is present. Such an inhibitor is most likely to be Lupus anticoagulant (LA) if there is no bleeding history. Factor VIII inhibitor is also possible but such presence of factor VIII inhibitor would be associated with significant history of bleeding which will help you differentiate from LA . If the PTT corrects initially but prolongs again after 1 to 2 hr incubation, it means a Factor VIII inhibitor is present.

 

Approaching LA diagnosis :

After you know that there is possible LA on mixing studies, you should proceed with confirmatory tests for LA. At least Two test systems are necessary to confirm LA – to avoid false negative tests because LAs are so heterogeneous . PTT based tests can be used. Dilute Russell Viper Venom tests are sensitive and quite specific for LAs. So, Lack of correction in mixing studies of either abnormal test is presumptive evidence for LA. These results can be further followed with neutralization studies using high phospholipid reagents. Correction by the neutralizing reagents confirms the presence of LAC.Remember that Lupus anticoagulants are partof a family of antibodies called antiphospholipid antibodies. These are also detected using a series of immunoassays:· Anticardiolipin IgG, IgM, orIgA antibody· Anti-b2 glycoprotein I IgGor IgM antibody. 

 

Approaching Factor VIII inhibitor Diagnosis:

Once the mixing study corrects initially but prolongs again after 1 to 2 hour incubation such a result is more consistent with Factor VIII inhibitor ( acquired Factor VIII inhibitor). You should obtain a careful history regarding previous bleeding from the patient. Alternatively, acquired factor VIII inhibitors can develop transiently after pregnancy and/ or major surgeries and such patients will not have any history of bleeding. Also, obtain a Factor VIII level which will be low in case of presence of inhibitor. Further confirmation and levels of of Factor VIII inhibitor can be obtained by Bethesda Titer. If these patients have high Factor VIII titer and have significant bleeding, you can not treat them with Factor VIII replacement because remember the inhibitor is an antibody and giving factor viii may further induce antibody response and can be threatening. If significant titers of Factor VIII inhibitor are present and if the patient is bleeding , you must use FEBA ( Factor EIGHT BYPASS ACTIVITY) or Factor VII to treat this patient’s acute bleeding .  

Visit https://ArcherReview.com for High-Yield USMLE AND IM BOARD REVIEWS 

 

Question of the Week # 429

429) A 72-year-old man presents for an out patient follow up after being discharged from the hospital two days ago. He was admitted for a transient ischemic attack on the right side of his body which resolved spontaneously. He was worked up and subsequently discharged. Review of his in-patient investigations reveal a carotid doppler which revealed 100% stenosis of the left carotid artery and a 40% stenosis of the right carotid artery. He smoked about 1 pack per day for past several years. His past medical history includes chronic atrial fibrillation for which he has been on Aspirin alone. During the last admission, he was started on Coumadin as well. Today, his INR is therapeutic at 2.5 . His fasting lipid profile shows a calculated LDL cholesterol of 60mg%.  On examination, there are no neurological deficits. His blood pressure is 110/70 mm Hg. In addition to recommending smoking cessation and lifestyle changes along with continuation of coumadin, which of the following is most appropriate at this time?

A) Carotid Endarterectomy of Right Carotid Artery

B) Carotid Stenting of left carotid artery

C)  Carotid Endarterectomy of Left Carotid Artery

D) Carotid Magnetic Resonance Angiography

E) No other intervention indicated

Question of the Week # 428

428) A 32-year-old male boxer presents to the emergency room after sustaining an injury during a local boxing match.  He was punched by the opponent over his right ear about six hours ago . He complains of pain and swelling over his right ear. He has no hearing deficit or tinnitus or headaches or blurred vision. He denies nausea or vomiting. Past medical history is unremarkable. On examination, his vitals are stable. His right ear is red, warm and swollen with a medium sized anterior auricular swelling which is tender to palpation. There is no facial swelling. If untreated, which of the following would be most likely course of this injury?

A) Spontaneous Resolution

B) Hearing Deficit

C) Permanent ear disfigurement

D) Otitis Externa

E) Mastoiditis

Question of the Week # 427

427) A 32-year-old male boxer presents to the emergency room after sustaining an injury during a local boxing match.  He was punched by the opponent over his right ear about six hours ago . He complains of pain and swelling over his right ear. He has no hearing deficit or tinnitus or headaches or blurred vision. He denies nausea or vomiting. Past medical history is unremarkable. On examination, his vitals are stable. His right ear is red, warm and swollen with a medium sized anterior auricular swelling which is tender to palpation. There is no facial swelling. Which of the following is the most appropriate management?

A) Compressive dressing

B) Needle aspiration of the Hematoma

C) Cold compresses, analgesics and antibiotics

D) Incision and Drainage

E) Observe and await  spontaneous hematoma resolution

Question of the Week # 426

426) A 70-year-old man with history of atrial fibrillation and metallic mitral valve presents to the out patient clinic for follow up. He has been taking warfarin for the past 5 years. His INR has been in therapeutic range between 3.0 to 4.0. However, over the last one month his INR has been in the range of  1.5 to 2.0 . His other medical problems include moderate osteoarthritis and mild cognitive dysfunction. He started taking Glucosamine supplements for “preserving his joints “and Ginseng to slow “ageing of his brain”  about two months ago. He has also been started on Aspirin by his cardiologist about 1 month ago. On examination, he is afebrile and vitals are stable. Abdominal examination is benign. A repeat INR is still sub-therapeutic at 1.5. Which of the following is the most appropriate management?

A) Increase Warfarin dose by 20%

B) Stop Glucosamine and repeat INR in 1 week

C) Continue Warfarin at same dose and repeat INR in 1 week

D) Stop Ginseng and repeat INR in 1 week

E) Stop Aspirin, increase Warfarin dose and repeat INR in 1 week

Question of the Week # 425

425) A 80 day old african american woman with advanced dementia is admitted to the intensive care unit for overwhelming sepsis secondary to a urinary tract infection. At presentation she was hypoxemic and was subsequently, intubated and placed on a ventilator. Blood and urine cultures are obtained and she is started on antibiotics A chest x-ray post-intubation shows endotracheal tube in place and bilateral diffuse alveolar infiltrates. On examination, his pulse is 110/min, Blood pressure is 110/80 mm Hg and respiratory rate is 18/min with the patient on Assist-Control mode on the ventilator. Pulse oximetry reveals 88% on Fio2 90%. Chest examination reveals diffuse crackles. Cardiac examination reveals tachycardia, there is no S3 gallop. Brain natriuretic peptide level is 50 pg/ml . A 2D echocardiogram shows normal left ventricular function with an ejection fraction of 60%. His ventilator settings are as follows : Assist-Control mode; Fio2 ( Fraction of inspired oxygen) : 90%, Respiratory rate : 18/minute, Tidal Volume : 500 ml, PEEP ( Positive End expiatory Pressure) : 5 cm H20 . Arterial blood gas analysis reveals ( on Fio2 70%): pH : 7.36, pCo2 : 45 mmHg, pO2 : 55 mm Hg, Bicarbonate : 23 Meq/L

Which of the following is indicated at this time?

A) Intravenous Furosemide

B) Swan-Ganz Catheter Placement

C) Increase PEEP by 3 cm H20

D) Increase Tidal Volume to 650 ml

E) Increase Fio2 to 100%

Question of the Week # 424

424) A 3 day old male infant is evaluated for a rash that developed previous night and has been progressing. The rash first started on his face as flat red patches but now it has become bumpy and some of them have pus in it. The baby is breast feeding and there is no history of fever. The mother is healthy and none of the family members are sick at home. The baby was born by an uncomplicated vaginal delivery. On examination, he is afebrile. There are numerous small flat red patches along with yellowish-white papules and numerous pustules all over his trunk and extremities. The lesions on his face seem to be resolving. Palms and soles are not involved. A Wright-stained smear of pustular fluid shows numerous eosinophils and occasional neutrophils. A picture of the rash is shown below:

 

Which of the following is the most likely diagnosis?

A) Miliaria

B) Eosinophilic Pustular Folliculitis

C) Erythema Toxicum

D) Milia

E) Staphylococcal Pyoderma

Question of the Week # 424

424)  A 30 year old man presents to the emergency room with complaints of  right lower extremity swelling and pain over the past two days. He has had recurrent diarrhea with loose, watery bowel movements for several weeks without any blood in it. He also reports developing a red, scaly rash around his nose, mouth , genital area and on the buttocks.  He has itching and pain in the areas affected by the rash. He denies any fever or night sweats or weightloss.  He does not drink alcohol. He is sexually active with his girl friend and always uses condoms. On examination, his vitals are stable. Cardiac and respiratory examination is normal. There is  angular cheilitis.  Laboratory investigations reveals a normocytic, normochromic anemia. Stool analysis does not show any leucocytes or blood and is negative for ova and parasites. Venous doppler reveals right lower extremity deep vein thrombosis extending up to common femoral vein. Skin examination shows findings as below:

 

In addition to starting anticoagulation, which of the following should be performed next?

A) Serum Zinc Level

B) CT scan of the abdomen

C) Protein C and S levels

D) Serum Glucagon Levels

E) Factor V leiden mutation

Question of the Week # 423

423) A 14 month old male baby is brought to your office by his concerned mother for recurrent diarrhea over the past 2 months. He also developed a scaly rash around his mouth, on the cheeks and on buttocks. He has been exclusively breast-fed for about 8 months and has been started on gradual weaning process over the last four months. He is otherwise, a healthy child. There is no family history of eczema. On examination, he is afebrile and vitals are stable. Physical examination shows lesions around the ano-genital area as shown below :

Similar lesions are seen over his cheeks and around the mouth. Which of the following is indicated in this patient at this time?

A) Exclusive Breastfeeding

B) Serum Lead level

C) Serum Zinc level

D) Glucoagon level

E) Sweat Chloride Level

Question of the Week # 422

422) A 54-year-old man with history of Diabetes Mellitus and End-Stage Renal Disease is evaluated in your office during a follow up visit after undergoing hemo-dialysis in the morning. He has been dependent on Hemo-Dialysis  for past four years and undergoes dialysis thrice a week. He reports recurrent epigastric abdominal pain that is burning in quality which is relieved by taking over the counter antacids. He denies any pain at this time. He denies any nausea or vomiting. He has no history of alcohol use or smoking. On examination, he is afebrile and vitals are stable. Abdominal examination is benign. Laboratory investigations are as follows:

WBC  8.0K/µL

Hemoglobin 10.5gm%

Serum amylase 200 IU/L ( N =  25 to 160 U/L)

Serum Lipase 150 IU/L (Normal = 25 to 80U/L)

AST  30 IU/L

ALT 40 IU/L

Total bilirubin 0.6gm%

Alkaline Phosphatase 80IU/L .

Which of the following is indicated in this patient at this time?

A) Ultrasound of the Gall Bladder

B) Nothing by mouth and IV hydration

C) No further investigations or treatment

D) Endoscopic Retrograde Cholangio Pancreatography

E) CT scan of the Abdomen

Question of the Week # 421

421) A 34-year-old woman with history of oligomenorrhea presents to your clinic to discuss her results of recent work-up. One week ago, she has undergone extensive work-up for her menstrual abnormality. A serum pregnancy test is negative. Thyroid stimulating hormone, serum prolactin  level and Follicle Stimulating Hormone levels are within normal limits. Serum total testosterone is 120ng/dl ( N = 30 to 90ng/dl) and serum free testosterone is 0.9 ng/dl ( N= 0.4 to 0.8 ng/dl) . A dehydro-epiandrosterone level is 400 mcg/dl (45- 270 ug/dL) . A pelvic ultrasound reveals multiple cysts in the ovaries bilaterally. On examination, she is obese with a BMI of 32. She has excess thick and pigmented hair above her upper lip and on the chin. Which of the following is indicated in this patient at this time?

A) Fasting Plasma Glucose

B) Random Blood Glucose

C) Hemoglobin A1C

D) Oral Glucose Tolerance Test

E) Start Metformin

Question of the Week # 420

420) A 34-year-old woman with past medical history of Hypothyroidism presents to the outpatient clinic for follow-up visit. She delivered a health male baby about one week ago and has been breast feeding without any issues. She has no complaints. During the pregnancy she required increase of her levothyroxine dose to 0.175 mcg from  her usual pre-pregnancy dose of 0.125mcg. Her TSH level about 2 weeks ago was 2.0µu/ml. She denies any cold or heat intolerance, weakness or constipation. On physical examination, vitals are stable. There is no goiter. Deep tendon reflexes are normal.  Which of the following is the most appropriate management at this time?

A) Decrease Levothyroxine to pre-pregnancy dose and recheck TSH in 6 weeks

B) Repeat TSH in 6 weeks before dose adjustment

C) Increase Levothyroxine and repeat TSH in 6 weeks

D) Repeat TSH now

E) Obatin Thyroid Peroxidase antibodies

Question of the Week # 419

419) A 26-year-old woman presents for an ante-natal check up after her home pregnancy test showed positive result. Her last menstrual period was 5 weeks ago. Her past medical history includes hypothyroidism for which she has been using 125 mcg of levo-thyroxine for the past five years. She did not require any dose adjustment of her thyroid hormone therapy in the past 4 years. Her most recent thyroid stimulating hormone level ( TSH) was performed 2 weeks ago and was 2.5µU/ml ( N = 0.5 to 5.0 µU/ml). She denies any cold intolerance, weakness or constipation. She has gained about 2 lbs weight in the past one month. On physical examination, vitals are stable. There is no goiter. Reflexes are 1+ in bilateral lower extremities and there is 1+ pre-tibial edema. Laboratory investigations reveal :

Thyroid Stimulating Hormone :  2.5 µU/ml( N = 0.5 to 5.0 µU/ml)

Serum Total T4: 13.9 µg/dl ( N = 5 to 12µg/dl)

Serum Free T4 :  1.9 ng/dl ( N = 0.9 to 2.4ng/dl)

Which of the following is the most recommendation?

A) Decrease Levothyroxine and recheck TSH in 4 weeks

B) Continue same dose Levothyroxine and repeat TSH in 4 weeks

C) Increase Levothyroxine and repeat TSH in 4 weeks

D) Repeat TSH in 8 to 10 weeks

E) Check Serum thyroid binding globulin levels

Question of the Week # 418

418) A 76-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. Her other history includes Diabetes and hypertension. She presents with complaints of increasing pain in her right lower extremity for the past 2 months. The pain appears upon standing or walking down the stairs for past few weeks. Her pain gets better upon walking uphill and when she sits down to rest. There is no history of limb swelling. On examination, vitals are stable. Pulses are palpable but slightly diminished in lower extremities. Reminder of physical examination is unremarkable. Which of the following is the most appropriate diagnosis ?

A) Peripheral Artery Disease

B) Chronic Venous Insufficiency

C) Lymphedema

D) Deep Vein Thrombosis

E) Lumbar Spinal Stenosis

Question of the Week # 417

417) A 72-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. Her other history includes Diabetes and hypertension. She presents with complaints of increasing pain in her right lower extremity upon walking a block for past few weeks. The pain gets better with rest. There is no history of limb swelling. On examination, vitals are stable. Physical examination is unremarkable with out any swelling or tenderness in her extremities.

Which of the following is the most appropriate diagnosis?

a) Peripheral artery disease

b) Chronic Venous insufficiency

C) Lymphedema

d) Deep Vein Thrombosis

e) Phlegmasia Alba Dolens

Which of the following is indicated next?

A) Venous Doppler

B) Compression Stockings

C) Clopidogrel

D) Check blood pressure at ankle and elbow levels

E) Leg elevation

Question of the Week # 416

416) A 60-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. She presents with increasing swelling and mild pain in her right lower extremity over past several months. The pain is present all the time and does not get better with rest. The swelling has progressively increased and now, she has unsightly thickening of the skin. On examination, there is non-pitting edema of the entire right lower extremity. The skin is thickened and can not be pinched and lifted.

Which of the following is the most likely diagnosis?

A) Chronic Venous Insufficiency

B) Phlegmasia Alba Dolens

C) Phlegmasia Cerulea Dolens

D) Lymphedema

D) Peripheral Arterial Disease

Question of the Week # 415

415) A 60-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. Her other history includes Diabetes and hypertension. She presents with complaints of increasing pain in her right lower extremity upon walking. The pain gets better with rest. On examination, there is mild swelling of her right extremity with a 2 cm very shallow, clean, weeping ulcer on the medial malleolus with granulation tissue in the base. There is hyperpigmentation surrounding the ulcer. There is no “pitting”  of the swelling and the skin can be easily lifted from the subcutaneous tissues. Dorsalis pedis and posterior tibial artery pulses are mildly diminished.

Which of the following is indicated for her ulcer at this time?

A) Leg elevation and absorbent dressing

B) Antibiotics

C) Compression stockings

D) Anti-coagulation

E) Angiography

Question of the Week # 414

414) A 62-year-old software engineer presents with complains of mild pain and swelling in his right lower extremity which has been progressively increasing over the past 6 months. The swelling is more towards the end of the day. Pain is worse on walking or standing and gets better with rest. On examination, vitals are stable. There is non-pitting edema of right lower extremity below the level of the knee. The limb looks normal above the level of the knee. There is some bluish discoloration of the skin over the distal portion of the leg. Small intradermal bluish vessels are noted in the skin of her right lower extremity. Dorsalis pedis and tibial pulses are intact. Which of the following is the most likely diagnosis?

A) Chronic Venous Insufficiency

B) Phlegmasia Alba Dolens

C) Phlegmasia Cerulea Dolens

D) Lymphedema

D) Peripheral Arterial Disease

Question of the Week # 413

413)  A 60-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. Now, she presents with pain in her right lower extremity that started about one week ago and is progressively worse. Over the last two days, she developed bluish discoloration of the right great toe . On examination, her vitals are stable. There is gross swelling of the entire right lower extremity with bluish discoloration of right great toe and extreme tenderness . Dorsalis and posterior tibial artery pulses are slightly diminished. Which of the following is the most likely diagnosis?

A) Chronic Venous Insufficiency

B) Phlegmasia Alba Dolens

C) Phlegmasia Cerulea Dolens

D) Lymphedema

D) Peripheral Arterial Disease

Question of the Week # 412

412)  An 78 year old man with history of dementia is evaluated in your office for three episodes of “syncope” over the past two months. He lives with his daughter at home. She reports that he fell to the floor and lost consciousness in the morning after getting up from his bed and the episodes would last for few minutes but he would return to his usual baseline mental status after the event. There is no history of chest pain or shortness of breath.  She has seen him become increasingly “stiff” over the years and he has had worsening of tremors in his hands. When he writes, the letters are very small and difficult to decipher.  He has been taking Donepezil and Memantine for Alzheimer’s for about 2 years.  On examination, his pulse is 90/min, Blood Pressure 110/60 mm Hg. He has Bradykinesia and Pill rolling tremor in his hands. Cardiac examination is normal with out any murmurs. Laboratory investigations revealed a normal hemoglobin, blood glucose and electrolytes. An electrocardiogram is within normal limits. Which of the following is indicated next?

A) Orthostatic Vitals

B) 24 hour Holter-Monitoring

C) Discontinue Memantine and Donepezil

D) CT Scan of the Head

E) Tilt-Table Test

Question of the Week # 411

411)  An 88 year old man with history of moderate dementia is evaluated in your office for recurrent episodes of “syncope” over the past few months. There is no history of any chest pain or shortness of breath for a similar complaint. Nursing home staff reports that lately, he has been noted to be more confused than usual on several occasions and becomes very drowsy. He was sent to the Emergency Room twice last month for the same issue. There is no history of complete loss of consciousness. As per his nursing home chart, his other medical issues include poorly-controlled Osteoarthritis pain, “Sun-Downing” and Insomnia. On examination, his vitals are stable. He is currently awake. There are no focal neurological deficits. Cardiac examination is normal with out any murmurs. Laboratory investigations revealed a normal hemoglobin, blood glucose and electrolytes. An electrocardiogram is within normal limits. Which of the following is indicated next?

A) Orthostatic Vitals

B) 24 hour Holter-Monitoring

C) Electroencephalogram

D) Review of his medications

E) Tilt-Table Test

Question of the Week # 410

410)  A 30 year old man presents to the emergency room after having had a syncopal episode. His girl friend reports he suddenly collapsed to the floor and lost consciousness for few minutes. There was no evidence of tonic clonic movements. After regaining his consciousness, he was completely alert and awake. He reports he has had sweating and nausea prior to the episode. He has had about 2 to 3 such episodes per year for past several years. He was admitted for similar episodes in the past and telemetry monitoring was uneventful. He denied any chest pain, shortness of breath or palpitations prior to the episode. He has no other significant medical problems. On examination, his vitals are stable. He is completely awake and oriented. There are no focal neurological deficits. Cardiac examination is normal with out any murmurs. Laboratory investigations revealed a normal hemoglobin, blood glucose and electrolytes. An electrocardiogram is within normal limits. Which of the following is indicated next?

A) Holter Monitoring

B) CT scan of the Head

C) Tilt-Table testing

D) Carotid Doppler

E) Electrophysiology Study

Question of the Week # 409

409)  A 64 year old post-menopausal woman with history of  hypertension and coronary artery disease presents to the Emergency Room with severe left sided chest pain that started 1 hour ago at rest. The pain radiates to her left shoulder and her jaw. Her history is significant for per-cutaneous coronary intervention to the left anterior coronary artery and placement of drug-eluting stent 9 months ago. Her medications include aspirin, Clopidogrel, Metoprolol and Lisinopril. One week ago, she had a dental extraction procedure and had discontinued Aspirin and Clopidogel prior to the procedure. She was scared of bleeding and has not resumed these medications yet.  A chest X-ray is normal. An electrocardiogram reveals  5mm ST segment elevations in the anterior leads and reciprocal depressions in the inferior leads. Which of the following is the most appropriate explanation of this patient’s presentation?

A) Pericarditis

B) Re-Stenosis within the stent

C) Stent Thrombosis

D) Rupture of a new plaque in anterior coronary artery

E) Stenosis  from progressive atherosclerosis of anterior coronary artery

Question of the Week # 408

408)  A 52 year old post-menopausal woman with history of  hypertension, coronary artery disease and early stage breast cancer is evaluated in your office prior to breast reconstruction surgery. She was diagnosed with left breast invasive ductal carcinoma one year ago and has undergone left modified radical mastectomy followed by chemotherapy. Her history is significant for cardiac catheterization 3 months ago with coronary stent placement. Medications include Aspirin, Clopidogrel, metoprolol, lisinopril and anastrozole.  She is physically active and walks about 3 blocks per day with out any chest pain or shortness of breath.  Physical examination is unremarkable except fore evidence of left mastectomy. A resting electrocardiogram, chest x-ray , complete blood count and electrolytes are normal. Which of the following is the most appropriate recommendation at this time?

A) Schedule exercise stress test  and if normal, clear for surgery

B) Discontinue Clopidogrel and clear for surgery

C) Obtain 2D echo and if normal, clear for surgery

D) Admit, discontinue clopidogrel, start heparin and then, proceed with surgery

E) Recommend delaying surgery at least another 8 months

Question of the Week # 407

407)  A 62 year old woman with history of bilateral knee osteoarthritis  presents with complaints of progressively increasing pain of her left knee for the past one week. Her knee hurts more on standing and walking down the stairs. She denies any fever or trauma. She has no other significant medical problems. She takes acetaminophen for her osteoarthritis pain. for urinary problems. On examination, she is afebrile. Left knee is normal with out any swelling, erythema or warmth. There is severe tenderness on the medial aspect of the left leg approximately two inches below her left knee joint. When passively stretched, she has full range of motion with out any pain. Which of the following is the most likely explanation of this patient’s presentation?

A) Anserine Bursitis

B) Pre-Patellar bursitis

C) Medial Meniscus injury

D) Medial Collateral ligament injury

E) Trochanteric bursitis

Question of the Week # 406

406)  A 65 year old woman is evaluated in your office for urinary problems. She reports involuntary loss of urine upon coughing almost daily for few months. She presented with similar problems 6 months ago and has been advised pelvic floor exercises and lifestyle modifications . These measures have not improved her symptoms. She denies any nocturia, frequency, hesitancy or urgency symptoms. She has no other medical problems On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy. When she is asked to cough in lithotomy position, there is large urinary leakage about 30 seconds after coughing which was difficult for her to stop. Complete blood count, Plasma glucose, Serum electrolytes and Urinalysis are within normal limits. Which of the following is the most appropriate next step?

A) Start Vaginal Estrogen

B) Recommend Vaginal Pessary

C) Obtain Urodynamic Studies

D) Mid-Urethral Sling  placement

E) Trial of Alpha-Adrenergic Agonists

Question of the Week # 405

405)  A 80 year old woman with advanced dementia is sent to your office for evaluation of a vaginal ulcer. The patient has a history of Stage III uterine prolapse. She had been fitted with a pessary for control of her symptoms about 6 months ago. She has no history of fever or chills. On examination, she is afebrile, blood pressure is 130/80. Pelvic examination revealed complete procidentia with impacted pessary and a 2  x 2 cm ulcer without any exudate. An attempt to remove the pessary is unsuccessful. Biopsies of the ulcer have been obtained. Which of the following is the appropriate initial management?

A) Vaginal Estrogen

B) Oral Antibiotics

C) Surgical removal of Pessary

D) Hysterectomy

E) Admit for parenteral antibiotics

Question of the Week # 404

404)  A 70 year old woman in excellent physical health presents to your office because she has noticed a mass falling out of her vagina for the past one year which is progressively worse. For the past six months, she has difficulty voiding. During voiding, she has to constantly change her position and sometimes, needs to push the mass inside in order to urinate. Lately, voiding has become even more difficult despite all these measures. She has problems with defecation which she describes as having to apply pressure on her vagina in order to completely evacuate her bowel. . She denies any fever or burning  urination.  She has normal bowel movements and has no problems with defecation. She is embarrassed to have sex anymore after having had urinary incontinence during sex. She blames herself for neglecting the mass without seeking medical attention for such a long time. Otherwise, she is in excellent physical health and has no other co-morbidity. She is willing to consider any option including surgery if feasible. On examination, vitals are stable. Pelvic examination revealed a total prolapse with total eversion of the vagina which was oedematous with marked ulceration in the dependent portion of the mass. Which of the following is the appropriate initial management?

A) Obtain Urodynamic studies

B) Biopsy

C) Admit for daily Vaginal packing with estrogen

D) Vaginal estrogen and Pessary

E) Vaginal Hysterectomy

Question of the Week # 403

403)  A 68 year old woman with history of Diabetes mellitus is evaluated in your office during routine follow-up visit. She reports that lately she has been experiencing pressure and bulge in her vaginal area and has a sensation of something falling out of her vagina. She denies any fever, burning, frequency or urgency of urination.  She has normal bowel movements and has no problems with defecation. She is sexually active with her husband and enjoys it. She denies any urinary incontinence even upon coughing or sneezing. On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy and a Grade 1 Cystocele.  Which of the following is the most appropriate recommendation?

A) Screen for latent Stress incontinence

B) Observation

C) Pessary

D) Surgery

E) Raloxifene

Question of the Week # 402

402)  A 68 year old woman with history of Diabetes mellitus is evaluated in your office during routine follow-up visit. She reports that lately she has been experiencing pressure and bulge in her vaginal area and has a sensation of something falling out of her vagina. She denies any fever, burning, frequency or urgency of urination.  She has normal bowel movements and has no problems with defecation. On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy and presence of moderate cystocele.   She has marked urinary leakage when she was asked to cough in lithotomy position. Complete blood count, Plasma glucose, Serum electrolytes and Urinalysis are within normal limits. She requests information regarding surgery for vaginal prolapse. Which of the following is the most appropriate statement regarding surgery for her cystocele?

A) Surgery may worsen her Incontinence

B) Surgery may increase urinary obstruction

C) If she were to undergo prolapse surgery, no additional incontinence treatment is needed

D) Surgery may cause defecation problems

E) Surgery is optimal option for her at this time.

Question of the Week # 401

401)  A 78 year old woman presents for annual health-maintenance examination. Her medical problems include Hypertension, Diabetes, Coronary artery disease and Chronic obstructive pulmonary disease. During review of systems, she reports that she has been experiencing involuntary loss of urine upon coughing almost daily for few months. She has been too embarrassed to disclose it and so, has not mentioned it during previous visits. However, the problem has been limiting her social activities and she really would like to “do something about it”. She denies any nocturia, frequency, hesitancy or urgency symptoms. Her medications include albuterol, ipratropium, glyburide, clopidogrel and losartan. She had a myocardial infarction followed by coronary stent placement six months ago. On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy and presence of moderate cystocele.   She has marked urinary leakage when she was asked to cough in lithotomy position. She has tried pelvic floor exercises and scheduled-voiding for past several weeks and has cut down on her coffee consumption however, these measures have not helped her much.  Complete blood count, Plasma glucose, Serum electrolytes and Urinalysis are within normal limits. Which of the following is the most appropriate recommendation for this patient?

A) Check Post-Void Residual volume

B) Vaginal Estrogen

C) Pessary

D) Mid-Urethral Sling placement

E) Oxybutynin

Question of the Week # 400

400)  A 28 year old woman with history of depression is brought to the emergency room by her friend after she purposefully took large number of acetaminophen tablets. Her friend can not estimate how many tablets she took but she says there were at least fifty extra strength tablets in the bottle and the bottle was found empty when she went to visit her. She last spoke with her 18  hours ago over the phone when she sounded very depressed. So, her friend reports she probably must have ingested these tablets at least  12 to 18 hrs ago. On examination, she is drowsy but arousable. Her liver function tests are within normal limits and an acetaminophen level is 15µg/ml . Serum electrolytes, creatinine , prothrombin time and INR are within normal limits. Which of the following is the initial step in management

A) Hemo-Dialysis

B) Supportive care with strict monitoring of Liver function, Creatinine and INR

C) Activated Charcoal

D) N-Acetyl Cysteine

E) Consult Liver Transplant expert

Question of the Week # 399

399)  A 65 year old man with history of diabetes mellitus is evaluated in your office during a routine follow-up visit. He does not have any complaints. He uses Glyburide and Metformin for his diabetes and Atorvastatin 80mg/day and Omega-3 Fatty Acids  for his dyslipidemia. He is compliant with diet and exercise. His weight has been stable. He does not smoke or consume alcohol. His most recent HgbA1C was 6.0% and a fasting lipid panel a month ago showed Total cholesterol of 125 mg%, LDL-C 70mg%, Triglycerides 100mg% and HDL-C 35mg%. You discuss with him that his lipid panel meets the recommendations with regard to LDL cholesterol and Non-HDL cholesterol goals. However, he insists that he be treated for his low HDL-cholesterol. You offer adding Niacin but after he heard about it’s side effects he refuses it and seeks alternatives.  Which of the following is the most appropriate recommendation for him?

A) Change Atorvastatin to Rosuvastatin

B) Add Cholestyramine

C) No further therapy

D) Discontinue Omega-3 Fatty Acids

E) Increase Atorvastatin

Question of the Week # 398

398)  A 45 year old man with well-controlled diabetes presents to your office with complaints of troublesome flushing of his face and trunk for the past one week. Frequently, the flushing is severe and causes stinging sensations. His past medical history is significant for dyslipidemia with an isolated low HDL cholesterol for which he was started on Niacin one week ago. On examination, his blood pressure is 120/88 mm Hg.  His face and trunk have flushed appearance. Reminder of physical examination is unremarkable. Which of the following is the most appropriate recommendation for him at this time?

A) Discontinue Niacin

B) Take Niacin with food

C) Diphenhydramine as needed

D) Take Aspirin before Niacin

E) Re-assure symptoms will bate in one week

Question of the Week # 397

397)  A 65 year old man with past medical history of Hypertension presents to your office to discuss his lipid profile results which were obtained two weeks ago.  He takes Losartan for his high blood pressure and is compliant with 2gm sodium diet. He smoked about 1 pack per day for the past 35 years. On examination, his blood pressure is 140/88 mm Hg. Reminder of physical examination is unremarkable. His fasting lipid panel reveals Total cholesterol 220 mg%, LDL-C 150mg%, Triglycerides 150mg%, HDL-C 40mg%. Which of the following is the most appropriate initial step?

A) Diet and lifestyle modifications alone

B) Diet, Lifestyle modification and Statin therapy

C) No Intervention

D) Omega 3 Fatty Acids

E) Repeat Lipid Panel in 3 months

Question of the Week # 396

396)  A 45 year old woman presents to your office for annual physical examination. She reports that she has had a fasting lipid panel done 6 months ago and her HDL – C was low at 25 mg%. She requests to be treated for this. She started healthy diet rich in fruits and vegetables. She used to smoke about 4 cigarettes/ day earlier but quit smoking after she came to know about her lipid results. She occasionally uses red wine in moderate amounts. She has also started aerobic exercises at least 3 days per week. Physical examination is unremarkable. A repeat lipid panel reveals Total cholesterol 128 mg%, LDL-C 80mg%, Triglycerides 100mg%, HDL-C 28mg%. Which of the following is the most appropriate next step?

A) Fenofibrate

B) Niacin

C) Ezetemibe

D) Atorvastatin

E) Omega-3-Fatty Acids

Question of the Week # 395

395)  A 65 year old man with history of Hypertension, Peripheral Artery disease and Dyslipidemia is seen during a follow-up office visit. His medications include Atorvastatin 80mg, Enalapril 20mg and Clopidogrel 75 mg/ day.  He does not have any new complaints and tolerating his medications well. He still smokes about 1 pack per day despite repeated counselling however, he has been strictly compliant with low-fat diet. On examination, his vitals are stable. Lower extremity dorsalis pedis are slightly diminished bilaterally. Reminder of the examination is unremarkable. A fasting lipid profile obtained a week ago showed :  Total Cholesterol : 205 mg% LDL cholesterol (calculated) 90mg%, HDL – cholesterol 45 mg%, Triglycerides 350mg%.  Liver function tests , Serum electrolytes, Creatinine and Complete blood count are within normal limits. Which of the following is the most appropriate next step?

A) Add Fenofibrate

B) Add Niacin

C) Add Cholestyramine

D) Change Atorvastatin to Rosuvastatin

E) Increase the dose of Atorvastatin

Question of the Week # 394

394)  A 36 year old woman with Type I diabetes mellitus presents to your office because she just learned that she is pregnant. She is excited and seeks your advise. Her home blood sugars are well controlled on a basal-bolus regimen of Glargine and Lispro insulin. Her other medications include Atorvastatin and aspirin. Her most recent HgbA1C was 6.0%. Her records also reveal that her most recent fasting lipid profile met the therapeutic goals at LDL of 80mg% and Non-HDL cholesterol of 100mg%. On examination, she is comfortable. Vitals are stable and reminder of the examination is unremarkable. An office based serum pregnancy test is positive. A repeat fasting lipid profile reveals Total Cholesterol : 250 mg% LDL cholesterol (calculated) 140mg%, HDL – cholesterol 40 mg%, Triglycerides 350mg%.  Liver function tests , Serum electrolytes, Creatinine and Complete blood count are within normal limitsWhich of the following is the most appropriate next step?

A) Therapeutic Abortion

B) Add Niacin to her Lipid Regimen

C) Discontinue Statin and Start Niacin

D) Discontinue Statin and advise Diet modification alone

E) Increase Atorvastatin

Question of the Week # 393

393)  A 36 year old homeless man is evaluated in the Emergency Room for intermittent fever, cough, night sweats and weight-losss. He also reports having chronic cough with progressively increasing bloody expectoration for the past 1 month. He has lost about 10lbs weight over the past 3 months. He smokes 1 pack per day and has a history of intravenos drug abuse. On examination, he is cachectic.  He is afebrile, Pulse is 84/min, Respiratory rate 18/min, Blood pressure 120/80 mm Hg, Oxygen saturation 98%.  Reminder of the physical examination is unremarkable. Which of the following is the most appropriate initial step in managing this patient?

A) Sputum samples for Acid Fast Bacilli

B) Start Multi-drug therapy for Tuberculosis

C) Obtain a Chest X-ray

D) Tuberculin Skin test

E) Air-Borne Isolation

F) Test for HIV

Question of the Week # 392

392)  A 28 year old woman presents with a history of amenorrhea of about 6 month duration. She does not have any breast discharge, visual deficits or headaches. Her home pregnancy test was negative a week ago. Her past medical history is significant for three missed abortions for which she underwent dilatation and curettage. On examination, her vitals are stable. Body mass index is about 22 . Breast examination is normal with out any discharge.  Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  A trial of medroxyprogesterone and a later trial of estrogen-progesterone combination fails to induce bleeding. Which of the following is the most appropriate next step?

A) Anti-phospholipid Antibodies

B) Hysteroscopy

C) Dehydro-epiandrosterone level

D) Pituitary MRI

E) Ultrasound of Ovaries

Question of the Week # 391

391)  A 26 year old woman is seen in the outpatient clinic for amenorrhea of about 6 months. The patient ah d been on oral contraceptives but discontinued 6 months ago. She reports having regular menstrual cycles prior to  starting oral contraceptives. She denies any excessive stress or physical activity. She does not have any breast discharge, visual deficits or headaches. presents to your office with complaints of change in her menstrual cycles. On examination, her vitals are stable. Body mass index is about 28 . Breast examination is normal with out any discharge. Pelvic exam is normal. Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  The patient is started on  medroxyprogesterone acetate at 10 mg/ day for 10 days and experiences menstrual bleeding a week after stopping progesterone. This patient is at increased risk for which of the following conditions?

A) Visual Deficits

B) Endometrial Cancer

C) Osteoporosis

D) Pituitary Necrosis

E) Vertebral Compression Fractures

Question of the Week # 390

390)  A 28 year old woman has had amenorrhea for the past 4 months. She reports having regular menstrual cycles prior to these episodes. She is sexually active and a home pregnancy test was negative on two occasions over the last one week. She denies any excessive stress or physical activity. She has had headaches almost daily over the past three months. She denies any visual deficits. Her past medical history is significant for schizophrenia for which she is using risperdal for several years with good control of her disease. On examination, her vitals are stable. Body mass index is about 28 . There is milky discharge on breast examination. Pelvic exam is normal. Serum pregnancy test is negative. A serum prolactin level is 30mcg/ml (5 to 20 mcg/L). A serum Thyroid Stimulating Hormone and Follicle Stimulating Hormone level are within normal limit. An MRI of the brain reveals 10 cm lobulated mass in the anterior skull base. Which of the following is the initial step in evaluating this patient?

A) Repeat Prolactin after Serum Dilution

B) Discontinue Risperdal

C) Trans-Sphenoidal Resection of the Tumor

D) Pituitary Irradiation

E) Bromocriptine

Question of the Week # 389

389)  A 26 year old woman is seen in the outpatient clinic for amenorrhea of about 6 months. The patient ah d been on oral contraceptives but discontinued 6 months ago. She reports having regular menstrual cycles prior to  starting oral contraceptives. She denies any excessive stress or physical activity. She does not have any breast discharge, visual deficits or headaches. presents to your office with complaints of change in her menstrual cycles. On examination, her vitals are stable. Body mass index is about 28 . Breast examination is normal with out any discharge. Pelvic exam is normal. Serum pregnancy test is negative. A serum Thyroid Stimulating Hormone, Prolactin level and Follicle Stimulating Hormone level are within normal limit.  The patient is started on  medroxyprogesterone acetate at 10 mg/ day for 10 days and experiences menstrual bleeding a week after stopping progesterone. Which of the following explains her amenorrhea?

A) Past use of Oral Contraceptive Pills

B) Uterine Adhesions

C) Hypothalamic amenorrhea

D) Polycystic Ovarian Syndrome

E) Premature Ovarian Failire

Question of the Week # 388

388)  A 58 year old man with history of  severe depression is brought to the emergency room with altered mental status. He has been on treatment with amitryptyline for depression for many months. He is accompanied by his wife who reports that they had re-filled one month supply of amitryptyline a week ago but today she discovered an empty bottle at his bedside.  He There is no history of fever, nausea, vomiting or diarrhea. There is no evidence of  any witnessed seizure.  On examination, he is disoriented and lethargic. He is afebrile, Pulse is 84/min, Respiratory rate 18/min, Blood pressure 120/80 mm Hg, Oxygen saturation 98%. He does not respond to verbal commands. Gag reflex is present. Respiratory examination is normal with out any wheezing, rhonchi or crepitations. Cardiac examination and abdominal exam is benign. Intravenous Naloxone and Thiamine were administered in the field without any response. An electrocardiogram is normal. Serum electrolytes and complete blood count, finger stick glucose and arterial blood gases are within normal limits. The patient is intubated and is placed on ventilator. Which of the following is the most appropriate next step?

A) Activated Charcoal

B) Procainamide

C) Sodium Biacrbonate

D) Lidocaine

E) Amiodarone

Question of the Week # 387

387)  A 56 year old man with history of depression and hypertension is brought to the Emergency Room by his sister for altered mental status. There is no history of fever, nausea, vomiting or diarrhea. There is no evidence of  any witnessed seizure. She is not aware of what medications he takes. On examination, he is disoriented and lethargic. He is afebrile, Pulse is 84/min, Respiratory rate 18/min, Blood pressure 80/40 mm Hg, Oxygen saturation 98%. He does not respond to verbal commands. Gag reflex is present. Respiratory examination si normal with out any wheezing, rhonchi or crepitations. Cardiac examination and abdominal exam is benign. Intravenous Naloxone and Thiamine were administered in the field without any response. An electrocardiogram is normal. Serum electrolytes and complete blood count, finger stick glucose are within normal limits. Arterial blood gases does not show any acidemia. A urine drug screen reveals:

Cocaine  – Negative

Amphetamines – Negatives

Benzodiazepenes – Positive

Opiates – Negative

Cannabis – Negative

Tricyclic Anti-Depressants – positive

A suction of his airway and central line are placed and he is started on intravenous fluids. His systolic blood pressure remains in 70 to 80 mm Hg range

Which of the following is the most appropriate next step?

A) Activated Charcoal

B) Intravenous Flumazenil

C) Serum Alkalinization

D) Start Norepinephrine

E) Intravenous Lidocaine

Question of the Week # 386

386)  A 54 year old man presents to the emergency room with dizziness and intermittent palpitations for the past 12 hours. He denies any syncopal episodes or headache or seizures. He has no significant cardiac history. He was seen in the outpatient clinic one week ago for pneumonia and was started on Moxifloxacin. His other medical problems include hypertension for which he is on enalapril and Gastro-esophageal reflux disease for which he takes esomoprazole.  Physical examination reveals regular heart sounds and no murmurs.  Complete Blood Count and Serum electrolytes are within normal limits. An electrocardiogram is obtained and is shown below:

Which of the following is the most appropriate action at this time?

A) Intravenous Magnesium sulfate

B) Discontinue Moxifloxacin

C) Discontinue Esomoprazole

D) Transvenous Pacing

E) Intravenous Isoproterenol

Question of the Week # 385

385)  A 74 year old man with advanced dementia is sent from nursing for evaluation of umbilical hernia. He is accompanied by his sister who thought that the bulge looked ” ugly” and demanded that he be evaluated for surgery.  The patient has been nursing home bound for the past four years. There is no history of nausea or vomiting. When fed, he eats normally. The patient is not oriented and is unable to give further history. He does not have living will or a power of attorney. On examination, his vitals are stable. He appears comfortable. Abdominal examination showed a palpable bulge in the umbilical area which is reducible. There is no erythema and the patient winces when pressure is applied. There is no rigidity. When tried to explain him about possible surgery, the patient does not comprehend. He is not oriented to place, person or time. Which of the following is the most appropriate action at this time?

A) Do not consent for surgery

B) Obtain Psychiatry evaluation for Capacity assessment

C) Re-Evaluate his competence to make decisions

D) Consent him for surgery

E) Obtain Consent from his sister

Question of the Week # 384

384)  A 55  year old airline pilot presents for a follow-up visit for hypertension. He was diagnosed with hypertension a year ago and has been on treatment with hydrochlorthiazide and lisinopril.  He denies any chest pain, palpitations or shortness of breath on exertion. He has no other significant health issues. His Hemoglobin a1C about 6 months ago was 5.0% . A lipid profile obtained 3 months ago showed a total chlesterol of 270mg% with HDL cholesterol of 34mg%. He  smokes about 1 pack per day but denies any drug or alcohol abuse.  There is no family history of Diabetes or coronary artery disease or abdominal aorta aneurysm. On examination, his blood pressure is 138/74. Cardiac examination shows regular heart sound with no S3 gallop or S4. There are no audible murmurs. Abdominal examination is benign and there are no audible bruits. A complete blood count, comprehensive metabolic panel and urinalysis are unremarkable. A resting electrocardiogram shows changes consistent with left ventricular hypertrophy. He had a colonoscopy five years ago which was normal. Which of the following is indicated at this time?

A) No additional Tests

B) Exercise Stress Test

C) Cardiac catheterization

D) Abdominal Ultrasound for Aortic aneurysm

E) Fecal Occult Blood Testing

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