Question of the Week #484

A 50-year-old African american woman presents to your clinic with increased thirst and increased urination. You review her old records and it appears like she had a Chest X-ray in the ER last year that showed bilateral hilar lymphadenopathy. She was advised follow-up but she did not comply at that time. Upon examination, you discover some subcutaneous skin nodules and biopsy of one of these comes back positive for non-caseating granulomas.

Laboratory studies from a week ago show:

Hemoglobin 15.2gm%

Calcium : 11.6mg%

Creatinine : 1.0mg%

Which of the following investigations may explain the underlying mechanism of her Hypercalcemia?

A. Biopsy of Hilar Lymph Node

B. 25 Hydroxy Vitamin D Level

C. PTH related peptides

D. 1,25 di-hydroxy Vitamin D level

E. Serum Protein Electrophoresis

Question of the Week # 445

445) A 45 year old african-american man presents to the emergency room with altered mental status. His past medical history is significant for skin nodules. One of the nodule was recently biopsied and it revealed non-caseating granuloma. On examination, his oral mucosae are dry.  Blood pressure is 90/60 . Skin examination  reveals multiple scattered skin nodules about 1 to 2cm in diameter. Chest X-ray reveals bilateral hilar adenopathy.   Laboratory Studies reveal

WBC 5400/µl

HGB: 11.8 gm%,

Platelets : 300k/µl

Calcium 14.2gm%

Creatinine 3.2mg%

Phosphorous 2.2mg%

He is started on agressive intravenous hydration. In addition to the above  measures, you should also proceed with  intervention directed to towards which of the following at this time ?

A) Reducing serum phosphorous

B) Reducing serum parathyroid hormone

C) Reducing Blood Calcitrol level

D) Promoting loop diuresis

E) Direct removal of calcium by Hemodialysis

Question of the Week # 330

330) A 55 year old man is brought by the EMS to the emergency room in a disoriented state. The patient has alcohol smell on his breath. Reviews of his past records reveal history of chronic alcohol abuse. His girlfriend arrives in the ER few minutes later and she reports that the patient has not been eating anything because he has been drinking heavily and vomiting over the past three days. On examination, he is afebrile, blood pressure 130/82 mm Hg, RR 18/min and Pulse 82/min. When the nurse attempts to check blood pressure, the patient develops carpo-pedal spasm (Trousseau sign). Chest is clear to auscultation.

Laboratory investigations reveal:

Ethanol level 140mg%

Serum Sodium 142 meq/L

Serum Potassium 3.2meq/L

Serum Chloride 106meq/L

Calcium 6.2 mg% (N = 9.0 to 10.5)

Bicarbonate 25 meq/L

Creatinine 1.2 mg%

Albumin 3.9 gm% (N = 3.5 to 5.0 gm %)

Patient is treated with Calcium gluconate and then, another dose of calcium chloride. Repeat serum calcium level is 5.8mg%. Trousseau sign is still positive.

Which of the following is the most appropriate next step in managing this patient?

A) Obtain Serum Ionized Calcium

B) Obtain Serum Magnesium Level

C) Obtain Paratharmone level

D) Start potassium chloride

E) Obtain Vitamin D level

Question of the Week # 318

318)  A 55 year old woman underwent a debulking surgery with total abdominal hysterectomy, Salpingo-oophorectomy, omentectomy and appendicectomy for a recently diagnosed Stage IIIC  Epithelial Ovarian Cancer. Her intra-operative course was complicated by severe blood loss and she received about 15 units of Packed Red Blood Cells. She is currently in the intensive care unit. Six hours after surgery, her blood pressure drops to 80/50 mm Hg. On examination, she is afebrile. She is drowsy but can be awakened. She denies any chest pain or shortness of breath. She has muscle tremors. Chest is clear to auscultation. Abdominal sutures are intact with no clinical evidence of Hematoma. An electrocardiogram is shown below:

Which of the following is the most likely explanation of the patient’s acute findings?

A) Hyperkalemia

B) Acute Myocardial Infarction

C) Circulatory Overload

D) Transfusion Associated Acute Lung injury

E) Citrate Toxicity

Question of the Week # 317

317)  A 68-year-old african-american man with history of NYHA Class III congestive heart failure  presents to your office for a follow up visit. His other medical problems include Hypertension, Stage II chronic kidney disease and Coronary artery disease. During his office visit three months ago , she was noted to have moderate hyperkalemia. At that time, his medications were adjusted which involved discontinuation of spironolactone and dose-reduction of ACE inhibitor. His other medications included Atenolol and Aspirin. She reports that she was admitted to hospital two weeks ago with severe hyperkalemia.  He denies any complaints at this time. A serum potassium level is 4.5mEq/l , serum creatinine 1.8mg% and most recent echocardiogram revealed a left ventricular ejection fraction of 35%  . His current medications include Atenolol, Hydrochlorthiazide and Aspirin. Which of the following is the most appropriate next step?

A) Re-start ACE inhibitor at a lower dose

B) Start Angiotensin Receptor Blocker (ARB)

C) Start Hydralazine and Isosorbide

D) Continue current medications

E) Start Spironolactone

Question of the Week # 316

316)  A 72-year-old man was admitted to the hospital with right leg deep vein thrombosis. He has a history of prostate cancer, well-controlled diabetes and mild renal insufficiency. His baseline creatinine is usually between 1.4 to 1.6mg%. His laboratory investigations at admission were normal except for increased creatinine at 1.4mg% . Venous doppler showed leg femoral deep vein thrombosis in femoral vein. He was started on Heparin drip and oral warfarin.  Three days after admission, the patient develops persistent hyperkalemia (6.5 to 7.0 mEq/l). Rest of his electrolytes are normal and renal function is at his baseline. His INR ( International Normalized Ratio) is 1.4. There are no EKG abnormalities. His Urine Osmolality is 300mOsm/kg, Urine K 20 mmol/L and Serum Osmolality 280 mOsm/kg.  He is given insulin and dextrose therapy however, hyperkalemia persists. Which of the following is the most appropriate next step in management?

A) Start Kayexalate

B) Discontinue Heparin and Start Enoxaparin

C) Discontinue Heparin and place Green field filter

D) Hemodilaysis

E) Intravenous Sodium bicarbonate

Question of the Week # 315

315)  A 64-year-old man with history of diabetes mellitus is evaluated in your office during a follow-up visit . He was admitted to the hospital one week ago because of incidentally discovered high serum potassium of 7.0mEq/L on his routine labs. He has history of hypertension and Stage I chronic kidney disease . His medications prior to the hospital admission included glyburide and enalapril. However, Enalapril was discontinued and he was started on hydrochlorthiazide during that admission. He denies any complaints at this time. A serum potassium level is 4.5mEq/l , serum creatinine 1.8mg% and urinalysis reveals proteinuria. 24 hour urine collection reveals 300mg proteinuria/24hrs. Which of the following is the most appropriate next step?

A) Re-start Enalapril at 50% of  previous dose

B) Start Losartan

C) Start Hydralazine and Isosorbide

D) Start Spironolactone

E) Renal biopsy

 

Question of the Week # 314

314)  A 70-year-old man presented to the Emergency room with a 2-day history of increased thirst and frequency of urination. He reports generalized muscle weakness. His past medical history is significant for hypertension, diabetes mellitus and Stage III chronic kidney disease. His medications include Insulin Glargine, Lispro insulin, Enalapril , Atenolol and Spironolactone.  Laboratory investigations reveal

Blood glucose 400mg%

Sodium 130 mEq/L

Potassium 7.5 mEq/L

Bicarbonate 26mEq/L

Chloride 100mEq/L

Creatinine 4.2mg%

An electrocardiogram is shown below:

 

Which of the following is the most appropriate next step?

A) Reduce the dose of Enalapril

B) Hemodialysis

C) Insulin Intravenous

D) Calcium Gluconate IV

E) Sodium biacrbonate IV

Question of the Week # 159, 160

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

A) Stop Metformin

B) Switch to insulin

C) Vitamin b12 and Calcium supplementation

D) Start Gabapentin

E) Start Thyroid Supplements

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

A) Diabetes related complications

B) Chronic Metformin Use

C) Poor Glycemic Control

D) Myelodysplastic Syndrome

E) Hypothyroidism 

Question of the Week # 158

158) A 55 year old man comes to the Emergency Room complaining of left upper quadrant discomfort. His physical examination reveals Splenomegaly. Laboratory investigations were sent but there was a significant delay in sending the specimen to the laboratory after collection. Laboratory investigations reveal a WBC count of 110,000/µl with neutrophilia,  basophilia and eosinophilia and Serum potassium of  3.0/µl. Leucocyte Alkaline Phosphatase level is low. A bone marrow biopsy is obtained and the results are pending. The most likely explanation of the patients hypokalemia :

A) Delay in specimen transport to lab

B) Marked Leucocytosis and Delay in specimen transport

C) Tumor Lysis

D) Splenomegaly

E) Renal loss

Question of the Week # 157

157) A 25 year old woman presents to your office with complaints of muscle cramps and weakness. She smokes 1 pack cigarettes per day and chews tobacco and flavored gum. She also has history of alcoholism and ingests about one pint of vodka every day for the past 2 years. She also uses “Ecstasy”  during weekend parties. She has a history of snoring in the night. On examination,  afebrile,  heart rate is 88/min and blood pressure is 150/98.  Laboratory investigations reveal a Sodium of 144 meq/L, potassium of 3.0meq/L, Chloride 98meq/L , Bicarbonate of 34meq/L and Creatinine of 0.8mg%. Urinary chloride is 45meq/L. Which of the following points in the patient’s history is most helpful in diagnosing her condition?

A) Alcohol use

B) Chewing tobacco and flavored gum

C) Snoring in the night

D) Smoking

E) Use of Ecstasy

Question of the Week # 156

156) A 25 year old woman presents to your office with complaints of muscle cramps and weakness. On examination, she is afebrile,  heart rate is 88/min and blood pressure is 150/98.  Ophthalmoscopic examination shows the following :

Laboratory investigations reveal a Sodium of 144 meq/L, potassium of 3.0meq/L, Chloride 98meq/L , Bicarbonate of 34meq/L and Creatinine of 0.8mg%. Urinary chloride is 45meq/L. The most likely diagnosis that explains this patient’s clinical features :

A) Gitelman’s syndrome

B) Chronic Laxative abuse

C) Diuretic Abuse

D) Primary Hyperaldosteronism

E) Bartter’s syndrome

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