Question of the Week # 479

479. A 57 year old female presents for second opinion of a left breast lesion that had been diagnosed as ‘eczema’ by her regular nurse practitioner, which briefly improved after a short course of topical steroids. On physical exam there is an erythematous, scaly lesion involving the left breast. Image is shown below. Her last mammogram was a year ago and it was “fine”. She does not report any family history of breast cancer. What is the next step in the patient’s management?

image br rash

A – Bilateral breast ultrasound

B – Bilateral mammography and punch biopsy of nipple

C – Maintain regular annual mammography appointment

D – Oral corticosteroids

E – Left breast MRI

Question of the Week # 456

Your patient is a 48-year-old postmenopausal female with recent onset of stage I hypertension.  She has a history of osteoporosis. On exam, her blood pressure is 155/90, heart rate is 80 and regular, and respirations are 16. Cardiovascular examination is unremarkable. She has no other medical history. She has previously been controlling her hypertension with lifestyle modifications and diet. Which of the following medications is the best choice for initial pharmacological treatment of her hypertension?

A. Calcium channel blocker

B. Thiazide diuretics

C. Angiotensin receptor blocker

D. Alpha-adrenergic blocker

E. Angiotensin converting enzyme inhibitor

Question of the Week # 448 and 449

Q448  ) A 78 year old man presents to emergency room with severe pain in his right lower extremity. Pain began after he stumbled and fell on a sidewalk. He does not report pain anywhere else and did not lose consciousness. No tingling or numbness in either extremity. He reports inability to bear weight because it is extremely painful. His past medical history is significant for coronary artery disease and hypertension. He does report about 8lbs weight-loss in the past 1 month.  On examination, he is afebrile. There is tenderness in the right thigh area. Laboratory investigations reveal Hemoglobin 10.5gm%, Platelet count 110k/ul, Calcium at 10.4 mg/dl ( N = 9.0 to 10.5 mg/dl) , Serum creatinine 2.0 mg/dl, Total protein 4.5 gm/dl, Albumin 2.0gm/dl and Ferritin 200 ng/ml.  Liver function tests including Alkaline phosphatase are within normal limits. Whole body bone scan is negative for any lesions. Serum protein electrophoresis is normal with out any monoclonal spike.

An x-ray of the femur is shown  below :


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

A) Colonoscopy

B) DEXA scan

C) 24 hour urine electrophoresis

D) Vitamin D level

E) Parathyroid hormone level


449) Which of the following is likely to explain the patient’s findings?

A) Metastatic colon cancer

B) Multiple Myeloma

C) Osteoporosis

D) Secondary Hyperparathyroidism

E) Metastatic Prostate cancer

Question of the Week # 446

446) A 64 year old woman presents to your office with productive cough and fever for the past three days. About two months ago, she was admitted for pneumonia. Past medical history is significant for Rheumatoid arthritis. Her medications include hydroxychloroquine and prednisone. Previously, she was treated with Azathiprine for about 6 years.

On examination, temperature is 101F, blood pressure 120/80 and heart rate of 106/min.  Chest examination reveals decreased breath sounds at left lower lobe. No hepatomegaly, spleen tip is palpable. Chest X-Ray reveals left lower lobe consolidation  Labs reveal WBC 1000/µl with differential count showing neutrophils of 30% and Hemoglobin 9.9 gm%

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

A) Hypogammaglobulinemia from Rheumatoid arthritis

B) Marrow suppression by Hydroxychloroquine

C) Marrow toxicity by Azathiprine

D) Myeloproliferative disorder

E) Felty Syndrome

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 # 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

Question of the Week # 382

382)  A 36  year old Caucasian man presents for a pre-employment health physical. He denies any health problems in the past. He does not smoke or drink alcohol. He denies drug abuse.  He enjoys good health and has no significant medical issues. He has no family history of Hypertension, Dyslipidemia, Diabetes or coronary artery disease.  On examination, his blood pressure is 118/74. Body Mass Index is 24kg/m2. 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, urinalysis and urine drug screen are unremarkable. Which of the following is indicated at this time?

A) No additional Tests

B) Serum Total Cholesterol and HDL – cholesterol

C) Hemoglobin A1C

D) Fasting Plasma Glucose

E) Prostate Specific Antigen

Question of the Week # 359

359)  A 50 year old woman with history of Diabetes Mellitus presents to your office with complaining of discomfort in her both legs for past few months. She describes unpleasant sensations as well as abnormal sensations such as including tingling, creeping and itching sensations deep in her legs while sitting. Walking a few steps relieves her symptoms. She denies any pain in the legs upon walking or at rest. Physical examination reveals slightly diminished pulses in bilateral lower extremities.  Which of the following is the first step in managing her symptoms?

A) Nerve Conduction Studies

B) Cilostozol

C) Dopamine Agonists

D) Obtain Serum ferritin

E) Gabapentin

Question of the Week # 358

358)  A 36 year old man presents to your office for an annual health examination. During review of systems, he reports  feeling excessively sleepy during the day and forgetful at work. He states no matter how much he slept, it  does not make him feel rested in the morning. He denies snoring at night. He is athletic and maintains his body weight in a healthy range. He denies alcohol consumption, smoking or excessive caffeine use. His girlfriend reports that he abruptly moves his legs often during the night and that disturbs her as well. She has noticed him flexing his leg and extending his great toe repeatedly. The patient is not aware of this and he denies any pain or discomfort in his legs. Physical examination is unremarkable. Laboratory investigations including complete blood count, serum creatinine, electrolytes and a thyroid stimulating hormone are within normal limits. Which of the following is the most likely diagnosis?

A) Complex Partial Seizures

B) Restless leg syndrome

C) Nocturnal Leg Cramps

D) Myoclonus

E) Periodic Limb Movement Disorder

F) Sleep Apnea

Question of the Week # 357

357)  A 52 year old man is seen in your office for pain in his legs that bothers him during sleep. He describes these episodes as aching and painful tightness particularly, in his posterior calves. The pain is relieved by forcefully stretching his leg muscles in opposite direction. He experiences these at least for about 2 to 3 nights per week and interferes with his sleep. He works as a coach for the local high-school soccer team and is physically very active. He has no other past medical problems and enjoys healthy living. On examination, his blood pressure is 122/80. Oral mucosa re moist.  There are no focal neuroligical deficits. Extremities appear normal with out any deformity, swelling or palpable tenderness. Peripheral pulses are normal. Serum electrolytes, Calcium, magnesium , a complete blood count, thyroid stimulating hormone and blood glucose are all within normal limits.  Which of the following is the most appropriate next step in managing his problem?

A) Start Ropinirole

B) Start Bromocriptine

C) Recommend non-pharmacological measures

D) Quinine Trial

E) Oral Iron Trial

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