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 :

bone

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 # 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 # 347

347)  A 34 year old man is recently diagnosed with Stage IIA Hodgkin’s  lymphoma and has received one cycle of chemotherapy with Adriamycin, Bleomycin, Vinblastine and Dacarbazine. He is scheduled to receive three more cycle followed by involved field radiation therapy.  One week after his first cycle of chemotherapy, he presents to your office with increasing swelling of his legs. He denies any fever, chest pain, rash or shortness of breath. On examination, breath sounds are decreased in bilateral lower lungs. There is 2+ edema in his lower extremities. Laboratory investigations show reduced albumin at 2.5gm%. Urinalysis reveals 3+ proteinuria with out any evidence o red cells or red cell casts. A MUGA ( Multigated Acquisition Scan) has been ordered to evaluate his cardiac function and results are pending. Which of the following is most likely explanation of his presentation?

A) Adriamycin Cardiomyopathy

B)  Allergic interstitial nephritis

C) Focal Segmental Glomerulosclerosis

D) Bleomycin nephrotoxicity

E) Minimal Change Disease

Question of the Week # 340

340)  A 52 year old woman with history of triple-negative, metastatic breast cancer presents to the Emergency Room with increasing shortness of breath. This is her third Emergency room visit in the past 2 months. Earlier, she was admitted to the hospital  twice for massive pleural effusion and underwent therapeutic thoracentesis.  She was told that the cancer had spread to her lungs and pleura. She received multiple courses of chemotherapy in the past and her cancer has progressed despite initial response to chemotherapy. Her oncologist recommended palliative care. On examination, she is afebrile,  respiratory rate is 24/min, Blood pressure 120/70 mm Hg and Heart Rate 106/min. Breath sounds are decreased on right side of the chest. D-dimer level is 60ng/ml ( normal < 500 ng/ml) . A chest X-ray is shown below:

Which of the following management options is most appropriate for this patient?

A) Obtain Pleural biopsy

B) Tube thoracostomy and Pleurodesis

C) Start Heparin and obtain CT Angiogram

D) Pleuro-perintoneal shunt

E) Repeat Therapeutic thoracentesis

Question of the Week # 339

339)  A 55 year old man presents to the Emergency Room with complaints of  swelling of his face and worsening cough for the past two days. Swelling increases on lying down. He complaints of shortness of breath for past 2 hours. He has no significant past medical problems.  He smoked about 1 pack per day for the past 25 years and consumes alcohol socially. On examination, he is in moderate respiratory distress with audible, loud Stridor. His face is grossly swollen and the veins over the neck, anterior chest  and the face are engorged. On auscultation, there are no crepitations, s1 and s2 are regular and normal and there is no s3 gallop . A chest X-ray is shown below:

Archer USMLE Step 3

 

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

A) Radiation Therapy

B) Chemotherapy

C) CT guided Per-cutaneous Needle Biopsy

D) Video-Assisted Thoracoscopic Surgery (VATS)

E) Epinephrine

Question of the Week # 338

338) A 65 year old man presents to the Emergency Room with complaints of  swelling of his face and worsening cough for the past two days. Swelling increases on lying down. He has no significant past medical problems.  He smoked about 1 pack per day for the past 45 years and consumes alcohol socially. On examination, his vitals are satble with a blood pressure of 130/80 mm Hg. His face is grossly swollen and the veins over the neck, anterior chest  and the face are engorged. There is no stridor. There is no laryngeal edema. Chest is clear to auscultation bilaterally. Cardiovascular examination shows normal s1 and s2 and there is no s3 gallop . A chest X-ray is shown below:

 

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

A) Radiation Therapy

B) Chemotherapy

C) CT guided Per-cutaneous Needle Biopsy

D) Video-Assisted Thoracoscopic Surgery (VATS)

E) Endotracheal Intubation

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 # 288

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

A) Recurrent tumor

B) Marijuana Use

C) Hypogonadism

D) Chemotherapy effect

E) Hyperthyroidism

Question of the Week # 270

270 )  A 62 year old man presents with complaints of chronic cough for the past two years. Cough occurs mostly in the morning and is associated with mild sputum production. Lately, he has noticed mild shortness of breath on exertion. He denies any chest pain or weightloss. He has a 50 pack year history of smoking. He has been counselled against smoking several times in the past but he believes it is quite difficult for him to quit smoking. He is concerned about lung cancer and requests if he can placed on an annual screening protocol. A chest x-ray and a CT scan of the chest show changes consistent with chronic obstructive pulmonary disease. There is no evidence of malignancy. Which of the following is the most appropriate screening recommendation for this patient?

A) Sputum Cytology every 6 months

B) Chest X-ray annually

C) No Screening

D) Spiral CT scan annually

E) PET scan annually

Question of the Week # 263

263 )  A 69 year old man with history of metastatic prostate cancer is admitted with nausea, vomiting and constipation of three days duration. He denies any abdominal pain. He was seen in the oncology clinic for severe bone pain and was started on sustained release Oxycodone as well as short acting oxycodone one week ago. His pain is well-controlled but he is distressed by his  newly developed symptoms.  On examination, his temperature is 98F, Heart rate is 130/min, Respiratory rate 20/min and Blood pressure 120/80 mm Hg. Chest is clear to auscultation and abdominal examination is benign. Obstructive series is negative for bowel obstruction. A CT scan of the adbomen does not reveal any small bowel obstruction. The patient is given promethazine and metoclopromide for vomiting. Which of the following opiod-induced adverse effects are expected to be persistent despite continued use of opiod analgesics ?

A) Nausea

B) Drowsiness

C) Constipation

D) Respiratory depression

E) Itching

Question of the Week # 261

261 )  A 30 year old woman presents to your office for a routine physical examination. She feels well and denies any symptoms. Her past medical history is significant for mediastinal Hodgkin’s lymphoma diagnosed at the age of 18 years. She was treated with chemotherapy and involved field radiation therapy at that time. She has a history of hypothyroidism that was diagnosed 8 years ago and has been on levothyroxine therapy. A Thyroid Stimulating Hormone level 2 months ago was within normal limits. Physical examination reveals normal vitals. There is no palpable goiter.  Rest of the physical exam is unremarkable. Routine labortatory investigations and chest x-ray are normal.  Which of the following is the most appropriate recommendation for this patient at this time?

A)   PET/ CT scan

B)    CT scan of Chest, Abdomen and Pelvis

C)     Mammogram

D)     Cardiac catheterization

E)    Anti-microsomal antibodies

Question of the Week # 254

254 )  A 72 year old man with history of metastatic prostate cancer is admitted with severe weakness and lethargy. He has been having vomiting and abdominal pain for the past two weeks.  He also reports intermittent diarrhea alternating with constipation over the past 2 months. Three months ago, he was noted to have progressive prostate cancer despite therapy with bicalutamide and leuprolide. His PSA at that time was 300ng/ml. He was started on Ketoconozole at that time and he is compliant with it. His most recent visit to the outpatient clinic was 4 weeks ago at which time his PSA was 60ng/ml. On examination, his temperature is 98F, Heart rate is 130/min, Respiratory rate 20/min and Blood pressure 70/40 mm Hg. Chest is clear to auscultation and abdominal examination is benign. A CT scan of the adbomen reveals enlarged prostate and osteoblastic bone metastases in pelvis but no evidence of bowel obstruction. Urinalysis and Chest x-ray are benign. The patient is started on intravenous isotonic saline. Which of the following is the most appropriate next step in managing this patient?

A) Start Chemotherapy

B) Refer to Hospice

C) Intravenous Hydrocortisone

D) Start Norepinephrine drip

E) Intravenous Biphosphonates

 

Question of the Week # 216

216 )  A 75 year old woman with past medical history of hypertension and diabetes is evaluated in your office for 20 lb weight loss. She reports decreased appetite and depressed mood for the past 6 months. Her history is significant for chronic smoking 1 pack per day for last 50 years. She lives alone and does all her daily activities by herself.  She has no known cardiac problems. She denies shortness of breath or cough. On examination, scleral icterus is noted. Lab studies show total bilirubin elevated at 10gm% with predominantly direct component. A subsequent CT of the abdomen shows a heterogeneous mass of about 4cm in diameter. A triphasic CT with pancreatic protocol shows invasion of the portal vein and encasement of superior mesenteric artery by the mass. There are no distant metastases. A chest X-Ray is normal. CA 19-9 level 1400U/ml.  Which of the following is the most appropriate next  step ?

A) Hospice Evaluation

B) Surgical resection

C) Fine needle aspiration biopsy

D) Chemotherapy

E) Radiation therapy

Question of the Week # 215

215 )  A 65 year old woman with past medical history of chronic smoking is evaluated in the office for painless jaundice. She has noticed yellow coloring of her skin about 3 weeks ago and it has been progressively increasing. She denies abdominal pain, fever or altered bowel movements. On examination, she has profoundly icteric sclerae. Lab studies show total bilirubin elevated at 5gm% with predominantly direct component. A subsequent CT of the abdomen shows a heterogeneous mass of about 4cm in diameter. A triphasic CT with pancreatic protocol shows no involvement of portal vein or superior mesenteric artery. No lymphadenopathy is evident. CA 19-9 level 400u/ML. Which of the following is the most appropriate next step?

A) Fine needle aspiration biopsy

B) Surgical resection

C) Radiation therapy

D) Chemotherapy

E) Hospice evaluation

 

Question of the Week # 214

214 )  A 58 year old woman presents to the office because  her friend noticed that she looked yellow and asked her to seek medical attention. Lately, her urine has turned dark yellow but she thought it was because of reduced fluid intake. She has lost 10lb weight in the last 3 months. She denies any abdominal pain, nausea or vomiting. She denies any fever. She smoked about 2 packs per day for the past 30 years. She quit smoking 1 month ago. Physical examination reveals profound scleral icterus. Laboratory investigations reveal a Hemoglobin 10gm%, MCV 88, Total Bilirubin 17gm% , Direct bilirubin 13gm%, AST 120U/L, ALT 110U/L and ALP 600U/L. A CT scan of the abdomen does not show any mass in the pancreas. Ultrasound of the abdomen reveals common bile duct diameter of 12mm. Which of the following is the most appropriate next step in management?

A) CA 19-9 level

B) Endoscopic Retrograde Cholangiopancreatography

C) CT guided biopsy of Pancreatic Head

D) Percutaneous Biliary Stent

E) Haptoglobin level

Question of the Week # 177

Q177) A 52 Year old obese man is evaluated in your office during a routine annual visit.  He denies any fatigue or recent weight changes. He has normal appetite and physically active. He had a colonoscopy 1 year ago that was normal. On physical examination, he is obese with a BMI of  34. Skin examination reveals the findings shown in the image below :

 

 

 

 

 

 

 

 

 

Which of the following is most likely to be seen in this patient?

A) Diabetes Mellitus, Type I

B) Gastric cancer

C) Increased Insulin levels

D) Hyperthyroidism

E) Addison’s disease

Question of the Week # 170

170) A 41 year old woman is evaluated in the office for 20lb weight loss over the last three months. She has a history of Hodgkin’s disease involving mediastinal and cervical lymph nodes and was treated with chemotherapy and Involved field radiation therapy at the age of 12.  She is born in the USA and never traveled outside United States. Her recent tuberculin skin test was 2mm about 1 month ago. Recent mammogram was normal. She denies any night sweats or pruritus. She reports chronic cough over the last 6 months associated with intermittent mild hemoptysis. On physical examination, there is no peripheral lymphadenopathy. A Chest X-ray is shown below:

 

 

 

 

 

 

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

A)     Tuberculosis

B)      Long term sequel of Hodgkin’s therapy

C)      Recurrent Hodgkin’s disease

D)     Radiation fibrosis

E)      Radiation Pneumonitis

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