Question of the Week #485

485. A 10-year-old female presents with a 3 week history of cough.  Initially she had a runny nose and was tired with a slight cough but as the runny nose resolved the cough seemed to get worse.  She states that the cough is dry sounding and occurs during the day and night.  She describes having coughing spasms that occasionally end in vomiting but between episodes of coughing she is fine.  Her mom reports that during a coughing spasm she will gasp for air and sometimes make a “whooping” noise.  A nasopharyngeal swab confirms a diagnosis of Bordatella pertussis.  Which of the following is true?

A. Her 3-month-old brother should be treated with azithromycin as prophylaxis

B. She should be started on azithromycin for more rapid resolution of cough.

C. Her classmates should be treated with clarithromycin as prophylaxis

D. She will have lifelong natural immunity against Bordatella pertussis.

E. Her classmates should receive a Tdap booster regardless of their vaccination status

Question of the Week # 476

476. You are evaluating a 12 month old male patient for rhinorrhea and poor appetite. He is friendly and alert. His temperature today is 103.6 degrees Fahrenheit, and his examination is significant for clear nasal discharge and multiple small vesicles on the anterior tonsillar pillars and posterior palate. His examination is otherwise normal. He is accompanied by his mother who seems to be very concerned. The patient has been feeding well and all his developmental milestones have been timely so far. A complete blood count is normal.  Which of the following is his most likely diagnosis?

12 month old male patient for rhinorrhea and poor appetite, temperature 103.6 F.

12 month old male patient for rhinorrhea and poor appetite, temperature 103.6 F.

A. Hand, foot, and mouth disease

B. Apthous stomatitis

C. Herpangina

D. Stevens-Johnson syndrome

E. Kawasaki disease

Question of the Week # 475

A 2-week-old infant is brought to the office for a regular postnatal follow-up. She was born after an uneventful term pregnancy to a 29-year-old G2P2 woman. Mother reports that the infant is feeding well and seems active. No evidence of any fever. The parents are worried about the ‘rash’ that appeared over the infant’s left cheek. On examination, a lesion is noted on the infant’s left cheek as shown below. Vital signs are within normal limits. What is the most appropriate next step in management of this finding?

lesion

A Surgical excision of the entire lesion
B Biopsy of the lesion
C Laser removal of the lesion
D Reassurance and observation
E Topical 5-fluoro-uracil

Question of the Week # 472

A 9-year-old boy is brought to the hospital with a wound to his left hand. He was in a fight with peer who bit him. His past medical history is unremarkable and he takes no medications. He has no known allergies. On examination, the child is crying. There is a 2-cm wound over the dorsum of his palm. What is the most appropriate course of action?
A. Clean the wound and prescribe amoxicillin-clavulanate.
B. Clean the wound and prescribe doxycycline.
C. Clean the wound and prescribe ciprofloxacin.
D. Clean the wound, close it with interrupted sutures and prescribe ciprofloxacin.
E. Clean the wound, close it with interrupted sutures and prescribe amoxicillin-clavulanate.

Question of the Week # 471

A 14-year-old girl with a history of Crohn’s disease presents with 2-day history of feeling ‘feverish’, malaise, lower abdominal pain and non-bloody diarrhea. She has about 10 episodes of diarrhea daily. She has had three similar episodes in the past 7 years. She denies any recent travel or sick contacts, rush, cough or other symptoms of infection. She has no known allergies and does not take any medications currently. She has been taking 5-ASA, but stopped 6 months ago as she had been asymptomatic for 10 months before that. On presentation, the patient is afebrile with a body temperature of 101.0 F and appears ill. Her blood pressure is 120/80 mmHg and heart rate of 90 beats/minute.  Abdominal examination is remarkable for abdominal tenderness in the lower abdomen, but no rebound or guarding. A subsequent CT scan shows dilatation of the left colonic lumen, as well as a thickened colon wall with pericolic fat stranding, particularly in the left colon. The admitting team determines the patient’s presentation is due to exacerbation of her disease. The patient is started on 5-ASA, metronidazole and prednisone and her condition improves within 10 days when she is symptom-free. What is the most appropriate plan after her symptoms have resolved?

A)     Continue 5-ASA, taper prednisone and discontinue metronidazole
B)      Continue 5-ASA and prednisone, discontinue metronidazole
C)      Discontinue ASA-5 and metronidazole and continue prednisone for 4 weeks, followed by taper
D)     Recommend therapy with infliximab an instruct to take 5-ASA when she starts experiencing symptoms, discontinue prednisone and metronidazole
E)      Continue 5-ASA and metronidazole for at least 4 weeks, taper prednisone

Question of the Week # 468

468) An 18-month-old girl is brought to the hospital by her parents because of a high fever and generalized “body shaking” 2 hours ago. The parents say that she was “pretty fussy” all day and her temperature at that time was 37.3 °C (99.2 °F). Over the past few hours, she began to “burn up,” with her temperature spiking to 39.7 °C (103.4 °F). They put her into her crib to go to sleep, and they heard “banging” coming from the baby monitor in their bedroom. When they arrived in her room 10 seconds later, her entire body was “shaking”. It lasted about 2 minutes, and did not recur. She was lethargic and drowsy for 5 minutes after the “shaking”. Nobody in the family has ever had a seizure before. Her temperature is 39.3 °C (102.8 F). Neurologic examination is unremarkable. A chest x-ray shows a left lower lobe consolidation.

A lumbar puncture shows:

Color clear

Glucose 55 mg/ml

Protein 22 mg/ml

Lymphocytes 4/ml

The parents are concerned about the severity of their daughter’s condition and what they can expect in the future. The most appropriate response is which of the following?

A. “Luckily, you got to the hospital in time to avoid complications such as hydrocephalus, hearing loss, speech or developmental delays, and mental retardation.”
B. “Since you do not have a family history of febrile seizures, chances are that she will go on to have idiopathic epilepsy.”
C. “This episode is due to her pulmonary infection, and it will never recur.”
D. “Your daughter will most likely have a complete recovery and there is only a very small chance that she will develop epilepsy.”
E. “Your daughter’s condition is very serious and a full evaluation for epilepsy is indicated at this time.”

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 # 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 # 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 # 356

356) A 7 year old boy is evaluated in your office for frequent episodes of “staring spells” while at school. His teacher reports that he does not seem to concentrate during the class and stares blankly in to space. He has had many such episodes in the past six months that got his teacher very concerned. Waving a hand in front of his eyes and calling out his name does not seem to disrupt these episodes. Often he returns to his norm when the boy next to him physically moves him or tickles him. He is otherwise, healthy and plays well with other kids without any issues. His mother also has noticed such episodes while he was watching television at home. On examination, he appears comfortable and healthy. There are no physical abnormalities.  He is attentive to your questions and does not seem to be distracted. Which of the following is the most appropriate next step?

A) Re-assurance

B) Obtain Electro-Encephalogram

C) Refer to Child Psychiatry

D) Start Methylphenidate trial

E) Refer to Neurology

Question of the Week # 355

355)  A 6 year old boy is brought to your office with history of staring spells. He has had three such episodes in the past one month. His mother reports that during the episode he states blankly in to space for about two to three minutes. He does not respond to verbal commands during such episodes. The episodes are usually, followed by a period during which he is either confused or drowsy for about 30 minutes. On two such occasions, he reported unpleasant taste sensation prior to the staring spells. On examination, he appears comfortable and healthy. There are no physical abnormalities. Basic laboratory investigations including thyroid stimulating hormone are normal. Which of the following is the most appropriate diagnosis?

A) Attention Deficit Hyperactivity Disorder

B) Absence Seizures

C) Complex Partial Seizures

D) Simple Partial Seizures

E) Generalized Seizures

Question of the Week # 348

348)  A 6 year old boy is evaluated in your office for complaints of generalized swelling of his body. His mother reports she has noticed increasing swelling of his face, abdomen and extremities over the past 3 weeks.  He does not have any significant past medical problems  There is no history of fever or sore-throat. He denies shortness of breath or cough. On examination,  he is afebrile,  Blood pressure 100/60 mm Hg,  Heart Rate 88/min, Respiratory rate is 16/minute. He appears comfortable. His face is grossly swollen. There is mild ascites. Lower extremities reveal gross edema up until the level of knees.  Urinalysis showed 3+ proteinuria, no red cell or casts. A 24 hour Urine total protein is obtained and it shows proteinuria at  7.0 gm/24 hours. Serum total protein 4.0gm% and albumin 2.0gm% .  He is advised to start sodium restricted diet. Which of the following management options is most appropriate next step for this patient?

A) Admit and start Albumin infusion

B) Corticosteroid Trial

C) Renal Biopsy

D) Obtain Anti-Streptolysin O titer

E) Furosemide

Question of the Week # 345

345)  A 8 year old boy is brought to the Emergency room by his mother with complaints of  shortness of breath. His mother reports she has noticed increasing swelling of his face, abdomen and extremities over the past 4 weeks. She scheduled an appointment with his pediatrician in the upcoming week however, she brought him to the ER today because he started getting distressed because of breathing difficult. The patient does not have any significant medical problems and mother reports he has always been a “good kid” at the school.  There is no history of fever or sore-throat. On examination,  he is afebrile,  Blood pressure 100/60 mm Hg (Standing) , 108/60 ( Lying Down) and Heart Rate 92/min ( Standing), 88/min (Lying Down). He is tachypneic with respiratory rate is 26/min and is using accessory muscles. His face is grossly swollen. Breath sounds are reduced on both sides and there is massive ascites with scrotal edema. Lower extremities reveal gross edema up until the level of knees.  Urinalysis showed 3+ proteinuria, no red cell casts or hematuria. Urine total protein is 8.0 gm/24 hours. Serum total protein 4.0gm% and albumin 2.0gm% .  A chest X-ray shows bilateral pleural effusions. Which of the following management options is most appropriate next step for this patient?

A) Renal Biopsy

B) Corticosteroid Trial

C) Furosemide

D) Furosemide with Albumin infusion

E) Consult Nephrology

Question of the Week # 336

336) A 21 year old hispanic woman is evaluated in your office for recently diagnosed Hypertension. On previous two visits, her blood pressure was 150/90 mm HG. She denies any family history of Hypertension.  Her Past medical history is significant for multiple Urinary tract infections and enuresis as a child. She has no other complaints. On examination, her repeat blood pressure is 148/92 mm HG. There are no abdominal bruits. Ultrasonography reveals scarring of  both kidneys. Which of the following is an important feature of this condition?

A) Positive Anti-DsDNA

B) Strong Genetic Pre-disposition

C) Association with Berry aneurysms

D) Postural Hypotension

E) Abdominal Striae

Question of the Week # 327

327) A 16 year old boy presents to your office for a Pre-participation sports physical examination. He is healthy and physically active and has no complaints. He has no chest pain or shortness of breath. He denies any drug use or smoking. His maternal grandfather recently died suddenly of cardiac arrest from severe Myocardial Infarction at age 82. On physical examination, he is afebrile, pulse 82/min, Respiratory rate 18/min and blood pressure 106/76 mm Hg. Chest is clear to auscultation. Cardiac examination reveals a mid-systolic murmur, grade 2/6 heard best along the left sternal border. The murmur decreases in intensity when he stands and increases when he is supine. S1 and S2 are normal. The second heart sound is physiologically split.  Cardiac impulse and carotid pulses are normal. The most appropriate action at this time:

A) Clear the patient for Sports participation

B) Refer to cardiology

C) Obtain 2D-Echocardiogram

D) Schedule Exercise Stress Test

E) Obtain Complete blood count

Question of the week # 311

311) A 3 year old male child is brought to the emergency room by his mother after he fell from his tricycle and sustained an injury to his head  . The child was found to be alert and awake after the fall, however, he reported mild pain on the right side of his head. His mother noted a small bruise and swelling over the right side of his scalp. There is no history of vomiting or nausea. He has no past history of convulsions or epilepsy. Family history is unremarkable. At this time, child is quiet and reports mild headache. On examination, he is alert and awake. He is not in distress. There is small contusion on the fronto-parietal aspect of his scalp. There is no evidence of hematoma. Palpation does not reveal any depressed fracture. Neurological examination is normal with out any deficits.  Rest of the physical exam is normal. Which of the following is the most appropriate management at this time?

A) Contact Child Protection Services

B) Perform Head CT scan

C) Admit to Hospital

D) Observe at home

E) Skull X-rays

Question of the week # 305

305) You have recently been posted by your employer to serve as a school physician in a school that is few miles away from your office. The school has about 250 students of whom 55% are girls and the rest are boys. The school teacher reports that they have not had a scoliosis screening program in place and wonders if you can implement such a program in the school. Which of the following is the most appropriate course of action?

A) Arrange scoliosis screening for all students between 10 and 16 years of age.

B) Arrange scoliosis screening for all students 10, 12, 14 and 16 years of age.

C) Contact the school nurse and review skills for scoliosis screening procedures.

D) Visually inspect for severe curves only when the back is examined for other reasons.

E) Screen girls for scoliosis at 15 years of age and boys at 16 years of age.

 

Question of the week # 304

304)

A 16-year-old male who presents to your office for his regular health checkup and for clearance before participation in then high school basketball team. During the physical examination, you note a mild convexity in the thoracic region of his spine with forward flexion at the hips. You ask him to lean forward with his feet together and bend 90 degrees at the waist. Based on your clinical examination, you estimate a lateral spinal curvature of about 5 degrees. You discuss these findings with the patient and his mother. Which of the following is the most appropriate action?

A. Recommend back-strengthening exercises.

B. Refuse medical clearance for participation in sports.

C. Order a radiograph of the back to quantify the curvature

D. Observation alone.

E. Refer for orthopedic consultation.

Question of the week # 303

303) A 11 year old girl is evaluated in your office for progressing lateral curvature of her spine. She denies any back pain or neurological symptoms. Her mother is very concerned about the child’s appearance.  On physical examination, there is gross convexity in the thoracic region of her spine with forward flexion at the hips. There is no tenderness or neurological deficits. An x-ray of the spine reveals 25º curvature ( cob angle) . Which of the following is the most appropriate management at this time?

A) Repeat Clinical exam and x-rays at 6 months

B) Refer to orthopedic evaluation

C) Bracing

D) Spinal fusion surgery

E) Recommend back strengthening exercises

Question of the week # 302

302) A 16 year old girl is evaluated in your office for one day duration of fever, cough and left pleuritic chest pain. On examination, her temperature is 100.5F, respiratory rate is 18/min, pulse 100/min and blood pressure 120/60 mm hg. Breath sounds are decreased in the left lower lobe. A Chest x-ray is obtained which reveals left lower lobe infiltrate. Incidentally, a 7 ° lateral curvature is seen on the chest x-ray. The patient is started oral azithromycin for her pneumonia and is discharged home. Which of the following is the most appropriate management for her  incidentally discovered scoliosis?

A) Clinical follow up  alone

B) Repeat x-rays every 6 months

C) Refer to orthopedic surgery

D) Bracing

E) No follow up required

Question of the week # 301

301) A five month old male infant is brought to the out patient department for evaluation of one month history of recurrent vomiting, diarrhea and skin rash . The baby was delivered normally at term with out any complications. Mother reports that she breastfed him for four months and recently has been feeding him exclusively with formula. Mother reports that the baby vomits intermittently after each feed and develops raised, red welts on his skin after each feeding. There is no blood or bile in the vomitus. Vomiting  occurs within 30 minutes after feeding. Suckling is normal. He also has mucousy, loose stools for the past three weeks with no blood.  There is no history of cough, cold or fever. On examination, the infant in no apparent distress and vitals are normal. Abdominal examination is benign with out any palpable masses or peristaltic waves. Rest of the physical is  normal. Laboratory investigations reveal Hb: 13.2 gm%; Haematocrit: 35%; WBC: 9,200/μl ; Platelets: 225,000/μl, Na 132 meq/L; K 3.8 meq/L; Cl 92 meq/L; albumin 4.6g%. Urinalysis is normal. Which of the following is the most appropriate next step in managing this condition?

A) Abdominal ultrasound

B) Lactose free formula

C) Start hydrolyzed formula feeds

D) IgE Radio-allergosorbent test

E) Observation

Question of the week # 300

300) A 14 year old girl is evaluated in your office for  moderate headache of one month duration . She denies any blurred vision, neck stiffness or fever. She is accompanied by her mother who reports that her performance at school has progressively declined over the last few months and she has deepening of voice for the past 4 months. On examination, Pulse 80/min;  Temperature: 98.4F  and Blood pressure: 135/100 mm of Hg. There is excessive hair on her face. Rest of the physical is normal except for faint purplish marks on her abdomen. Laboratory investigations including complete blood count, comprehensive metabolic panel and Urine analysis are within normal limit. Which of the following is the most appropriate next step ?

A) 24 hour urinary cortisol

B) MRI brain

C) CT scan of the abdomen

D) Dexamethasone Suppression Test

E) Plasma catecholamines

F) Urine Drug Screen

Question of the week # 299

299) A 10 month old male infant  is brought by his concerned mother to the Emergency room with complaints of vomiting and bloody diarrhea. Mother reports that he suffered from “stomach flu” symptoms about 1 week ago which resolved spontaneously.  He had 4 episodes of vomiting since yesterday and has been crying intermittently every 15 minutes. There is no blood or bile in the vomitus. He had four loose stools with blood in it. There is no history of fever or cough or cold. His past medical history is unremarkable. On examination, temperature is 98.4F,  pulse 112, respiratory rate 30/min and blood pressure at 80/50 mm hg. Oral mucosa appear moist and skin turgor is adequate. Abdomen is soft with no palpable masses. Bowel sounds are present. Stool guaiac is strongly positive. Stool is sent for cultures and abdominal x-rays are obtained. An x-ray image is shown below:

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

A) Abdominal ultrasound

B) Gastrograffin enema

C) Surgery

D) Rectal tube placement

E) Flexible sigmoidoscopy

Question of the week # 298

298) A 6 year old boy presents to your office with a limp on the right side. He denies any falls or trauma. Mother reports that the limp has been present for several weeks. She reports that the patient was seen in the Emergency Room when the limp was first observed. X-rays obtained at that time were normal and so, he was discharged. There is no history of fever. He denies any pain. Family history is unremarkable. On examination, he is afebrile . His right lower extremity appears one inch shorter than the left. Upon standing and walking, his pelvis appears to be tilted towards the left. Which of the following is most likely to be abnormal in this condition?

A) External rotation of hip

B) Tibial tuberosity

C) X-ray of the Knee

D) Erythrocyte Sedimentation Rate

E) Internal rotation and abduction of hip

Question of the week # 296

296) A 6 month old Asian infant  is brought by his concerned aunt for evaluation of dark blue areas on the child’s buttocks. She says she was called to baby-sit the infant since his mother found a new job 2 days ago. She noted the rash and became suspicious that the child may have been abused. The mother arrives in Emergency room an hour later and reports that the rash has been present since birth. The mother is divorced and lives alone with the child. On examination, there are bluish-green patches on bilateral buttocks and on the lower back. They are irregular in shape and  margins are indistinct. There is no swelling or tenderness. An image of the skin findings is shown below:

Which of the following is the most appropriate next step ?

A) Order Skeletal Survey

B) Reassure that rash may fade away in few years

C) Contact Child Protection services

D) Obtain Coagulation parameters

E) Obtain Platelet count

Question of the week # 295

295) A 10 year old boy is brought to your office for evaluation of rash in bilateral axillae and groin for the past 2 months. He denies any itching or any other skin rashes.  However, he reports that the area has become progressively rough to touch. He is otherwise, healthy. On examination, there are  reddish brown patches in bilateral axillae and groin. There is maceration and scaling in the web spaces between the toes of bilateral feet. Rest of the examination is normal. A KOH mount is obtained and is negative. Wood’s lamp examination reveals coral red fluorescence. A picture of  the rash is shown below:

Which of the following is the most appropriate next step ?

A) Topical corticosteroid

B) Topical Selenium Sulfide

C) Oral erythromycin

D) Topical Clotrimazole

E) Oral Metronidazole

Question of the week # 280

280) A 2 year old child is brought by her mother to the emergency department because the child has not been ambulating since yesterday after he tripped over an object and fell. Physical examination reveals tenderness and swelling in left mid-thigh. Eyes are normal without any hemorrhages. Skin reveals several bruises. Teeth are translucent and show yellow discoloration. Moderate scoliosis is evident. A skeletal survey reveals rib fractures and multiple fractures in various stages of healing. There is diffuse osteopenia. There is a spiral fracture of left femur shaft.  The limb is splinted and an orthopedic consult is obtained. Which of the following is the most appropriate action?

A) Contact social services

B) Contact Child Protection Services

C) Place the child in foster care

D) Obtain Head CT

E) Obtain detailed family history

Question of the week # 279

279 ) A 14 month-old child is brought by her concerned father to the Emergency department with a history that the child slipped out and fell on the ground from a table that is 10 feet in height. He says the accident occurred last night when he let the child stand on the table. The child cries when the right thigh is touched and does not move the right lower extremity. Rest of the physical examination is normal. There are no suspicious bruises or contusions on the skin. An x-ray of the right femur is shown below.

A skeletal survey is obtained and does not show any other fractures. There are no skull fractures or retinal hemorrhages or neurological deficits.

Based on the x-ray findings and the history, which of the following is the most likely diagnosis?

A) Osteogenesis Imperfecta

B) Fibrous Dysplasia

C) Accidental Injury

D) Child Abuse

E) Pathological Fracture from Ewing Sarcoma

Question of the week # 278

278) A 34 year old mother brings her 18 month old child to the emergency room. She is in tears and reports that the child was playing on the sofa and has fallen down 1 day ago landing on his left foot and since then has not been moving his left lower extremity. The child is crying incessantly. Physical examination reveals tenderness and swelling in the left mid-thigh. An x-ray of the left lower extremity shows a non-displaced hair line fracture of the femur shaft and the fracture age consistent with reported history of time of injury. Which of the following is the most appropriate next step in management?

A) Contact Child Protection Services

B) Skeletal Survey

C) Open reduction and internal fixation

D) Bone scan

E) CT head

Question of the week # 277

277) A 32 year old woman with history of Systemic Lupus Erythematosus is evaluated during a routine antenatal visit. Her last menstrual period was 18 weeks ago. She is using prenatal pills and has no complaints. She is being maintained on prednisone.  Physical examination is benign and her blood pressure is normal. Her laboratory investigations show positive ANA, Anti-Ds DNA and Anti-SSA (Anti-Ro) antibodies in high titers. Anticardiolipin antibodies and Lupus anticoagulant testing is negative.  She is concerned about the risk to her baby because she heard that her antibodies can cross the placenta. Which of the following conditions is most likely to occur in the baby due to passive transfer of maternal antibodies?

A) Lupus Nephritis

B) Aplastic anemia

C) No risk with passive transfer

D) Complete Heart Block

E) Hydrops fetalis

Question of the Week # 255

A 16 year old woman is brought to your office by her mother for medical evaluation. Her mother has been out of country on a long business trip for 8 months and upon her return, she was shocked to notice that her daughter looked much skinnier than she was 8 months ago. The patient has lost about 30 lbs weight in the past 8 months and reports irregular menstruation. She is fearful of gaining weight and has been exercising excessively.  Physical examination reveals a very thin woman with a Body Mass Index (BMI) of 16. She has fine, downy dark hair all over her body. Which of the following findings are frequently seen in association with this condition?

A)     Diarrhea

B)     Tachycardia

C)      Hyperkalemia

D)     Decreased Bone mineral density

E)     Metabolic Acidosis

Question of the Week # 244

244 )  A 10-year-old Caucasian boy presents with right scrotal pain of 7 hours duration. The pain is acute in onset, constant and does not change with position. The patient denies any fever, chills, dysuria, nausea or vomiting. He denies any recent history of trauma. On physical examination, the patient is afebrile and is in moderate distress secondary to pain. There is no urethral discharge. Cremasteric reflex is present bilaterally. There is bluish discoloration and localized tenderness in the upper part of the testes. Labs reveal a normal Complete Blood Count and Urinalysis. What is the most likely clinical diagnosis in this patient?

A)     Testicular torsion

B)      Strangulated Hernia

C)      Congenital Hydrocele

D)     Torsion of Testicular appendix

E)      Acute Epidydimitis

 

 

 

 

Question of the Week # 237

237 )  A 25-year old primi-para is evaluated for soreness in her breasts. She just started breast feeding her three day old male infant. She also reports low grade fever over the past few hours. On examination, her temperature is 99.2F. Her breasts are hard and swollen. They are warm to touch. She has pain on movement of the breast. Which of the following is the most appropriate recommendation?

A) Hand expression of milk between feedings

B) Use of  ”Breast Pump”

C) Correction of improper “Latch on”

D) Re-assurance

E) Breast massage

Question of the Week # 236

236)  A 25-year woman presents to your office with complaints of soreness in her right nipple. She had a uneventful delivery 10 days ago. She has been breast feeding for the past ten days. She had some nipple soreness initially however, it resolved after five days. The soreness returned on the eighth day and is persistent since then . The pain is present through out the nursing episode. On examination, she is afebrile. Her right breast is full. There is no erythema or tenderness. Which of the following is the most appropriate recommendation to the patient?

A) Hand expression of milk between feedings

B) Use of  “Breast Pump”

C) Correction of improper “Latch on”

D) Re-assurance

E) Breast massage

Question of the Week # 235

235)  A 25-year woman presents to your office with complaints of soreness in her right nipple. She had a uneventful delivery 10 days ago. She has been breast feeding for the past ten days. She had some nipple soreness initially however, it resolved after five days. The soreness returned on the eighth day and is persistent since then . The pain is present through out the nursing episode. On examination, she is afebrile. Her right breast is full. There is no erythema or tenderness. Which of the following is the most likely cause of her clinical presentation?

A) Poor positioning of infant while feeding

B) Prolonged suckling

C) Inadequate feeding

D) Infection

E)  “Normal” Nipple Sensitivity

 

Question of the Week # 234

234 )  A 25-year old primi-para is evaluated for soreness in her breasts. She just started breast feeding her three day old male infant. She also reports low grade fever over the past few hours. On examination, her temperature is 99.2F. Her breasts are hard and swollen. They are warm to touch. She has pain on movement of the breast. Which of the following is the most likely cause of her clinical presentation?

A) Poor positioning of infant while feeding

B) Prolonged suckling

C) Inadequate feeding

D) Infection

E) Plugged ducts

Question of the Week # 227

227 )  A 32 year old man is evaluated in the clinic for intensely itchy rash . The rash appeared suddenly on his trunk 24 hours ago  and has spread to his extremities. He denies any fever or  using any recent medications. His travel history is significant for a trip to Colarado 3 days ago where he stayed with his friend in a hotel room. He enjoyed camping in the mountains and spent his evenings in the hotel building’s swimming pool. On examination, there  are multiple red papules all over his body and extremities but not on the head and the neck. Some of the papules are tender. Which of the following is the most appropriate next step in management?

A) Doxycycline

B) Lyme Serology

C) Ciprofloxacin

D) Reassurance

E) Amoxicillin-Clavulunate

Question of the Week # 226

226 )  A 2 year old male child is brought by his pregnant mother for evaluation of a rash all over his body. The rash developed 48 hours ago and is associated with fever. She also has a 12 year old daughter at home who is being treated for acute lymphoid leukemia. On examination, the patient has rash in different stages including papules, pustules and vesicles. You suspect chickenpox. The mother denies any history of chickenpox in the past. Which of the following is the most appropriate recommendation?

A)     Varicella vaccine to the male child

B)      Varicella vaccine to the mother

C)      Varicella Zoster immunoglobulin to mother and the daughter

D)     Varicella vaccine to mother and VZIG to the daughter

E)      Varicella vaccine to the mother and the daughter

Question of the Week # 204

204) A 16 year old boy presents for pre-participation examination prior to athletic training in his college campus. He denies any history of dizziness or palpitations or shortness of breath upon exertion. He denies any syncopal episodes.  His father died of cardiac arrest during a marathon at the age of 32 years. Physical examination reveals a systolic murmur that increases with valsalva maneuver.  Electrocardiogram reveals changes consistent with left ventricular hypertrophy. An echocardiogram reveals asymmetric septal hypertrophy and Systolic Anterior Motion (SAM) of the Anterior Mitral Leaflet. Which of the following is an indication for Implantable Cardioverter-Defibrillator in this patient?

A) Left Ventricular Thickness of 22mm

B) Increase in blood pressure upon exercise

C) His age

D) Systolic Anterior Motion of Mitral leaflet

E) Decrease in blood pressure during exercise

 

Question of the Week # 203

203) A 16 year old boy presents for pre-participation examination prior to athletic training in his college campus. He denies any history of dizziness or palpitations or shortness of breath upon exertion. He denies any syncopal episodes. He denies any family history of Sudden Cardiac Death.  Physical examination reveals a systolic murmur that increases with valsalva maneuver.  Electrocardiogram reveals changes consistent with lEft ventricular hypertrophy. An echocardiogram reveals asymmetric septal hypertrophy and Systolic Anterior Motion (SAM) of the Anterior Mitral Leaflet. The findings are discussed with patient and he intends to participate in athletics because he does not have any symptoms. Which of the following is the most appropriate next step?

A) Clear the patient for athletic training

B) Start Beta Blocker Therapy

C) Exercise Stress Test

D) Cardiac catheterization

E) Implantable Cardioverter-Defibrillator

Question of the Week # 201

201) A 16 year old male athlete is rushed to the Emergency Room after he collapsed during a basket ball match.  In the Emergency Room, he is found to be in cardiac arrest  and cardio-pulmonary resuscitation is begun as per ACLS protocol. A electrocardiogram reveals ventricular fibrillation which is successfully defibrillated with 200 joules. The patient is currently awake but confused. His mother is present at the bed-side and denies any family history of sudden cardiac death. Which of the following is the most common cause of sudden death in young athletes?

A) Aortic dissection

B) Long QT syndrome

C) Blunt trauma to the chest

D) Hypertrophic Obstructive Cardiomyopathy

E) Mitral valve prolapse

Question of the Week # 195

195)  A 3 year old male child is brought to emergency room by his concerned mother because of history of fever for the past 5 days. The patient also has developed a red rash on his extremities.  On physical examination, temperature is 102F. The tongue is very inflamed and has red, enlarged papillae. Posterior pharynx is erythematous without any exudate.  There is a palpable cervical lymph node of 1.8cm on the right side of the neck. There is conjunctival erythema bilaterally. Erythema is noted on palms and soles. and skin appears to be peeling off around the nails. Laboratory investigations reveal a WBC count of 15,000/µl, platelet count of 550000 per μl and an ESR of 50mm/hr. Which of the following therapeutic interventions are most helpful in preventing the complications associated with this condition?

a)      Penicillin

b)      Corticosteroids

c)       Aspirin

d)      Intravenous Immunoglobulin

e)      Clindamycin

Question of the Week # 194

194)  A 3 year old male child is brought to emergency room by his concerned mother because of history of fever for the past 5 days. The patient also has developed a red rash on his extremities.  On physical examination, temperature is 102F. The tongue is very inflamed and has red, enlarged papillae. Posterior pharynx is erythematous without any exudate.  There is a palpable cervical lymph node of 1.8cm on the right side of the neck. There is conjunctival erythema bilaterally. Erythema is noted on palms and soles. and skin appears to be peeling off around the nails. Laboratory investigations reveal a WBC count of 15,000/µl, platelet count of 550000 per μl and an ESR of 50mm/hr. Which of the following is the complication that is most likely to develop if this condition is not treated early in the course?

A) Toxic Shock Syndrome
B) Acute Glomerulonephritis
C) Coronary artery aneurysm
D) Carditis
E) Aortic regurgitation

Question of the Week # 184

Q184)  A 10 year old boy is evaluated in the emergency room after he tripped over and fell during a basketball game. There is no history of loss of consciousness. He denies any injury except  some pain in the occipital area of the skull.  He also reports chronic fatigue. A routine skull x-ray is obtained for evaluation and is shown below:

Which of the following is most likely to be associated with these incidental skull x-ray findings ?

A) Monoclonal gammopathy

B) Pituitary tumor

C) Hemolysis

D) Paget disease

E) Glioma

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