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 # 465

465) A 6-year-old boy is brought to the emergency department 2 hours after he was bitten by a peer in kindergarten in a fight. The child’s mother is frantic and wants to “sue the center for allowing such behavior!” The child is up-to-date on his vaccinations. The other child is very healthy and his vaccinations are current. On physical examination, there is puncture wound on the right hand. You gently clean the wound and consult with the hand surgeon who says that there does not appear to be any damage to the nerves, muscles, tendons, or joints of the hand. What is the most appropriate next step?

A. close the wound with a suture
B. obtain a wound culture
C. provide ampicillin-sulbactam
D. send him home with a follow-up appointment within 48 hours
E. vigorously irrigate and debride the wound

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 # 455

You are evaluating a 63-year-old female with a complaint of abdominal pain radiating to her back. She has diminished appetite and pruritus. Her past history is significant for a 40-year history of tobacco use. She has three glasses of wine once a week.

The patient is afebrile, with blood pressure of 123/85, and her heart rate is 74. She appears jaundiced, with scleral icterus. Her abdomen is tender to palpation in the epigastric region, and her liver is palpable 2 cm below the right costal margin. Laboratory tests reveal total bilirubin of 6.0. direct bilirubin of 4.8, alkaline phosphatase of 1000, and AST is 42, with and ALT of 40. Which of the following initial diagnostic test will you order?

A. Abdominal ultrasound

B. Percutaneous liver biopsy

c. Percutaneous transhepatic cholangiography

D. CT abdomen and pelvis

E. Endoscopic retrograde cholangio-pancreatography.

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 # 291

291) A 66 year old man with past medical history of hypertension and  type-2 diabetes mellitus is evaluated in your office during a regular follow up visit for his diabetes. During this visit, he reports problem getting and maintaining an erection.  On the times that he does have an erection, they are very soft.  He says this problem began approximately 10 months ago and has slowly worsened but he was too embarrassed to disclose this during his previous visits. He still has a strong sexual desire and this problem has caused strain in his current relationship.  He is physically very active walking two to three miles per day. His medications include glipizide and hydrocholrthiazide. He says his home blood sugars have been “perfect”. A Hemoglobin A1C 2 weeks ago was 6.0gm% .  He currently does not smoke after having quit smoking 15 years ago. Physical examination shows blood pressure 140/90 mmHg, pulse 86, respiratory rate 20 bpm. Genitilia and testicles are normal in size . Peripheral pulses are normal. Rest of the physical examination is normal. Which of the following is the most appropriate next step in managing this patient?

A) Obtain Serum Total Testosterone

B) Obtain Nocturnal Penile Tumescence

C) Start Sildenafil

D) Prescribe Vacuum assisted erection device

E) Switch Hydrochlorthiazide to ACE inhibitor

 

Question of the week # 290

290) A 72 year old man with history of Diabetes Mellitus and peripheral vascular disease is evaluated in your office for impotence. He denies any premature ejaculation and states that he can not even attain an erection. Further studies confirm erectlie dysfunction secondary to organic causes. The patient denies any history of angina in the past. His medications include Aspirin, Clopidogrel, Glargine insulin and Lispro. His most recent HGBA1C was 6.5%. You offer him sildenafil for erectlie dysfunction. He is now concerned about the possible side effects. Which of the following is the most common side effect of sildenafil?

A) Headache

B) Nasal congestion

C) Diarrhea

D) Blurred vision

E) Flu like symptoms

Question of the week # 289

289) A 32 year old male athlete is evaluated in the office for bilateral breast enlargement. He is a state champion in running and is scheduled to participate in the national level running championship in few weeks. He is very concerned about his appearance.   He denies using any illicit drugs or exogenous androgens or aromatase inhibitors  is seen in the office during a routine follow up visit.  His past medical history is unremarkable. Physical examination reveals gynecomastia bilaterally. His laboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 18.5 g/dL ( Normal = 13.0 to 16.5 gm%),

Mean cell volume (MCV)  84  fL

Platelet count 310k/µl

Which of the following is most useful in establishing the diagnosis?

A) Erythropoetin level

B) Urine Drug Screen

C) Serum Total Testosterone

D) Urine Testosterone/ Epitestosterone ratio

E) Serum Free Testosterone

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 # 287

287) A 38 year old caucasian man  is seen in the office due to decreased libido and energy. His past medical history is significant for testicular cancer diagnosed 1 year ago and was treated with radical orchiectomy of left testicle and chemotherapy. He denies smoking tobacco but admits using Marijuana on a daily basis for the past few months. His family history is unremarkable.  Physical examination  reveals gynecomastia and absent left testicle. Body mass index is 24.  His routine laboratory investigations including complete blood count are within normal limits. Serum total testosterone level is reduced and Serum LH concentration is elevated. The patient is started on Testosterone replacement therapy with a testosterone skin gel. Which of the following is the most appropriate step in follow up care of  this patient after starting testosterone therapy?

A) Digital Rectal exam and Serum PSA level at one year

B) Hematocrit at 6 months and then, every year

C) DEXA scan at one year

D) Serum Testosterone level at 6 months

E) Serum LH at one month.

Question of the week # 286

286) A 55 year old woman with history of diabetes mellitus and hypertension is admitted with chest pain. Chest pain started about 30 minutes ago but now resolved after she received sublingual nitroglycerin. An electrocardiogram obtained by EMS showed ST segment depressions but a repeat electrocardiogram in the Emergency room is normal. She is placed on Aspirin, low molecular weight heparin, atorvastatin and metoprolol. She denies any easy bruising, nose bleeding or any other gross bleeding. She denies smoking , alcohol or drug abuse She has not been admitted to any hospital and has never received anticoagulants in the past. Physical examination  is benign . Laboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 15 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 8k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. Three sets of cardiac enzymes are negative. Cardiology team held aspirin and low molecular weight heparin immediately. A peripheral blood smear is shown below:

 

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

A) Platelet transfusion

B) Heparin induced platelet antibodies

C) Start Lepirudin

D) Send CBC in a citrate tube

E) IV Gamma Globulin

Question of the week # 285

285) A 26 year old man is seen in the office because he was found to have abnormal blood counts during a health check up prior to his life insurance application. He says he was told to see his physicians because his platelet count was very low. He denies any easy bruising, nose bleeding or any other gross bleeding. He has no other medical problems. He denies smoking , alcohol or drug abuse. He denies any recent infections. He leads a very active lifestyle and is a professional soccer player. He proudly states that he won his team the state level championship a year ago and likes to aggressively pursue this career. Physical examination  is benign. There is no splenomegaly. Repeat aboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 15 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 45k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative.

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

A) Intavenous Immunoglobulin

B) Recommend against soccer for life

C) Splenectomy

D) Observation

E) Prednisone

Question of the week # 284

284) A 32 year old pregnant woman is evaluated in the emergency room for new onset abdominal pain. She has mild nausea and vomited once prior to arrival in the emergency room. She denies any bleeding . This is her first pregnancy and she is at 34 weeks gestation.  Physical examination reveals normal blood pressure. There is mild tenderness in epigastric region. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 7 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 50k/µl

Lactic Dehydrogenase  1200U/L

AST 120U/L

ALT 180U/L

Serum Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. Amylase and lipase are normal. A peripheral blood smear shows reduced number of platelets and some fragmented red blood cells. Antinuclear antibodies, Anti-phospholipid antibodies, Lupus anticoagulant profile, HIV testing and Hepatitis C are negative.

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

A) Platelet transfusion

B) Intravenous Methyl Prednisolone

C) Induction of labor

D) Observation

E) Plasmapheresis

Question of the week # 283

283) A 26 year old man is seen in the office during a pre-employment health check-up. He has no medical problems. He denies smoking , alcohol or drug abuse. Physical examination  is benign. Laboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 15 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 45k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative.Upon further questioning, he denies any easy bruising, nose bleeds or gross bleeding. There is no family history of thrombocytopenia or bleeding disorder.

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

A) Intavenous Immunoglobulin

B) Prednisone

C) Observation

D) Bone marrow biopsy

E) Platelet transfusion

Question of the week # 282

282) A 32 year old woman is seen in the antenatal clinic during her regular antenatal visit. This is her first pregnancy and she is at 32 weeks gestation. She takes prenatal vitamins. She currently has no complaints. Physical examination  is benign. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 14 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 70k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative. The patient is concerned about her abnormal platelet counts. She denies any easy bruising or nose bleeds or gross bleeding. Her complete blood count 3 months ago was completely normal.

Which of the following is the most appropriate response?

A) “You will require treatment with steroids”

B) “Urgent delivery with cesarean section is required.”

C) “Your platelet count will normalize within 2 to 12 weeks after delivery”

D) “You will require Bone marrow biopsy”

E) “No treatment needed since it is immune thrombocytopenia”

Question of the week # 281

281) A 22 year old woman is seen in the office for a rash on legs. She had an upper respiratory tract infection one week ago which resolved spontaneously. She is not on any medications. She has no other significant mast medical history. She has easy bruising which started 5 days ago but denies any nose bleeds or gross bleeding. Her last menstrual period was one week ago and she has regular cycles with no history of menorrhagia. Family history is negative for any bleeding disorders or thrombocytopenia. She denies any smoking , alcohol or drug abuse. Physical examination  is benign except for  petechiae on her bilateral lower extremities. There is no splenomegaly on examination. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 14 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 18k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative.

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

A) Ristocetin cofactor assay

B) Prednisone

C) Observation

D) Bone marrow biopsy

E) Plasmapheresis

F) Platelet transfusion

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