Question of the Week # 333

333) A 75 year old woman with past medical history of  Type 2 Diabetes mellitus, Hypertension and Ischemic stroke presents to your office for a new patient visit. She has been under the care of another primary care physician who has retired from practice so the patient has decided to establish care with you. She has left sided residual weakness from her old cerebrovascular accident. She has no other complaints. She requests you for a refill of warfarin which she has been taking for three years . This drug was prescribed by her former physician for “stroke prevention” . Her recent echcardiogram shows an ejection fraction of 60% and a recent cardiovascular stress test was negative for ischemia. Her other medications include Metformin, Glyburide and enalapril.  Her laboratory investigations including complete blood count are normal and her  INR is 1.5. Which of the following is the most appropriate  management?

A) Increase warfarin to achieve a target INR of 2.0 to 3.0

B) Discontinue Warfarin and start Aspirin/Dipyridamole combination

C) Continue low-dose Warfarin with target INR 1.5 to 2.0

D) Add Aspirin to her current regimen

E) Add Clopidogrel to her current regimen

Question of the Week # 323

323)  A 65 year old man is evaluated in your office for slowly progressing involuntary shaking movements in his hands. He noticed these movements about 10 months ago which have slightly worsened now.  Occasionally, he was told by his wife that his head shakes as well. The movements have led him to feel socially embarrassed because they are worse when he attempts to write or hold a cup of coffee or fasten a shirt button. He denies any tremors in his legs. He denies any problems with his gait or muscle pain or stiffness. He reports drinking wine on daily basis since the tremors have started because he thinks alcohol appears to improve the tremors. He denies using any medications. There is no family history of tremors or seizures. On examination, he appears comfortable. Tremors are visible bilaterally with his arms outstretched and they are increased when asked to hold a cup filled with water. His handwriting is large and tremulous. Gait is normal with normal arm-swing. There are no other neurological deficits. Routine chemistry panels including TSH and Liver function tests are normal. Which of the following is the most appropriate next step in management?

A)  MRI brain with contrast

B) Vitamin B12 level

C) Trial of Dopamine Agonist

D) Initiate Propranolol Therapy

E) Serum Cerulopalsmin level

F) Start oral Primidone

Question of the Week # 309

309)  A 76-year-old man presented with a 4-month history of recurrent vertigo. He reports feeling a sensation of spinning dizziness on turning the neck to his left. He also reports left sided headaches and decreased hearing on the left. Each episode lasted about 15 to 20 minutes and occurred when he turned his head to the left. He denies any ringing sensation in ears,  nausea or vomiting. He denies any chest-pain, shortness of breath or palpitations.  His past medical history is significant for hypertension and diet controlled diabetes. His medications include  hydrochlorothiazide and enalapril. He also has history chronic neck pain due to cervical spondylosis for which he uses tylenol. On examination, his blood pressure in supine position is 140/88 mmHg and  blood pressure on standing is is 130/86. Tympanic membranes are visible and there is some cerumen in the left ear. Using a 512Hz tuning fork , bone conduction is found to be better than air conduction on the left and Weber test shows lateralization to the left. Dix-Hallpike’s and Lhermitte’s signs are negative. There are no other neurological deficits. Gait is normal. Range of motion of the neck is limited on lateral movements and neck pain is elicited by turning to left side. An X-ray of cervical spine shows severe spondylosis with discopathy and osteophytes from C2 to C4 vertebrae.  Which of the following is the most appropriate management of  his dizziness?

A) Discontinue Hydrochlorthiazide

B) Cervical Collar

C) Cerumen Disimpaction

D) Increase Diuretics and add Meclizine

E) Methylprednisolone

Question of the Week # 308

308)  A 76-year-old man presented with a 4-month history of recurrent vertigo. He reports feeling a sensation of spinning dizziness on turning the neck to his left. He also reports left sided headaches and decreased hearing on the left. Each episode lasted about 15 to 20 minutes and occurred when he turned his head to the left. He denies any ringing sensation in ears,  nausea or vomiting. He denies any chest-pain, shortness of breath or palpitations.  His past medical history is significant for hypertension and diet controlled diabetes. His medications include  hydrochlorothiazide and enalapril. He also has history chronic neck pain due to cervical spondylosis for which he uses tylenol. On examination, his blood pressure in supine position is 140/88 mmHg and  blood pressure on standing is is 130/86. Tympanic membranes are visible and there is some cerumen in the left ear. Using a 512Hz tuning fork , bone conduction is found to be better than air conduction on the left and Weber test shows lateralization to the left. Dix-Hallpike’s and Lhermitte’s signs are negative. There are no other neurological deficits. Gait is normal. Range of motion of the neck is limited on lateral movements and neck pain is elicited by turning to left side. An X-ray of cervical spine shows severe spondylosis with discopathy and osteophytes from C2 to C4 vertebrae.  Which of the following is the most likely explanation for his Vertigo?

A) Orthostatic Hypotension

B) Vertebral artery occlusion from cervical spondylosis

C) Cerumen Impaction

D) Meniere’s disease

E) Labyrinthitis

Question of the week # 276

276) A 70 year old obese woman is evaluated in your office during an annual follow up visit. Her other medical problems include hypertension, chronic sinusitis, nasal polyps, asthma, osteoarthritis and a history of transient ischemic attack about 2 months ago. She uses acetaminophen for her arthritis pain because ibuprofen makes her “swell up” and causes severe “breathing problems”. Upon review of her medications, you note that she is not on any antiplatelet therapy.  Physical examination is unremarkable except for nasal polyps. Which of the following recommendations is most appropriate management for this patient?

A) Warfarin

B) Aspirin and Dipyridamole

C) Aspirin

D) Clopidogrel

E) Dipyridamole

F) No anti-platelet therapy

Question of the week # 275

275) A 70 year old obese woman is evaluated in your office during an annual follow up visit. She has a history of moderate osteoarthritis and she takes over the counter ibuprofen for arthritis pain. She was recently hospitalized with one episode of gastro-intestinal bleeding about 6 months ago. She is being maintained on a proton pump inhibitor. Her other medical problems include hypertension and a history of transient ischemic attack about 2 months ago. Upon review of her medications, you note that she is not on any antiplatelet therapy.  Physical examination is unremarkable. Which of the following recommendations is most appropriate management for  this patient?

A) Warfarin

B) Aspirin and Dipyridamole

C) Aspirin

D) Clopidogrel

E) Dipyridamole

F) No anti-platelet therapy

Question of the Week # 250

250 )  A 30 year old woman presents to your office with complaints of fatigue and headache.  She reports that the headaches occur almost daily and are mild to moderate. They are not associated with nausea or vomiting and are unrelated to menstrual cycles. She also reports chronic diffuse abdominal pain and pelvic pain for the past several months for which she did not seek any medical attention. Her chart reveals that she was seen by your colleague few months ago for similar complaints. She was asked to return after few laboratory investigations but she had been non-compliant with her follow-ups. Physical examination reveals an anxious appearing woman who otherwise appears healthy. She does not make an eye contact. Abdominal and pelvic examination is benign. There are no tender points. There are no neurological deficits. The most appropriate next step in managing this patient:

A)     Support and Counseling

B)     Refer to Psychiatry

C)      Start Selective Serotonin Reuptake Inhibitors

D)     Trial of Tricyclic anti-depressants

E)     Screen for Domestic Violence

Question of the Week # 210

210 )  A 42 year old woman in otherwise good health presents to the Emergency room for sudden onset of severe headache 2 hour ago. She has no previous history of headache or migraine . Upon arrival in the ER, she described her headache as “10 out of 10” in severity. She thinks this is the worst headache of her life. She denies any fever or visual problems or drug abuse.  Her physical and neurological examination is benign. There is no neck stiffness at this time.  A computed tomography (CT) scan of the head is obtained, which did not reveal any abnormalities. A subsequent  lumbar puncture reveals bloody fluid which shows decreasing red color in subsequent collection tubes. The last collection tube shows red fluid but much decreased color as opposed to the first collection tube. Which of the following is the most appropriate management decision?

A) Repeat Lumbar Puncture at a different site

B) Immediate CSF centrifugation

C) Neurosurgery evaluation

D) Re-assurance and analgesic therapy

E) Subcutaneous Sumatriptan

Question of the Week # 209

209)  A 35 Year old woman presents for evaluation of recurrent headaches for the past few months.  Lately, she has been waking up with a headache almost daily though it tends to improve in the latter half of the day. She is frustrated as she can not even get some sleep during the attack since lying down makes her feel worse . She has associated nausea. She has transient attacks of light flashes  that resolve spontaneously. Her menstrual history is unremarkable. On physical examination, she has no neurological deficits. Funduscopic examination shown below:

Which of the following information, if elicited in the patient history, would increase the clinical suspicion of the diagnosis?

A)     Constipation

B)      Family History

C)      Recent weight gain

D)      Galactorrhea

E)      Urinary incontinence

Question of the Week # 208

208)  A 31 Year old woman with suspected diagnosis of Idiopathic intracranial hypertension underwent a lumbar puncture. An MRI of the brain that was obtained prior to lumbar puncture did not reveal any structural abnormalities or mass effect. Laboratory investigations including coagulation parameters were normal. About 12 hours after the procedure, she complains of moderate to severe headache. Headache is mainly in the occipital region which increases while sitting up and improves on lying flat. She has two episodes of vomiting in the last one hour. She also complains of dizziness and ringing sensation in her ears.  Physical examination does not reveal any papilledema or focal neurological deficits. Most appropriate next step in managing this patient?

A)     Blood cultures

B)      MRI of the Lumbar Spine

C)      Non-Contrast CT scan of brain

D)     Observation

E)      Acetazolamide

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