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 # 71

Q71) A 65 y/o African American man is brought by his daughter to you and requests a PSA test because there is a hx of prostate ca in their family. You perform PSA and DRE. DRE does not reveal any palpable mass. The lab test reveal : PSA : 8ng/ml, Free PSA: 1.5ng/ml. You reveal the results to patient and his daughter. The daughter asks you if her father has a cancer. Your best response is :

A) The PSA level increases with age and your father’s PSA  is in the  age-appropriate range
B) PSA level is very nonspecific and your father does not have a cancer
C) The fact that the free PSA is only 1.5ng/ml as opposed to a bound of 6.5 indicates that your father most likely has a cancer etiology rather than benign cause
D) PSA will not help in diagnosing carcinoma prostate
E) I did this test only because you requested for it, I do not think this results mean anything.

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