USMLE Step3 Question of the Week #493

#493. A 77-year-old male is brought into the Emergency Department after the staff at his nursing home witnessed a syncopal event. Once a week a barber comes to the nursing home to provide haircuts and shaving services. After the barber raised the head of the patient’s bed and started to shave his neck, the patient suddenly lost consciousness. The barber called for help, and the patient was regaining consciousness by the time staff arrived. Within a few minutes the patient was at his baseline mental status and did not lose control of his bladder or bowels or bite his tongue during the episode. The barber didn’t notice any abnormal movements by the patient but reports he was trying a new “natural” shaving foam this morning. The patient has a history of Parkinson’s disease and hypertension. He does not smoke or drink alcohol. Blood pressure is 124/84 mm Hg and heart rate is 92 beats/minute sitting and 128/82 mm Hg and 88 beats/minute after standing two minutes. What would be the next best step in management?

A. Immediate referral for permanent pacemaker

B. Carbamazepine

C. Referral to an Electrophysiologist

D. Carotid endarterectomy

E. Reassurance, education and clinical follow-up

cardio@jamesv

USMLE Step3 Question of the Week #492

#492.  A 37-year-old woman with a history of bulimia nervosa presents with chest pain. Patient describes it as a sharp pain, localized to the middle of the chest, and occurred acutely last night after vomiting.  Current medications are fluoxetine 60 mg orally daily and a daily multivitamin.

On physical exam, patient appears ill and diaphoretic.  Vital signs show temperature of 37 °C (98.6 °F), blood pressure of 135/85 mm Hg, pulse of 90 /min, respiratory rate of 30 / min, and oxygen saturation of 98% on room air.  Oropharynx is erythematous, dentition is poor and back molars show significant erosion.  There is dullness to percussion and diminished breath sounds over the lower lobe of the left lung.  Remainder of the physical exam is normal.   EKG and laboratory tests are normal.  Chest x-ray shows a small left pleural effusion and evidence of pneumomediastinum.

Which of the following is the definitive diagnostic step in this patient?

A. Esophagogastroduodenoscopy

B. Barium swallow study

C. Helical CT of the chest without contrast

D. Gastrografin swallow study

E. Thoracentesis

 

@card-hageman

Question of the Week #490

490. An 18-year-old male presents to the Emergency Department for evaluation of chest pressure for an hour. The pain is radiating to his jaw. On examination, he is diaphoretic, and he complains of nausea. Past medical history is unremarkable. Urine reveals positive benzolegonine. Below is his ECG. What is the most likely cause of the patient’s symptoms?

ekg

A. Early repolarization

B. Ischemia

C. Cocaine induced myocardial infarction

D. Atrial fibrillation

E. Wolf-Parkinson-White Syndrome

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 # 426

426) A 70-year-old man with history of atrial fibrillation and metallic mitral valve presents to the out patient clinic for follow up. He has been taking warfarin for the past 5 years. His INR has been in therapeutic range between 3.0 to 4.0. However, over the last one month his INR has been in the range of  1.5 to 2.0 . His other medical problems include moderate osteoarthritis and mild cognitive dysfunction. He started taking Glucosamine supplements for “preserving his joints “and Ginseng to slow “ageing of his brain”  about two months ago. He has also been started on Aspirin by his cardiologist about 1 month ago. On examination, he is afebrile and vitals are stable. Abdominal examination is benign. A repeat INR is still sub-therapeutic at 1.5. Which of the following is the most appropriate management?

A) Increase Warfarin dose by 20%

B) Stop Glucosamine and repeat INR in 1 week

C) Continue Warfarin at same dose and repeat INR in 1 week

D) Stop Ginseng and repeat INR in 1 week

E) Stop Aspirin, increase Warfarin dose and repeat INR in 1 week

Question of the Week # 418

418) A 76-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. Her other history includes Diabetes and hypertension. She presents with complaints of increasing pain in her right lower extremity for the past 2 months. The pain appears upon standing or walking down the stairs for past few weeks. Her pain gets better upon walking uphill and when she sits down to rest. There is no history of limb swelling. On examination, vitals are stable. Pulses are palpable but slightly diminished in lower extremities. Reminder of physical examination is unremarkable. Which of the following is the most appropriate diagnosis ?

A) Peripheral Artery Disease

B) Chronic Venous Insufficiency

C) Lymphedema

D) Deep Vein Thrombosis

E) Lumbar Spinal Stenosis

Question of the Week # 417

417) A 72-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. Her other history includes Diabetes and hypertension. She presents with complaints of increasing pain in her right lower extremity upon walking a block for past few weeks. The pain gets better with rest. There is no history of limb swelling. On examination, vitals are stable. Physical examination is unremarkable with out any swelling or tenderness in her extremities.

Which of the following is the most appropriate diagnosis?

a) Peripheral artery disease

b) Chronic Venous insufficiency

C) Lymphedema

d) Deep Vein Thrombosis

e) Phlegmasia Alba Dolens

Which of the following is indicated next?

A) Venous Doppler

B) Compression Stockings

C) Clopidogrel

D) Check blood pressure at ankle and elbow levels

E) Leg elevation

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