Question of the Week # 412

412)  An 78 year old man with history of dementia is evaluated in your office for three episodes of “syncope” over the past two months. He lives with his daughter at home. She reports that he fell to the floor and lost consciousness in the morning after getting up from his bed and the episodes would last for few minutes but he would return to his usual baseline mental status after the event. There is no history of chest pain or shortness of breath.  She has seen him become increasingly “stiff” over the years and he has had worsening of tremors in his hands. When he writes, the letters are very small and difficult to decipher.  He has been taking Donepezil and Memantine for Alzheimer’s for about 2 years.  On examination, his pulse is 90/min, Blood Pressure 110/60 mm Hg. He has Bradykinesia and Pill rolling tremor in his hands. Cardiac examination is normal with out any murmurs. Laboratory investigations revealed a normal hemoglobin, blood glucose and electrolytes. An electrocardiogram is within normal limits. Which of the following is indicated next?

A) Orthostatic Vitals

B) 24 hour Holter-Monitoring

C) Discontinue Memantine and Donepezil

D) CT Scan of the Head

E) Tilt-Table Test

Question of the Week # 411

411)  An 88 year old man with history of moderate dementia is evaluated in your office for recurrent episodes of “syncope” over the past few months. There is no history of any chest pain or shortness of breath for a similar complaint. Nursing home staff reports that lately, he has been noted to be more confused than usual on several occasions and becomes very drowsy. He was sent to the Emergency Room twice last month for the same issue. There is no history of complete loss of consciousness. As per his nursing home chart, his other medical issues include poorly-controlled Osteoarthritis pain, “Sun-Downing” and Insomnia. On examination, his vitals are stable. He is currently awake. There are no focal neurological deficits. Cardiac examination is normal with out any murmurs. Laboratory investigations revealed a normal hemoglobin, blood glucose and electrolytes. An electrocardiogram is within normal limits. Which of the following is indicated next?

A) Orthostatic Vitals

B) 24 hour Holter-Monitoring

C) Electroencephalogram

D) Review of his medications

E) Tilt-Table Test

Question of the Week # 406

406)  A 65 year old woman is evaluated in your office for urinary problems. She reports involuntary loss of urine upon coughing almost daily for few months. She presented with similar problems 6 months ago and has been advised pelvic floor exercises and lifestyle modifications . These measures have not improved her symptoms. She denies any nocturia, frequency, hesitancy or urgency symptoms. She has no other medical problems On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy. When she is asked to cough in lithotomy position, there is large urinary leakage about 30 seconds after coughing which was difficult for her to stop. Complete blood count, Plasma glucose, Serum electrolytes and Urinalysis are within normal limits. Which of the following is the most appropriate next step?

A) Start Vaginal Estrogen

B) Recommend Vaginal Pessary

C) Obtain Urodynamic Studies

D) Mid-Urethral Sling  placement

E) Trial of Alpha-Adrenergic Agonists

Question of the Week # 405

405)  A 80 year old woman with advanced dementia is sent to your office for evaluation of a vaginal ulcer. The patient has a history of Stage III uterine prolapse. She had been fitted with a pessary for control of her symptoms about 6 months ago. She has no history of fever or chills. On examination, she is afebrile, blood pressure is 130/80. Pelvic examination revealed complete procidentia with impacted pessary and a 2  x 2 cm ulcer without any exudate. An attempt to remove the pessary is unsuccessful. Biopsies of the ulcer have been obtained. Which of the following is the appropriate initial management?

A) Vaginal Estrogen

B) Oral Antibiotics

C) Surgical removal of Pessary

D) Hysterectomy

E) Admit for parenteral antibiotics

Question of the Week # 404

404)  A 70 year old woman in excellent physical health presents to your office because she has noticed a mass falling out of her vagina for the past one year which is progressively worse. For the past six months, she has difficulty voiding. During voiding, she has to constantly change her position and sometimes, needs to push the mass inside in order to urinate. Lately, voiding has become even more difficult despite all these measures. She has problems with defecation which she describes as having to apply pressure on her vagina in order to completely evacuate her bowel. . She denies any fever or burning  urination.  She has normal bowel movements and has no problems with defecation. She is embarrassed to have sex anymore after having had urinary incontinence during sex. She blames herself for neglecting the mass without seeking medical attention for such a long time. Otherwise, she is in excellent physical health and has no other co-morbidity. She is willing to consider any option including surgery if feasible. On examination, vitals are stable. Pelvic examination revealed a total prolapse with total eversion of the vagina which was oedematous with marked ulceration in the dependent portion of the mass. Which of the following is the appropriate initial management?

A) Obtain Urodynamic studies

B) Biopsy

C) Admit for daily Vaginal packing with estrogen

D) Vaginal estrogen and Pessary

E) Vaginal Hysterectomy

Question of the Week # 403

403)  A 68 year old woman with history of Diabetes mellitus is evaluated in your office during routine follow-up visit. She reports that lately she has been experiencing pressure and bulge in her vaginal area and has a sensation of something falling out of her vagina. She denies any fever, burning, frequency or urgency of urination.  She has normal bowel movements and has no problems with defecation. She is sexually active with her husband and enjoys it. She denies any urinary incontinence even upon coughing or sneezing. On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy and a Grade 1 Cystocele.  Which of the following is the most appropriate recommendation?

A) Screen for latent Stress incontinence

B) Observation

C) Pessary

D) Surgery

E) Raloxifene

Question of the Week # 402

402)  A 68 year old woman with history of Diabetes mellitus is evaluated in your office during routine follow-up visit. She reports that lately she has been experiencing pressure and bulge in her vaginal area and has a sensation of something falling out of her vagina. She denies any fever, burning, frequency or urgency of urination.  She has normal bowel movements and has no problems with defecation. On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy and presence of moderate cystocele.   She has marked urinary leakage when she was asked to cough in lithotomy position. Complete blood count, Plasma glucose, Serum electrolytes and Urinalysis are within normal limits. She requests information regarding surgery for vaginal prolapse. Which of the following is the most appropriate statement regarding surgery for her cystocele?

A) Surgery may worsen her Incontinence

B) Surgery may increase urinary obstruction

C) If she were to undergo prolapse surgery, no additional incontinence treatment is needed

D) Surgery may cause defecation problems

E) Surgery is optimal option for her at this time.

Question of the Week # 401

401)  A 78 year old woman presents for annual health-maintenance examination. Her medical problems include Hypertension, Diabetes, Coronary artery disease and Chronic obstructive pulmonary disease. During review of systems, she reports that she has been experiencing involuntary loss of urine upon coughing almost daily for few months. She has been too embarrassed to disclose it and so, has not mentioned it during previous visits. However, the problem has been limiting her social activities and she really would like to “do something about it”. She denies any nocturia, frequency, hesitancy or urgency symptoms. Her medications include albuterol, ipratropium, glyburide, clopidogrel and losartan. She had a myocardial infarction followed by coronary stent placement six months ago. On examination, vitals are stable. Pelvic examination reveals changes consistent with vaginal atrophy and presence of moderate cystocele.   She has marked urinary leakage when she was asked to cough in lithotomy position. She has tried pelvic floor exercises and scheduled-voiding for past several weeks and has cut down on her coffee consumption however, these measures have not helped her much.  Complete blood count, Plasma glucose, Serum electrolytes and Urinalysis are within normal limits. Which of the following is the most appropriate recommendation for this patient?

A) Check Post-Void Residual volume

B) Vaginal Estrogen

C) Pessary

D) Mid-Urethral Sling placement

E) Oxybutynin

Question of the Week # 325

325 )  A 87 year old Caucasian man is evaluated in your office for progressive hearing loss. He reports defective hearing on both sides that started more than a year ago and has gradually worsened. The problem is particularly worse when he is in a crowded or noisy environment. He also reports frequent occurrence of roaring sounds and sounds similar to “ringing bells” in his ears. On otoscopic examination, he has mild cerumen impaction in bilateral ears. The Tympanic membranes are intact. Which of the following is the most characteristic feature seen with this condition?

A) Inability to hear “Vowel” sounds in the speech

B) Audiogram showing bilateral high-frequency sensory-neural hearing loss

C) Weber Test showing lateralization towards Right ear

D) A negative Rinne test

E) Otosclerosis

%d bloggers like this: