Question of the Week# 483

A 50-year-old previously healthy man comes to his physician for a scheduled follow-up examination. He works as an electrician, which involves a significant amount of physical activity when working. He says he also runs 5 miles twice a week and is on a low-fat, low-cholesterol diet. His father died of a ‘heart attack’ at the age of 54, and he has smoked one pack of cigarettes daily for the past 25 years. He denies alcohol or illicit drug use. He says he leads a low-stress lifestyle and has no complaints. His current medication include lisinopril. On presentation, his blood pressure is 135/85 mm Hg. Laboratory studies from a week ago show:

Total cholesterol     287 mg/dL

HDL                        65 mg/dL

LDL                        180 mg/dL

Which of the following is the best next step in patient care?

A Initiate drug therapy for control of his hyperlipidemia
B Educate the patient about diet and exercise and repeat the tests within 4 weeks
C Educate the patient about diet and exercise and repeat the tests within a year
D Initiate a mandatory low-fat diet for the patient
E No intervention is indicated

 

Question of the Week # 447

447) A 54 year old caucasian man is seen in your office for initial visit examination. He recently moved from Texas to your town and would like to establish care with you. He has no significant past medical problems except for Gastro-Esophageal Reflux Disease for twenty years. He previously suffered hearburn symptoms that were controlled with over the counter ranitidine . Later, his symptoms became refractory and he was started on omeprazole by his previous physician. He currently takes 20 mg of Omeprazole and is very happy that he has been asymptomatic for the past 1 year.  He has had colonoscopy 2 years ago and this was normal. His father died of Colon cancer at the age of 70. He does not smoke.

Which of the following is the most appropriate action at this time ?

A) Instruct him to continue Omeprazole and follow up in 1 year.

B) Refer to gastroenterology for Upper Endoscopy

C) 24 hour Esophageal pH monitoring

D) Stool Guaic test and Flexible Sigmoidoscopy

E) Stool test for H.Pylori antigen

Question of the Week # 399

399)  A 65 year old man with history of diabetes mellitus is evaluated in your office during a routine follow-up visit. He does not have any complaints. He uses Glyburide and Metformin for his diabetes and Atorvastatin 80mg/day and Omega-3 Fatty Acids  for his dyslipidemia. He is compliant with diet and exercise. His weight has been stable. He does not smoke or consume alcohol. His most recent HgbA1C was 6.0% and a fasting lipid panel a month ago showed Total cholesterol of 125 mg%, LDL-C 70mg%, Triglycerides 100mg% and HDL-C 35mg%. You discuss with him that his lipid panel meets the recommendations with regard to LDL cholesterol and Non-HDL cholesterol goals. However, he insists that he be treated for his low HDL-cholesterol. You offer adding Niacin but after he heard about it’s side effects he refuses it and seeks alternatives.  Which of the following is the most appropriate recommendation for him?

A) Change Atorvastatin to Rosuvastatin

B) Add Cholestyramine

C) No further therapy

D) Discontinue Omega-3 Fatty Acids

E) Increase Atorvastatin

Question of the Week # 398

398)  A 45 year old man with well-controlled diabetes presents to your office with complaints of troublesome flushing of his face and trunk for the past one week. Frequently, the flushing is severe and causes stinging sensations. His past medical history is significant for dyslipidemia with an isolated low HDL cholesterol for which he was started on Niacin one week ago. On examination, his blood pressure is 120/88 mm Hg.  His face and trunk have flushed appearance. Reminder of physical examination is unremarkable. Which of the following is the most appropriate recommendation for him at this time?

A) Discontinue Niacin

B) Take Niacin with food

C) Diphenhydramine as needed

D) Take Aspirin before Niacin

E) Re-assure symptoms will bate in one week

Question of the Week # 397

397)  A 65 year old man with past medical history of Hypertension presents to your office to discuss his lipid profile results which were obtained two weeks ago.  He takes Losartan for his high blood pressure and is compliant with 2gm sodium diet. He smoked about 1 pack per day for the past 35 years. On examination, his blood pressure is 140/88 mm Hg. Reminder of physical examination is unremarkable. His fasting lipid panel reveals Total cholesterol 220 mg%, LDL-C 150mg%, Triglycerides 150mg%, HDL-C 40mg%. Which of the following is the most appropriate initial step?

A) Diet and lifestyle modifications alone

B) Diet, Lifestyle modification and Statin therapy

C) No Intervention

D) Omega 3 Fatty Acids

E) Repeat Lipid Panel in 3 months

Question of the Week # 396

396)  A 45 year old woman presents to your office for annual physical examination. She reports that she has had a fasting lipid panel done 6 months ago and her HDL – C was low at 25 mg%. She requests to be treated for this. She started healthy diet rich in fruits and vegetables. She used to smoke about 4 cigarettes/ day earlier but quit smoking after she came to know about her lipid results. She occasionally uses red wine in moderate amounts. She has also started aerobic exercises at least 3 days per week. Physical examination is unremarkable. A repeat lipid panel reveals Total cholesterol 128 mg%, LDL-C 80mg%, Triglycerides 100mg%, HDL-C 28mg%. Which of the following is the most appropriate next step?

A) Fenofibrate

B) Niacin

C) Ezetemibe

D) Atorvastatin

E) Omega-3-Fatty Acids

Question of the Week # 395

395)  A 65 year old man with history of Hypertension, Peripheral Artery disease and Dyslipidemia is seen during a follow-up office visit. His medications include Atorvastatin 80mg, Enalapril 20mg and Clopidogrel 75 mg/ day.  He does not have any new complaints and tolerating his medications well. He still smokes about 1 pack per day despite repeated counselling however, he has been strictly compliant with low-fat diet. On examination, his vitals are stable. Lower extremity dorsalis pedis are slightly diminished bilaterally. Reminder of the examination is unremarkable. A fasting lipid profile obtained a week ago showed :  Total Cholesterol : 205 mg% LDL cholesterol (calculated) 90mg%, HDL – cholesterol 45 mg%, Triglycerides 350mg%.  Liver function tests , Serum electrolytes, Creatinine and Complete blood count are within normal limits. Which of the following is the most appropriate next step?

A) Add Fenofibrate

B) Add Niacin

C) Add Cholestyramine

D) Change Atorvastatin to Rosuvastatin

E) Increase the dose of Atorvastatin

Question of the Week # 394

394)  A 36 year old woman with Type I diabetes mellitus presents to your office because she just learned that she is pregnant. She is excited and seeks your advise. Her home blood sugars are well controlled on a basal-bolus regimen of Glargine and Lispro insulin. Her other medications include Atorvastatin and aspirin. Her most recent HgbA1C was 6.0%. Her records also reveal that her most recent fasting lipid profile met the therapeutic goals at LDL of 80mg% and Non-HDL cholesterol of 100mg%. On examination, she is comfortable. Vitals are stable and reminder of the examination is unremarkable. An office based serum pregnancy test is positive. A repeat fasting lipid profile reveals Total Cholesterol : 250 mg% LDL cholesterol (calculated) 140mg%, HDL – cholesterol 40 mg%, Triglycerides 350mg%.  Liver function tests , Serum electrolytes, Creatinine and Complete blood count are within normal limitsWhich of the following is the most appropriate next step?

A) Therapeutic Abortion

B) Add Niacin to her Lipid Regimen

C) Discontinue Statin and Start Niacin

D) Discontinue Statin and advise Diet modification alone

E) Increase Atorvastatin

Question of the Week # 384

384)  A 55  year old airline pilot presents for a follow-up visit for hypertension. He was diagnosed with hypertension a year ago and has been on treatment with hydrochlorthiazide and lisinopril.  He denies any chest pain, palpitations or shortness of breath on exertion. He has no other significant health issues. His Hemoglobin a1C about 6 months ago was 5.0% . A lipid profile obtained 3 months ago showed a total chlesterol of 270mg% with HDL cholesterol of 34mg%. He  smokes about 1 pack per day but denies any drug or alcohol abuse.  There is no family history of Diabetes or coronary artery disease or abdominal aorta aneurysm. On examination, his blood pressure is 138/74. Cardiac examination shows regular heart sound with no S3 gallop or S4. There are no audible murmurs. Abdominal examination is benign and there are no audible bruits. A complete blood count, comprehensive metabolic panel and urinalysis are unremarkable. A resting electrocardiogram shows changes consistent with left ventricular hypertrophy. He had a colonoscopy five years ago which was normal. Which of the following is indicated at this time?

A) No additional Tests

B) Exercise Stress Test

C) Cardiac catheterization

D) Abdominal Ultrasound for Aortic aneurysm

E) Fecal Occult Blood Testing

Question of the Week # 383

383)  A 38 year old african-american male nurse is evaluated in your office because his blood pressure was found to be elevated when the doctor Employee Health Center checked his blood pressure. He was checked in the Employee Health 3 months ago and at that time, his blood pressure was 146/94 mm Hg and a repeat reading by the same doctor was 148/92 mm Hg  a month ago. He checked his blood pressure at home two times at his home and it was ranging between 120/76 to 124/82.  He does not trust this doctor at his work place so, he decided to come and visit you. He denies any dizziness, chest pain, palpitations or shortness of breath. He does not smoke or does not drink alcohol. Several members in family have history of Hypertension. On examination, his blood pressure is 150/94.  His Body Mass Index is 26kg/m2. Cardiac examination shows regular heart sounds. There are no audible murmurs. An electrocardiogram reveals positive voltage criteria for left ventricular hypertrophy. A subsequent 2D-Echo reveals left ventricular hypertrophy with good ejection fraction at 60% and no valvular problems.  Serum creatinine is 1.0mg% and Urinalysis is normal. A lipid profile has been ordered. Which of the following  is the most appropriate investigation to be ordered next?

A) Exercise Stress Test

B) Ambulatory Blood Pressure Monitoring

C) Hemoglobin A1C

D) Plasma Metanephrines

E) Captopril Renal Scan

Question of the Week # 382

382)  A 36  year old Caucasian man presents for a pre-employment health physical. He denies any health problems in the past. He does not smoke or drink alcohol. He denies drug abuse.  He enjoys good health and has no significant medical issues. He has no family history of Hypertension, Dyslipidemia, Diabetes or coronary artery disease.  On examination, his blood pressure is 118/74. Body Mass Index is 24kg/m2. Cardiac examination shows regular heart sound with no S3 gallop or S4. There are no audible murmurs. Abdominal examination is benign and there are no audible bruits. A complete blood count, comprehensive metabolic panel, urinalysis and urine drug screen are unremarkable. Which of the following is indicated at this time?

A) No additional Tests

B) Serum Total Cholesterol and HDL – cholesterol

C) Hemoglobin A1C

D) Fasting Plasma Glucose

E) Prostate Specific Antigen

Question of the Week # 334

334) A 50 year old male nurse is evaluated in your office for a recently discovered lung nodule. About 1 month ago, he had whole body CT scans because he read over the internet that these can be helpful in early detection of cancer. A high resolution CT scan of chest revealed a 7 mm nodule with very smooth edges. The margins are well-defined and there is no calcification. The patient has never smoked in his life and he has no family history of cancer. He has no other risk factors for lung cancer.  He denies any night sweats, weightloss or chronic cough. His recent Tuberculin skin test was negative. Laboratory investigations including complete blood count and comprehensive metabolic panel are within normal limits.

Which of the following is the most appropriate management option?

A) Obtain a Positron Emission Tomography scan ( PET/CT scan)

B) No further follow-up

C) CT guided biopsy of the nodule

D) Follow-up CT scan at 6-12 months and then at 2 years if no change

E) Refer to Cardiothoracic surgery for Wedge Resection

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 # 307

307) A 35 year old woman is evaluated in your office during an antenatal visit. Her last menstrual period was 8 weeks ago. She tells you that 2 weeks after she missed her regular menstrual period she checked herself with home pregnancy kit and tested positive. She works in a day-care center. She is concerned now because she received Rubella vaccination 4 weeks ago after an exposure to a sick child without knowing that she was pregnant. She read about the dangers to fetus on the internet and is very worried. Physical examination is benign.

Which of the following is the most appropriate course of action?

A. Refer her to medical termination of pregnancy
B. Tell her that there is a high established risk to fetus and she should strongly consider termination of pregnancy
C. Counsel her about theoretical risk to fetus and continue pregnancy care
D. Administer Rubella immunoglobulin
E. Reassure her that there is no risk to fetus.

Question of the Week # 306

306) A 32 year old man with history of immune thrombocytopenic purpura is evaluated in your office during a follow up visit. His previous treatments include intravenous immunoglobulin (IVIG) and steroids for his immune thrombocytopenia. He has responded to IVIG in the past however, the response was transient despite steroid maintenance. The patient was maintained on steroids for 2 months initially and achieved a sub-optimal response with peak platelet count reaching 30k/µl. He began very slow steroid taper over the last 4 weeks but his platelets have dropped to 8k/μl again during the taper. Hence, the patient is scheduled for Splenectomy. On examination, he has no bleeding or echymoses. Platelet count today is 10k/μl. Which of the following is the most appropriate step in preparing this patient for surgery?

A) Pneumococcal , Meningococcal and HIB vaccines 1 week prior to surgery

B) Pneumococcal and meningococcal vaccines 2 weeks prior to surgery

C) Pneumococcal, Menigococcal and HIB vaccines 2 weeks prior to surgery

D) Daily oral Penicillin Prophylaxis

E) No vaccines required in adults

Question of the week # 305

305) You have recently been posted by your employer to serve as a school physician in a school that is few miles away from your office. The school has about 250 students of whom 55% are girls and the rest are boys. The school teacher reports that they have not had a scoliosis screening program in place and wonders if you can implement such a program in the school. Which of the following is the most appropriate course of action?

A) Arrange scoliosis screening for all students between 10 and 16 years of age.

B) Arrange scoliosis screening for all students 10, 12, 14 and 16 years of age.

C) Contact the school nurse and review skills for scoliosis screening procedures.

D) Visually inspect for severe curves only when the back is examined for other reasons.

E) Screen girls for scoliosis at 15 years of age and boys at 16 years of age.

 

Question of the week # 304

304)

A 16-year-old male who presents to your office for his regular health checkup and for clearance before participation in then high school basketball team. During the physical examination, you note a mild convexity in the thoracic region of his spine with forward flexion at the hips. You ask him to lean forward with his feet together and bend 90 degrees at the waist. Based on your clinical examination, you estimate a lateral spinal curvature of about 5 degrees. You discuss these findings with the patient and his mother. Which of the following is the most appropriate action?

A. Recommend back-strengthening exercises.

B. Refuse medical clearance for participation in sports.

C. Order a radiograph of the back to quantify the curvature

D. Observation alone.

E. Refer for orthopedic consultation.

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 # 274

274) A 76 year old obese woman with history of uncontrolled Hypertension and Type 2 Diabetes  is evaluated in your office during a follow-up visit. She has history of atrial fibrillation and has been taking warfarin for stroke prevention. However, she has difficulty keeping up with her appointments for INR monitoring and does not wish to continue warfarin. Mini mental status examination reveals mild dementia. Get up and Go test does no show any increased risk of fall. She denies any active bleeding. Rest of her physical examination is unremarkable. Her INR is 1.3 and her previous INRs have been sub-therapeutic. Laboratory investigations including complete blood count, serum creatinine and liver function tests are within normal limits. Which of the following management options is most appropriate for this patient?

A) Aspirin alone

B) Aspirin and Dipyridamole

C) Reduced intensity warfarin

D) Low Molecular Weight Heparin

E) Dabigatran

Question of the Week # 273

273 ) A 58 year old man with history of chronic smoking and coronary artery disease is seen in your office for a second opinion regarding smoking cessation. He suffered an acute myocardial infarction two years ago and has had percutaneous coronary intervention with stent placement. He has not had any coronary events in the past 2 years. He denies any chest pain. He was recently placed on Nicotine patches for treatment of tobacco use by his primary care physician. The patient is concerned that the nicotine may increase his risk of having a coronary event and requests you for a second opinion regarding nicotine patch therapy. Physical examination is unremarkable. Which of the following is the most appropriate response?

A) Nicotine replacement  is contraindicated in patients with cardiovascular diseases

B) Periodic counselling alone is very effective for smoking cessation.

C) Nicotine patch is not an independent risk factor for acute myocardial infarction

D) Your doctor knows what is best for you and you should follow his recommendations.

E) Varenicline is completely safe smoking cessation strategy in patients with cardiovascular disease.

Question of the Week # 272

272 ) A 58 year old man with history of chronic obstructive pulmonary disease and seizure disorder is evaluated in your office during a follow-up visit. He uses tiotropium inhaler on a daily basis and his pulmonary symptoms are adequately controlled. However, he reports inability to comply with smoking cessation recommendations. He has tried counseling sessions and Nicotine replacement therapy in the past without any success. The patient has been counseled again during this visit. Which of the following recommendations is most appropriate for this patient?

A) Nortriptyline

B) Varenicline

C) Bupropion and Telephone Counseling

D) Group therapy

E) Topiramate

Question of the Week # 271

271 )  A 52 year old man is distressed about his inability to quit smoking despite several office-based counseling and telephone counseling sessions. He has tried alternative therapies such as hypnosis and acupuncture without any benefit. His history is significant for severe depression for which he has been on treatment with Fluoxetine. He was recently diagnosed with coronary artery disease and had a stent placed 4 months ago. He understands that his smoking behavior greatly increases his risk of having a coronary event. He says he feels increasingly depressed about his inability to quit smoking. He denies any suicidal ideation. Which of the following is the most appropriate recommendations for this patient?

A) Nicotine replacement therapy

B) Varenicline

C) Buporopion

D) Rimonabant

E) Group therapy

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 # 227

227 )  A 32 year old man is evaluated in the clinic for intensely itchy rash . The rash appeared suddenly on his trunk 24 hours ago  and has spread to his extremities. He denies any fever or  using any recent medications. His travel history is significant for a trip to Colarado 3 days ago where he stayed with his friend in a hotel room. He enjoyed camping in the mountains and spent his evenings in the hotel building’s swimming pool. On examination, there  are multiple red papules all over his body and extremities but not on the head and the neck. Some of the papules are tender. Which of the following is the most appropriate next step in management?

A) Doxycycline

B) Lyme Serology

C) Ciprofloxacin

D) Reassurance

E) Amoxicillin-Clavulunate

Question of the Week # 226

226 )  A 2 year old male child is brought by his pregnant mother for evaluation of a rash all over his body. The rash developed 48 hours ago and is associated with fever. She also has a 12 year old daughter at home who is being treated for acute lymphoid leukemia. On examination, the patient has rash in different stages including papules, pustules and vesicles. You suspect chickenpox. The mother denies any history of chickenpox in the past. Which of the following is the most appropriate recommendation?

A)     Varicella vaccine to the male child

B)      Varicella vaccine to the mother

C)      Varicella Zoster immunoglobulin to mother and the daughter

D)     Varicella vaccine to mother and VZIG to the daughter

E)      Varicella vaccine to the mother and the daughter

Question of the Week # 190

190) A 45 year old man presents to your office for follow up of his dyslipidemia that was diagnosed 6 month. His lipid panel at that time was consistent with high Total cholesterol , Low HDL and high triglyceride levels. He was instructed on dietary modification. He presents for a follow up visit today and reports that he had been strictly compliant with reduced fat diet. His social history is significant for smoking 1 pack per day for the past 25 years . He reports drinking about 1 pint vodka per day for past 10 years. He read on an online magazine  that drinking alcohol would boost his “Good” cholesterol. At this time, a repeat fasting lipid profile reveals:

Total Cholesterol : 250mg%

HDL cholesterol : 35mg%

Triglycerides: 500mg%

The most important step at this time to address his lipid abnormalities:

A) Niacin

B) Gemfibrozil

C) Fenofibrate

D) Alcohol cessation

E) Smoking cessation

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