Question of the week # 311

311) A 3 year old male child is brought to the emergency room by his mother after he fell from his tricycle and sustained an injury to his head  . The child was found to be alert and awake after the fall, however, he reported mild pain on the right side of his head. His mother noted a small bruise and swelling over the right side of his scalp. There is no history of vomiting or nausea. He has no past history of convulsions or epilepsy. Family history is unremarkable. At this time, child is quiet and reports mild headache. On examination, he is alert and awake. He is not in distress. There is small contusion on the fronto-parietal aspect of his scalp. There is no evidence of hematoma. Palpation does not reveal any depressed fracture. Neurological examination is normal with out any deficits.  Rest of the physical exam is normal. Which of the following is the most appropriate management at this time?

A) Contact Child Protection Services

B) Perform Head CT scan

C) Admit to Hospital

D) Observe at home

E) Skull X-rays

Question of the week # 310

310) A 28 year old man is admitted with abdominal pain and diarrhea of one day duration. Abdominal pain is diffuse in nature, mild to moderate and is associated with cramps and vomiting. He reports having had recurrent attacks of abdominal pain and diarrhea for several months. His past medical history is significant for Vitiligo and Hypothyroidism. He denies any allergies, atopy or Asthma. Family history is unremarkable. On examination, his mucous membranes and dry and he appears moderately dehydrated. He is afebrile, Blood pressure is 90/60 mm HG, heart rate 120/min, Respiratory rate 18/min. There is no peripheral lymphadenopathy. Skin examination reveals hypopigmented patches consistent with Vitiligo on his chest and the extremities. Abdominal examination is benign , Spleen is not palpable. CT scan of the chest, abdomen and pelvis are normal. Stool anlaysis performed several times during his previous episodes did not reveal any evidence of parasitic infection or leukocytes or blood. Laboratory investigations and peripheral smear are shown below:

WBC 6.0k/µl

Differential: Neutrophils 45%, Lymphocytes 34% ( N = 20 to 40%), Monocytes 6%, Eosinophils 15% ( normal range 1 to 4%)

Hemoglobin 14.5 g/dL ( Normal = 13.0 to 16.5 gm%),

Mean cell volume (MCV)  84  fL

Platelet count 310k/µl

Stool Ova and Parasites negative

TSH 4 μIU/ml ( 0.3 - 5.0 uIU/ml)

Which of the following diagnoses is most likely explanation for the patient's clinical presenation?

A) Giardiasis

B) Addison's disease

C) Vitiligo

D) Chronic Myeloid Leukemia

E) Lymphoma

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 # 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 # 303

303) A 11 year old girl is evaluated in your office for progressing lateral curvature of her spine. She denies any back pain or neurological symptoms. Her mother is very concerned about the child's appearance.  On physical examination, there is gross convexity in the thoracic region of her spine with forward flexion at the hips. There is no tenderness or neurological deficits. An x-ray of the spine reveals 25º curvature ( cob angle) . Which of the following is the most appropriate management at this time?

A) Repeat Clinical exam and x-rays at 6 months

B) Refer to orthopedic evaluation

C) Bracing

D) Spinal fusion surgery

E) Recommend back strengthening exercises

Question of the week # 302

302) A 16 year old girl is evaluated in your office for one day duration of fever, cough and left pleuritic chest pain. On examination, her temperature is 100.5F, respiratory rate is 18/min, pulse 100/min and blood pressure 120/60 mm hg. Breath sounds are decreased in the left lower lobe. A Chest x-ray is obtained which reveals left lower lobe infiltrate. Incidentally, a 7 ° lateral curvature is seen on the chest x-ray. The patient is started oral azithromycin for her pneumonia and is discharged home. Which of the following is the most appropriate management for her  incidentally discovered scoliosis?

A) Clinical follow up  alone

B) Repeat x-rays every 6 months

C) Refer to orthopedic surgery

D) Bracing

E) No follow up required

Question of the week # 301

301) A five month old male infant is brought to the out patient department for evaluation of one month history of recurrent vomiting, diarrhea and skin rash . The baby was delivered normally at term with out any complications. Mother reports that she breastfed him for four months and recently has been feeding him exclusively with formula. Mother reports that the baby vomits intermittently after each feed and develops raised, red welts on his skin after each feeding. There is no blood or bile in the vomitus. Vomiting  occurs within 30 minutes after feeding. Suckling is normal. He also has mucousy, loose stools for the past three weeks with no blood.  There is no history of cough, cold or fever. On examination, the infant in no apparent distress and vitals are normal. Abdominal examination is benign with out any palpable masses or peristaltic waves. Rest of the physical is  normal. Laboratory investigations reveal Hb: 13.2 gm%; Haematocrit: 35%; WBC: 9,200/μl ; Platelets: 225,000/μl, Na 132 meq/L; K 3.8 meq/L; Cl 92 meq/L; albumin 4.6g%. Urinalysis is normal. Which of the following is the most appropriate next step in managing this condition?

A) Abdominal ultrasound

B) Lactose free formula

C) Start hydrolyzed formula feeds

D) IgE Radio-allergosorbent test

E) Observation

Question of the week # 300

300) A 14 year old girl is evaluated in your office for  moderate headache of one month duration . She denies any blurred vision, neck stiffness or fever. She is accompanied by her mother who reports that her performance at school has progressively declined over the last few months and she has deepening of voice for the past 4 months. On examination, Pulse 80/min;  Temperature: 98.4F  and Blood pressure: 135/100 mm of Hg. There is excessive hair on her face. Rest of the physical is normal except for faint purplish marks on her abdomen. Laboratory investigations including complete blood count, comprehensive metabolic panel and Urine analysis are within normal limit. Which of the following is the most appropriate next step ?

A) 24 hour urinary cortisol

B) MRI brain

C) CT scan of the abdomen

D) Dexamethasone Suppression Test

E) Plasma catecholamines

F) Urine Drug Screen

Question of the week # 299

299) A 10 month old male infant  is brought by his concerned mother to the Emergency room with complaints of vomiting and bloody diarrhea. Mother reports that he suffered from "stomach flu" symptoms about 1 week ago which resolved spontaneously.  He had 4 episodes of vomiting since yesterday and has been crying intermittently every 15 minutes. There is no blood or bile in the vomitus. He had four loose stools with blood in it. There is no history of fever or cough or cold. His past medical history is unremarkable. On examination, temperature is 98.4F,  pulse 112, respiratory rate 30/min and blood pressure at 80/50 mm hg. Oral mucosa appear moist and skin turgor is adequate. Abdomen is soft with no palpable masses. Bowel sounds are present. Stool guaiac is strongly positive. Stool is sent for cultures and abdominal x-rays are obtained. An x-ray image is shown below:



Which of the following is the most appropriate next step in managing this condition?

A) Abdominal ultrasound

B) Gastrograffin enema

C) Surgery

D) Rectal tube placement

E) Flexible sigmoidoscopy

Question of the week # 298

298) A 6 year old boy presents to your office with a limp on the right side. He denies any falls or trauma. Mother reports that the limp has been present for several weeks. She reports that the patient was seen in the Emergency Room when the limp was first observed. X-rays obtained at that time were normal and so, he was discharged. There is no history of fever. He denies any pain. Family history is unremarkable. On examination, he is afebrile . His right lower extremity appears one inch shorter than the left. Upon standing and walking, his pelvis appears to be tilted towards the left. Which of the following is most likely to be abnormal in this condition?

A) External rotation of hip

B) Tibial tuberosity

C) X-ray of the Knee

D) Erythrocyte Sedimentation Rate

E) Internal rotation and abduction of hip

Question of the week # 297

297) A 64 year old man is seen in the office for pre-operative evaluation of right inguinal hernia repair. His past medical history is significant for diabetes and recurrent right foot cellulitis. His most recent episode of right foot cellulitis was 2 weeks ago for which he received a 2 week course of oral antibiotics. His surgery is scheduled within one week. On examination, he is afebrile. He has reducible right inguinal hernia and bilateral lower extremity stasis dermatitis. His laboratory investigations reveal:

Platelet Count 240k/μl ( Normal 150–400k/μl)

Prothrombin time 22 seconds ( Normal 10 to 13 secs)

Partial Thromboplastin time : 34 sec ( Normal 22 to 37 secs)

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

A) Obtain PTT mixing studies

B) Administer Oral Vitamin K

C) Intravenous Fresh Frozen Plasma

D) Intravenous Factor VIII

E) Von Willebrand Factor Assay

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Question of the week # 296

296) A 6 month old Asian infant  is brought by his concerned aunt for evaluation of dark blue areas on the child's buttocks. She says she was called to baby-sit the infant since his mother found a new job 2 days ago. She noted the rash and became suspicious that the child may have been abused. The mother arrives in Emergency room an hour later and reports that the rash has been present since birth. The mother is divorced and lives alone with the child. On examination, there are bluish-green patches on bilateral buttocks and on the lower back. They are irregular in shape and  margins are indistinct. There is no swelling or tenderness. An image of the skin findings is shown below:

Which of the following is the most appropriate next step ?

A) Order Skeletal Survey

B) Reassure that rash may fade away in few years

C) Contact Child Protection services

D) Obtain Coagulation parameters

E) Obtain Platelet count

Question of the week # 295

295) A 10 year old boy is brought to your office for evaluation of rash in bilateral axillae and groin for the past 2 months. He denies any itching or any other skin rashes.  However, he reports that the area has become progressively rough to touch. He is otherwise, healthy. On examination, there are  reddish brown patches in bilateral axillae and groin. There is maceration and scaling in the web spaces between the toes of bilateral feet. Rest of the examination is normal. A KOH mount is obtained and is negative. Wood's lamp examination reveals coral red fluorescence. A picture of  the rash is shown below:

Which of the following is the most appropriate next step ?

A) Topical corticosteroid

B) Topical Selenium Sulfide

C) Oral erythromycin

D) Topical Clotrimazole

E) Oral Metronidazole

Question of the week # 294

294) A 71 year old woman presents to the emergency room with complaints of bright red bleeding per rectum. She denies any abdominal pain, nausea or vomiting. She has a history of paroxysmal atrial fibrillation. Her medications include aspirin and beta blocker. About 10 days ago, she had a screening colonoscopy. She had a 3cm polyp in the sigmoid colon which was removed at that time.  She reports that she did not experience any bleeding immediately after polyp removal and is concerned about this episode that occured so many days after the procedure. On physical examination she is afebrile . Abdominal examination is benign. Rectal examination reveals bright red blood and no palpable hemorrhoids. Patient is anxious about her diagnosis.  Which of the following is the most appropriate statement?

A) " Your bleeding is mostly secondary to ischemic colitis"

B) " Bleeding can occur up to two weeks after polypectomy".

C) " Your bleeding is related to Aspirin use".

D)  " We will have to repeat colonoscopy to confirm that a cancer has not been missed"

E) " You will need diagnostic laporoscopy to evaluate the cause"

Question of the week # 293

293) A 70 year old man is evaluated in the emergency room for abdominal pain , fever, nausea and vomiting that began 8 hours after he underwent a screening colonoscopy. The pain is severe and is mostly in the left lower quadrant of the abdomen. He reports that his colonoscopy procedure was uneventful except that he had a 2cm sessile polyp which was removed during the procedure. He denies any rectal bleeding. On examination, temperature is 102 F, blood pressure 100/60 mmHg, pulse 120, respiratory rate 28/min. Abdominal examination reveals severe tenderness,  guarding and rigidity in the left lower quadrant. Laboratory investigations show:

WBC 28k/µl with left shift

Hemoglobin 13.5 g/dL

Mean cell volume (MCV)  84  fL

Platelet count 310k/µl

Which of the following is most important next step in management?

A) Obtain urgent surgical consult

B) Rectal tube placement

C) Serum amylase level

D) Supportive care alone

E) Barium enema

Question of the week # 292

292) A 66 year old man is evaluated in the emergency room for abdominal pain and fever. The patient underwent a screening colonoscopy in the outpatient Gastroenterology clinic 8 hours ago and had a 3cm sessile polyp removed. He complains of moderate pain in left lower quadrant that started one hour ago. He denies nausea or vomiting or rectal bleeding. On examination, temperature is 100.8F, blood pressure 140/90 mmHg, pulse 102, respiratory rate 20 bpm. Abdominal examination reveals tenderness and guarding in the left lower quadrant. There is no rigidity or rebound tenderness. His laboratory investigations including complete blood count and comprehensive metabolic panel are within normal limits. Which of the following is the most appropriate next step in managing this patient?

A) Exploratory Laporotomy

B) Rectal tube placement

C) Flexible sigmoidoscopy

D) CT Scan of the Abdomen

E) Conservative management

Question of the week # 291

291) A 66 year old man with past medical history of hypertension and  type-2 diabetes mellitus is evaluated in your office during a regular follow up visit for his diabetes. During this visit, he reports problem getting and maintaining an erection.  On the times that he does have an erection, they are very soft.  He says this problem began approximately 10 months ago and has slowly worsened but he was too embarrassed to disclose this during his previous visits. He still has a strong sexual desire and this problem has caused strain in his current relationship.  He is physically very active walking two to three miles per day. His medications include glipizide and hydrocholrthiazide. He says his home blood sugars have been "perfect". A Hemoglobin A1C 2 weeks ago was 6.0gm% .  He currently does not smoke after having quit smoking 15 years ago. Physical examination shows blood pressure 140/90 mmHg, pulse 86, respiratory rate 20 bpm. Genitilia and testicles are normal in size . Peripheral pulses are normal. Rest of the physical examination is normal. Which of the following is the most appropriate next step in managing this patient?

A) Obtain Serum Total Testosterone

B) Obtain Nocturnal Penile Tumescence

C) Start Sildenafil

D) Prescribe Vacuum assisted erection device

E) Switch Hydrochlorthiazide to ACE inhibitor

 

Question of the week # 290

290) A 72 year old man with history of Diabetes Mellitus and peripheral vascular disease is evaluated in your office for impotence. He denies any premature ejaculation and states that he can not even attain an erection. Further studies confirm erectlie dysfunction secondary to organic causes. The patient denies any history of angina in the past. His medications include Aspirin, Clopidogrel, Glargine insulin and Lispro. His most recent HGBA1C was 6.5%. You offer him sildenafil for erectlie dysfunction. He is now concerned about the possible side effects. Which of the following is the most common side effect of sildenafil?

A) Headache

B) Nasal congestion

C) Diarrhea

D) Blurred vision

E) Flu like symptoms

Question of the week # 289

289) A 32 year old male athlete is evaluated in the office for bilateral breast enlargement. He is a state champion in running and is scheduled to participate in the national level running championship in few weeks. He is very concerned about his appearance.   He denies using any illicit drugs or exogenous androgens or aromatase inhibitors  is seen in the office during a routine follow up visit.  His past medical history is unremarkable. Physical examination reveals gynecomastia bilaterally. His laboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 18.5 g/dL ( Normal = 13.0 to 16.5 gm%),

Mean cell volume (MCV)  84  fL

Platelet count 310k/µl

Which of the following is most useful in establishing the diagnosis?

A) Erythropoetin level

B) Urine Drug Screen

C) Serum Total Testosterone

D) Urine Testosterone/ Epitestosterone ratio

E) Serum Free Testosterone

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 # 287

287) A 38 year old caucasian man  is seen in the office due to decreased libido and energy. His past medical history is significant for testicular cancer diagnosed 1 year ago and was treated with radical orchiectomy of left testicle and chemotherapy. He denies smoking tobacco but admits using Marijuana on a daily basis for the past few months. His family history is unremarkable.  Physical examination  reveals gynecomastia and absent left testicle. Body mass index is 24.  His routine laboratory investigations including complete blood count are within normal limits. Serum total testosterone level is reduced and Serum LH concentration is elevated. The patient is started on Testosterone replacement therapy with a testosterone skin gel. Which of the following is the most appropriate step in follow up care of  this patient after starting testosterone therapy?

A) Digital Rectal exam and Serum PSA level at one year

B) Hematocrit at 6 months and then, every year

C) DEXA scan at one year

D) Serum Testosterone level at 6 months

E) Serum LH at one month.

Question of the week # 286

286) A 55 year old woman with history of diabetes mellitus and hypertension is admitted with chest pain. Chest pain started about 30 minutes ago but now resolved after she received sublingual nitroglycerin. An electrocardiogram obtained by EMS showed ST segment depressions but a repeat electrocardiogram in the Emergency room is normal. She is placed on Aspirin, low molecular weight heparin, atorvastatin and metoprolol. She denies any easy bruising, nose bleeding or any other gross bleeding. She denies smoking , alcohol or drug abuse She has not been admitted to any hospital and has never received anticoagulants in the past. Physical examination  is benign . Laboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 15 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 8k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. Three sets of cardiac enzymes are negative. Cardiology team held aspirin and low molecular weight heparin immediately. A peripheral blood smear is shown below:



 

Which of the following is the most appropriate next step in management?

A) Platelet transfusion

B) Heparin induced platelet antibodies

C) Start Lepirudin

D) Send CBC in a citrate tube

E) IV Gamma Globulin

Question of the week # 285

285) A 26 year old man is seen in the office because he was found to have abnormal blood counts during a health check up prior to his life insurance application. He says he was told to see his physicians because his platelet count was very low. He denies any easy bruising, nose bleeding or any other gross bleeding. He has no other medical problems. He denies smoking , alcohol or drug abuse. He denies any recent infections. He leads a very active lifestyle and is a professional soccer player. He proudly states that he won his team the state level championship a year ago and likes to aggressively pursue this career. Physical examination  is benign. There is no splenomegaly. Repeat aboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 15 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 45k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative.

Which of the following is the most appropriate next step in managing this patient?

A) Intavenous Immunoglobulin

B) Recommend against soccer for life

C) Splenectomy

D) Observation

E) Prednisone

Question of the week # 284

284) A 32 year old pregnant woman is evaluated in the emergency room for new onset abdominal pain. She has mild nausea and vomited once prior to arrival in the emergency room. She denies any bleeding . This is her first pregnancy and she is at 34 weeks gestation.  Physical examination reveals normal blood pressure. There is mild tenderness in epigastric region. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 7 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 50k/µl

Lactic Dehydrogenase  1200U/L

AST 120U/L

ALT 180U/L

Serum Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. Amylase and lipase are normal. A peripheral blood smear shows reduced number of platelets and some fragmented red blood cells. Antinuclear antibodies, Anti-phospholipid antibodies, Lupus anticoagulant profile, HIV testing and Hepatitis C are negative.

Which of the following is the most appropriate next step in management?

A) Platelet transfusion

B) Intravenous Methyl Prednisolone

C) Induction of labor

D) Observation

E) Plasmapheresis

Question of the week # 283

283) A 26 year old man is seen in the office during a pre-employment health check-up. He has no medical problems. He denies smoking , alcohol or drug abuse. Physical examination  is benign. Laboratory investigations reveal:

WBC 8.8k/µl

Hemoglobin 15 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 45k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative.Upon further questioning, he denies any easy bruising, nose bleeds or gross bleeding. There is no family history of thrombocytopenia or bleeding disorder.

Which of the following is the most appropriate next step in managing this patient?

A) Intavenous Immunoglobulin

B) Prednisone

C) Observation

D) Bone marrow biopsy

E) Platelet transfusion

Question of the week # 282

282) A 32 year old woman is seen in the antenatal clinic during her regular antenatal visit. This is her first pregnancy and she is at 32 weeks gestation. She takes prenatal vitamins. She currently has no complaints. Physical examination  is benign. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 14 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 70k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative. The patient is concerned about her abnormal platelet counts. She denies any easy bruising or nose bleeds or gross bleeding. Her complete blood count 3 months ago was completely normal.

Which of the following is the most appropriate response?

A) "You will require treatment with steroids"

B) "Urgent delivery with cesarean section is required."

C) "Your platelet count will normalize within 2 to 12 weeks after delivery"

D) "You will require Bone marrow biopsy"

E) "No treatment needed since it is immune thrombocytopenia"

Question of the week # 281

281) A 22 year old woman is seen in the office for a rash on legs. She had an upper respiratory tract infection one week ago which resolved spontaneously. She is not on any medications. She has no other significant mast medical history. She has easy bruising which started 5 days ago but denies any nose bleeds or gross bleeding. Her last menstrual period was one week ago and she has regular cycles with no history of menorrhagia. Family history is negative for any bleeding disorders or thrombocytopenia. She denies any smoking , alcohol or drug abuse. Physical examination  is benign except for  petechiae on her bilateral lower extremities. There is no splenomegaly on examination. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 14 g/dL,

Mean cell volume (MCV)  84  fL

Platelet count 18k/µl

Liver function tests, Electrolytes, Creatinine, Prothrombin time and Partial thromboplastin time are within normal limits. A peripheral blood smear shows reduced number of platelets with out any schistocytes or blasts or nucleated red cells. Antinuclear antibodies, HIV testing and Hepatitis C are negative.

Which of the following is the most appropriate next step in managing this patient?

A) Ristocetin cofactor assay

B) Prednisone

C) Observation

D) Bone marrow biopsy

E) Plasmapheresis

F) Platelet transfusion

Question of the week # 280

280) A 2 year old child is brought by her mother to the emergency department because the child has not been ambulating since yesterday after he tripped over an object and fell. Physical examination reveals tenderness and swelling in left mid-thigh. Eyes are normal without any hemorrhages. Skin reveals several bruises. Teeth are translucent and show yellow discoloration. Moderate scoliosis is evident. A skeletal survey reveals rib fractures and multiple fractures in various stages of healing. There is diffuse osteopenia. There is a spiral fracture of left femur shaft.  The limb is splinted and an orthopedic consult is obtained. Which of the following is the most appropriate action?

A) Contact social services

B) Contact Child Protection Services

C) Place the child in foster care

D) Obtain Head CT

E) Obtain detailed family history

Question of the week # 279

279 ) A 14 month-old child is brought by her concerned father to the Emergency department with a history that the child slipped out and fell on the ground from a table that is 10 feet in height. He says the accident occurred last night when he let the child stand on the table. The child cries when the right thigh is touched and does not move the right lower extremity. Rest of the physical examination is normal. There are no suspicious bruises or contusions on the skin. An x-ray of the right femur is shown below.



A skeletal survey is obtained and does not show any other fractures. There are no skull fractures or retinal hemorrhages or neurological deficits.

Based on the x-ray findings and the history, which of the following is the most likely diagnosis?

A) Osteogenesis Imperfecta

B) Fibrous Dysplasia

C) Accidental Injury

D) Child Abuse

E) Pathological Fracture from Ewing Sarcoma

Question of the week # 278

278) A 34 year old mother brings her 18 month old child to the emergency room. She is in tears and reports that the child was playing on the sofa and has fallen down 1 day ago landing on his left foot and since then has not been moving his left lower extremity. The child is crying incessantly. Physical examination reveals tenderness and swelling in the left mid-thigh. An x-ray of the left lower extremity shows a non-displaced hair line fracture of the femur shaft and the fracture age consistent with reported history of time of injury. Which of the following is the most appropriate next step in management?

A) Contact Child Protection Services

B) Skeletal Survey

C) Open reduction and internal fixation

D) Bone scan

E) CT head

Question of the week # 277

277) A 32 year old woman with history of Systemic Lupus Erythematosus is evaluated during a routine antenatal visit. Her last menstrual period was 18 weeks ago. She is using prenatal pills and has no complaints. She is being maintained on prednisone.  Physical examination is benign and her blood pressure is normal. Her laboratory investigations show positive ANA, Anti-Ds DNA and Anti-SSA (Anti-Ro) antibodies in high titers. Anticardiolipin antibodies and Lupus anticoagulant testing is negative.  She is concerned about the risk to her baby because she heard that her antibodies can cross the placenta. Which of the following conditions is most likely to occur in the baby due to passive transfer of maternal antibodies?

A) Lupus Nephritis

B) Aplastic anemia

C) No risk with passive transfer

D) Complete Heart Block

E) Hydrops fetalis

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 # 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 # 269

269 )  A 42 year old man is evaluated in the Emergency room for sudden onset pain and swelling in the right knee. He denies any trauma. His past medical history is significant for chronic alcohol abuse, diabetes and stage III chronic kidney disease.  On physical examination, temperature is 100.5F and heart rate 110. Right knee is grossly swollen, warm, tender and erythematous. Rest of the physical examination is within normal limits. Arthrocentesis is performed and results reveal polymorphonuclear leucocytes of 50,000/µl and intra-cellular negatively birefringent needle shaped crystals under polarized microscopy. Synovial fluid gram stain is negative and bacterial cultures are pending. Complete blood count shows a white blood cell count of 18,000/µl with left shift. Which of the following is the most appropriate management recommendation?

A) Colchicine

B) Indometacin

C) Oral Prednisone

D) Broad spectrum antibiotics

E) Intra-articular Triamcinolone

Question of the Week # 268

268 )  A 62 year old man with history of chronic alcohol abuse, Hepatitis C and gout is admitted for nausea, vomiting and diarrhea.  His medications include colchicine for gout prophylaxis and multivitamins. The patient admits that he has increased his alcohol intake to about 4 pints vodka per day over the past two weeks. He has not been drinking or eating adequately. On physical examination, his vitals reveal a heart rate of 110 and blood pressure of 90/60. Oral mucosa are dry with poor skin turgor. Abdominal examination is benign. Laboratory investigations reveal acute renal insufficiency with a creatinine of 4mg% and BUN of 90mg%. His liver functuion tests are elevated with an AST of 160U/L, ALT  70U/L and ALP 240U/L. Total bilirubin is 2.0mg%. Complete blood count shows hemoglobin of 8.6gm%, WBC count of 1.6k/µl with absolute neutrophil count of 500/µl and Platelets 56k/μl. His laboratory investigations three months ago were with in normal limits. CT scan of the abdomen does not show any evidence of liver cirrhosis or Splenomegaly. The patient is started on intravenous hydration, thiamine and folic acid. Which of the following is the most appropriate next step in managing this patient''s pancytopenia?

A) Renal biopsy

B) Liver Biopsy

C) Stop colchicine

D) Bone marrow biopsy

E) Parvo virus RNA

How to nail that Residency Interview?

Question of the Week # 267

267 )  A 32 year old woman is evaluated in your office for increasing headaches over the past few months. She has a 5 year history of intermittent headaches. The headaches are throbbing in nature and are localized to frontal area. They are often accompanied by nausea and vomiting. Her episodes are usually preceded by irritability and food craving. She usually takes ibuprofen at the onset of headache which seem to relieve her pain. She recently broke up with her partner and has been under severe emotional stress since then. Lately, her headaches have become more frequent occurring about 4 to 5 times per month. The episodes interfere with her quality of life. She denies any headache at this time.  Physical examination including neurological and ophthalmoscopic exam is normal.  Her last menstrual period was 16 weeks ago and a urine pregnancy test returns positive. Which of the following strategies is most appropriate for this patient?

A) Biofeedback

B) Lumbar puncture

C) Start Propranolol

D) Start Sumatriptan

E) Start Valproic acid

Question of the Week # 266

266 )  A 70 year old man is evaluated in the emergency room for severe fatigue and exertional shortness of breath. He was diagnosed with pulmonary embolism 4 months ago and is on Coumadin. He denies any melena or hematochezia. There is no other history of gross bleeding.  On examination, his blood pressure is 100/70 mm Hg and he is afebrile.  Physical examination is normal. Stool for occult blood is negative.  His hemoglobin one month ago was 12gm/dl. Laboratory investigations reveal:

WBC 10k/µl

Hemoglobin 6.2 g/dL,

Mean cell volume (MCV)  102  fL

Platelet count 170k/µl

Lactic Dehydrogenase 140U/L

Haptoglobin 100U/L

Reticulocyte count 12%

INR : 8.0

Which of the following is the most appropriate next step in managing this patient?

a) Direct Coombs Test

b) Vitamin B12 and Folate levels

c)  Bonemarrow biopsy

d) Start Corticosteroids

e) CT scan of the Abdomen

Question of the Week # 265

265 )  A 52 year old woman presents to your office with complaints of increased thirst and increased urinary frequency. Her other medical problems include Hypertension and Dyslipidemia. Blood pressure has been under control on enalapril. Her family history is significant for diabetes mellitus and Hypertension.  Physical examination reveals an obese woman in no apparent distress. Blood pressure is at 135/80 mm Hg. Velvety thickened skin is noted in bilateral axillae. Which of the following results will establish the diagnosis that could explain the symptoms and physical examination findings in this patient?

A) Random plasma glucose > 180mg%

B) Hemoglobin A1c > 6.5%

C) Fasting Blood Sugar > 110 mg%

D)  Oral Glucose Tolerance Test  , plasma glucose ≥120 mg% at 2 hours

E)  Urine glucose > 300 mg%

Question of the Week # 264

264 )  A 52 year old woman presents to your office with complaints of increased thirst and increased urinary frequency. Her family history is significant for diabetes mellitus and Hypertension. A glucometer reading obtained in the office shows 260mg%. Hemoglobin A1C is 7.0% . The patient is subsequently started on Metformin. Three days after starting Metformin, she presents with nausea and diarrhea. She denies any fever or abdominal pain. Physical examination is within normal limits. Random glucometer reading shows 130mg%. Comprehensive metabolic panel is within normal limits. Which of the following is the most appropriate next step in managing this patient's symptoms?

A) Discontinue Metformin

B) Check lactic acid level

C) Recommend Metformin to be taken with meals.

D)  Check serum ketones

E) Insulin drip