Sunday, August 28, 2011

Question of the Week # 253

253 )  A 75 year old african-american woman with history of Alzheimer's dementia and recent cerebro-vascular accident is transferred from the Nursing home for deterioration in mental status and fever. As per the nursing home staff, she has stopped feeding and has been having fever for the past three days. On examination, her temperature is 102F, Heart rate is 130/min, Respiratory rate 28/min and Blood pressure 80/45 mm Hg. Chest is clear to auscultation and abdominal examination is benign. A foley catheter is in place draining very cloudy urine. Dipstick urinalysis revealed 2+ protein, positive leucoesterase and nitrite. Blood cultures are obtained and the intravenous normal saline is started via. two large bore needles. In managing her Septic Shock, which of the following is the most appropriate goal that must be met in the first 6 hours of adequate resuscitation?

A) Mean Arterial Blood pressure > 50mm Hg

B) Serum Creatinine < 1.5 mg%

C) Urine output > 0.25ml/kg/hr

D) Mixed Venous Saturation > 65%

E) Hematocrit > 30%

Note: Surviving Sepsis guidelines

Question of the Week # 252

252 )  A 75 year old african-american woman with history of Alzheimer's dementia and recent cerebro-vascular accident is transferred from the Nursing home for deterioration in mental status and fever. As per the nursing home staff, she has stopped feeding and has been having fever for the past three days. On examination, her temperature is 102F, Heart rate is 130/min, Respiratory rate 28/min and Blood pressure 80/45 mm Hg. Chest is clear to auscultation and abdominal examination is benign. A foley catheter is in place draining very cloudy urine. Dipstick urinalysis revealed 2+ protein, positive leucoesterase and nitrite. Blood cultures are obtained and the intravenous normal saline is started via. two large bore needles. Which of the following is the most important next step in managing this patient?

A) Put in reverse trendelenberg position

B) Place a central venos catheter

C) Start Dopamie infusion via. peripheral access

D) Intravenous Hydrocortisone

E) Obtain Arterial Blood Gas analysis

note: Surviving Sepsis guidelines

Saturday, August 20, 2011

Question of the Week # 251

251 )  A 65 year old woman is evaluated in your office for pain in bilateral feet for the past four weeks. The pain is burning in quality and is associated with intense itching. Her past medical history is significant for difficult to control Type II Diabetes Mellitus. Her recent HgbA1C was 7.9% and Creatinine was 1.8mg%.  On physical examination, she is obese, afebrile and in no apparent distress. She has diminished pinprick and vibration sensation in glove and stocking pattern in bilateral upper and lower extremities. Dorsalis pedis and posterior tibial pulses are mildly diminished. There are multiple erythematous tiny vesicles between the toes and on the plantar aspect of the both feet.  Which of the following is the most appropriate treatment option for this patient's pain?

A)      Oral Pregabilin

B)      Topical Corticosteroids

C)      Oral Cefazolin

D)     Topical Terbinafine

E)     Topical Acyclovir

Question of the Week # 250

250 )  A 30 year old woman presents to your office with complaints of fatigue and headache.  She reports that the headaches occur almost daily and are mild to moderate. They are not associated with nausea or vomiting and are unrelated to menstrual cycles. She also reports chronic diffuse abdominal pain and pelvic pain for the past several months for which she did not seek any medical attention. Her chart reveals that she was seen by your colleague few months ago for similar complaints. She was asked to return after few laboratory investigations but she had been non-compliant with her follow-ups. Physical examination reveals an anxious appearing woman who otherwise appears healthy. She does not make an eye contact. Abdominal and pelvic examination is benign. There are no tender points. There are no neurological deficits. The most appropriate next step in managing this patient:

A)     Support and Counseling

B)     Refer to Psychiatry

C)      Start Selective Serotonin Reuptake Inhibitors

D)     Trial of Tricyclic anti-depressants

E)     Screen for Domestic Violence

Tuesday, August 9, 2011

Question of the Week # 249

249 )  A 64 year old  man is evaluated in your office for a left sided headache that started 24 hours ago. He describes the headache as a burning sensation over his left temple and the forehead. He also reports fatigue and malaise for the past one day. He has no significant past medical history.   On examination, he has a low grade fever at 100.4F, Blood pressure is 120/70 mm Hg. Physical examination reveals hyperesthesia on his left forehead and skin findings as shown in the picture below:



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

A) Mupirocin cream

B) Start Oral Cephalexin

C) Refer to Ophthalmology

D) Refer to Dermatology

E) Topical Acyclovir

Friday, August 5, 2011

Question of the Week # 248

248 )  A 34 year old  african-american man with past medical history of HIV infection is evaluated in the Emergency Room for severe shortness of breath on exertion for the past few hours. He also reports dry cough for the past 3 days. He has been non-compliant with Anti-retroviral therapy and his most recent CD4 count was 160 cells/┬Ál. On examination, he is febrile with a temperature of 101F, respiratory rate is 22, Blood pressure is 120/70 mm Hg. Oxygen saturation is 86% by pulse-oximetry. Chest examination reveals scattered rhonchii bilaterally. He is immediately placed on 4 liters oxygen by nasal cannula and his repeat oxygen saturation is 94%.  Arterial blood gases on 4 liters nasal oxygen show Ph 7.45, Po2 75, Pco2 32, Hco3- 24. A chest x-ray shows bilateral interstitial infiltrates. A Lactic Dehydrogenase level is elevated at 700U/L.   Which of the following is most appropriate management ?

A) Intubation

B) Start Trimethoprim/ Suflamethoxazole

C) Start Trimethoprim/ Sulfamethoxazole, Levofloxacin and Corticosteroids

D) Start Trimethoprim/ Sulfamethoxazole and Corticosteroids

E) Start Levofloxacin

 

Tuesday, August 2, 2011

Question of the Week # 247

247 )  A 32 year old  hispanic woman with past medical history of HIV infection on Anti-retroviral therapy evaluated in your office because she is concerned about her potential exposure to Tuberculosis. Her father has come to visit her from Mexico and he was diagnosed with cavitary tuberculosis of left lung three week ago. He is currently receiving multi-drug anti-tuberculosis therapy. The patient says she has been taking care of her father at home since the diagnosis was made. A Tuberculin skin test is administered and is negative after 72 hours. Patient denies any fever, cough, chest pain or weight loss. Which of the following is most appropriate management ?

A) Re-assurance

B) Repeat PPD in 3 months

C) Start Isoniazid

D) Chest X-ray

E) Repeat PPD in one year

Question of the Week # 246

246 )  A 32 year old Mexican woman is evaluated in your office because she is concerned about her potential exposure to Tuberculosis. Her father has come to visit her from Mexico and he was diagnosed with cavitary tuberculosis of left lung three week ago. He is currently receiving multi-drug anti-tuberculosis therapy. The patient says she has been taking care of her father at home since the diagnosis was made. A Tuberculin skin test is administered and is negative after 72 hours. Patient denies any fever, cough, chest pain or weight loss. Which of the following is most appropriate management ?

A) Re-assurance

B) Repeat PPD in 3 months

C) Start Isoniazid

D) Chest X-ray

E) Repeat PPD in one year

Question of the Week # 245

245 )  A 52-year-old man presents with acute onset of pain in his left testis which started abruptly after unprotected sexual intercourse. The pain started 3 hours ago, it is severe and constant. He denies any fever, chills, nausea or vomiting. On physical examination, the patient is afebrile and in severe distress. Testcular examination reveals a normal sized diffusely tender left testicle. Cremasteric reflex is absent on the left. A routine testicular ultrasound reveals normal testicles. A Complete Blood Count and Urinalysis are normal. What is the next step in management of this condition?

A)     Observation and Antibiotics

B)      Surgical exploration

C)      Repeat Testicular Doppler Ultrasound

D)     Laparotomy

E)      Observation alone

Question of the Week # 244

244 )  A 10-year-old Caucasian boy presents with right scrotal pain of 7 hours duration. The pain is acute in onset, constant and does not change with position. The patient denies any fever, chills, dysuria, nausea or vomiting. He denies any recent history of trauma. On physical examination, the patient is afebrile and is in moderate distress secondary to pain. There is no urethral discharge. Cremasteric reflex is present bilaterally. There is bluish discoloration and localized tenderness in the upper part of the testes. Labs reveal a normal Complete Blood Count and Urinalysis. What is the most likely clinical diagnosis in this patient?

A)     Testicular torsion

B)      Strangulated Hernia

C)      Congenital Hydrocele

D)     Torsion of Testicular appendix

E)      Acute Epidydimitis

 

 

 

 

Question of the Week # 243

243) A 65 year old man with a long history of COPD and history of metastatic colon cancer presents with complaints of increasingly severe shortness of breath that occurred at rest today. He reports that his symptoms are much more severe than his usual baseline. On examination , he is afebrile and tachypneic. Blood pressure is normal. Chest exam reveals occassional rhonchii. EKG shows sinus tachycardia. Arterial blood gases are obtained on the room air and show Ph : 7.45 Po2 40 PCo2 50 and Bicarbonate of 36. Chest X-ray shows changes of emphysema. His home medications include ipratropium and albuterol inhalers. He is placed on 4 liters oxygen by nasal cannula.

Which of the following is the most appropriate next step?

A) Intravenos corticosteroids

B) Intubation

C) Spiral CT scan and empiric Low molecular weight heparin

D) Non invasive positive pressure ventilation

E) Bed-side Spirometry