Question of the Week # 72

A 55 y/o african american man with newly diagnosed Stage B prostate cancer undergoes radical prostatectomy and is referred to you from surgical clinic for routine follow up. The patient requests how often he should follow up with you and what tests he would need. Your best response is:

A) You do not need any follow up because you had a local cancer that was completely resected
B) PSA need to be tested every six months for 5 years and thereafter, every year
C) Bone scan to evaluate metastasis is needed every year
D) Digital Rectal Exam every year to look for local recurrence
E) You need endocrine therapy before we proceed further

Question of the Week # 71

Q71) A 65 y/o African American man is brought by his daughter to you and requests a PSA test because there is a hx of prostate ca in their family. You perform PSA and DRE. DRE does not reveal any palpable mass. The lab test reveal : PSA : 8ng/ml, Free PSA: 1.5ng/ml. You reveal the results to patient and his daughter. The daughter asks you if her father has a cancer. Your best response is :

A) The PSA level increases with age and your father’s PSA  is in the  age-appropriate range
B) PSA level is very nonspecific and your father does not have a cancer
C) The fact that the free PSA is only 1.5ng/ml as opposed to a bound of 6.5 indicates that your father most likely has a cancer etiology rather than benign cause
D) PSA will not help in diagnosing carcinoma prostate
E) I did this test only because you requested for it, I do not think this results mean anything.

Question of the Week # 70

Q70) A 40-year-old man presents to your office for regular follow up. He has history of  hypertension  for which he has been on Hydrochlorthiazide and Lisinopril. Lately, his blood pressure has not been well controlled and this has been documented both in the office and outside during several visits. The patient says he has had increasing fatigue and irritability over the last few months and has difficulty concentrating at work. He  thinks his boss has never been supportive and he attributes his irritability to this. He has smoked 2 packs of cigarettes per day for the past 15 years. On physical examination he is a obese male with a neck circumference of 18cm. He has a ruddy complexion. His vitals reveal a HR of 90 and a BP of 152/92.  Reminder of the physical exam is normal. EKG reveal changes consistent with long standing hypertension. A CBC, electrolyes and creatinine are normal. Which of the following is the most important investigation that can identify the cause of  his uncontrolled hypertension?

( A ) Ambulatory blood pressure monitoring

( B ) Pulmonary function studies

( C ) Polysomnography

( D ) Arterial blood gases

(E)  Urine drug screen

Question of the week # 69

Q69) You are treating an 18-year-old white male college freshman for allergic rhinitis. It is September and he tells you that he has severe symptoms every autumn, which impair his academic performance. He has a strongly positive family history of atopic dermatitis. Which one of the following is the most appropriate management?

a) Intranasal decongestants

b) Intranasal glucocorticoids

c) Intranasal cromolym sodium

d) Intranasal antihistamine

e) RAST testing

Question of the Week # 67, 68

Q67) A 44 year old woman presents to your office with pain and swelling of the small joints in his hands and wrists. The symptoms have been progressing over the past 4 months. She denies any fever or weightloss. She reports stiffness in his both hands that occurs every morning and lasts for 2 hours. On examination, she has symmetrical involvement of both the wrists and two of her left proximal interphalangeal joints. The involved joints are swollen and tender. Laboratory tests shows normal ESR, negative rheumatoid factor, and a negative anti-CCP antibody. X-ray of the wrist and hands reveal mild joint space narrowing with only very small peripheral erosions. The most appropriate next step in management :

A. Prednisone
B. Start NSAID and follow-up in one month.
C. Start NSAID and Methotrexate
D. Start Infliximab
E. Start NSAID and Hydroxychloroquine

Q68) The patient in the above question is started on appropriate therapy. He returns to your clinic in 1 month for regular follow up and his disease is well controlled with near complete remission. The most important next step in follow up of this patient :

A. DEXA scan in 1 year
B. PPD placement
C. Check hepatitis B serology
D. Ophthalmology referral at 3 months
E. Liver function tests

Question of the Week # 61

A 24 year old woman presents to the Emergency Room with complaints of  left sided weakness and slurred speech. The patient has history of Systemic Lupus Erythematosus. Her SLE was diagnosed 2 years ago when she had malar rash and abnormal blood counts. She reports that she has not received any treatment for it since her physician felt this was not needed at that time. She denies any history of kidney involvement. She denies any joint pains or rash. Physical examination revealed left hemiparesis consistent with cerebrovascular accident. A CT of the head reveals right parietal infarct with out any bleed. An EKG is obtained and is normal.  Anti-cardiolipin antibody is +ve which was also positive 1 year ago as per her old records . The patient is started on adequate therapy and follows up in your office 1 month later. Which of the following interventions is most appropriate to prevent recurrent stroke in her case?

a)        Aspirin  for life

b)       Warfarin for 1 year

c)        Warfarin for 6 months

d)       Warfarin for life

e)        Hydroxychloroquine

Question of the Week # 60

A middle aged man presents with a history of foot pain on walking for a few weeks. The patient has a history of long standing diabetes mellitus for more than 15 years. He has been on Metformin and Glyburide combination. His HGBA1C that was obtained 3 months ago revealed inadequate control  at 9%. He reports pain and swelling in his right foot for about one month.  On examination the foot is swollen & tender to touch. Neurlogical examination reveals loss of vibratory sensation and position sensation in bilateral feet. There is also impaired light touch until the level of knees bilaterally. Joint motion at the level of ankle is within normal limits. Complete blood count , creatinine and ESR are with in normal limits. Most likely working diagnosis for his right foot pain  is :

a)      Chronic  Gout

b)       Septic arthritis

c)        Peripheral Neuropathy

d)       Charcot arthropathy

e)       Reflex Sympathetic Dystrophy

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