Question of the Week # 216

216 )  A 75 year old woman with past medical history of hypertension and diabetes is evaluated in your office for 20 lb weight loss. She reports decreased appetite and depressed mood for the past 6 months. Her history is significant for chronic smoking 1 pack per day for last 50 years. She lives alone and does all her daily activities by herself.  She has no known cardiac problems. She denies shortness of breath or cough. On examination, scleral icterus is noted. Lab studies show total bilirubin elevated at 10gm% with predominantly direct component. A subsequent CT of the abdomen shows a heterogeneous mass of about 4cm in diameter. A triphasic CT with pancreatic protocol shows invasion of the portal vein and encasement of superior mesenteric artery by the mass. There are no distant metastases. A chest X-Ray is normal. CA 19-9 level 1400U/ml.  Which of the following is the most appropriate next  step ?

A) Hospice Evaluation

B) Surgical resection

C) Fine needle aspiration biopsy

D) Chemotherapy

E) Radiation therapy

Question of the Week # 215

215 )  A 65 year old woman with past medical history of chronic smoking is evaluated in the office for painless jaundice. She has noticed yellow coloring of her skin about 3 weeks ago and it has been progressively increasing. She denies abdominal pain, fever or altered bowel movements. On examination, she has profoundly icteric sclerae. Lab studies show total bilirubin elevated at 5gm% with predominantly direct component. A subsequent CT of the abdomen shows a heterogeneous mass of about 4cm in diameter. A triphasic CT with pancreatic protocol shows no involvement of portal vein or superior mesenteric artery. No lymphadenopathy is evident. CA 19-9 level 400u/ML. Which of the following is the most appropriate next step?

A) Fine needle aspiration biopsy

B) Surgical resection

C) Radiation therapy

D) Chemotherapy

E) Hospice evaluation

 

Question of the Week # 214

214 )  A 58 year old woman presents to the office because  her friend noticed that she looked yellow and asked her to seek medical attention. Lately, her urine has turned dark yellow but she thought it was because of reduced fluid intake. She has lost 10lb weight in the last 3 months. She denies any abdominal pain, nausea or vomiting. She denies any fever. She smoked about 2 packs per day for the past 30 years. She quit smoking 1 month ago. Physical examination reveals profound scleral icterus. Laboratory investigations reveal a Hemoglobin 10gm%, MCV 88, Total Bilirubin 17gm% , Direct bilirubin 13gm%, AST 120U/L, ALT 110U/L and ALP 600U/L. A CT scan of the abdomen does not show any mass in the pancreas. Ultrasound of the abdomen reveals common bile duct diameter of 12mm. Which of the following is the most appropriate next step in management?

A) CA 19-9 level

B) Endoscopic Retrograde Cholangiopancreatography

C) CT guided biopsy of Pancreatic Head

D) Percutaneous Biliary Stent

E) Haptoglobin level

Question of the Week # 213

213 )  A 38 year old woman with manic depressive illness is evaluated in the emergency department for slurred speech and severe fatigue of one day duration. She also has nausea and vomiting since morning. She denies any recent fever. She has been on Lithium Carbonate for the past 3 months and her level was therapeutic 1 month ago. She is a very compliant patient and denies overdosing herself with lithium. Her past medical history is significant for hypertension for which she was started on combination of  Hydrochlorthiazide and Enalapril one week ago. She does report “salt craving” for past few days and has been taking excessive amount dietary salt though she is aware that it is not good for blood pressure. Physical examination reveals coarse tremors and fasciculations. Laboratory investigations reveal slightly increased serum creatinine at 1.2mg%. Her  baseline creatinine is 1.0mg%.  Today, the Lithium level is 3.0 mmol/L. Which of the following is responsible for acute lithium toxicity in this patient?

A) Acute renal failure

B) Drug interaction

C) Increased absorption

D) Excess Salt intake

E) Intentional overdose

Question of the Week # 212

212 )  A 40 year old man is brought by his sister to the Emergency room for a change in his mental status. The patient appears slightly confused but as per his sister, he reported weakness and blurred vision yesterday. She also noticed that his gait has been abnormal and un-coordinated for the past one day. She reports that he was diagnosed with a psychiatric disorder few months ago and was started on a medication 4 months ago. He seems to be compliant with his medications but  has not followed up with his psychiatrist for the past 3 months. His Past Medical History is unremarkable except for the mental illness. Physical examination reveals a slightly confused male. Neck examination shows mild but diffuse enlargement of thyroid with out any nodules. Nystagmus and exaggerated reflexes are noted.  The drug that is most likely responsible for this patient’s presentation?

A) Fluoxetine

B) Venlafaxine

C) Lithium

D) Amitryptyline

E) Escitalopram

Question of the Week # 211

211 )  A 42 year old woman in otherwise good health presents to the Emergency room for severe headache. She has history of migraines in the past for which she uses sumatriptan at the onset of Headache and usually, she has relief. Though this is not the worst headache of her life, she says that it is very severe and is upset that the headache did not resolve even after injecting herself  with a triptan. She denies any fever.  Her physical and neurological examination is benign. There is no neck stiffness.  A computed tomography (CT) scan of the head is obtained, which did not reveal any abnormalities. A subsequent  lumbar puncture reveals bloody fluid. The specimen was transported to the lab for further evaluation. It was processed in the laboratory 12 hours later and the report indicates “Xanthochromia” Which of the following most likely explains  the CSF findings?

A) Status migranosus

B) Meningitis

C) Sub-arachnoid Hemorrhage

D) Sentinel bleed

E) Delay in CSF processing

Question of the Week # 210

210 )  A 42 year old woman in otherwise good health presents to the Emergency room for sudden onset of severe headache 2 hour ago. She has no previous history of headache or migraine . Upon arrival in the ER, she described her headache as “10 out of 10” in severity. She thinks this is the worst headache of her life. She denies any fever or visual problems or drug abuse.  Her physical and neurological examination is benign. There is no neck stiffness at this time.  A computed tomography (CT) scan of the head is obtained, which did not reveal any abnormalities. A subsequent  lumbar puncture reveals bloody fluid which shows decreasing red color in subsequent collection tubes. The last collection tube shows red fluid but much decreased color as opposed to the first collection tube. Which of the following is the most appropriate management decision?

A) Repeat Lumbar Puncture at a different site

B) Immediate CSF centrifugation

C) Neurosurgery evaluation

D) Re-assurance and analgesic therapy

E) Subcutaneous Sumatriptan

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