Question of the Week # 242

242) A 64 year old man is evaluated in the clinic for moderately severe pain in his both legs for the past 6 months. He describes the pain that occurs upon standing and worse on walking. The pain is worse walking downhill and slightly less while walking uphill. He reports that the pain interferes with his activities and he has to sit for about 30 minutes each time to obtain relief from the pain.  His history is significant for diabetes mellitus and chronic smoking about 1 pack per day for the past 45 years. On examination, he is afebrile and heart sounds are regular. Dorsalis pedis artery pulses are diminished bilaterally. Neurological examination is normal. Which of the following is the most appropriate next step in evaluating his pain?

A)     Clopidogrel

B)      Angiography

C)      MRI lumbar spine

D)     Ankle Brachial Index

E)     Supervised Exercise

Question of the Week # 241

241) A 44 year old man is evaluated in the clinic for moderately severe pain in his bilateral lower extremities for the past 6 months. He describes pain that occurs at rest and is increased on walking. The pain is worse in winters. His history is significant for chronic smoking about 2 packs per day for the past 25 years. He denies any history of thrombosis. On examination, he is afebrile and heart sounds are regular. Distal lower extremities are tender to touch. An ulcer measuring 2cm is noted on the left great toe. Posterior tibial and dorsalis pedis artery pulses are diminished. There is erythema and tenderness along the course of great saphenous vein. Laboratory investigations including complete blood count, chemistry panel and anti-nuclear antibodies are with in normal limits. Which of the following is most helpful in distinguishing this disorder from other vaso-occlusive diseases?

A)     Raynaud phenomenon

B)     Superficial Phlebitis

C)      Digital ulcers

D)     Young age

E)     Diminished arterial pulses

Question of the Week # 240

240) A 55 year old woman is evaluated in the emergency room for acute development of double vision and droopy right eyelid. She also reports pain in her right eye. She denies any fever.  She has no significant past medical history. On physical examination, she is afebrile and her blood pressure 132/88 mm Hg. Head and neck examination reveals ptosis of the right eyelid. Pupillary light reflex is lost. She can not adduct her right eye past the midline. The right eye is deviated downwards and laterally as shown in the picture below. There is no sensory loss on her face and the function of her other facial muscles are intact. Power is normal in all her extremities and deep tendon reflexes are intact.

The  most appropriate next step in management?

A)     Temporal artery biopsy

B)     Obtain Erythrocyte Sedimentation Rate

C)     Observation

D)     Magenetic Resonance Angiography (MRA)

E)     Ptosis Surgery

Question of the Week # 239

239) A 64 year old woman is evaluated in the emergency room for acute development of double vision and droopy left eyelid. She denies any fever or headache.  Her past medical history is significant for diabetes mellitus and hypertension. On physical examination, she is afebrile and her blood pressure 132/88 mm Hg. Head and neck examination reveals ptosis of the left eyelid. Pupillary light reflex is intact . She can not adduct her left eye past the midline. The left eye is deviated downwards and laterally as shown in the picture below. There is no sensory loss on her face and the function of her other facial muscles are intact. Power is normal in all her extremities and deep tendon reflexes are intact.

Which of the following is the most likely eventual outcome of her condition?

A)     Sub-arachnoid hemorrhage

B)     Spontaneous resolution

C)     Cerebellar ataxia

D)     Persistent visual deficits

E)     Aneurysmal Rupture

Question of the Week # 238

238) A 64 year old woman is evaluated in the emergency room for acute development of double vision and droopy left eyelid. She denies any fever or headache.  Her past medical history is significant for diabetes mellitus and hypertension. On physical examination, she is afebrile and her blood pressure 132/88 mm Hg. Head and neck examination reveals ptosis of the left eyelid. Pupillary light reflex is intact . She can not adduct her left eye past the midline. The left eye is deviated downwards and laterally as shown in the picture below. There is no sensory loss on her face and the function of her other facial muscles are intact. Power is normal in all her extremities and deep tendon reflexes are intact.

 

Which of the following is the most likely cause of her symptoms?

A)     Ophthalmoplegic migraine

B)     Diabetic Mono-neuropathy

C)     Posterior communicating artery aneurysm

D)     Weber syndrome

E)     Lateral medullary syndrome

Question of the Week # 237

237 )  A 25-year old primi-para is evaluated for soreness in her breasts. She just started breast feeding her three day old male infant. She also reports low grade fever over the past few hours. On examination, her temperature is 99.2F. Her breasts are hard and swollen. They are warm to touch. She has pain on movement of the breast. Which of the following is the most appropriate recommendation?

A) Hand expression of milk between feedings

B) Use of  ”Breast Pump”

C) Correction of improper “Latch on”

D) Re-assurance

E) Breast massage

Question of the Week # 236

236)  A 25-year woman presents to your office with complaints of soreness in her right nipple. She had a uneventful delivery 10 days ago. She has been breast feeding for the past ten days. She had some nipple soreness initially however, it resolved after five days. The soreness returned on the eighth day and is persistent since then . The pain is present through out the nursing episode. On examination, she is afebrile. Her right breast is full. There is no erythema or tenderness. Which of the following is the most appropriate recommendation to the patient?

A) Hand expression of milk between feedings

B) Use of  “Breast Pump”

C) Correction of improper “Latch on”

D) Re-assurance

E) Breast massage

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