Question of the Week # 330

330) A 55 year old man is brought by the EMS to the emergency room in a disoriented state. The patient has alcohol smell on his breath. Reviews of his past records reveal history of chronic alcohol abuse. His girlfriend arrives in the ER few minutes later and she reports that the patient has not been eating anything because he has been drinking heavily and vomiting over the past three days. On examination, he is afebrile, blood pressure 130/82 mm Hg, RR 18/min and Pulse 82/min. When the nurse attempts to check blood pressure, the patient develops carpo-pedal spasm (Trousseau sign). Chest is clear to auscultation.

Laboratory investigations reveal:

Ethanol level 140mg%

Serum Sodium 142 meq/L

Serum Potassium 3.2meq/L

Serum Chloride 106meq/L

Calcium 6.2 mg% (N = 9.0 to 10.5)

Bicarbonate 25 meq/L

Creatinine 1.2 mg%

Albumin 3.9 gm% (N = 3.5 to 5.0 gm %)

Patient is treated with Calcium gluconate and then, another dose of calcium chloride. Repeat serum calcium level is 5.8mg%. Trousseau sign is still positive.

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

A) Obtain Serum Ionized Calcium

B) Obtain Serum Magnesium Level

C) Obtain Paratharmone level

D) Start potassium chloride

E) Obtain Vitamin D level

Question of the Week # 329

329) A 62 year old man presents to your office complaining of dry cough for past several months. Recently, he also noticed shortness of breath on exertion. He denies any fever, hemoptysis or weight loss. He has no history of infections. He does not smoke. He worked as a soft-ware consultant for past 40 years. He has no other medical problems and has never been hospitalized.  On examination, he is afebrile, blood pressure 120/80 mm Hg, RR 18/min and Pulse 82/min. There are no palpable chest-wall masses or lymphadenopathy. On auscultation, fine crackles are heard at bilateral lung bases. A high resolution CT scan of the lungs shows sub-pleural cyst formation with honey combing. The patient undergoes an open lung biopsy for confirmation of diagnosis. Which of the following histo-pathological patterns is likely to be found in this condition?

A) Non-specific Interstitial Pneumonia ( NSIP)

B) Desquamative Interstitial Pneumonia (DIP)

C) Usual Interstitial Pneumonia (UIP)

D) Bronchiolitis Obliterans Organizing Pneumonia (BOOP)

E) Acute Interstitial Pneumonia (AIP)

Question of the Week # 328

328) A 66 year old man is seen in your office for progressive shortness of breath on exertion for the past one year. He also reports dry cough. He denies any fever, hemoptysis or weight loss. He has no history of infections. He denies smoking. He has no other medical problems and has never been hospitalized.  On examination, he is afebrile, blood pressure 120/80 mm Hg, RR 18/min and Pulse 82/min. There are no palpable chest-wall masses or lymphadenopathy. On auscultation, crackles are heard all over the lung fields, more pronounced at lung bases. Extremities show mild digital clubbing.

A chest x-ray is shown below:

 

Which of the following is expected to be seen with this disease?

A) Young age at onset

B) Rapid progression

C) High Resolution CT scans showing ill-defined cysts and pleural plaques

D) Poor or no response to steroids

E) Obstructive pattern on Pulmonary function tests

Question of the Week # 327

327) A 16 year old boy presents to your office for a Pre-participation sports physical examination. He is healthy and physically active and has no complaints. He has no chest pain or shortness of breath. He denies any drug use or smoking. His maternal grandfather recently died suddenly of cardiac arrest from severe Myocardial Infarction at age 82. On physical examination, he is afebrile, pulse 82/min, Respiratory rate 18/min and blood pressure 106/76 mm Hg. Chest is clear to auscultation. Cardiac examination reveals a mid-systolic murmur, grade 2/6 heard best along the left sternal border. The murmur decreases in intensity when he stands and increases when he is supine. S1 and S2 are normal. The second heart sound is physiologically split.  Cardiac impulse and carotid pulses are normal. The most appropriate action at this time:

A) Clear the patient for Sports participation

B) Refer to cardiology

C) Obtain 2D-Echocardiogram

D) Schedule Exercise Stress Test

E) Obtain Complete blood count

Question of the Week # 326

326)  A 55 year old african-american man presents to your office with complaints of shortness of breath that has slowly progressed over the past several months. He also reports chest pain which in non-pleuritic in nature. He has lost about 10lbs weight in the past three months. He has changed several jobs but he currently works as a sales representative for a drug company. On examination, his temperature is 100F, Pulse 98/min, RR 20/min and Blood Pressure 100/60 mm HG.  He is in mild distress due to shortness of breath. On chest examination, there is dullness to percussion over the right side of the chest. No masses are palpable. Laboratory investigations reveal WBC 8k/μl with normal differential, Hgb 10.5gm%, Platelets 550k/μl, Calcium 11.2gm% ( (Normal 8.9 to 10.5 mg%)

A chest-x-ray is shown below:

Which of the following element in the history would be most helpful in making a presumptive diagnosis of his presentation?

A) Smoking

B) Family history of Cancer

C) Bone pain

D) Flank pain and Hematuria

E) Previous Occupation

Question of the Week # 325

325 )  A 87 year old Caucasian man is evaluated in your office for progressive hearing loss. He reports defective hearing on both sides that started more than a year ago and has gradually worsened. The problem is particularly worse when he is in a crowded or noisy environment. He also reports frequent occurrence of roaring sounds and sounds similar to “ringing bells” in his ears. On otoscopic examination, he has mild cerumen impaction in bilateral ears. The Tympanic membranes are intact. Which of the following is the most characteristic feature seen with this condition?

A) Inability to hear “Vowel” sounds in the speech

B) Audiogram showing bilateral high-frequency sensory-neural hearing loss

C) Weber Test showing lateralization towards Right ear

D) A negative Rinne test

E) Otosclerosis

Question of the Week # 324

324)  A 45 year old woman with history of Rheumatoid Arthritis presents to the emergency room increasing pain and swelling in her joints. She reports progressively increasing pain and stiffness of her bilateral wrist joints over the past two weeks. She now developed rapidly increasing pain and swelling in her right knee which prompted this Emergency Room visit. Her medications include Ibuprofen and Methotrexate. On examination, she is afebrile. There is mild swelling and tenderness in bilateral wrist joints. Right knee is warm, swollen and tender. Flexion and extension of the right knee  are severely painful.  Laboratory investigations are as follows:

WBC 9.0k/µl

Differential: Neutrophils 65%, Lymphocytes 24%, Monocytes 7%

Hemoglobin 11.5 g/dL ( Normal = 13.0 to 16.5 gm%),

Mean cell volume (MCV)  84  fL

Platelet count 510k/µl ( Normal 180 to 350k⁄μl )

ESR : 70 mm/hr

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

A)  Pulse Methyl Prednisolone

B)  Oral Prednsione

C) Arthrocentesis

D) Discontinue Methotrexate and start Infliximab

E) Intra-articular Glucocorticoids

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