Question of the Week # 432

432) A 62-year-old man presents with painless, progressive enlargement in the left side of his neck over the past 3 months. He denies any fever, night sweats or chills. He denies any pain, dysphagia, cough, hemoptysis, chestpain, shortness of breath, history of trauma or dental infection. His past medical history is significant for  100 pack-year history of smoking and daily alcohol abuse. On examination, he is afebrile. He has a large 5 cm , hard, non-tender and matted lymphadenopathy on the left lateral aspect of his neck . He has no other lymph node enlargement. No rash. Reminder of the exam including oral cavity examination is normal. There are no obvious tongue, pharyngeal or tonsillar lesions.  HIV and VDRL are negative. A CT scan of the chest, abdomen and pelvis does not reveal any lymphadenopathy or obvious mass lesions. Which of the following is the most appropriate next step in management?

A) Open biopsy of the neck mass

B) Pan-endoscopy

C)  Fine Needle Aspiration Cytology ( FNAC)

D) Test for HPV ( Human Papilloma Virus) and EBV ( Ebstein Barr Virus)

E) Prescribe antibiotic therapy and re-evaluate in 4 weeks

Question of the Week # 431

431) A 25 year old G2P1L1 at 32 weeks gestation presents with right leg swelling and pain progressively increasing over the past two days. Her previous pregnancy was uneventful except for uncomplicated C-section and she has a 2 year old healthy male child. Past medical history is negative for any significant health issues. There is no family history of clots or cancer.  Physical examination is consistent with 32 week gestation. Right lower extremity is swollen about 3cm more in calf-circumference when compared to the left. There is tenderness in right calf. A Doppler ultrasound reveals thrombosis in superficial femoral vein. Factor V leiden mutation, Lupus anticoagulant, anti-cardioloipin antibodies, prothrombin gene mutation are negative. Anti-thombin III is within normal limits. She is scheduled for C-section in 6 weeks. Which of the following is the most appropriate Statement concerning her management?

A)     Since this is not deep vein thrombosis, start her on LMWH ( Low Molecular Weight Heparin) at prophylactic doses

B)      Start warfarin and continue for total 6 months

C)      Start LMWH, discontinue 2 days prior to C-section, start unfractionated heparin followed by discontinuation 4 hrs prior to C-section and then start LMWH 12 hrs after surgery followed by Warfarin for 6 months.

D)     Start LMWH, discontinue 2 days prior to C-section, start unfractionated heparin followed by discontinuation 4 hrs prior to C-section and then start LMWH 12 hrs after surgery followed by Warfarin for 6 weeks post-partum

E)      Start LMWH now through delivery followed by warfarin for 6 months post-partum.

Question of the Week # 430

430 ) A 70  year-old man is evaluated in your office for fatigue and unsteady gait. His symptoms started 2 months and progressively increasing. He also reports numbness and paresthesias in his bilateral lower extremities. His other issues include ill-fitting dentures for which he used dental adhesives for past 2 years. His past medical history is also significant for gastric bypass surgery approximately 8 years ago for recurrent peptic ulcer disease. He receives Vitamin B12 Subcutaneously every 3 to 6 months. On presentation, he is confined to a wheelchair. Neurological examination revealed markedly decreased vibratory sensation and proprioception in the lower extremities bilaterally. Both pin-prick and light touch sensations were moderately reduced below the knees. Muscle power, bulk, tone, and reflexes were normal. Rest of his physical examination is normal. Laboratory investigations reveal hemoglobin = 8.5 g/dL, MCV= 74 fL, MCHC = 33.6gm/dl, leukopenia with a WBC =1.9k/µl and absolute neutrophil count = 475 cells/µL. His platelet count, iron studies, folate and syphilis serologies were within normal limits.  Vitamin B12 was 900pg/ml ( N = 180 to 400pg/ml) . Serum Zinc level is  600µg/dl  ( Normal is 70-150 µg/dl).

Which of the following is most appropriate at this time?

A) Check Methyl Malonic Acid Level

B) Start Penicillamine

C)  Bone Marrow Biopsy

D) CT scan of the Head

E) Discontinue dental adhesives and check Copper levels

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