Day 16 Flashcards

1
Q

Q1-A man with a history of prostate cancer comes to the emergency department with severe back pain and leg weakness. He has tenderness of the spine, hyperreflexia, and decreased sensation below his umbilicus.
What is the most appropriate next step in the management of this patient?

A-Dexamethasone
B-MRI
C-X-ray
D-Radiation
E-Flutamide
F-Finasteride
A

Ans: A. When there is obvious cord compression; the most important step is to begin steroids urgently in order to decrease the pressure on the cord. Radiation is necessary in those with metastatic cancer to the cord, but it does not work as fast as giving steroids. X-ray may show vertebral damage, and MRI is the most accurate imaging study, but preventing permanent paralysis with steroids is more important to do first. Leuprolide is actually dangerous without first blocking the peripheral receptors to testosterone with flutamide. GnRH agonists will give a transient burst up in testosterone levels. Finasteride is a 5-alpha reductase inhibitor that is not helpful for prostate cancer. Finasteride is used for benign prostatic hypertrophy and male pattern hair loss. Ketoconazole is a second-line agent in inhibiting androgens. The fastest way to lower androgen levels is with orchiectomy, but this step is rarely necessary. Biopsy is done if the etiology is not clear. The key issue in this question is timing: What decompresses the spine fastest? The answer is glucocorticoids like dexamethasone.

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2
Q

Q2-A patient with long-standing Rhumatoid arthritis is to have coronary bypass surgery. Which of the following is most important prior to surgery?

A-Cervical spine x-ray
B-Rheumatoid factor
C-Extra dose of methotrexate
D-ESR
E-Pneumococcal vaccination
A

Ans: A. RA is associated with C1/C2 subluxation. Cervical spine imaging to detect possible instability of the vertebra is essential prior to the hyperextension of the neck that typically occurs with endotracheal intubation. Methotrexate does not work acutely and additional doses are not useful. Although pneumococcal vaccination is useful in any immunocompromised person, there is no particular indication for vaccination surrounding surgical procedures.

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3
Q

Q3-A 34-year-old woman with a history of SLE is admitted with pneumonia and confusion. As you are wrestling with the decision over a bolus of high-dose steroids in a person with an infection, you need to determine if this is a flare of lupus, or simply an infection with sepsis causing confusion.
Which of the following will help you the most?

A-Rise in anti-Sm
B-Rise in ANA
C-Decrease in complement
D-Decrease in complement and rise in anti-DS DNA
E-MRI of the brain
F-Response to steroids
A

Ans: D. although anti-Sm is specific for SLE, the level does not change in an acute flare. ANA levels do not tell severity of disease. MRI of the brain is most often normal in lupus cerebritis unless there has been a stroke. In an acute lupus flare, complement levels drop and anti-DS DNA levels rise.

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4
Q

Q4-A 75-year-old man comes to the office with fatigue that has become progressively worse over the last several months. He is also short of breath when he walks up one flight of stairs. He drinks 4 vodka martinis a day. He complains of numbness and tingling in his feet. On physical examination he has decreased sensation of his feet. His hematocrit is 28% and his MCV is 114 fL (elevated).
What is the most appropriate next step in management?

A-Vitamin B12 level
B-Folate level
C-Peripheral blood smear
D-Schilling test
E-Methylmalonic acid level
A

Ans: C. although a macrocytic anemia could be from B12 or folate deficiency, direct alcohol effect on the bone marrow, or liver disease, the first step is a peripheral smear. This is to detect hypersegmented neutrophils. Once hypersegmented neutrophils are seen, then you would get B12 and folate levels.

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5
Q

Q5-A 75-year-old woman comes with decreased position and vibratory sensation of the lower extremities, a hematocrit of 28%, MCV of 114 fL, and hypersegmented neutrophils.Her B12 level is decreased, but near the borderline of normal. What is the most appropriate next step in the management of this patient?

A-Methylmalonic acid level
B-Anti-intrinsic factor antibodies
C-Anti-parietal cell antibodies
D-Schillings test
E-Folate level
A

Ans: A. USMLE Step 2 CK frequently tests the fact that while both B12 and folate deficiency increase homocysteine levels, only B12 is associated with an increased MMA.The B12 level can be normal in as many as a third of patients with B12 deficiency because the carrier protein, transcobalamin, is an acute phase reactant and can be elevated from many forms of stress such as infection, cancer, or trauma. When the story suggests B12 deficiency and the B12 level is equivocal, use an increased MMA level to confirm the diagnosis of vitamin B12 deficiency.

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6
Q

Q6-Which of the following is a complication of B12 or folate replacement?

A-Seizures
B-Hemolysis
C-Hypokalemia
D-Hyperkalemia
E-Diarrhea
A

Ans: C. Hyperkalemia from massive tissue or cellular breakdown has many causes. Hypokalemia from cell production is rare. When replacing B12 and folate, particularly if there is pancytopenia, cells in the marrow are produced so rapidly that the marrow packages up all the potassium, lowering the serum level. Observe and replace.

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7
Q

Q7-Which of the following can be found on smear in sickle cell disease?

A-Basophilic stippling
B-Howell-Jolly bodies
C-Bite cells
D-Schistocytes
E-Morulae
A

Ans: B. these are precipitated remnants of nuclear material seen inside the red cells of a patient who does not have a spleen. There is no change in therapy or management based on the presence of Howell-Jolly bodies. Basophilic stippling is associated with a number of causes of sideroblastic anemia, especially lead poisoning. Bite cells are seen in glucose 6 phosphate dehydrogenase deficiency. Schistocytes are fragmented red cells seen with intravascular hemolysis. Morulae are seen inside neutrophils in Ehrlichia infections.

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8
Q

Q8-A 46-year-old man with sickle cell disease is admitted with an acute pain crisis. His only routine medication is folic acid. His hematocrit on admission is 34%. On the third hospital day, the hematocrit drops to 22%.
What is the best initial test?

A-Reticulocyte count
B-Peripheral smear
C-Folate level
D-Parvovirus B-19 IgM level
E-Bone marrow
A

Ans: A. Patients with sickle cell disease usually have very high reticulocyte counts because of the chronic compensated hemolysis. Parvovirus B-19 causes an aplastic crisis which freezes the growth of the marrow. Nothing will be visible on blood smear. Although the bone marrow will show giant pronormoblasts, this would not be done routinely, and certainly never as the initial test. The first clue to parvovirus is a sudden drop in reticulocyte level.

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9
Q

Q9-A 57-year-old man comes to the emergency department for shortness of breath, blurry vision, confusion, and priapism. His WBC count is found to be 225,000/μL. The cells are predominantly neutrophils with about 4% blasts.
What is the most appropriate next step in the management of this case?

A-Leukapheresis
B-BCR-ABL testing
C-Bone marrow biopsy
D-Bone marrow transplant
E-Consult hematology/oncology
F-Hydroxyurea
A

Ans: A. In acute leukostasis reaction, it is more important to remove the excessive white cells from the blood than to establish a specific diagnosis. Specific testing is not as important as treatment. No matter what the etiology, you still have to take the cells off. The symptoms are caused by blocking the delivery of oxygen to tissues because the red cells simply cannot get to the tissues. Afterward, you can establish a specific diagnosis. Hydroxyurea will lower the cell count, but not as rapidly as leukapheresis.

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10
Q

Q10-Which of the following is the most useful to determine dosing of chemotherapy in Hodgkin’s disease?

A-Echocardiogram
B-Bone marrow biopsy
C-Gender
D-MUGA or nuclear ventriculogram

A

Ans: D. Adriamycin (or doxorubicin) is cardiotoxic. The nuclear ventriculogram is the most accurate method of assessing left ventricular ejection fraction. Use the MUGA scan to determine whether cardiac toxicity has occurred prior to the development of symptoms.

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11
Q

Q11-A 69-year-old woman is admitted with severe back pain that has suddenly worsened. She also feels a “pop” when she coughs followed by tenderness over the ribs. X-ray shows lytic lesions. Her calcium level is 2 points above normal, the hematocrit is 27%, and her creatinine is elevated. Urinalysis shows trace protein, but the 24-hour urine show 5 grams of protein.
What do you expect to find on technetium bone scan?

A-Normal
B-Lytic lesions at the site of the fractures
C-Increased uptake diffusely
D-Decreased uptake

A

Ans: A. The radionuclide bone scan will be normal because lytic lesions do not pick up the nuclear isotope. Nuclear bone scan shows increased uptake with osteoblastic activity, which is absent in myeloma.

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12
Q

Q12-What is the explanation for the difference between the urinary level of protein on urinalysis and the 24-hour urine?

A-False positive 24-hour urine is common in myeloma.
B-Calcium in urine creates a false negative urinalysis.
C-Uric acid creates a false positive 24-hour urine.
D-Bence-Jones protein is not detected by dipstick.
E-IgG in urine inactivate the urine dipstick.

A

Ans: D. Bence-Jones protein is detected by urine immunoelectrophoresis. The urine dipstick will detect only albumin.

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13
Q

Q13-What is the single most accurate test for myeloma?

A-Skull x-rays
B-Bone marrow biopsy
C-24-hour urine
D-SPEP (Serum Protein Electrophoresis)
E-Urine immunoelectrophoresis (Bence-Jones protein)
A

Ans: B. Nothing besides myeloma is associated with greater than 10% plasma cells on bone marrow biopsy. The most common wrong answer is SPEP(Serum Protein Electrophoresis). Of those with an “M-spike” of immunoglobulins, 99% do not have myeloma. Most IgG spikes are from monoclonal gammopathy of unknown significance that does not progress or need treatment. Skull x-rays show lytic lesions, but this is not as specific as massive plasma cell levels in the marrow.

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14
Q

Q14-A 26-year-old woman comes to the emergency department with markedly increased menstrual bleeding, gum bleeding when she brushes her teeth, and petechiae on physical examination. Physical examination is otherwise normal. The platelet count is 17,000/μL.
What is the most appropriate next step in therapy?

A-Bone marrow biopsy
B-Intravenous immunoglobulins
C-Prednisone
D-Antiplatelet antibodies
E-Platelet transfusion
A

Ans: C. The bleeding in this case is mild, meaning there is no intracranial bleeding or major GI bleeding, and the platelet is not profoundly low. Prednisone is the best initial therapy. Initiating prednisone is more important than checking for increased megakaryocytes or the presence of antiplatelet antibodies, which is characteristic of ITP.

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15
Q

Q15-A 41-year-old man recently diagnosed with AIDS comes to the emergency department with pain on swallowing that has become progressively worse over the last several weeks. There is no pain when not swallowing. His CD4 count is 43 mm3.The patient is not currently taking any medications.
What is the most appropriate next step in management?

A-Esophagram
B-Upper endoscopy
C-Intravenous amphotericin
D-Oral fluconazole
E-Oral nystatin
A

Ans: D. The most commonly asked infectious esophagitis question is esophageal candidiasis in a person with AIDS. Oral candidiasis (thrush) need not be present in order to have esophageal candidiasis. One does not automatically follow from the other. Although other infections such as CMV and herpes can also cause esophageal infection, over 90% of esophageal infections in patients with AIDS are caused by Candida.Empiric therapy with fluconazole is the best course of action. If fluconazole does not improve symptoms, then endoscopy is performed. Intravenous amphotericin is used for confirmed candidiasis not responding to fluconazole. Oral nystatin swish and swallow is not sufficient to control esophageal candidiasis. Nystatin treats oral candidiasis.

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16
Q

Q16-A 47-year-old woman comes to see you because of pain in her epigastric area for the last several months. She denies nausea, vomiting, weight loss, or blood in her stool. On physical examination, you find no abnormalities.
What is the most likely diagnosis?

A-Duodenal ulcer disease
B-Gastric ulcer disease
C-Gastritis
D-Non-ulcer dyspepsia
E-Pancreatic cancer
A

Ans: D. This is often a very hard question for the average medical student. This is because of the selection bias of which cases you, as a student, see admitted to the hospital. Non-ulcer dyspepsia is, by far, the most common cause of epigastric pain and at a minimum account for 50% to 90% of all cases of epigastric pain. This is particularly true in patients under the age of 50.

17
Q

Q17-A 45-year-old man comes to the office with several weeks of epigastric pain radiating up under his chest which becomes worse after lying flat for an hour. He also has a “brackish” taste in his mouth and a sore throat.
What is the most appropriate next step in the management of this patient?

A-Ranitidine
B-Liquid antacid
C-Lansoprazole
D-Endoscopy
E-Barium swallow
F-24-hour pH monitoring
A

Ans: C. Lansoprazole is a PPI that should be used to control the symptoms of GERD.When the diagnosis is very clear (such as in this case), with epigastric pain going under the sternum, bad taste, and sore throat, confirmatory testing is not necessary. H2 blockers such as ranitidine are effective in about 70% of patients, but are clearly inferior to PPIs. Endoscopy does not diagnose GERD and is certainly not necessary when the diagnosis is so clear. Barium swallow shows major anatomic abnormalities of the esophagus and is worthless in GERD.

18
Q

Q18-A 59-year-old woman comes to the clinic because her symptoms of epigastric pain from an endoscopically confirmed duodenal ulcer have not responded to several weeks of a PPI, clarithromycin, and amoxicillin.
What is the most appropriate next step in the management of this patient?

A-Refer for surgery
B-Switch the PPI to ranitidine
C-Abdominal CT scan
D-Urea breath testing
E-Vagotomy
A

Ans: D. If there is no response to DU therapy with PPIs, clarithromycin, and amoxicillin, the first thought should be antibiotic resistance of the organism. Persistent H. pylori infection can be detected with several methods such as urea breath testing, stool antigen detection, or a repeat endoscopy for biopsy. It would be very hard to choose between these, and that is why they are not all given as choices in this question. Capsule endoscopy cannot detect H. pylori. Vagotomy and surgery were done more frequently in the past before we knew that H. pylori was the cause of most ulcers and we did not routinely eradicate it. H2 blockers and sucralfate add nothing to a PPI and have less efficacy, not more.

19
Q

Q19-A 60 year-old patient with diabetes for 20 years comes to the office with several months of abdominal fullness, intermittent nausea, constipation, and a sense of “bloating.” On physical examination, a “splash” is heard over the stomach on auscultation of the stomach when moving the patient.
What is the most appropriate next step in the management of this patient?

A-Abdominal CT scan
B-Colonoscopy
C-Erythromycin
D-Upper endoscopy
E-Nuclear gastric emptying study
A

Ans: C. When the diagnosis of diabetic gastro paresis seems clear, there is no need to do diagnostic testing unless there is a failure of therapy. Erythromycin and metoclopromide increase gastrointestinal motility. The most accurate test for diabetic gastroparesis is the nuclear gastric emptying study, although it is rarely needed.

20
Q

Q20- A 69-year-old woman comes to the emergency department with multiple red/black stools over the last day. Her past medical history is significant for aortic stenosis. Her pulse is 115 per minute and her blood pressure is 94/62 mm Hg. The physical examination is otherwise normal.
What is the most appropriate next step in the management of this patient?

A-Colonoscopy
B-Nasogastric tube placement
C-Upper endoscopy
D-Bolus of normal saline
E-CBC, Consult gastroenterology
A

Ans: D. The precise etiology of severe GI bleeding is not as important as a fluid resuscitation. There is no point in checking for orthostasis with the person’s systolic blood pressure under 100 mm Hg or when there is a tachycardia at rest. Endoscopy should be performed, but it is not as important to do first as fluid resuscitation. When blood pressure is low, normal saline (NS) or Ringer lactate are better fluids to give than 5% dextrose in water (D5W). D5W does not stay in the vascular space to raise blood pressure as well as NS.

21
Q

Q21- A 74-year-old man is admitted to the hospital with pneumonia. Several days after the start of antibiotics, he begins to have diarrhea. The stool C. diff toxin is positive and he is started on metronidazole, which leads to resolution of diarrhea over a few days. Two weeks later the diarrhea recurs and the C. diff toxin is again positive.
What is the most appropriate next step in the management of this patient?

A-Retreat with metronidazole orally
B-Use vancomycin orally
C-Sigmoidoscopy and treat only if pseudomembranes are found
D-Intravenous metronidazole
E-Wait for stool culture
F-Intravenous vancomycin
A

Ans: A. Recurrent episodes of C. diff-associated diarrhea are best treated with another course of metronidazole. Intravenous metronidazole is used only if oral therapy cannot be used, such as in a patient with an adynamic ileus. Stool is never cultured for C. diff because it simply will not grow in culture. The difficulty in culturing C. diff is the source of the name of the organism. Endoscopy looking for pseudomembranes will diagnose antibiotic associated diarrhea, but is not a necessary step given the availability of stool toxin assay.

22
Q

Q22- Which of the following is the most effective method of screening for colon cancer?

A-Colonoscopy
B-Sigmoidoscopy
C-Fecal occult blood testing (FOBT)
D-Barium enema
E-Virtual colonoscopy with CT scanning
F-Capsule endoscopy
A

Ans: A. Since 40% of colon cancer occurs proximal to the rectum and sigmoid colon, sigmoidoscopy is not nearly as sensitive in detecting lesions as colonoscopy. Barium studies, CT colonoscopy, and capsule endoscopy do not allow for biopsy. FOBT has more false positives and false negatives than colonoscopy. In addition, a positive FOBT must be followed up with colonoscopy.

23
Q

Q23- Which of the following is associated with the worst prognosis in pancreatitis?

A-Elevated amylase
B-Elevated lipase
C-Intensity of the pain
D-Low calcium
E-C-reactive protein (CRP) rising
A

Ans: D. Severe pancreatic damage decreases lipase production and release leading to fat malabsorption in the gut. Calcium binds with fat (saponifies) in the bowel, leading to calcium malabsorption. Although amylase and lipase are elevated in pancreatitis, there is no correlation between the height of these enzyme levels and disease severity

24
Q

Q24-A 54-year-old man has been evaluated in the office for fatigue, erectile dysfunction, and skin darkening. He is found to have transferrin saturation (iron divided by TIBC) above 50%. His AST is 2 times the upper limit of normal.
What would you do next to confirm the diagnosis?

A-Echocardiography
B-Glucose level
C-Abdominal MRI and HFE (C282y) gene testing
D-Liver biopsy
E-Prussian blue stain of the bone marrow
A

Ans: C. MRI will show increased iron deposition in the liver. An abnormal MRI combined with an abnormal genetic test for hemochromatosis can spare the patient the need for a liver biopsy. There is an association with diabetes; however, glucose levels will not confirm a diagnosis of hemochromatosis. Prussian blue is the stain of blood cells for iron. Prussian blue is also used to diagnose sideroblastic anemia. Iron chelation therapy is used in hemochromatosis for those who:
1. Cannot be managed with phlebotomy
2. Are anemic and have hemochromatosis from overtransfusion such as thalassemia
Deferoxamine, deferasirox, or deferiprone should not be started until the diagnosis is confirmed. Deferasirox and deferiprone are huge breakthrough medications because they are effective orally. Deferoxamine has to be given lifelong by injection.

25
Q

Q25-A 40-year-old man is evaluated for seizures. He achieves partial control with the addition of a second antiepileptic medication. He drives to work each day.
What do you do about his ability to drive?

A-Confiscate his license
B-Allow him to drive if he is seizure-free for 1 year
C-Allow him to drive as long as his seizure history is noted on his license
D-Recommend that he find an alternate means of transportation
E-Do not let him leave the office unless he is picked up by someone; no further driving
F-Allow him to drive as long as he is accompanied

A

Ans: D. You do not have the right, as a physician, to confiscate a patient’s driver’s license. The rules on seizure disorder and motor vehicles vary from state to state. Reporting his condition to the department of motor vehicles does not have the same clarity as, for instance, reporting child abuse, in which the doctor is legally protected for all reports made in good faith. You cannot hold a patient (incarcerate) for seizures in the way that you can for tuberculosis. Being accompanied in a car does not prevent seizures.