355) A 6 year old boy is brought to your office with history of staring spells. He has had three such episodes in the past one month. His mother reports that during the episode he states blankly in to space for about two to three minutes. He does not respond to verbal commands during such episodes. The episodes are usually, followed by a period during which he is either confused or drowsy for about 30 minutes. On two such occasions, he reported unpleasant taste sensation prior to the staring spells. On examination, he appears comfortable and healthy. There are no physical abnormalities. Basic laboratory investigations including thyroid stimulating hormone are normal. Which of the following is the most appropriate diagnosis?
A) Attention Deficit Hyperactivity Disorder
B) Absence Seizures
C) Complex Partial Seizures
D) Simple Partial Seizures
E) Generalized Seizures
354) A 74 year old woman is being treated in the hospital for community acquired pneumonia. She has been receiving ceftriaxone and azithromycin. On second day after admission she is found by the nurse to be staring in to the space and shaking her left extremity. When you walk in to the room, she recognizes you and reports that she is unable to control movements in her left extremity. On examination, she is afebrile and vitals are stable. A rhythmic movement of her left upper extremity is noted. She is conscious and is repeatedly grinding her teeth. An electroencephalogram has been ordered. Based on the clinical information, which of the following is the most likely diagnosis?
A) Complex Partial Seizures
B) Generalized Tonic-Clonic Seizures
C) Absence Seizures
E) Drug induced myoclonus
353) A 54 year old woman is found by her husband wandering and trying to undress herself two miles away from her home . Her husband tried to question her, however, she did not recognize him, did not respond to his questions and when he tried to restrain her, she became physically aggressive. Upon presentation in the Emergency Department, she appears confused and does not recall the event. There is no history of drug abuse or alcoholism. There is no history of any significant past medical problems. Examination shows normal vitals. There are no focal neurological deficits. She is confused and not oriented to place and person. Which of the following is the most likely diagnosis?
A) Temporal Lobe Epilepsy
B) Depersonalization Disorder
C) Domestic abuse
D) Dissociative Fugue
E) Manic Episode
352) A 26 year old man is brought by the Emergency Medical Services because he was found on the streets of Miami and as per by-standers, was unable to recall where he came from. Upon questioning in the Emeregency Room, he denies any drug abuse or alcoholism. He reports that his name is John and he worked as a plumber. He does not remember if he had a family or what work he did. He says he can not remember how he got to Miami and where he traveled from. A flight ticket receipt from Las-Vegas to Miami is found in his coat pocket. He has an identity card in his wallet that states his name as Steven and that he serves as a Cop in Los Angeles Police Department. He appears comfortable. Examination shows normal vitals. There are no focal neurological deficits. An official from Los Angeles police department reports that Steven had always been a great colleague, did not have any problems in the past and he was surprised that he suddenly did not show up at work for the past two days. Which of the following is the most likely diagnosis?
A) Post Traumatic Stress Disorder
B) Dissociative Identity disorder
C) Dissociative amnesia
E) Dissociative Fugue
351) A 22 year old woman presents to the emergency room with complaints of shortness of breath, dizziness and tingling in her extremities. Her past medical history is unremarkable. She denies any history of blood clots in her family. She denies any recent long flight trips. She does not smoke. On examination, pulse is 110/min and respiratory rate is 26/min. She is afebrile and blood pressure is within normal limits. Pulse oximetry reveals 99% on room air. There are no physical abnormalities . A D-dimer level is 50µg/l . An electrocardiogram shows sinus tachycardia without ant ST-T changes. Chest x-ray is unremarkable. Which of the following is the most appropriate next step in management?
A) Start Conazepam
B) Re-breathing in to a paper bag
C) Start Calcium Gluconate
D) Re-assure and teach to deliberately slow down respiration
E) Admit to ward and start high flow oxygen
350) A 68 year old man with recently diagnosed Parkinson’s disease is evaluated during a follow-up visit. He was started on medications to help with the motor symptoms of his disease. He reports that the medications have not helped him much however, he has been experiencing difficulty concentrating on his job and has lost interest in life. He reports inability to relish his life, sadness and decreased appetite. On examination, his mood is depressed . His facial expressions are masked. He has a resting tremor and generalized slowness of movements. Which of the following is the most appropriate next step in management?
A) Discontinue Anti-parkinson’s medications
B) Increase the dose of anti-parkinson’s medications
C) Inquire about Suicidal ideation
D) Refer to Neurology
E) Admit to Psychiatry ward
349) A 46 year old man presents to your office with generalized itching. The itching is severe during shower and for past few weeks, it has become intolerable. He denies any headache, chest pain or shortness of breath. He does not smoke and consumes alcohol only occasionally. He works as a public health officer in New York City. He reports no sleep related problems, denies snoring at night or day-time drowsiness. He denies any past medical problems . On examination, he is overweight, afebrile, Blood pressure 110/60 mm Hg, Heart Rate 88/min, Respiratory rate is 16/minute. Physical examination is benign. There is no splenomegaly. A CT Scan of the chest, abdomen and pelvis does not reveal any neoplasm. Laboratory investigations reveal :
WBC : 9.0k/µl
Hemoglobin 20gm% ( N = 13.5 to 16.5gm%
Mean Corpuscular Volume ( MCV) 65µl
Platelet count 280k/µl
Serum Creatinine 0.8mg%
Serum Calcium 9.8mg%
Erythropoetin Level 3U/L ( Normal 5 to 25U/L)
Which of the following is features can be seen with this condition?
A) Low serum uric acid
B) Iron deficiency
C) Elevated HGBA2 fraction on HGB electrophoresis
D) Reduced Leucocyte Alkaline Phosphatase
E) Elevated Reticulocyte Count
348) A 6 year old boy is evaluated in your office for complaints of generalized swelling of his body. His mother reports she has noticed increasing swelling of his face, abdomen and extremities over the past 3 weeks. He does not have any significant past medical problems There is no history of fever or sore-throat. He denies shortness of breath or cough. On examination, he is afebrile, Blood pressure 100/60 mm Hg, Heart Rate 88/min, Respiratory rate is 16/minute. He appears comfortable. His face is grossly swollen. There is mild ascites. Lower extremities reveal gross edema up until the level of knees. Urinalysis showed 3+ proteinuria, no red cell or casts. A 24 hour Urine total protein is obtained and it shows proteinuria at 7.0 gm/24 hours. Serum total protein 4.0gm% and albumin 2.0gm% . He is advised to start sodium restricted diet. Which of the following management options is most appropriate next step for this patient?
A) Admit and start Albumin infusion
B) Corticosteroid Trial
C) Renal Biopsy
D) Obtain Anti-Streptolysin O titer
347) A 34 year old man is recently diagnosed with Stage IIA Hodgkin’s lymphoma and has received one cycle of chemotherapy with Adriamycin, Bleomycin, Vinblastine and Dacarbazine. He is scheduled to receive three more cycle followed by involved field radiation therapy. One week after his first cycle of chemotherapy, he presents to your office with increasing swelling of his legs. He denies any fever, chest pain, rash or shortness of breath. On examination, breath sounds are decreased in bilateral lower lungs. There is 2+ edema in his lower extremities. Laboratory investigations show reduced albumin at 2.5gm%. Urinalysis reveals 3+ proteinuria with out any evidence o red cells or red cell casts. A MUGA ( Multigated Acquisition Scan) has been ordered to evaluate his cardiac function and results are pending. Which of the following is most likely explanation of his presentation?
A) Adriamycin Cardiomyopathy
B) Allergic interstitial nephritis
C) Focal Segmental Glomerulosclerosis
D) Bleomycin nephrotoxicity
E) Minimal Change Disease
346) A 54 year old woman presents to your office with progressively increasing swelling of her bilateral lower extremities and abdominal distension. She denies any fever, cough or shortness of breath. Her medical history is significant for hypertension and osteoarthritis. She takes Enalapril and Hydroclorthiazide for her hypertension and Ibuprofen for osteoarthritis on a daily basis . She denies any rash. On examination, she is afebrile, Blood pressure 130/80 mm Hg and respiratory rate is 18/min . Auscultation reveals reduced breath sounds on both sides. Abdominal exam is remarkable for shifting dullness consistent with ascites. Lower extremities reveal gross edema up until the level of knees. Urinalysis shows no eosinophils or redcells or casts, 3+ proteinuria, no nitrite or leukoesterase. Urine total protein is 6.0 gm/24 hours. Serum total protein 4.0gm% , albumin 2.0gm%. SGOT, SGPT and Alkaline phosphatase are within normal limits. Serum creatinine is o.8mg%. Skin examination si normal with out any rash. Which of the following management options is most appropriate next step for this patient?
A) Discontinue Enalapril
B) Renal Biopsy
C) Discontinue Ibuprofen
E) Obtain Anti-Nuclear Antibodies
F) Trial of Corticosteroids