A56-year-old Black male construction worker comes for evaluation of a worsening, nonproductive cough that he first noticed 2 months before. During the last week the cough has worsened and has become productive of yellow, blood-tinged sputum. He reports his appetite is poor, and he has lost approximately 15 lbs over the past 2 months. You take a social history and find out he has smoked two packs of cigarettes a day since he was 16 years old. He states that he drinks approximately 10 beers per week. You perform a physical examination. He appears chronically ill; however, his vital signs are normal. The head and neck examination is within normal limits. There are decreased breath sounds in the left upper chest. Breath sounds are distant in the other lung fields. The diaphragms are low. There is no palpable hepatosplenomegaly. You order a posterior-to-anterior (PA) and lateral CXR. The chest radiogram shows opacity of the left upper lobe. There are no pleural effusions. The cardiac silhouette is not enlarged. The mediastinum does not appear enlarged.
The patient has the follow-up test that you recommend. It shows a 5-cm mass compressing the left upper lobe bronchus with consolidation of the left upper lobe. Two 1 cm peribronchial lymph nodes near the left main stem bronchus and several 1.52.0 cm mediastinal lymph nodes are seen. The hilar nodes do not appear enlarged. There are no enlarged lymph nodes visualized in the right chest. There are no lesions seen in the right lung. There are emphysematous changes involving both lungs.
A biopsy of the lung mass shows a small cell carcinoma. What should be done next?
A. MRI of the brain with and without gadolinium contrast
B. complete pulmonary function studies followed by a left pneumonectomy
C. left upper lobectomy
D. radiation of the left upper lobe mass and the mediastinal lymph nodes
E. chemotherapy
Correct Answer: A Section: (none)
Explanation:
Because there is a smoking history, it is appropriate to order a spiral CT scan to better delineate whether the mass is a tumor, an infectious process, or both. Tumor blocking a bronchus can frequently be associated with a pneumonia involving lung behind the compressed bronchus; therefore, the evaluation should include collecting the appropriate cultures along with the further imaging. The full staging of small cell lung cancer is very important both for prognosis to relate to the patient and his family and to define the most appropriate therapy. Therefore, it is appropriate to order the MRI studies of the head along with CT scans with contrast of the abdomen and pelvis, a bone scan and a bone marrow aspirate and biopsy to determine if the disease is limited to the thorax or has metastasized to other organs. Small cell lung cancer limited to the thorax is potentially a disease that can achieve complete, long-term remissions with appropriate therapy. Small cell lung cancer metastatic beyond the chest can be well palliated but, at this time, our current treatments are unable to induce a long-term disease-free remission. Surgery alone is not an appropriate treatment for small cell lung cancer. Even with a successful complete tumor resection, without systemic therapy (chemotherapy), the small cell lung cancer recurs in 100% of cases within months to several years.
Question 632:
A56-year-old Black male construction worker comes for evaluation of a worsening, nonproductive cough that he first noticed 2 months before. During the last week the cough has worsened and has become productive of yellow, blood-tinged sputum. He reports his appetite is poor, and he has lost approximately 15 lbs over the past 2 months. You take a social history and find out he has smoked two packs of cigarettes a day since he was 16 years old. He states that he drinks approximately 10 beers per week. You perform a physical examination. He appears chronically ill; however, his vital signs are normal. The head and neck examination is within normal limits. There are decreased breath sounds in the left upper chest. Breath sounds are distant in the other lung fields. The diaphragms are low. There is no palpable hepatosplenomegaly. You order a posterior-to-anterior (PA) and lateral CXR. The chest radiogram shows opacity of the left upper lobe. There are no pleural effusions. The cardiac silhouette is not enlarged. The mediastinum does not appear enlarged. What next should be ordered?
A. Culture sputum, blood, and urine; administer a broad-spectrum antibiotic; order apical lordotic x-ray views.
B. Culture sputum, blood, and urine; order a spiral CT scan of the chest.
C. Culture sputum, blood, and urine; order an MRI of the chest.
D. Treat with broad-spectrum antibiotics for pneumonia, and tell him to come back in3 months to repeat the chest radiography.
E. Culture sputum, blood, and urine; order a positron emission tomographic (PET) scan.
Correct Answer: B Section: (none)
Explanation: Because there is a smoking history, it is appropriate to order a spiral CT scan to better delineate whether the mass is a tumor, an infectious process, or both. Tumor blocking a bronchus can frequently be associated with a pneumonia involving lung behind the compressed bronchus; therefore, the evaluation should include collecting the appropriate cultures along with the further imaging. The full staging of small cell lung cancer is very important both for prognosis to relate to the patient and his family and to define the most appropriate therapy. Therefore, it is appropriate to order the MRI studies of the head along with CT scans with contrast of the abdomen and pelvis, a bone scan and a bone marrow aspirate and biopsy to determine if the disease is limited to the thorax or has metastasized to other organs. Small cell lung cancer limited to the thorax is potentially a disease that can achieve complete, long-term remissions with appropriate therapy. Small cell lung cancer metastatic beyond the chest can be well palliated but, at this time, our current treatments are unable to induce a long-term disease-free remission. Surgery alone is not an appropriate treatment for small cell lung cancer. Even with a successful complete tumor resection, without systemic therapy (chemotherapy), the small cell lung cancer recurs in 100% of cases within months to several years.
Question 633:
A37-year-old White executive secretary comes to you after she found a lump in her right breast while she was showering. She describes a lesion beneath her right nipple. You question her about her personal and family history. She began menarche at age 12, and she is still having regular menstrual periods. She has had two children; the first was born when she was 25 years old. She has no family history of breast, ovarian, or colon cancer on either her maternal or paternal side. You perform a physical examination including a careful examination of her breasts. You note that her breasts contain many small cysts bilaterally. However, you also palpate a localized, firm, nontender mass below the right areola. You also describe a peau d'orange appearance of the areola.
Amammogram is performed; however, the mammogram demonstrates no abnormality involving either breast. What next should be done?
A. Tell your patient to feel reassured and return if the mass enlarges.
B. Tell her to stop drinking caffeine, not to eat chocolate, and to reduce the stress in her life.
C. Return for another physical examination and mammogram in 6 months.
D. Order an ultrasound of the right breast and lymph node basin.
E. Order a CT scan of the breast, chest, and axilla.
Correct Answer: D Section: (none)
Explanation:
Any new palpable breast lesion in females (or males) of any age necessitates a mammographic evaluation and biopsy. Delay is inadvisable. Serum tumor markers, such as CA-27/29 (or even less specifically CEA), are useful to follow tumor response to therapy; however tumor markers are not reliable as diagnostic tools in breast cancer because of a relatively low sensitivity. Lobular carcinomas are frequently not visualized on mammogram, particularly standard mammograms; ultrasound however detects these tumors and should be ordered when a palpable lesion is not detected on a mammogram.
Question 634:
A37-year-old White executive secretary comes to you after she found a lump in her right breast while she was showering. She describes a lesion beneath her right nipple. You question her about her personal and family history. She began menarche at age 12, and she is still having regular menstrual periods. She has had two children; the first was born when she was 25 years old. She has no family history of breast, ovarian, or colon cancer on either her maternal or paternal side. You perform a physical examination including a careful examination of her breasts. You note that her breasts contain many small cysts bilaterally. However, you also palpate a localized, firm, nontender mass below the right areola. You also describe a peau d'orange appearance of the areola. What should you advise her?
A. She appears to have fibrocystic disease and that she should return for a repeat physical examination in 6 months.
B. Ask her to make another appointment to see you in 2 months.
C. Order a mammogram.
D. Obtain serum markers CA-27/29 and CEA.
E. Order a breast ultrasound.
Correct Answer: C Section: (none)
Explanation:
Any new palpable breast lesion in females (or males) of any age necessitates a mammographic evaluation and biopsy. Delay is inadvisable. Serum tumor markers, such as CA-27/29 (or even less specifically CEA), are useful to follow tumor response to therapy; however tumor markers are not reliable as diagnostic tools in breast cancer because of a relatively low sensitivity. Lobular carcinomas are frequently not visualized on mammogram, particularly standard mammograms; ultrasound however detects these tumors and should be ordered when a palpable lesion is not detected on a mammogram.
Question 635:
A 19-year-old woman begins chemotherapy for an acute leukemia. Although you determine that her renal function is unimpaired prior to the initiation of treatment, you feel that she may be at high risk for development of tumor lysis syndrome given her condition's typically good response to chemotherapy.
Which of the following is typically seen as a feature of tumor lysis syndrome?
A. hypokalemia
B. hypocalcemia
C. hypophosphatemia
D. acute necrosis of renal tubules
E. urine alkalinization
Correct Answer: B Section: (none)
Explanation:
Tumor lysis syndrome refers to a series of metabolic disturbances resultant from cancer treatment. It generally occurs when a large number of cancer cells are killed rapidly, releasing the contents of those cells into the systemic circulation. These contents include various ions. Tumor lysis syndrome is typically characterized by a combination of hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and lactic acidosis. Besides treatment of electrolyte abnormalities, urine alkalinization and aggressive hydration are frequently included as a part of treatment. Patients with tumor lysis syndrome may also develop oliguric acute renal failure, which arises from the precipitation of uric acid, hypoxanthine, or calcium phosphate within the renal tubules. Acute tubular necrosis is generally not seen in the setting of tumor lysis syndrome. Allopurinol reduces the synthesis of uric acid by blocking the metabolism of xanthine and hypoxanthine to uric acid via xanthine oxidase inhibition. This makes it useful in reducing the risk of hyperuricemia from tumor lysis. Urinary alkalinization and aggressive hydration are also components of treatment. Probenecid and sulfinpyrazone enhance urate excretion by blocking the reabsorption of urate from the proximal tubule. Colchicine is effective in treating acute gout attacks by inhibiting leukocyte migration and phagocytosis. Indomethacin, and other NSAIDs, can be effective in treating acute gout attacks by inhibiting urate crystal phagocytosis. However, low-dose aspirin may actually increase the risk of gout.
Question 636:
A 19-year-old woman begins chemotherapy for an acute leukemia. Although you determine that her renal function is unimpaired prior to the initiation of treatment, you feel that she may be at high risk for development of tumor lysis syndrome given her condition's typically good response to chemotherapy.
Which of the following is an appropriate medication to use as a preventative measure prior to and during her treatment for leukemia?
A. indomethacin
B. colchicine
C. allopurinol
D. probenecid
E. sulfinpyrazone
Correct Answer: C Section: (none)
Explanation:
Tumor lysis syndrome refers to a series of metabolic disturbances resultant from cancer treatment. It generally occurs when a large number of cancer cells are killed rapidly, releasing the contents of those cells into the systemic circulation. These contents include various ions. Tumor lysis syndrome is typically characterized by a combination of hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and lactic acidosis. Besides treatment of electrolyte abnormalities, urine alkalinization and aggressive hydration are frequently included as a part of treatment. Patients with tumor lysis syndrome may also develop oliguric acute renal failure, which arises from the precipitation of uric acid, hypoxanthine, or calcium phosphate within the renal tubules. Acute tubular necrosis is generally not seen in the setting of tumor lysis syndrome. Allopurinol reduces the synthesis of uric acid by blocking the metabolism of xanthine and hypoxanthine to uric acid via xanthine oxidase inhibition. This makes it useful in reducing the risk of hyperuricemia from tumor lysis. Urinary alkalinization and aggressive hydration are also components of treatment. Probenecid and sulfinpyrazone enhance urate excretion by blocking the reabsorption of urate from the proximal tubule. Colchicine is effective in treating acute gout attacks by inhibiting leukocyte migration and phagocytosis. Indomethacin, and other NSAIDs, can be effective in treating acute gout attacks by inhibiting urate crystal phagocytosis. However, low-dose aspirin may actually increase the risk of gout.
Question 637:
A 48-year-old woman presents for evaluation of progressively worsening dyspnea. She relates the onset of symptoms to a "walking pneumonia" that she had a year ago. Her breathing has worsened progressively since that time. She has a "smoker's cough" productive of some clear or white phlegm, for which she frequently sucks on cough drops. She started smoking regularly at the age of 18. She currently smokes about a pack of cigarettes a day, down from as much as two packs per day. She is not on any medications regularly. She has no history of heart disease and has always had normal blood pressure
You recommend smoking cessation to your patient. She asks why, at this point, she should quit. Which of the following statements is true?
A. Her pulmonary function will improve 50% or more if she quits.
B. Quitting will not affect her pulmonary status but may reduce her risk of having a heart attack.
C. At this point, quitting will not improve her survival.
D. She is going to require supplemental oxygen and smoking will represent a significant fire hazard.
E. If she is able to stay off of cigarettes, the rate of worsening of her lung function will slow.
Correct Answer: E Section: (none)
Explanation:
COPD is a group of chronic and progressive pulmonary disorders that cause reduced expiratory flow. Most of the obstruction is fixed, although some reversibility can be found. COPD affects approximately 16 million Americans and smoking is, by far, the greatest risk factor. Onset is typically in the fifth decade and the typical presenting symptoms are dyspnea and cough. Patients often relate these to an acute illness (walking pneumonia in this case) but the decline in pulmonary function has been present for some time prior to the onset of symptoms. The physical examination has poor sensitivity and may, in early disease, only show wheezing on forced expiration and a prolonged expiratory phase of respiration. Clubbing is not typically a manifestation of COPD and its presence should lead to a search for another cause, such as lung cancer. In the setting of pulmonary hypertension, sometimes one can hear a pronounced pulmonic component to the second heart sound, although hyperinflation may obscure this finding. Bilateral pulmonary crackles would be more consistent with pulmonary edema. Supraclavicular adenopathy should lead to a workup to exclude cancer, especially of breast, lung, ovarian, or GI origin. Hyperinflation of the lungs is the most likely CXR finding in this case. This would manifest as flattened diaphragms with elongated lungs and a long, narrow cardiac shadow. Kerley B lines would be more characteristic of pulmonary edema from left-sided heart failure, rather than COPD. A pulmonary mass with adenopathy would be more consistent with lung cancer--certainly a possibility in a long-time smoker, but much less common than COPD. A residual infiltrate from pneumonia a year ago would be highly unlikely.
Question 638:
A 48-year-old woman presents for evaluation of progressively worsening dyspnea. She relates the onset of symptoms to a "walking pneumonia" that she had a year ago. Her breathing has worsened progressively since that time. She has a "smoker's cough" productive of some clear or white phlegm, for which she frequently sucks on cough drops. She started smoking regularly at the age of 18. She currently smokes about a pack of cigarettes a day, down from as much as two packs per day. She is not on any medications regularly. She has no history of heart disease and has always had normal blood pressure
Which of the following is most likely to be found on a CXR?
A. cardiomegaly
B. residual infiltrate from inadequately treated pneumonia
C. a pulmonary mass with hilar adenopathy
D. hyperinflation of the lungs
E. Kerley B lines
Correct Answer: D Section: (none)
Explanation:
COPD is a group of chronic and progressive pulmonary disorders that cause reduced expiratory flow. Most of the obstruction is fixed, although some reversibility can be found. COPD affects approximately 16 million Americans and smoking is, by far, the greatest risk factor. Onset is typically in the fifth decade and the typical presenting symptoms are dyspnea and cough. Patients often relate these to an acute illness (walking pneumonia in this case) but the decline in pulmonary function has been present for some time prior to the onset of symptoms. The physical examination has poor sensitivity and may, in early disease, only show wheezing on forced expiration and a prolonged expiratory phase of respiration. Clubbing is not typically a manifestation of COPD and its presence should lead to a search for another cause, such as lung cancer. In the setting of pulmonary hypertension, sometimes one can hear a pronounced pulmonic component to the second heart sound, although hyperinflation may obscure this finding. Bilateral pulmonary crackles would be more consistent with pulmonary edema. Supraclavicular adenopathy should lead to a workup to exclude cancer, especially of breast, lung, ovarian, or GI origin. Hyperinflation of the lungs is the most likely CXR finding in this case. This would manifest as flattened diaphragms with elongated lungs and a long, narrow cardiac shadow. Kerley B lines would be more characteristic of pulmonary edema from left-sided heart failure, rather than COPD. A pulmonary mass with adenopathy would be more consistent with lung cancer--certainly a possibility in a long-time smoker, but much less common than COPD. A residual infiltrate from pneumonia a year ago would be highly unlikely.
Question 639:
A 48-year-old woman presents for evaluation of progressively worsening dyspnea. She relates the onset of symptoms to a "walking pneumonia" that she had a year ago. Her breathing has worsened progressively since that time. She has a "smoker's cough" productive of some clear or white phlegm, for which she frequently sucks on cough drops. She started smoking regularly at the age of 18. She currently smokes about a pack of cigarettes a day, down from as much as two packs per day. She is not on any medications regularly. She has no history of heart disease and has always had normal blood pressure.
Which of the following physical examination findings are you most likely to find in this patient?
A. prolonged expiratory phase of respiration
B. supraclavicular adenopathy
C. rales one-quarter of the way up in both lungs
D. clubbing of fingers E. prominent first heart sound
Correct Answer: A Section: (none)
Explanation:
COPD is a group of chronic and progressive pulmonary disorders that cause reduced expiratory flow. Most of the obstruction is fixed, although some reversibility can be found. COPD affects approximately 16 million Americans and smoking is, by far, the greatest risk factor. Onset is typically in the fifth decade and the typical presenting symptoms are dyspnea and cough. Patients often relate these to an acute illness (walking pneumonia in this case) but the decline in pulmonary function has been present for some time prior to the onset of symptoms. The physical examination has poor sensitivity and may, in early disease, only show wheezing on forced expiration and a prolonged expiratory phase of respiration. Clubbing is not typically a manifestation of COPD and its presence should lead to a search for another cause, such as lung cancer. In the setting of pulmonary hypertension, sometimes one can hear a pronounced pulmonic component to the second heart sound, although hyperinflation may obscure this finding. Bilateral pulmonary crackles would be more consistent with pulmonary edema. Supraclavicular adenopathy should lead to a workup to exclude cancer, especially of breast, lung, ovarian, or GI origin. Hyperinflation of the lungs is the most likely CXR finding in this case. This would manifest as flattened diaphragms with elongated lungs and a long, narrow cardiac shadow. Kerley B lines would be more characteristic of pulmonary edema from left-sided heart failure, rather than COPD. A pulmonary mass with adenopathy would be more consistent with lung cancer--certainly a possibility in a long-time smoker, but much less common than COPD. A residual infiltrate from pneumonia a year ago would be highly unlikely.
Question 640:
A74-year-old male with a history of hypertension, CAD, and a 50 pack-year history of smoking presents with complaints of pain and cramping sensation of the thigh and buttock areas for the past 2 months. On detailed history, patient reports that the pain is usually during ambulation and relieves with sitting down. The pain does not change with respect to sitting or supine position. He denies any recent trauma, weakness of the legs, or paresthesias. He takes his prescription medications regularly and denies using alcohol, drugs, or any herbs/ supplements. Which of the following should be performed as an initial test to help confirm your clinical impression?
Which of the following measures should be implemented for the management of this patient's condition?
A. referral to vascular surgeon
B. glucosamine and chondroitin sulfate
C. subcutaneous injections of low molecular weight heparin
D. smoking cessation and walking program
E. pentoxyfylline
Correct Answer: D Section: (none)
Explanation:
Peripheral arterial disease (PAD) affects roughly 12% of the U.S. population with higher prevalence rates in persons over the age of 70. The classic symptoms of PAD are intermittent claudication which is usually described by patients as cramping pain in the calf, legs, thighs, or buttocks during any type of exercise that quickly relieves with rest. This scenario of worsening with activity and relief with rest is consistent with the disease process, as the pain results from ischemia. The ischemia is worse during periods of increased oxygen demand where the vascular insufficiency fails to meet the demand. Not all patients with PAD are symptomatic, thus an assessment of risk factors and a thorough physical examination are usually key to making the diagnosis in asymptomatic patients. The ABI is an easy, inexpensive, noninvasive test with a high correlation to angiography that can be done in the office. ABI is the usual initial test to screen for PAD.
A value of greater than 1.0 is considered normal, whereas values less than 0.9 are consistent with varying grades of PAD: · 1.0 or greater: normal · 0.810.9: mild PAD · 0.510.8: moderate PAD · <0.5: severe PAD The sensitivity of the ABI can be increased if performed post exercise. The ABI, however, has its limitations in patients with noncompressible, calcified vessels such as the elderly or in patients with diabetes. An ABI of greater than 1.3 may suggest the above scenario and its utility would be suspect. In these cases, more detailed testing may be warranted. Other modalities to assess PAD include arterial Dopplers, magnetic resonance angiography, and conventional angiography. The initial therapy for patients with PAD should be a trial of a structured walking program along with smoking cessation. Walking programs have been shown to increase walking distance without symptoms. In addition, walking also improves endothelial function, collateral vessel formation and function, and control of blood pressure, lipids, and blood sugars.
Pentoxyfylline has been traditionally recommended for PAD; however its efficacy is modest at best based on newer trial data. Antiplatelet agents may also be added for PAD as it will improve cardiovascular risk and perhaps modify the pathogenesis for PAD. Ultimately, risk factor modification is key for prevention and reduction of complications and comorbidities. Severe PAD or patients who require more specialized intervention may require vascular surgery consultation.
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