A 70 Year Old Male Complains Of 2 Months Of Low Back Pain And Fatigue

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DIRECTIONS: Each item below contains a question or incomplete statement followed by suggested responses. Select the one best response to each question.

308. A 55-year-old male is being evaluated for constipation. There is no history of prior gastrectomy or of upper GI symptoms. Hemoglobin is 10 g/dL, mean corpuscular volume (MCV) is 72 fL, serum iron is 4 |g/dL (normal is 50 to 150 |g/dL), iron-binding capacity is 450 |g/dL (normal is 250 to 370 |g/dL), saturation is 1% (normal is 20 to 45%), and ferritin is 10 |g/L (normal is 15 to 400 |g/L). The next step in the evaluation of this patient's anemia is a. Red blood cell folate b. Iron absorption studies c. Colonoscopy d. Bone marrow examinaton

309. A 50-year-old woman complains of pain and swelling in her proximal interphalangeal joints, both wrists, and both knees. She complains of morning stiffness. She had a hysterectomy 10 years ago. Physical exam shows swelling and thickening of the PIP joints. Hemoglobin is 10.3 g/dL, MCV is 80 fL, serum iron is 8 |mol/L, iron-binding capacity is 200 |g/dL (normal is 250 to 370 |g/dL), and saturation is 10%. The most likely explanation for this woman's anemia is a. Occult blood loss b. Vitamin deficiency c. Anemia of chronic disease d. Sideroblastic anemia

310. A 35-year-old female who is recovering from Mycoplasma pneumonia develops increasing weakness. Her Hgb is 9.0 g/dL and her MCV is 110. The best test to determine whether the patient has a hemolytic anemia is a. Serum bilirubin b. Reticulocyte count and blood smear c. Mycoplasma antigen d. Serum LDH

Items 311-313

311. A 70-year-old male complains of 2 months of low back pain and fatigue. He has developed fever with purulent sputum production. On physical exam, he has pain over several vertebrae and rales at the left base. Laboratory results are as follows:

Hemoglobin: 7 g/dL MCV: 86 fL (normal 86 to 98) WBC: 12,000/|L BUN: 44 mg/dL Creatinine: 3.2 mg/dL Ca: 11.5 mg/dL Chest x-ray: LLL infiltrate Reticulocyte count: 1%

The most likely diagnosis is a. Multiple myeloma b. Lymphoma c. Metastatic bronchogenic carcinoma d. Primary hyperparathyroidism

312. The definitive diagnosis is best made by a. 24-h urine protein b. Greater than 10% plasma cells in bone marrow c. Renal biopsy d. Rouleaux formation on blood smear

313. Renal insufficiency may have developed in this patient secondary to a. Obstruction of collecting tubules by Bence-Jones protein b. Hypercalcemia c. Amyloid deposition d. Plasma cell infiltration of the kidney e. All of the above

314. After undergoing surgical resection for carcinoma of the stomach, a 60-year-old male develops numbness in his feet. On exam, he has lost proprioception in the lower extremities and has a wide-based gait and positive Romberg sign. A peripheral blood smear shows macrocytosis and hyper-segmented polymorphonuclear leukocytes. The neurologic dysfunction is secondary to a deficiency of which vitamin?

a. Folic acid b. Thiamine c. Vitamin K

d. Vitamin B12

Items 315-316

315. A 60-year-old asymptomatic man is found to have a leukocytosis when a routine CBC is obtained. Physical exam shows no abnormalities. The spleen is of normal size. Lab data includes:

Leukocytes: 40,000/|L (normal 4,300 to 10,800)

Peripheral blood smear shows a differential that includes 97% small lymphocytes. The most likely diagnosis is a. Acute monocytic leukemia b. Chronic myelogenous leukemia c. Chronic lymphocytic leukemia d. Tuberculosis

316. This patient will require chemotherapy a. If the white blood cell count rises b. If lymphadenopathy develops c. To control anemia or thrombocytopenia d. Only when acute lymphocytic leukemia develops

317. A 67-year-old male presents with hemoptysis 1 week in duration. He has smoked P/2 packs of cigarettes per day for 50 years and has been unable to quit smoking despite nicotine replacement therapy and bupropion. He has mild COPD for which he uses an ipratropium inhaler. Chest x-ray reveals a 3-cm perihilar mass. The most likely cause of this patient's hemoptysis is a. Adenocarcinoma of the lung b. Squamous cell carcinoma of the lung c. Bronchoalveolar cell carcinoma d. Bronchial adenoma

318. A 38-year-old female presents with recurrent sore throats. She is on no medications, does not use ethanol, and has no history of renal disease. Physical exam is normal. A CBC shows Hgb of 9.0 g/dL, MCV is 85 fL (normal), white blood cell count is 2,000/^L, and platelet count is 30,000/^L. The best approach to diagnosis is a. Erythropoietin level b. Serum B12

c. Bone marrow biopsy d. Liver spleen scan

Items 319-320

319. A 50-year-old female complains of vague abdominal pain, constipation, and a sense of fullness in the lower abdomen. On physical exam the abdomen is nontender, but there is shifting dullness to percussion. The next step in evaluation is a. Abdominal ultrasound b. Pelvic examination c. CA 125 cancer antigen d. Sigmoidoscopy

320. This patient was found to have a right adnexal mass on physical examination. Abdominal ultrasound confirms the finding. Abdominal paracentesis reveals malignant cells consistent with ovarian cancer. Risk factors for this malignancy include a. Infertility b. Oral contraceptives c. Coitus early in life d. Multiple sexual partners

Items 321-322

321. A 40-year-old male complains of hematuria and an aching pain in his flank. Laboratory data show normal BUN, creatinine, and electrolytes. Hemoglobin is elevated at 18 g/dL and serum calcium is 11 mg/dL. A solid renal mass is found by ultrasound. The most likely diagnosis is a. Polycystic kidney disease b. Renal carcinoma c. Adrenal adenoma d. Urolithiasis

322. The best choice for cure in this patient is a. Nephrectomy b. Radiation therapy c. Interferon a d. Interleukin 2

323. A 20-year-old male finds a mass in his scrotum. The first step in evaluating this mass is a. Palpation and transillumination b. HCG and a-fetoprotein c. Scrotal ultrasonography d. Evaluation for inguinal adenopathy

324. A 65-year-old man presents with painless hematuria. He has a 45-year history of tobacco use. He denies fever, chills, and dysuria. General physical exam is unremarkable. On rectal exam, the prostate is small, nonnodular, and nontender. A urinalysis shows 100 red blood cells per high-power field. No white cells or protein are present. Three months previously, the patient had an abdominal ultrasound for right upper quadrant pain; on review, both kidneys were normal. The most useful diagnostic test at this time is a. Urine culture and sensitivity b. PSA

c. Renal biopsy d. Cystoscopy

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