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* archur434
 #727521  
  passion790 - 03/29/13 11:40
 
  434) A 44 year old woman is evaluated in your office for one month history of worsening fatigue. She also reports tingling and numbness in bilateral lower extremities. Her past medical history is significant for morbid obesity for which she underwent gastric bypass surgery four years ago. She has lost about 80lbs weight since her surgery. Her medications include oral ferrous sulfate, folic acid and vitamin b-complex. Physical examination reveals absent ankle jerks. Laboratory Studies reveal WBC 5400/µl HGB: 9.8 gm%, MCV 74 fl, Platelets : 300k/µl, Serum ferritin 280ng/ml, Transferrin saturation 26% . A bone marrow aspirate smear is shown below :

http://usmlestep3blog.com/

Archer USMLE

Which of the following is the most likely cause of patient’s presentation?

A) Iron deficiency

B) Copper deficiency

C) Vitamin B12 deficiency

D) Zinc deficiency

E) Pure red cell aplasia
 
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* Re:archur434
#2862615
  marphes101 - 03/29/13 12:07
 
  its sidroblastic anemia due to copper defeciency  
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* Re:archur434
#2862740
  oslerformatch - 03/29/13 15:21
 
  Its iron def or vitamin b12,,,MCV is low ,,,Or it is mixed?PAtient has reduced reflexes which are a sign of vit b12 def....
I would go for vitamin b 12
 
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* Re:archur434
#2862744
  passion790 - 03/29/13 15:24
 
  no its sounds like its copper deficiency, occurs as a result of zincemia in bariatric surgery. copper defi causes neuro+ hema symptoms. It cannot be Vit B12 def, MCV is low.  
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* Re:archur434
#2862748
  oslerformatch - 03/29/13 15:31
 
  Ya u r right,,Its copper def,,,,Wiki has one image,,,,Same as teh one posted here.
it occurs after surgery,
Ringed sederoblasts
 
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* Re:archur434
#2862751
  passion790 - 03/29/13 15:35
 
  well, I got this info from archur blog. Someone explained it v well.  
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* Re:archur434
#2862849
  hellfireomega - 03/29/13 17:26
 
  B) Copper deficiency. A person who undergoes gastric bypass surgery can develop a copper deficiency due to poor absorption.

http://ajcp.ascpjournals.org/content/132/2/191/F2.expansion.html
 
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* Re:archur434
#2863596
  acromegaly - 03/31/13 11:59
 
  nice question  
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* Re:archur434
#2863661
  passion790 - 03/31/13 13:32
 
  417) A 72-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. Her other history includes Diabetes and hypertension. She presents with complaints of increasing pain in her right lower extremity upon walking a block for past few weeks. The pain gets better with rest. There is no history of limb swelling. On examination, vitals are stable. Physical examination is unremarkable with out any swelling or tenderness in her extremities.

Which of the following is the most appropriate diagnosis?

a) Peripheral artery disease

b) Chronic Venous insufficiency

C) Lymphedema

d) Deep Vein Thrombosis

e) Phlegmasia Alba Dolens

Which of the following is indicated next?

A) Venous Doppler

B) Compression Stockings

C) Clopidogrel

D) Check blood pressure at ankle and elbow levels

E) Leg elevation

416) A 60-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. She presents with increasing swelling and mild pain in her right lower extremity over past several months. The pain is present all the time and does not get better with rest. The swelling has progressively increased and now, she has unsightly thickening of the skin. On examination, there is non-pitting edema of the entire right lower extremity. The skin is thickened and can not be pinched and lifted.

Which of the following is the most likely diagnosis?

A) Chronic Venous Insufficiency

B) Phlegmasia Alba Dolens

C) Phlegmasia Cerulea Dolens

D) Lymphedema

D) Peripheral Arterial Disease
 
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* Re:archur434
#2863667
  passion790 - 03/31/13 13:40
 
  415) A 60-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. Her other history includes Diabetes and hypertension. She presents with complaints of increasing pain in her right lower extremity upon walking. The pain gets better with rest. On examination, there is mild swelling of her right extremity with a 2 cm very shallow, clean, weeping ulcer on the medial malleolus with granulation tissue in the base. There is hyperpigmentation surrounding the ulcer. There is no “pitting” of the swelling and the skin can be easily lifted from the subcutaneous tissues. Dorsalis pedis and posterior tibial artery pulses are mildly diminished.

Which of the following is indicated for her ulcer at this time?

A) Leg elevation and absorbent dressing

B) Antibiotics

C) Compression stockings

D) Anti-coagulation

E) Angiography


414) A 62-year-old software engineer presents with complains of mild pain and swelling in his right lower extremity which has been progressively increasing over the past 6 months. The swelling is more towards the end of the day. Pain is worse on walking or standing and gets better with rest. On examination, vitals are stable. There is non-pitting edema of right lower extremity below the level of the knee. The limb looks normal above the level of the knee. There is some bluish discoloration of the skin over the distal portion of the leg. Small intradermal bluish vessels are noted in the skin of her right lower extremity. Dorsalis pedis and tibial pulses are intact. Which of the following is the most likely diagnosis?

A) Chronic Venous Insufficiency

B) Phlegmasia Alba Dolens

C) Phlegmasia Cerulea Dolens

D) Lymphedema

D) Peripheral Arterial Disease


413) A 60-year-old woman with history of stage III melanoma of the right lower extremity underwent a lymph node dissection about one year ago. Now, she presents with pain in her right lower extremity that started about one week ago and is progressively worse. Over the last two days, she developed bluish discoloration of the right great toe . On examination, her vitals are stable. There is gross swelling of the entire right lower extremity with bluish discoloration of right great toe and extreme tenderness . Dorsalis and posterior tibial artery pulses are slightly diminished. Which of the following is the most likely diagnosis?

A) Chronic Venous Insufficiency

B) Phlegmasia Alba Dolens

C) Phlegmasia Cerulea Dolens

D) Lymphedema

D) Peripheral Arterial Disease


412) An 78 year old man with history of dementia is evaluated in your office for three episodes of “syncope” over the past two months. He lives with his daughter at home. She reports that he fell to the floor and lost consciousness in the morning after getting up from his bed and the episodes would last for few minutes but he would return to his usual baseline mental status after the event. There is no history of chest pain or shortness of breath. She has seen him become increasingly “stiff” over the years and he has had worsening of tremors in his hands. When he writes, the letters are very small and difficult to decipher. He has been taking Donepezil and Memantine for Alzheimer’s for about 2 years. On examination, his pulse is 90/min, Blood Pressure 110/60 mm Hg. He has Bradykinesia and Pill rolling tremor in his hands. Cardiac examination is normal with out any murmurs. Laboratory investigations revealed a normal hemoglobin, blood glucose and electrolytes. An electrocardiogram is within normal limits. Which of the following is indicated next?

A) Orthostatic Vitals

B) 24 hour Holter-Monitoring

C) Discontinue Memantine and Donepezil

D) CT Scan of the Head

E) Tilt-Table Test



411) An 88 year old man with history of moderate dementia is evaluated in your office for recurrent episodes of “syncope” over the past few months. There is no history of any chest pain or shortness of breath for a similar complaint. Nursing home staff reports that lately, he has been noted to be more confused than usual on several occasions and becomes very drowsy. He was sent to the Emergency Room twice last month for the same issue. There is no history of complete loss of consciousness. As per his nursing home chart, his other medical issues include poorly-controlled Osteoarthritis pain, “Sun-Downing” and Insomnia. On examination, his vitals are stable. He is currently awake. There are no focal neurological deficits. Cardiac examination is normal with out any murmurs. Laboratory investigations revealed a normal hemoglobin, blood glucose and electrolytes. An electrocardiogram is within normal limits. Which of the following is indicated next?

A) Orthostatic Vitals

B) 24 hour Holter-Monitoring

C) Electroencephalogram

D) Review of his medications

E) Tilt-Table Test

 
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* Re:archur434
#2863674
  passion790 - 03/31/13 13:48
 
  410) A 30 year old man presents to the emergency room after having had a syncopal episode. His girl friend reports he suddenly collapsed to the floor and lost consciousness for few minutes. There was no evidence of tonic clonic movements. After regaining his consciousness, he was completely alert and awake. He reports he has had sweating and nausea prior to the episode. He has had about 2 to 3 such episodes per year for past several years. He was admitted for similar episodes in the past and telemetry monitoring was uneventful. He denied any chest pain, shortness of breath or palpitations prior to the episode. He has no other significant medical problems. On examination, his vitals are stable. He is completely awake and oriented. There are no focal neurological deficits. Cardiac examination is normal with out any murmurs. Laboratory investigations revealed a normal hemoglobin, blood glucose and electrolytes. An electrocardiogram is within normal limits. Which of the following is indicated next?

A) Holter Monitoring

B) CT scan of the Head

C) Tilt-Table testing

D) Carotid Doppler

E) Electrophysiology Study


409) A 64 year old post-menopausal woman with history of hypertension and coronary artery disease presents to the Emergency Room with severe left sided chest pain that started 1 hour ago at rest. The pain radiates to her left shoulder and her jaw. Her history is significant for per-cutaneous coronary intervention to the left anterior coronary artery and placement of drug-eluting stent 9 months ago. Her medications include aspirin, Clopidogrel, Metoprolol and Lisinopril. One week ago, she had a dental extraction procedure and had discontinued Aspirin and Clopidogel prior to the procedure. She was scared of bleeding and has not resumed these medications yet. A chest X-ray is normal. An electrocardiogram reveals 5mm ST segment elevations in the anterior leads and reciprocal depressions in the inferior leads. Which of the following is the most appropriate explanation of this patient’s presentation?

A) Pericarditis

B) Re-Stenosis within the stent

C) Stent Thrombosis

D) Rupture of a new plaque in anterior coronary artery

E) Stenosis from progressive atherosclerosis of anterior coronary artery
 
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