1. A 60 year old post-menopausal woman presents with low back pain of 2 weeks duration. The pain is worse in the evening and sometimes keeps her up at night. The pain began shortly after she had rearranged some furniture in her living room. She has tried acetaminophen (Tylenol) which helped a little; ibuprofen provided a bit more relief but upset her stomach. She denies fever, chills, weight loss, or other pains. She currently takes combination estrogen- progesterone replacement therapy and a multivitamin each day. Prior to her back injury she walked 30 minutes each day. The remainder of review of systems is negative. A physical examination reveals a healthy appearing woman walking with care, unable to bend over without pain. The blood pressure is 135/84 mmHg in both arms, pulse is 88 bpm, 18 breaths per minute. Her temperature is 99.4°F orally. There is no lymphadenopathy; a slight left carotid bruit, a II/VI systolic ejection murmer at the 2nd intercostal space without radiation (noted on previous examinations), the lungs are clear, there is point tenderness at the L2 region without radiation and there is pain on bilateral straight leg raise. The most appropriate next step is [1]:

   A. Reassure the patient, continue daily activities and use acetaminophen and hot compresses
   B. Order a radiograph of the lower spine, serum chemistries, ESR, CBC
   C. Order a radiograph of the lower spine only
   D. Order a radiograph of the lower spine and an electrocardiogram (ECG)
   E. Order an immediate echocardiogram and blood cultures

2. The patient returns after one week feeling no better. A radiograph was obtained in an outside emergency room and was essentially normal with only mild osteopenia. Abnormal laboratory results included an ESR of 89mm/hr, a hematocrit of 32% (hemoglobin 10.3gm/dL) with a mean corpuscular volume of 82fl (normal 84-98 fl), platelets 380K/µl, blood urea nitrogen 43mg/dL, creatinine 2.1mg/dL (was 1.3mg/dL 18 months previously), calcium 10.2mg/dL (normal <10mg/dL). The most appropriate next step is [2]:

   A. Order both urine and serum protein electrophoreses, serum globulin fraction
   B. Order repeat blood cultures and transesophageal echocardiogram
   C. Order urine electrolytes and refer to a nephrologist
   D. Order an intravenous pyelogram and a nuclear medicine renal function scan
   E. Repeat renal function tests, urine with electrolytes and culture, abdominal radiograph

3. A 70 year old man with a 100 pack-year smoking history presents with dysphagia. He also drinks about 2 shots of whisky per day. There is 4 year history of gastroesphageal reflux by symptomatology which has been treated with large doses of antacids and occasional courses of Histamine-2 receptor antagonists (H-2 blockers). There was a 10 pound weight loss over the past two months along with malaise. The patient denies nausea, vomiting, hematemesis, hematochezia, melana, fevers, or chills. Physical examination reveals a thin, cachectic man in no distress. Vital signs and examination are otherwise normal. The most appropriate next step is [3]:

   A. Order a swallowing study (pharyngeal and upper esophageal function)
   B. Order a barium or gastrograffin upper gastrointestinal radiographic series
   C. Begin high dose anti-reflux therapy with a proton-pump blocker (eg. omeprazole)
   D. Order a computerized tomographic scan
   E. Referral for immediate upper endoscopic evaluation

4. Which of the following is NOT a risk factor for breast cancer [4] ?

   A. Family History
   B. Fibrocystic Breast Disease
   C. Previous Breast Cancer
   D. Caffeine
   E. Late menarche / Early Menopause

5. A 55 year old man presents for routine physical examination. He has no specific complaints, and would like a flu vaccination. He has a 30 pack-year smoking history but quit 6 years ago. He is currently a general manager of a dye manufacturing firm, having recently been promoted after many years working with various dyes in the manufacturing plant. Routine screening questions are negative as is a routine physical examination. Routine serum chemistries including renal function tests and a complete blood count are normal. A urinalysis shows 1+ blood; microscopic examintion reveals 10-20 red blood cells and 1 white blood cell per high powered field. There are no bacteria on gram stain. The most appropriate next step is [5]:

   A. Return in 6 months for followup visit
   B. Repeat the urinalysis with culture
   C. Repeat the urinalysis with urine cytology
   D. Refer immediately to urologist for cystoscopy
   E. Order a computerized tomographic of the abdomen and pelvis

6. A 35 year old woman presents with increasing abdominal fullness with 6 pound weight gain over the past 2 months despite 30 minutes of aerobic exercise each day and no dietary changes. She had seen another primary care physician 2 weeks ago who told her that this was normal "menstrual fluctuations and water retension." She has a grandmother with breast cancer and an aunt with colon cancer. Her menstrual cycles have been normal and she has otherwise been in good health. She takes no medications, consumes one glass of wine each night with dinner, and does not use illegal drugs. She has one healthy child age 6 and underwent a tubal ligation shortly thereafter. She denies fevers, chills, nausea, vomiting, malaise. Her only complaint is the increased abdominal girth. A physical examination is unremarkable, including abdominal evaluation for mass and ascites. A pelvic examination reveals mild questionable fullness without pain on examination of the left adnexa. The most appropriate next step is [6]:

   A. Schedule patient for abdominal and pelvic ultrasound procedure
   B. Schedule patient for abdominal computerized tomographic scan with intravenous contrast
   C. Reassure the patient
   D. Order a complete blood count and serum chemistries
   E. Order a complete blood count, serum chemistries, and a CA-125

7. A 47 year old woman with a long history of alcohol abuse and recurrent alcoholic hepatitis presents with jaundice. She had one episode of jaundice 15 years previously after eating raw shellfish. She has occasional nausea and gas pains. She denies weight loss, vomiting, hematemsis, anorexia, hematochezia, melana, easy bleeding or bruising, or abdominal pain. Examination is unremarkable except for scleral and subungual icterus with generalized mild jaundice. Laboratory analysis reveals a normal complete blood count, electrolytes, and renal function. The glucose is mildly elevated at 120mg/dL. AST (SGOT) 65, ALT (SGPT) 32, Alkaline phosphatase 290 (normal <110), Total bilirubin 8mg/dL, direct bilirubin 5.5mg/dL, amylase 865 (normal <80). The most likely diagnosis is [7]:

   A. Hepatocellular Carcinoma
   B. Pancreatic Carcinoma
   C. Colon Carcinoma
   D. Chronic Pancreatitis
   E. Splenic Infarction

8. Which of the following is NOT a risk factor for cervical cancer [8]:

   A. Exposure to diethylstilbestrol (DES) in utero
   B. Use of cervical cap for contraception
   C. Early onset of sexual activity
   D. Human Papillomavirus (HPV) Types 16 or 18
   E. HIV Infection

9. Which of the following chemotherapeutic agents is most often associated with delayed onset dilated cardiomyopathy [9] ?

   A. Cyclophosphamide
   B. Hydroxyurea
   C. 5-Fluorouracil
   D. Doxorubicin
   E. Vincristine

10. Human immunodeficiency virus (HIV) infected patients have a greatly increased risk of all of the following cancers EXCEPT [10]:
A. Kaposi Sarcoma
B. Cervical Cancer
C. Non-Hodgkin's Lymphoma
D. Central Nervous System Lymphoma
E. Malignant Melanoma

Answers

1. B (A thorough evaluation is indicated for low back pain in this patient.)
2. A
3. E (A negative radiographic procedure will not be sufficient to rule esophageal carcinoma.)
4. D (Breast implants are also NOT a risk factor for breast cancer.)
5. C (Immediate referral is not necessary, though with patient's occupation and likely exposure
6. to analine dyes and smoking, cystoscopy even with negative cytology is reasonable)
7. A (Computerized tomography is less sensitive than ultrasound for ovarian, pelvic pathology.)
8. B ("Painless Jaundice" is the classical presentation of pancreatic cancer.)
9. B
10. D
11. E