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Case Studies: Each of the numbered items or incomplete statements below is followed by answers or by completions of the statement. Select the one lettered answer or completion that is best in each case.

1. A 23-year-old man known to have neurofibromatosis, type 1 (von Recklinghausen’s disease), presents with a left lower quadrant abdominal mass and signs of neurologic deficits in his left leg. In the ensuing workup, it is determined that he has higher than normal values of catabolites of epinephrine and norepinephrine in a 24-hour urinary collection. He is currently normo¬tensive. Before invasive steps are taken to biopsy and eventually remove his left lower quadrant abdominal mass, which of the following is the most appropriate next step in management?

(A) CT scan of the head looking for meningiomas

(B) MRI of his adrenal glands

(C) MRI of the acoustic nerves

(D) Radionuclide scans from the neck to the pelvis looking for extraadrenal pheochromocytomas

(E) Radiation therapy to the left lower quadrant abdominal mass

2. A 29-year-old woman comes to the physician for follow-up of a right breast lump. The patient first noticed the lump four months ago. It was aspirated at that time and cytology was negative, but the cyst recurred about one month later. The cyst was re-aspirated two months ago and again the cytology was negative. The lump recurred. Examination reveals a mass at 10 o’clock, approximately 4 cm from the areola. Ultrasound demonstrates a cystic lesion. Which of the following is the most appropriate next step in management?

(A) Excisional biopsy

(B) Mammography in six months

(C) Repeat FNA in two months

(D) Tamoxifen therapy

(E) Ultrasound in six months

3. A 60-year-old woman complains of a one-year history of bone pains, anorexia, weight loss and constipation. Serum calcium is elevated, and she is diagnosed with primary hyperparathyroidism. She is treated surgically, with removal of her parathyroid adenoma. She then has a long period of hypocalcemia and requires continuous treatment with vitamin D and calcium. After six months she becomes normocalcemic and does not need therapy. Which of the following conditions best explains the fluctuations in this patient’s calcium levels?

(A) Her remaining three parathyroid glands were destroyed

(B) She had severe bone disease

(C) She had pancreatitis from hyperparathyroidism

(D) She has unrecognized pseudohypoparathyroidism

(E) The wrong parathyroid gland was  removed

4. An 82-year-old nursing-home resident with moderate dementia secondary to Alzheimer disease has been agitated for the past month. She has been accusing the staff at the nursing home of stealing her belongings. Over the past two weeks she has also become physically aggressive toward the staff. Which of the following is the most appropriate management?

(A) Administer low doses of benzo¬diazepines when the patient becomes agitated

(B) Begin a trial of a low dose of an antidepressant medication, such as fluoxetine

(C) Begin a trial of a low dose of an atypical antipsychotic medication, such as risperidone

(D) Recommend insight-oriented psychotherapy

(E) Recommend the frequent use of physical restraints as part of a behavior modification regimen

Source: Step 2 CK Qbank, Kaplan Medical, © 2008.

Answer