Case Files 19-24 (J)

Question 1

An afebrile 45yo M with no history of lung disease or smoking presents with CC of productive cough x 3 weeks. What is your most likely diagnosis? What is your next step?

Answer 1

Diagnosis: Acute Bronchitis

Next step: Short acting bronchodilators, antitussives

Question 2

What is acute bronchitis?

Answer 2

inflammation of the tracheobronchial tree

Question 3

What color of sputum is indicative of a bacterial infection?

Answer 3

Trick Question. the color of your lung butter is irrelevant

Question 4

A febrile 45yo M with no history of lung disease or smoking presents with CC of productive cough x 3 weeks. What is your most likely diagnosis? What is your next step?

Answer 4

Diagnosis: pneumonia Next Step: Chest Xray

Question 5

What is Rhinosinusitis?

Answer 5

Inflammation of the nasal cavity and obstruction of 1+ paranasal sinus.

Question 6

What is the most likely etiology of bronchitis/URIs/Sinusitis/Pharyngitis?

Answer 6

the vast majority is viral. common viruses are Influenza, parainfluenza, adenovirus, rhinovirus, and Ebstein-Barr

Question 7

What are the three most common bacterial infections in the head and upper airway? What are the first line agents to treat them?

Answer 7

Strep pneumoniae, H. influenea, and Moraxella catarrhalis 1st line agents are 10-14 days of amoxicilin or Trimethoprim-sulfa

Question 8

The #1 cause of pharyngitis is…

Answer 8

Viral. But you still have to rule out Group A Strep

Question 9

a 7yo girl comes in with abrupt onset of sore throat, fever, palatal petechiae, tender cervical adenopathy, and no cough. What is the most likely diagnosis.

Answer 9

This person hits every criteria of the CENTOR score. The most likely diagnosis is GAS. Epstein-Barr (Mono) can present very similarly. A “classic” sign of mono is splenomegaly and LUQ pain.

Question 10

a 7yo daughter of some crazy ass anti-vaxers, comes in with abrupt onset of sore throat, fever, drooling, tender cervical adenopathy, and no cough. What is the most likely diagnosis. What is the causative agent.

Answer 10

This is very suggestive of epiglottis. This is an emergency as you can loose the airway. This is caused by H. Ifluenza type B (HiB)

Question 11

What are the complications of an untreated GAS infection?

Answer 11

Rheumatic fever, glomerulonephritits (can occur with or without appropriate antibiotic treatment), toxic shock, mitral valve vegetations–>prolapse later in life.

Question 12

What is the most common cause of otitis externa (swimmers ear)?

Answer 12

Pseudomonas Patients with DM are at risk of OE becoming “malignant OE”

Question 13

a 56yo obese male presents with substernal chest pain, SOB, and diaporesis that began with minimal exertion. What is the most likely diagnosis? What is the next diagnostic step? Therapeutic step?

Answer 13

Unstable angina. Next step in dx: ECG and CX. Then Troponin, CBC, CK, CK-MB Next step in treatment: IV access and MONA. (Morphine, Oxygen, Nitro, Aspirin) + Beta-blockers and glycoprotein IIb/IIIa inhibitor. Avoid/discontinue short acting dihydropyridines (nifedipine)

Question 14

What are the 4 classes of Angina per the New York Heart Association?

Answer 14

Class I: Angina only with strenuous activity Class II: Angina with above average activity level Class III: Angina with ADLs Class IV: Angina at rest

Question 15

What are the common causes of angina?

Answer 15

Atherosclerosis, Coronary artery spasm, cocaine use

Question 16

What drugs should be given post MI?

Answer 16

the combination of Nitro and Beta blockers has been shown to reduce the risk of a subsequent MI. ACE-Inhibitors given within 24 hours prevent Left Ventricular remodeling and thus recurrent ischemic events.

Question 17

What are the risk factors for CAD?

Answer 17

Smoking, age, DM, DLP, HTN, family history, male gender, post-menapause, homocystinemia, LVH.

Question 18

If angina persists for >30 min with rest what is likely occurring?

Answer 18

a myocardial infarct

Question 19

a 50yo male with a 1 week history of URI comes in with sharp chest pain that radiates to the trapezius and increases with respiration and decreases with leaning forward. on EKG you find ST elevation in most leads. What is the most likely diagnosis?

Answer 19

Pericarditis. A MI has dull pain and the ST elevation will correspond with the focus (II, III, and AVF if the LAD is involved)

Question 20

a 50yo male comes in with a tearing chest pain that radiates to his back. On Xray you find a widened mediastinum. What is the most likely diagnosis?

Answer 20

Aortic Dissection

Question 21

a 50yo male comes in with a “boring” chest pain that radiates to his back. He has an elevated amylase. What is the most likely diagnosis?

Answer 21

Pancreatitis

Question 22

a 50yo male with a 1 week history of URI comes in with pleuritic chest pain, fever, and dyspnea. What is the most likely diagnosis?

Answer 22

pneumonia

Question 23

a thin 50yo Caucasian male smoker comes in with a sudden onset unilateral pleurtic chest pain. On exam he has decreased breath sounds. What is the most likely diagnosis?

Answer 23

spontaneous pneumothorax

Question 24

a 50yo male comes in with a sudden onset pleuritic chest pain, tachycardia, tachypnea, and hypoxemia. What is the most likely diagnosis?

Answer 24

pulmonary embolism

Question 25

a 46yo female with CKD and long standing uncontrolled HTN presents with periorbital edema and decreased urination. on UA she has hyaline casts, 3+ protein, and glucose. Negative for ketones. What is her most likely diagnosis. Next Step?

Answer 25

Acute Kidney injury on CKD next step: Serum electrolytes, BUN, Cr.

Question 26

a 46yo female with CKD and long standing uncontrolled HTN presents with periorbital edema and anuria. Chest xray shows pulmonary edema. What is the most likely diagnosis? therapy needed?

Answer 26

end-stage renal disease (ESRD) Therapy: Dialysis and eventually renal transplant.

Question 27

What are the most common etiologies of CKD?

Answer 27

diabetes, HTN, and glomerulonephritis

Question 28

What lab do you get to evaluate GFR?

Answer 28

serum creatinine

Question 29

How do you stage CKD?

Answer 29

Based off of GFR: Normal: 90-120 mL/min Stage I: >90 mL/min but in the presence of signs of CKD (proteinuria, hematuria) Stage II: 60-89 mL/min Stage III: 30-59 mL/min Stage IV: 15-29 mL/min Stage V:

Question 30

What common drugs affect kidney function?

Answer 30

NSAIDs, aminoglycosides, radiographic contrast

Question 31

Which HTN drugs are recommended in patients with CKD?

Answer 31

ACE-I or ARB, and a loop diuretic note: combining ACE-I and ARB requires evaluating Cr and K after 5 days

Question 32

a 25 yo female presents with 1 week of vaginal discharge. she describes a green-yellow discharge with a foul odor. on pelvic exam you note a “strawberry cervix.” What is the next diagnostic step? What is the most likely diagnosis? What are you likely to find? What is the recommended treatment?

Answer 32

The next step is to perform a wet mount. She most likely has Trichomonas (STI) You are likely to find motile, flagellated trichomonads and WBCs. Treatment is metronidazole 2g po

Question 33

a 25 yo female presents with 1 week of vaginal discharge. She states that it appeared following taking antibiotics for a UTI. She describes a thick white discharge with no odor. On pelvic exam you note vaginal erythema. For some reason you decide to stick a pH strip in there and note that it is between 4.0-5.0. What is the next diagnostic step? What is the most likely diagnosis? What are you likely to find? What is the recommended treatment?

Answer 33

The next step is to perform a wet mount and KOH prep. She most likely has vulvovaginal candidiasis (not a STI) You are likely to find budding yeast or pseudohyphae Treatment is vaginal suppository of flucanazole.

Question 34

a 25 yo female presents with 1 week of vaginal discharge. she describes a thin homogeneous grey discharge with a fishy odor. For some reason you decide to stick a pH strip in there and note that it >4.5. What is the next diagnostic step? What is the most likely diagnosis? What are you likely to find? What is the recommended treatment?

Answer 34

The next step is to perform a wet mount. She most likely has Bacterial Vaginosis You are likely to find clue cells and WBCs. Treatment is either metronidazole or clindamycin

Question 35

a 25 yo female presents with 1 week of vaginal discharge. she describes a mucopurulent discharge with no odor. On pelvic exam you note cervical bleeding and cervical motion tenderness. What is the next diagnostic step? What is the most likely diagnosis? What is the recommended treatment?

Answer 35

The next step is to perform genprobe. She most likely has G/C Treatment is ceftriaxone (for Gonorrhea) and Azithromycin or amoxicillin (for chlamydia)

Question 36

a 62yo male presents to your clinic for bloody stools. He has a history of constipation. He endorses pain with sitting. What is the next diagnostic step? What is the most likely diagnosis?

Answer 36

the next step is an anoscopy. The most likely diagnosis is external hemorrhoids.

Question 37

a 62yo male presents to your clinic for bloody stools. He has a history of constipation. He denies any pain. What is the next diagnostic step? What is the most likely diagnosis?

Answer 37

the next step is an anoscopy. The most likely diagnosis is internal hemorrhoids.

Question 38

a 62yo male presents to your clinic for blood on his toilet paper. He has a history of constipation. He endorses pain with bowel movement. What is the next diagnostic step? What is the most likely diagnosis?

Answer 38

the next step is an anoscopy. The most likely diagnosis is anal fissure.

Question 39

a 62yo male presents to your clinic for LLQ pain, a fever of 101.4 and bloody stool. What is the most likely diagnosis?

Answer 39

Diverticulitis

Question 40

What is the difference between ulcerative colitis and Crohn disease?

Answer 40

UC: continuous inflammation starting at the rectum and working up. It affects only the innermost lining of the intestine. Chron’s: Skip lesions involving the entire thickness of the intestinal wall anywhere from mouth to anus. Both: have flares and are associated with bloody diarrhea

Question 41

When do you perform colon cancer screening. What are the available options. What are the intervals between tests for each option.

Answer 41

Starting at age 50 OR 10 years prior to age of diagnosis of colon cancer in a `1st degree relative. 3 options: -fecal occult blood testing (FOBT) (x3) every year -flexible sigmoidoscopy (with or without FOBT) every 3 years -Colonoscopy every 10 years

Question 42

a 55 yo male presents to follow-up on his fecal occult blood testing. 2 of 3 came?back positive for blood. What is the next step.

Answer 42

Colonoscopy. If either of the 2 “lesser” tests comes back positive they earn a colonoscopy.

Question 43

On a routine colonoscopy a man is found to have several asymptomatic diverticuli. What is the best management for this patient?

Answer 43

a high fiber diet. diverticuli only become a problem if inflamed. the most common cause of inflammation is fecaliths.

Question 44

a 45 yo school teacher presents with a productive cough x 2 weeks. She denies any recent hospitalizations. She states that two days ago she developed a fever Tm 102. she is tachycardic and tachypnic. What is the next diagnostic step? What is the most likely diagnosis? What is the bug? What is the next therapeutic step?

Answer 44

The next diagnostic step is a chest Xray. the most likely diagnosis is community acquired pneumonia The most common organisms to cause lobar pneumoniae are H. influenzae, Strep Pneumo, and Moraxella. The most common organisms to cause atypical pneumonia are mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella. The next therapeutic step is antibiotics.

Question 45

A 45 yo obese female is about to go back to surgery for a gastric sleeve. She says she read something about hospital acquired pneumonia and wants you to ease her fears. What are the risk factors? What are the common causes?

Answer 45

The risk factors for HAP are: intubation, NG feeds, pre-existing lung disease, and multisystem failure. The common bacterial causes are the same as CAP plus pseudomonas, klebsiella, Acinetobacter. In the post influenza patient think S. Aureus

Question 46

Who should get the pneumococcal vaccine?

Answer 46

anyone > 65yo, adults with COPD, asplenia, Smokers, immunocompromised