Case Files 31-36 (J)

Question 1

A 12month old boy is brought in by his mother for 6 hours of intermittent inconsolable crying followed by vomiting of bilious emesis. He has been passing a small amount of stool that the mother calls “odd”

What is the most likely diagnosis?
What does this stool look like?
Whats the next diagnostic step?
Whats the next therapeutic step?

Answer 1

Intussusception

the stool will classically be called “currant jelly” stool.

The next step is abdominal xray to rule out a perforation. once confirmed that there is no perforation, you will order a barium enema to diagnose.

You treat this the same way you diagnose it! with an enema.

Question 2

What is the most common GI obstruction in infants?

Answer 2

Hypertrophic pyloric stenosis.

Question 3

What is the prototypical patient that presents with pyloric stenosis?

Answer 3

3-6 week old male with non-bilious projectile vomiting and an olive shaped mass in the RUQ

Question 4

_____% of patients with congenital malrotation will become symptomatic before 1 mo of age.

Answer 4

60%

Question 5

a one month old baby comes in with bilious vomiting and inconsolable crying. on PE you discover tenderness in the RUQ.

What is the most likely diagnosis?
What is the diagnostic step of choice?
What is the next therapeutic step?

Answer 5

Malrotation

If hemodynamically stable the test of choice is an upper GI series.

Surgery is the only treatment

Question 6

What is the classic xray finding for an intestinal volvulus?

Answer 6

a “beak-like” appearance with contrast.

Question 7

What are the “3 Ds” of the forgetful geriatric patient?

Answer 7

Dementia, Delirium, and Depression.

Question 8

What is in the differential diagnosis of memory loss in the geriatric patient?

Answer 8

The “3 Ds”, stroke, thyroid, syphilis, medications, low B12, and other metabolic conditions.

Question 9

What is the most widely used screening tool for dementia?

Answer 9

the Folstein MMSE. It has a sensitivity/Specificity for dementia of 87/82 percent

a quick test is the clock test

Question 10

What are the 6 common areas of mental function affected by dementia?

Answer 10

• Retaining new information (short term memory)
• Complex tasks (paying bills)
• Reasoning (counting backwards by 7)
• Spacial orientation (getting lost)
• language (>7 F words in 1 min)
• Behavior (agitation, confusion, paranoia)

Question 11

you have an 77 year old patient whose daughter brings her in because over the past 18 months she has progressively been “getting worse” with her short term memory and has been getting lost and frustrated.

What type of dementia is this?

Answer 11

Classic Alzheimer. defined as gradual progression of dysfunction in >1 mental function.

Question 12

___ is also known as pseudodementia due to it being a common cause of memory disturbance.

Answer 12

Depression

Question 13

What are the common drugs used to treat Alzheimer?

Answer 13

Donepezil, Galantamine, Rivastigmine, Tacrine, Memantine.

memorize these. Or don’t. I’m not your fucking mom.

Question 14

you have an 77 year old patient whose daughter brings her in because last week she suddenly began having memory problems. She states that a few days later she began having trouble speaking. Her daughter states that her only medications are lipitor, metformin and HCTZ, and that she still smokes about 1/2 pack a day.

What type of dementia is this?

Answer 14

Vascular Dementia. She has been having strokes. note the sudden onset and “step-wise” progression with every stroke. she has all 4 of the most common risk factors: HTN, HLD, DM, and smoking.

Question 15

you have an 77 year old patient whose daughter brings her in because for the past 6 months she has been having “episodes” where she is “out of it.” Her daughter describes periods of time where she will simply stare off into space or where she will talk gibberish. She states that her daytime naps have been getting more frequent.

What type of dementia is this?

Answer 15

Lewy Body Dementia. this type of dementia is known for its fluctuations in cognition.

you will classically see episodes of daytime drowsiness, staring off into space, disorganized speech, hallucinations, and parkinsonian extrapyramidal signs (tremor, bradykinesia, rigidity, and postural instability)

Question 16

you have an 77 year old patient whose daughter brings her in because for the past 6 months she has been having memory loss, frequently falling, and urinary incontinence.

What type of dementia is this?

Answer 16

Normal Pressure Hydrocephalus. A potentially reversible form of dementia.

Classic triad of memory loss, gait ataxia (leading to falls), and urinary incontinence.

Question 17

you have an 60 year old patient whose daughter brings her in because for the past 6 months she has “completely changed.” “She’s just mean now, and she was never this way before.” On physical exam you notice that she is constantly tapping her foot.

What kind of dementia is this?

Answer 17

Frontotemporal lobe dementia.

Question 18

Obesity costs $_____ per year world wide in health care and lost production.

Answer 18

$100 BILLION!

not going to be on the test but god damn!

Question 19

What is the screening tool for obesity?

Answer 19

BMI. Even though it sucks as it is not accurate measure for: CHF, short, tall, pregnant, elderly, athletic/muscular patients.

Question 20

Obesity is defined as a BMI greater than____.

Answer 20

30

Question 21

What are the risk factors for obesity?

What is the main contributor to the current epidemic?

Answer 21

lower education, lower SES, cessation of smoking(!)

an increase in caloric intake and a decrease in physical activity. Sorry it’s not “muh genes”

Question 22

How much weight is needed to lower a patients risk of CVD?

How can that be achieved?

Answer 22

5% that’s it. That’s a 10 lb weight loss for the average american (20 for the average Ft Hood spouse)

a caloric deficit of 500 kcal/day produces a 1 lb/week weight loss. physical activity is an important part but can not produce weight loss alone, dietary changes must be made.

Question 23

what is the best way to improve insulin sensitivity?

Answer 23

physical activity

Question 24

Who qualifies for bariatric surgery?

Answer 24

BMI >40 or >35 with comorbid conditions

Question 25

What is metabolic syndrome?

Answer 25

3/5 of the following:

• Abd circumference of >40in (M)/35 in (F)
• Serum Triglycerides >150
• HDL 130/85
• fasting glucose >100

Question 26

How do you diagnose a migraine?

Answer 26

This is not from case files but is a good mnemonic from a doc I worked with years ago.

Remember that a migraine POUNDS.

Pulsatile 
One(ish)-day duration (4-72 hours)
Unilateral 
Nausea/vomiting
Disabling 
Sleep helps

Question 27

Why is a sudden onset “worst headache of my life” a headache “red flag?”

Answer 27

you have to consider SAH

Question 28

Why is increasing severity and frequency and brought on by physical activity, a headache “red flag?”

Answer 28

you have to consider mass lesion

Question 29

Why is a new onset headache after age 50 associated with jaw pain with chewing, a headache “red flag?”

Answer 29

you have to consider temporal arteritis

Question 30

Why is a new onset headache in an immunocompromised patient , a headache “red flag?”

Answer 30

you have to consider meningitis and brain abcess

Question 31

Why are fever, rash, and/or stiff neck a headache “red flag?”

Answer 31

you have to consider meningitis, encephalitis, and Lyme

Question 32

A 21 yo male presents with an excruciating unilateral headache behind his left eye that occurs every day and lasts for about 20 min. When you walk into the room you see him pacing unable to get comfortable.

what kind of headache is this?
how do you treat this?

Answer 32

Cluster headache. M»»F, frequent, episodic, deep, very painful, unilateral, typically behind the eye, lasting 15-180min.

Treat acutely with O2, dihydroergotamine, and triptans.

Treat prophylactically with verapamil, lithium, ergotamine, and predisone.

Question 33

a 21 yo male presents with recurring headache with a bilateral bandlike distribution. They are not aggrivated by physical activity, or accompanied by nausea, vomiting, photophobia, or phonophobia. They typically last a couple of hours but have been as short as 30 min or as long as a couple of days.

what kind of headache is this?
how do you treat this?

Answer 33

This is a classic tension headache.

Acute treatment is NSAIDs and tylenol. Avoid caffeine and opiods if possible.

Prophylactic treatment is TCAs, CCBs, and Beta blockers.

Question 34

Which medications have been shown to cause Medication Overuse Headaches (MOH) formerly called “rebound headaches”

Answer 34

NSAIDs, Tylenol, Caffeine, Triptans and Ergotamine (my headache medication is causing my headaches!)

Question 35

What is the LDL goal for a person with CHD or CHD equivalent (high risk)? 2+ risk factors (moderate risk)? 0-1 risk factors (low risk)?

Answer 35

High risk:

Question 36

What is CHD equivalent when considering LDL goal?

Answer 36

Peripheral arterial disease (claudication), cerebrovascular disease, AAA, and Type 2 diabetes,

Question 37

What are the 5 risk factors to consider when determining someones LDL goal?

Answer 37

• Smoker
• HTN
• HDL45yo(M)/>55yo(F)
• family history of 1st degree relative with CHD with onset

Question 38

What are the common secondary causes of dyslipidemia?

Answer 38

Diabetes, hypothyroid, obstructive liver disease, CKD

Question 39

The mainstay treatment of HLD is?

Answer 39

diet and exercise! And when that fails (because ‘Murica) statins.