CDM Cases Flashcards by Lauren Chorny

16yo L knee pain x2mo. pain at front of knee, below kneecap, worse with activity (running, walking up steps). no clicking, nl strength, tender over medial and lateral patella. no pain on joint lines.

DDx?

patellar instability
patellofemoral pain syndrome
synovial plica

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16yo L knee pain x2mo. pain at front of knee, below kneecap, worse with activity (running, walking up steps). no clicking, nl strength, tender over medial and lateral patella. no pain on joint lines.
occasionally buckles, pops on standing,

signs/symptoms of underlying dx?

movie sign or theater sign
pain with stairs
pain with squatting

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next steps in management?

activity modification

referral to physical therapy

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medial knee pain ddx

medial compartment arthritis
MCL sprain
meniscus injury
pes anserinus pain syndrome

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lateral knee pain ddx

lateral compartment arthritis
LCL sprain
meniscus injury
iliotibial band syndrome

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focal anterior knee pain ddx

patellar or quadriceps tendinitis
prepatellar or infrapatellar bursitis
osgood-schlatter disease
synovial plica

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vague anterior knee pain ddx

chondromalacia patellae
patellofemoral pain
osteoarthritis exacerbation
chronic patellar dislocation/subluxation
referred from hip
avascular necrosis
patellar stress fracture

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posterior knee pain ddx

popliteal (baker’s) cyst
popliteal artery aneurysm or entrapment
hamstring strain
gastrocnemius strain

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lachman/anterior drawer test

tibia pulled forward relative to femur

tests ACL

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posterior drawer

tibia pushed backward relative to femur

PCL

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mcmurray/apley, thessaly

meniscus compressed between femur and tibia with twisting motion
meniscus

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ober’s test

the IT band put on stretch with the patient lying on their side
iliotibial band

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patellar apprehension test

patella pulled to each side to test how far it will go and if the patient feels that it will dislocate
patellar laxity (medial patellofemoral ligament)

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varus stress

pressure placed medially to laterally on knee

LCL

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valgus stress

pressure placed laterally to medially on knee

MCL

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common treatment for ACL tear

surgery for younger individuals

conservative care and eventual replacement for older individuals with arthritis

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common treatment for PCL tera

conservative therapy or surgery

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common treatment for MCL sprain

conservative (therapy)

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common treatment for LCL sprain

conservative (therapy) unless complete tear, then surgery

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common treatment for meniscus tear

conservative (therapy) if degenerative or not causeing mechanical symptoms (catching, popping, or locking of the knee)
surgery for mechanical symptoms

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common treatment for ITB syndrome

conservative (therapy)

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42yo M with palpable thyroid nodule and otherwise normal thyroid. no sx thyroid.

most important next steps?

neck ultrasound

thyroid function test

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42yo M with palpable thyroid nodule and otherwise normal thyroid. no sx thyroid.
TSH wnl, U/S reveals 2cm nodule with internal microcalcifications. FNA showed psammoma bodies.

what’s the diagnosis?

papillary thyroid cancer

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42yo M with palpable thyroid nodule and otherwise normal thyroid. no sx thyroid.
TSH wnl, U/S reveals 2cm nodule with internal microcalcifications. FNA showed psammoma bodies.
undergoes total thyroidectomy for papillary thyroid cancer. now ha perioral numbness and tingling.

what’s the laboratory abnormality?

hypocalcemia

hypothyroidism

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45yo F with heat intolerance and weight loss. more anxious, exophthalmos. worsened over several months. elevated FT4 and low TSH. thyroid smooth and grossly enlarged. most likely diagnosis?

Grave's disease

45yo F with heat intolerance and weight loss. more anxious, exophthalmos. worsened over several months. elevated FT4 and low TSH. thyroid smooth and grossly enlarged. what's associated with Graves' disease?

diffuse palpable goiter with audible bruit exophthalmos pretibial myxedema

45yo F with heat intolerance and weight loss. more anxious, exophthalmos. worsened over several months. elevated FT4 and low TSH. thyroid smooth and grossly enlarged. fails medical therapy and undergoes total thyroidectomy. desats on extubation, vocal cords closed. what anatomic structure was injured?

recurrent laryngeal nerve

45yo AA male for routine BP check. recent dx, started on HCTZ 12.5mg qd. truck driver, no exercise, fast food, smokes. elev Cr , urine alb/cr ratio, hgbA1c. BP remains high. what's the next best step in management?

add losartan 25mg once a day.

45yo AA male for routine BP check. recent dx, started on HCTZ 12.5mg qd. truck driver, no exercise, fast food, smokes. elev Cr , urine alb/cr ratio, hgbA1c. BP remains high. next visit in 1mo, what lab test should be obtained given recent med change?

basic metabolic panel to check renal function

45yo AA male for routine BP check. recent dx, started on HCTZ 12.5mg qd. truck driver, no exercise, fast food, smokes. elev Cr , urine alb/cr ratio, hgbA1c. BP remains high. what lifestyle changes should be recommended as part of your balanced healthcare plan?

quit smoking DASH diet increase physical activity weight loss

6mo F, initially diff breastfeeding, switched to formula, thin wispy hair. diaper rash. dropping weight in growth chart. What condition can be diagnosed based on current information?

failure to thrive

6mo F, initially diff breastfeeding, switched to formula, thin wispy hair. diaper rash. dropping weight in growth chart. spits up food, vomits, arches back, nonwatery soft stools. mom neg HIV. no travel. UTD milestones. what lab or imaging workup would you order?

basic metabolic panel complete blood count urinalysis

risk factors for FTT

medical conditions: prematurity, developmental delay, congenital abnormalities, low birth weight, poor oral hygiene, reflux psychosocial: disordered feeding, family stressors, family history of partner abuse, poor parenting skills, poverty, restricted diet (religious or other)

commonly recommended testing in failure to thrive (in general)

``` CBC BMP VBG serum lactate ammonia bilirubin glucose urinalysis ```

commonly recommended testing in failure to thrive (specialized based on history)

``` HIV mycobacterium tuberculosis cystic fibrosis (lipase) milk protein allergy (trial of diet alteration) intestinal malabsorption (celiac panel) congenital anomaly (lung/heart/kidney/bladder) pyloric stenosis (abdominal ultrasound) neglect (skeletal survey) hyperthyroidism (TSH) ```

gastroesophageal reflux disease

signs of GERD in infants

``` frequent regurgitation or vomiting prolonged feeding refusal to feed back arching postprandial irritability ```

signs and symptoms of GERD in infants that require further evaluation

FTT fever persistent forceful or bilious vomiting apnea lethargy/seizures/neurodevelopmental delay persistent diarrhea or constipation or GI bleeding abdominal tenderness/distention or hepatosplenomegaly

lifestyle changes | can start cimetidine

12yo F noticed midline mass on neck that becomes inflamed intermittently then resolves spontaneously. 2cm well-defined. mass moves up with tongue protrusion and with swallowing what is most likely dx?

thyroglossal duct cyst

midline neck mass generally above thyroid cartilage moves with swallowing

branchial cleft cyst

lateral neck mass, almost always anterior to the sternocleidomastoid does not move with swallowing usually diagnosed in childhood

head and neck cancer

``` usually diagnosed in adulthood risk factors (smoking, HPV) solid, firm, immobile can be in any distribution, usually associated with lymphadenopathy often an underlying mass or lesion ```

thyroid mass

within the thyroid | generally near midline

detailed history with review of systems referral to ENT for monitoring and possible excision thorough physical exam

middle third of the hyoid bone

47yo M hx T2DM. VSS. no hx anemia or CKD. baseline Cr 1.1. what portions of ROS important for current health status given his diabetes?

``` cardiovascular constitutional eye genitourinary integumentary/skin neurological ```

47yo M hx T2DM. VSS. no hx anemia or CKD. baseline Cr 1.1. meds: Metformin 50mg BID, simvastatin 20mg, aspirin 81mg 3mo ago:HgbA1c 7.3; LDL 165; BP 146/84 today: Hgba1C 7.7; LDL 170; Cr 1.23; BP 145/95 ASCVD risk 12% not compliant with diet/exercise routine. eating out more, work stress. has gym membership. next best steps in management?

increase metformin start lisinopril change simvastatin to atorvastatin 40mg daily recommend further lifestyle modifications

discontinue lisinopril and start an ARB

4yo F wcc. no pmhx. UTD vax. +daycare. rarely goes outside and plays and has never ridden tricycle. BMI 90%ile. vss. what vaccines at 4yo visit?

Dtap (diphtheria, tetanus, pertussis) MMR polio (IPV) varicella

4yo F wcc. no pmhx. UTD vax. +daycare. rarely goes outside and plays and has never ridden tricycle. BMI 90%ile. vss. what milestones to ask for 4yo exam?

draw a person with 2-4 body parts hopping and standing on one foot for up to 2 seconds knows first and last name sing a song from memory

age 1 milestones

cries when mom or dad leaves repeats sounds or actions to get attention says mama and dada and exclamations like "uh-oh" tries to say words you say gets to a sitting position without help pulls up to stand, walks holding on to furniture ("cruising")

age 2 milestones

copies others, especially adults and older children shows defiant behavior points to things or pictures when they are named says sentences with 2-4 words builds towers of 4 or more blocks stands on tiptoe begins to run

age 3 milestones

separates easily from mom and dad says first name, age, sex talks well enough for strangers to understand most of the time carries on a conversation using 2-3 sentences screws and unscrews jar lids or turns door handle copies a circle with a pencil or crayon

age 4 milestones

should be able to recite their full name like to play with other children can sin ga song like 'itsy bitsy spider' by themselves can draw a person with 2-4 body parts can begin to hop and stand on 1 leg for short periods of time can catch a bounced ball most of the time can play board or card games

age5 milestones

wants to please and be like friends can tell what's real and what's make believe tells a simple story using full sentences can draw a person with at least 6 body parts counts 10 or more things hops; may be able to skip can use the toilet on their own knows address

4yo F wcc. no pmhx. UTD vax. +daycare. rarely goes outside and plays and has never ridden tricycle. BMI 90%ile. vss. what advice would you give the family regarding patient's weight and physical activities?

she should do a variety of physical activities | she should limit sugary drinks

18yoF. well visit. starting college. UTD vax. sexually active since 14 w 4 male partners. all STI testing negative. always used condoms. no pmhx. OCPs. when should she have her first pap smear?

18yoF. well visit. starting college. UTD vax. sexually active since 14 w 4 male partners. all STI testing negative. always used condoms. no pmhx. OCPs. small lump in lower lateral quadrant. sometimes tender/painful that changes with menstrual cycle. possible nodularity. what is the best initial test for this breast lump?

breast ultrasound

18yoF. well visit. starting college. UTD vax. sexually active since 14 w 4 male partners. all STI testing negative. always used condoms. no pmhx. OCPs. small lump in lower lateral quadrant. sometimes tender/painful that changes with menstrual cycle. possible nodularity. breast u/s: 2cm mass, without cystic features concerning for malignancy what most important step in determining management of this condition?

core needle biopsy

3yo M. +SOB, runny nose for a few days. no change appetite. no diarrhea. +vomit. inc wet diapers and frequency. born @36wks, UTD vax, no sig pmhx. no smoke exposure. awake/alert. dry mucus membranes, mild abd tenderness, tachycardia what tests for initial workup?

basic metabolic panel complete blood count urinalysis

admission to the hospital under pediatrics service intravenous fluid bolus intravenous insulin

electrocardiogram chest x0ray brain natriuretic peptide (BNP)

echocardiogram | thyroid stimulating hormone level

workup for atrial fibrillation

``` cbc electrolytes renal function TSH troponin (if ischemia suspected) echocardiogram ```

possible causes of atrial fibrillation

``` heart disease (hypertrophic, ischemic, hypertensive, valvular, congenital) thromboembolic disease obstructive sleep apnea obesity diabetes CKD hypo- or hyperthyroidism infection electrolyte disorders drug use surgical stress (often cardiac surgery) ```

76yo F new SOB for few weeks. dec exercise tolerance, takes more rest, inc LE swelling. pmhx HTN. meds: lisinopril, HCTZ, amlodipine. misses doses. BP 174/94; RR 18; O2 87% RA. tachy, 3/6 systolic murmur at apex radiates to axilla, irregular S1 w variable intensity. dec breath sounds b/l, scattered rales, mild pitting bilateral edema BNP 5900. troponin T 39. ekg +afib wRVR. echo: LVH and nl LV systolic fxn. LA enlargement, mod MR, no effusion. TSH, HgbA1c, and lipid obtained most appropriate next steps in management of patient?

diltiazem, PO furosemide IV heparin nomogram, IV

management of afib w rapid ventricular rate if unstable (ischemia, hypotension, or severe heart failure)

cardoversion

management of afib w rapid ventricular rate if stable

rate control with ccb or bb initiate anticoagulation if symptoms < 48hrs or TEE no apical thrombus => consider cardioversion if symptoms >48hrs or no TEE or TEE no apical thrombus => anticoagulate 3+ weeks prior to cardioversion

76yo F new SOB for few weeks. dec exercise tolerance, takes more rest, inc LE swelling. pmhx HTN. meds: lisinopril, HCTZ, amlodipine. misses doses. BP 174/94; RR 18; O2 87% RA. tachy, 3/6 systolic murmur at apex radiates to axilla, irregular S1 w variable intensity. dec breath sounds b/l, scattered rales, mild pitting bilateral edema BNP 5900. troponin T 39. ekg +afib wRVR. echo: LVH and nl LV systolic fxn. LA enlargement, mod MR, no effusion. TSH, HgbA1c, and lipid obtained started on apixiban. HgbA1c 5.6; other labs wnl. continued bp issues. d/c on chlorthalidone and amlodipine. based on information currently available, what is the CHA2DS2-VASc score for the patient?

``` 5 age(2) heart failure (1) HTN (1) female (1) ```

CHA2DS2-VASc score

(C) CHF history = +1 (H) hypertension = +1 (A2) age (A2): <65 = 0; 65-74 = +1; >75 = +2 (D) diabetes = +1 (S2) stroke/TIA/thromboembolism (S2): +2 (VA) vascular disease (PAD, aortic plaque, prior MI) +1 (Sc) sex category (female) +1

CHA2DS2-VASc score vs. stroke risk

``` 0 -> 0% 1 -> 1.3% 2 -> 2.2% 3 -> 3.2% 4 -> 4.0% 5 -> 6.7% 6 -> 9.8% 7 -> 9.6% 8 -> 12.5% 9 -> 15.2% ```

31yo F ED new onset confusion. nonsensical statements, hallucinating. pmhx diabetes. uses multiple substances incl cocaine, heroin. frequent alcohol user (up to 2 pints per day). 3d camping with natural cleanse. yesterday sweaty and tremulous. exam: sweaty, tremulous, talking to wall, on tangetns, no abd pain, glucose 187. most important initial steps in workup?

liver function tests basic metabolic panel complete blood count

IV lorazepam admission to the hospital thiamine

66yo M in mid Dec. not seen since early 50s. +smoker, +alcohol. healthy diet, no exercise. +omeprazole. denies vax since last visit. what vaccines are most appropriate to give at today's visit?

influenza PPSV23 Tdap zoster

66yo M in mid Dec. not seen since early 50s. +smoker, +alcohol. healthy diet, no exercise. +omeprazole. denies vax since last visit. what screening tests?

abdominal ultrasound colonoscopy CT of thorax, low dose

66yo M in mid Dec. not seen since early 50s. +smoker, +alcohol. healthy diet, no exercise. +omeprazole. denies vax since last visit. +metabolic syndrome. what are components of metabolic syndrome according to Adult Treatment Panel III?

serum TGs >150 or drug tx for elevated TGs serum HDL <40 in men and <50 in women or drug tx for low HDL fasting plasma glucose >100 or drug tx for elevated blood glucose abd obesity >40in men, >35in women BP >130/85 or drug tx for HTN

acute diverticulitis

CT abdomen pelvis with IV and oral contrast

67yoM x2d constipation, LLQ pain. 8/10, continuous, nonradiating. no BM, but +flatus. no hx surg. no hematochezia or melena. famhx +colon cancer. -smoking. T 101.5. TTP LLQ w/o rebound. mild vol guarding. dx diverticulitis. start IVF. elev wbc, nl Cr. electrolytes stable Hgb 10. CT -> thickening sigmoid colon w/o perf or abscess. T 102.4. BP 94/62. HR 118. s/p 1L NS, antiemetics, IV morphine what are the most appropriate next steps in management?

IV ceftriaxone and metronidazole IV fluid resuscitation patient should be made nil per os (NPO)

67yoM x2d constipation, LLQ pain. 8/10, continuous, nonradiating. no BM, but +flatus. no hx surg. no hematochezia or melena. famhx +colon cancer. -smoking. T 101.5. TTP LLQ w/o rebound. mild vol guarding. dx diverticulitis. start IVF. elev wbc, nl Cr. electrolytes stable Hgb 10. CT -> thickening sigmoid colon w/o perf or abscess. T 102.4. BP 94/62. HR 118. s/p 1L NS, antiemetics, IV morphine resolves. f/u PCP in 2wks feeling at baseline. asks why he developed diverticulitis and what he can do moving forward. what further therapy, if any, should be considered as part of his follow-up care?

colonoscopy

Required: - is the patient currently taking any anticoagulation? - has the patient had a prior EGD, GI bleed, or hx PUD or varices? Correct responses: - does the patient have a known history of cirrhosis? - is the patient on any anticoagulation? - does the patient have any NSAID use? - has the patient had a previous endoscopy? - is she using antiplatelet agents such as aspirin? - does the patient have any known bleeding disorders? - does the patient have odynophagia? - previous history of H pylori?

67yo F. pmhx HTN, afib, HLD. acute hematemesis +mild confusion, abd pain x2d. started 2hrs ago. x3 episodes nonbloody, became bloody and had 4 large volume. ate salmon at a restaurant and initially thought food poisoning. +diarrhea, +cramping. +dark stools. +drink 5th/day x7yrs. -smoking. +lightheaded/dizzy T 99.1; BP 102/40. HR 113. RR 22. pale, older. jaundice, distended abd, pitting LE edema. +asterixis too encephalopathic. no doc for a few yrs. no hx endoscopy. int melena x1wk. dx last year with "liver failure." daily ibuprofen for headaches since younger. what are the most important etiologies of bleeding that need to be considered for treatment?

peptic ulcer disease | esophageal/hepatic varices

67yo F. pmhx HTN, afib, HLD. acute hematemesis +mild confusion, abd pain x2d. started 2hrs ago. x3 episodes nonbloody, became bloody and had 4 large volume. ate salmon at a restaurant and initially thought food poisoning. +diarrhea, +cramping. +dark stools. +drink 5th/day x7yrs. -smoking. +lightheaded/dizzy T 99.1; BP 102/40. HR 113. RR 22. pale, older. jaundice, distended abd, pitting LE edema. +asterixis too encephalopathic. no doc for a few yrs. no hx endoscopy. int melena x1wk. dx last year with "liver failure." daily ibuprofen for headaches since younger. RUQ u/s 5yrs ago w nodular liver. pt obtunded. T 101.8. BP 78/36. HR 122. RR 24. besides variceal bleeding, what are the complications of cirrhosis that we must consider either evaluating for now or which may impact our immediate treatment of this patient going forward?

ascites hepatic encephalopathy spontaneous bacterial peritonitis

67yo F. pmhx HTN, afib, HLD. acute hematemesis +mild confusion, abd pain x2d. started 2hrs ago. x3 episodes nonbloody, became bloody and had 4 large volume. ate salmon at a restaurant and initially thought food poisoning. +diarrhea, +cramping. +dark stools. +drink 5th/day x7yrs. -smoking. +lightheaded/dizzy T 99.1; BP 102/40. HR 113. RR 22. pale, older. jaundice, distended abd, pitting LE edema. +asterixis too encephalopathic. no doc for a few yrs. no hx endoscopy. int melena x1wk. dx last year with "liver failure." daily ibuprofen for headaches since younger. RUQ u/s 5yrs ago w nodular liver. pt obtunded. T 101.8. BP 78/36. HR 122. RR 24. Hgb 5.7. Plt 78. INR 1.4. has not filled meds in 6mo. no anticoagulant. what are the next most important steps in management?

Required: - blood transfusion - IV fluid resuscitation - IV proton pump inhibitors - IV octreotide - IV ceftriaxone (3rd gen ceph or FQ or pip/taz) - consult gastroenterology for EGD correct: - 2 large-bore peripheral IVs - IV fluid resuscitation with crystalloid - blood transfusion - complete blood count - proton pump inhibitor infusion - IV octreotide - ICU admission - IV ceftriaxone - plan for EGD - diagnostic pericentesis

systemic lupus erythematosus (SLE)

antinuclear antibody basic metabolic panel complete blood count

oral hydroxychloroquine

high diffusing capacity for carbon monoxide catastrophic pulmonary complication of lupus is diffuse alveolar hemorrhage

32yo F w rash on face, shoulders, arms x3mo. wrose when outside. occasional mouth sores and joint pain x2yrs mostly in fingers/ankles. famhx arthritis, "eczema." mom hosp B cell lymphoma and father died of MI at 47. -alcohol. -smoke. comfortable. rash is erythematous, annular, and exhibits scaling. localized to cheeks, neck, and lower arms. hypopigmentation. joints swollen with synovitis and mild erythema. small mucositis with superficial ulceration wbc 2.5. hgb 11.8. plt 98. Cr 0.5. ESR 88. started on HCQ. 3wks later +SOB, chest pain, fever. intubated. cxr b/l fluffy infiltrates. infectious w/u neg. echo w preserved EF. coarse rhonchi and rales, scattered wheezing. adm labs wbc 1.74. hgb 7.2. plt 55k. PT 12. Cr 1.67. uRBCs 60. C4 6. 3d high dose methylprednisolone and cyclophosphamide. 8th day of hosp, develops R LE pain, white toes that turn blue. vasc surg consulted and undergoes CT angio -> acute arterial occlusion of peroneal and comon femoral artery of RLE. urgent endarterectoy. susp underlying atherosclorosis what hematologic abnormality is associated with the cause of this patient's arterial clot?

increased partial thromboplastin time

systemic complications of SLE: constitutional

fever, fatigue, myalgia, weight loss

systemic complications of SLE: musculoskeletal

arthritis, often migratory, polyarticular, and symmetrical

systemic complications of SLE: skin

malar rash, oral ulcers, photosensitivity

systemic complications of SLE: cardiac

raynaud phenomenon, vasculitis, pericarditis, Libman sacks endocarditis

systemic complications of SLE: hematologic

pancytopenia, thromboembolic disease (with or without antiphospholipid syndrome)

systemic complications of SLE: neurologic

CNS lupus or lupus cerebritis

systemic complications of SLE: ophthalmologic

keratoconjunctivitis sicca (secondary to Sjogren's syndrome), but any eye structure can be inflamed or involved

systemic complications of SLE: pulmonary

diffuse alveolar hemorrhage, interstitial lung disease

systemic complications of SLE: renal

nephritis

32yo F w rash on face, shoulders, arms x3mo. wrose when outside. occasional mouth sores and joint pain x2yrs mostly in fingers/ankles. famhx arthritis, "eczema." mom hosp B cell lymphoma and father died of MI at 47. -alcohol. -smoke. comfortable. rash is erythematous, annular, and exhibits scaling. localized to cheeks, neck, and lower arms. hypopigmentation. joints swollen with synovitis and mild erythema. small mucositis with superficial ulceration wbc 2.5. hgb 11.8. plt 98. Cr 0.5. ESR 88. started on HCQ. 3wks later +SOB, chest pain, fever. intubated. cxr b/l fluffy infiltrates. infectious w/u neg. echo w preserved EF. coarse rhonchi and rales, scattered wheezing. adm labs wbc 1.74. hgb 7.2. plt 55k. PT 12. Cr 1.67. uRBCs 60. C4 6. 3d high dose methylprednisolone and cyclophosphamide. 8th day of hosp, develops R LE pain, white toes that turn blue. vasc surg consulted and undergoes CT angio -> acute arterial occlusion of peroneal and comon femoral artery of RLE. urgent endarterectoy. susp underlying atherosclorosis anti-beta-2-glycoprotein antibody IgG >180. dilute russell viper venom time 88sec (elev) given dx of antiphospholipid syndrome, which anticoagulant is most appropriate for long term treatment of this condition?

oral warfarin

exceptions to the use of direct oral anticoagulants

``` antiphospholipid syndrome mechanical heart valves atrial fibrillation due to mitral stenosis severe renal or liver disease pregnancy cancer ```

tx antiphosphlipid syndrome

warfarin or unfractionated heparin or LMWH

tx mechanical heart valves

warfarin or UFH

tx a fib d/t mitral stenosis

warfarin or UFH or LMWH

tx severe renal or liver disease

consider warfarin consider UFH LMWH c/i renal failure

tx pregnancy

LMWH or UFH

tx cancer

DOACs have been recently shown to be equivalent to LMWH, though data is new, so choose LMWH

19yo F. suprapubic pain x2d. intermittent 4/10. +dysuria. +frequency. -sex. -McBurney's. -rebound. which of the following tests would you order as part of initial workup?

urinalysis

19yo F. suprapubic pain x2d. intermittent 4/10. +dysuria. +frequency. -sex. -McBurney's. -rebound. u/a 2+ nitrite, +leuks, -RBCs. clx pending which of the following treatments is appropriate for this patient at this time?

nitrofurantoin other options: TMP/SMX, cefalexin, ciprofloxacin, fosfomycin

pyelonephritis

19yo F. suprapubic pain x2d. intermittent 4/10. +dysuria. +frequency. -sex. -McBurney's. -rebound. u/a 2+ nitrite, +leuks, -RBCs. clx pending 3x over 1yr for recurrent UTIs. pan-sens E. coli. worsening UTI sx. more fatigued. +n/v. +flank pain. T 102.3. R CVA tender. in ED: Cr 0.89. mild hypoNa, hypoCl w metabolic acidosis. elev lactate, u/a +leuks and +nitrites, 3+ blood w 32 RBCs. what other workup should be obtained?

CT abdomen and pelvis with IV contrast | - test of choice to detect infectious or mechanical complications assoc with complicated UTIs

consult to urology for urgent evaluation for stenting and stone removal IV ceftriaxone

13yo F w back pain x2wks. elite gymnast. mostly midline, may be R of center. radiating to R buttocks and back of thigh. Worse with extension. exacerbated when standing on R leg. L4/L5. which of the following conditions would be highest on your differential diagnosis?

apophysitis of the vertebral body | spondylolysis

13yo F w back pain x2wks. elite gymnast. mostly midline, may be R of center. radiating to R buttocks and back of thigh. Worse with extension. exacerbated when standing on R leg. L4/L5. which of the following would be the appropriate firstline imaging study for the suspected diagnosis?

plain radiographs of the lumbar spine

13yo F w back pain x2wks. elite gymnast. mostly midline, may be R of center. radiating to R buttocks and back of thigh. Worse with extension. exacerbated when standing on R leg. L4/L5. dx with spondylolysis, no evidence of spondylolisthesis. what treatment options should you consider?

acetaminophen physical therapy rest from gymnastics

basic metabolic panel complete blood count type and screen

55yo M in ED w lightheaded, +n/v. 3 episodes of vomiting dark maroon/blood. stool black and sticky. pmhx chronic LBP relieved w PT and heating pads. recently taking naproxen 4-5x/day. BP 92/58, HR 112. PE: pale, melena on rectal exam Hgb 6; Hct 28%; K 3.4; Cr 1.4; BUN 76; Gluc 106; sinus tach, INR 1.2 next most important steps in management?

blood transfusion start IV omeprazole consult gastroenterology for EGD

upper GI bleed labs

``` CBC BMP Type and screen LFTs troponin ```

upper GI bleed other workup

EKG chest or abdominal imaging (if concerned for perforation) CT angio if embolization if needed

upper GI bleed inpatient treatment

``` IV proton pump inhibitors (omeprazole) IV octreotide (if concerned for varices) antibiotics (if cirrhosis) blood transfusions as indicated fluid resuscitation endoscopy (if no perforation) ```

discontinue NSAIDs | start oral proton pump inhibitors

upper GI bleed outpatient treatment

oral PPI for 4-8 weeks stop all NSAIDs stop alcohol/tobacco if related treat H. pylori if positive consider repeat EGD as needed to ensure healing follow up biopsy results if concern for malignancy

73yo M for annual. breathing more heavily past few weeks, needing more rest, no longer walks d/t fatigue. gained weight. sleeps on reclincer. hx HTN (poor control d/t med adherence) nosurg. drinks 3 beers nightly. what other signs and symptoms would be considered "major criteria" when making a clinical diagnosis in this case?

distended neck veins rales waking up at night with acute shortness of breath S3

major criteria for heart failure

2+ of: - acute pulmonary edema - cardiomegaly - hepatojugular reflux - neck vein distention - paroxysmal nocturnal dyspnea or orthopnea - pulmonary rales - third heart sound (S3 gallop) - weight loss of >4.5kg in 5 days in response to treatment

minor criteria for heart failure

1 major + 2 minor: - ankle edema - dyspnea on exertion - hepatomegaly - nocturnal cough - pleural effusion - tachycardia (>120)

chest radiograph and transthoracic echocardiogram

73yo M for annual. breathing more heavily past few weeks, needing more rest, no longer walks d/t fatigue. gained weight. sleeps on reclincer. hx HTN (poor control d/t med adherence) nosurg. drinks 3 beers nightly. SOB moving from chair to exam table. c/o doing dishes and ADLs in morning. abd distention. S3 gallop, blowing holosystolic murmur with radiation to axilla. JVD, +hepatojugular reflux, +abd ascites. +b/l pitting edema to knee. EKG NSR w LVH, no ischemic changes; Echo rEF 25%. cxr normal card size with small b/l pleural effusions and vasc congestion w/o covert pulmonary edema. based on NYHA, how would you classify this patient?

class III

NYHA functional classes

I: comfortable at rest, no sx activity, no limitations II: comfortable at rest, sx with more than normal activity (mowing,vacuuming, brisk walking), slight limitations III: comfortable at rest, sx with ordinary activites (ADLs), marked limitations in ADLs IV: short of breath at rest, sx at rest, cannot do any activity without significant symptoms

73yo M for annual. breathing more heavily past few weeks, needing more rest, no longer walks d/t fatigue. gained weight. sleeps on reclincer. hx HTN (poor control d/t med adherence) nosurg. drinks 3 beers nightly. SOB moving from chair to exam table. c/o doing dishes and ADLs in morning. abd distention. S3 gallop, blowing holosystolic murmur with radiation to axilla. JVD, +hepatojugular reflux, +abd ascites. +b/l pitting edema to knee. EKG NSR w LVH, no ischemic changes; Echo rEF 25%. cxr normal card size with small b/l pleural effusions and vasc congestion w/o covert pulmonary edema. most specific diagnosis given currently available information?

heart failure with reduced ejection fraction

73yo M for annual. breathing more heavily past few weeks, needing more rest, no longer walks d/t fatigue. gained weight. sleeps on reclincer. hx HTN (poor control d/t med adherence) nosurg. drinks 3 beers nightly. SOB moving from chair to exam table. c/o doing dishes and ADLs in morning. abd distention. S3 gallop, blowing holosystolic murmur with radiation to axilla. JVD, +hepatojugular reflux, +abd ascites. +b/l pitting edema to knee. EKG NSR w LVH, no ischemic changes; Echo rEF 25%. cxr normal card size with small b/l pleural effusions and vasc congestion w/o covert pulmonary edema. undergoes cardiac cath w/ minimal CAD and markedly inc left sided pressures. +diuresis. nonischemic cardiomyopathy. referred to advanced heart failure clinic. at his first appointment, they discuss lifestyle modifications. what lifestyle modification should be recommended to this patient?

alcohol cessation moderate salt restriction regular physical activity

73yo M for annual. breathing more heavily past few weeks, needing more rest, no longer walks d/t fatigue. gained weight. sleeps on reclincer. hx HTN (poor control d/t med adherence) nosurg. drinks 3 beers nightly. SOB moving from chair to exam table. c/o doing dishes and ADLs in morning. abd distention. S3 gallop, blowing holosystolic murmur with radiation to axilla. JVD, +hepatojugular reflux, +abd ascites. +b/l pitting edema to knee. EKG NSR w LVH, no ischemic changes; Echo rEF 25%. cxr normal card size with small b/l pleural effusions and vasc congestion w/o covert pulmonary edema. undergoes cardiac cath w/ minimal CAD and markedly inc left sided pressures. +diuresis. nonischemic cardiomyopathy. referred to advanced heart failure clinic. which drugs improve mortality in heart failure with reduced ejection fraction?

lisinopril spironolactone metoprolol losartan

therapy for heart failure

ACEi or ARB beta blocker (carvedilol, metoprolol) mineralocorticoid receptor antagonist (spironolactone)

gout osteoarthritis pseudogout

fluid analysis inflammatory markers x-ray of the knee

58yo M in WV. L knee pain worsening x1wk. working on losing weight. jogs. pain worse when running, as day progresses, woken up from sleep. swelling, sore, generally unwell. pmhx HTN (amlodipine,HCTZ), CAD (stent, aspirin, metoprolol), psoriasis. pain w passive ROM throughout knee. xr: medial joint space narrowing, subchondral sclerosis, osteophytes. clear straw/yellow w no crystals. stopped running and walks instead. wears brace, ices. no pain, clicking, catching. which of the following would be the next best steps in management?

continued home exercise continued weight loss ice and compression

bipolar disorder brief psychotic disorder methamphetamine use

17yo M depression. diff conc, follwoing rule, always busy, constantly moving, disorganized. few months ago made appt for depression. now feels great, God-like, so smart, bought a motorcycle online, new sexual partners. God talks to him. labs wnl. petition for psych placement and is admitted. dx bipolar I with active mania. what treatments could be considered for the treatment of bipolar disorder?

``` aripriprazole carbamazepine lithium risperidone valproic acid quetiapine ``` NOT CBT and NOT SSRIs

17yo M depression. diff conc, follwoing rule, always busy, constantly moving, disorganized. few months ago made appt for depression. now feels great, God-like, so smart, bought a motorcycle online, new sexual partners. God talks to him. labs wnl. petition for psych placement and is admitted. dx bipolar I with active mania. started on lithium and quetiapine with goo d response. d/c from psych hospital. you remember lithium has numerous side effects and special considerations including which of the following?

``` arrhythmias cardiac malformations of fetus (in pregnant mother taking medication) CNS depression diminished renal concentrating ability hypothyroidism interaction with ibuprofen ```

52yo M health fair anemia. labs were hgb 10.2, hct 33.4, leuk 14. colonoscopy last year w 1 polyp removed labs hgb 14.4, leuk 12.1, hct 44, mcv 88, TB 1.2, TChol 210, LDL 143. no pmhx. ROS +generalized fatigue, scleral icterus, nonpalpable rash on LE. what is the name of this physical exam finding and what laboratory abnormality is it generally associated?

petechiae | assoc with thrombocytopenia

complete blood count with diferential haptoglobin liver profile including direct and indirect bilirubin lactic acid dehydrogenase (LDH)

direct antiglobulin test

52yo M health fair anemia. labs were hgb 10.2, hct 33.4, leuk 14. colonoscopy last year w 1 polyp removed labs hgb 14.4, leuk 12.1, hct 44, mcv 88, TB 1.2, TChol 210, LDL 143. no pmhx. ROS +generalized fatigue, scleral icterus, nonpalpable rash on LE. wbc 24; hgb 9.8; plt 44; DBili 0.7; IBili 4.0; Alb 2.9; LDH 1490; Hapto < 30; smear -> abs inc in fx of leuks w/o dysplasia or blasts. normochromic normocyt anemia w reduce plts. abs reticulocytosis and spherocytes. DAT +. admitted and started on steroids. flow cyt -> monoclonal pop of mature B-cells. anemia worsens. shotty firm lymph nodes in axilla, groin, and neck < 5mm. repeat labs hgb 7.8, plt 12, wbc 36, LDH 240, retic 0.25%, hapto 150. peripheral smear -> no spherocytes, dec plt what is the next step in management?

bone marrow biopsy

52yo M health fair anemia. labs were hgb 10.2, hct 33.4, leuk 14. colonoscopy last year w 1 polyp removed labs hgb 14.4, leuk 12.1, hct 44, mcv 88, TB 1.2, TChol 210, LDL 143. no pmhx. ROS +generalized fatigue, scleral icterus, nonpalpable rash on LE. wbc 24; hgb 9.8; plt 44; DBili 0.7; IBili 4.0; Alb 2.9; LDH 1490; Hapto < 30; smear -> abs inc in fx of leuks w/o dysplasia or blasts. normochromic normocyt anemia w reduce plts. abs reticulocytosis and spherocytes. DAT +. admitted and started on steroids. flow cyt -> monoclonal pop of mature B-cells. anemia worsens. shotty firm lymph nodes in axilla, groin, and neck < 5mm. repeat labs hgb 7.8, plt 12, wbc 36, LDH 240, retic 0.25%, hapto 150. peripheral smear -> no spherocytes, dec plt bone marrow -> malignant infiltration w dec erythrocyte and plt precursors. started on rituximab and chemo. looks unwell, lost 10lbs unint, night sweats, fatigue, fever, early satiety, febrile, diffuse enlarged lymph nodes, massively enlarged spleen. this presentation is most concerning for what disease process?

Richter transformation tx CLL -> sudden conversion of CLL to diffuse large B-cell lymphoma

echocardiogram | trend cardiac enzymes

42yo F 3d continuous chest pain. sharp, substernal, radiates to neck. initially thought muscle train, but persisted. pmhx HTN (amlodipine), -card exam, -lung exam. EKG diffuse ST elevation echo: normal syst fxn, LVEF 65%, small pericardial effusion. cxr nl mediastinum. dx acute pericarditis. no travel, fevers night sweats, weight loss, arthritis, or famhx autoimmune what additional testing or workup would you order at this time?

no additional testing

rare etiologies of pericarditis

neoplasia - hx, wt loss, unexpl fevers, unexpl mass TB - risk factors, endemic, fever, wt loss, nt sweats purulent - severe sepsis, tamponade, risk of bacteremia/fungemia, HIV, risk of TB, any sev lung infxn autoimmune - personal or famhx, assoc joint swelling, rash

colchicine | ibuprofen

complete blood count CT angiography of the thorax electrocardiogram troponin

``` congestive heart failure inflammatory bowel disease orthopedic surgery malignancy nephrotic syndrome ```

right bundle branch block S1Q3T3 sinus tachycardia

88yo F in LT care, SOB. +palpitations, midsternal chest pain. dx adv dementia. hosp 3 mo ago for mechanical fall w femoral neck fx surgical repair. taken off ppx enoxaparin. pmhx alzheimers, htn (amlodipine and lisinopril), diastolic heart failure (furosemide), osteoporosis (alendronate). +tachyp. neg nucl stress test when c/o int dyspnea. no hx renal dysfxn. ekg new rbbb and sinus tach, trop and BNP mildy elev. abg -> resp alk w hypoxia and elev A-a gradient. CTA -> saddle PE. BP drops to 70/40. new JVD (8cm). start fluids & pressors, but blood pressure remains low with new-onset confusion. how would you classify this patient's pulmonary embolus?

massive pulmonary embolism

88yo F in LT care, SOB. +palpitations, midsternal chest pain. dx adv dementia. hosp 3 mo ago for mechanical fall w femoral neck fx surgical repair. taken off ppx enoxaparin. pmhx alzheimers, htn (amlodipine and lisinopril), diastolic heart failure (furosemide), osteoporosis (alendronate). +tachyp. neg nucl stress test when c/o int dyspnea. no hx renal dysfxn. ekg new rbbb and sinus tach, trop and BNP mildy elev. abg -> resp alk w hypoxia and elev A-a gradient. CTA -> saddle PE. BP drops to 70/40. new JVD (8cm). start fluids & pressors, but blood pressure remains low with new-onset confusion. decision is made to proceed with tx given risk of death of PE. which of the following should be administered immediately?

tissue plasminogen activator

88yo F in LT care, SOB. +palpitations, midsternal chest pain. dx adv dementia. hosp 3 mo ago for mechanical fall w femoral neck fx surgical repair. taken off ppx enoxaparin. pmhx alzheimers, htn (amlodipine and lisinopril), diastolic heart failure (furosemide), osteoporosis (alendronate). +tachyp. neg nucl stress test when c/o int dyspnea. no hx renal dysfxn. ekg new rbbb and sinus tach, trop and BNP mildy elev. abg -> resp alk w hypoxia and elev A-a gradient. CTA -> saddle PE. BP drops to 70/40. new JVD (8cm). start fluids & pressors, but blood pressure remains low with new-onset confusion. decision is made to proceed with tx given risk of death of PE. responds to therapy. O2 req decrease, becomes asymp. pt asks whether she needs to be on med for clots when she leaves. what is the most appropriate response?

yes you should be on anticoagulation therapy for at least 3 months, but possibly longer. at a future time we can reassess the risks and benefits of anticoagulation.

depression screening detailed medication review perform an objective cognitive assessment

71yo M routine exam. since death of wife, unable to drive, got lost, can't remember like he used to. moved to assistive living after water/electric shut off due to nonpayment. refuses group activities. used to enjoy painting. says hates painting. hx OA, stage IV CKD, CAD with quad bypass, father died of PD, mother of stroke. fine tremor with writing. walks slowly. married for 40yrs before wife died of breast cancer.. forgetfulness, mild constipation, fatigue, and generalized malaise but otherwise ROS-. what laboratory workup should be obtained in this patient?

thyroid stimulating hormone B12 complete blood count

71yo M routine exam. since death of wife, unable to drive, got lost, can't remember like he used to. moved to assistive living after water/electric shut off due to nonpayment. refuses group activities. used to enjoy painting. says hates painting. hx OA, stage IV CKD, CAD with quad bypass, father died of PD, mother of stroke. fine tremor with writing. walks slowly. married for 40yrs before wife died of breast cancer.. forgetfulness, mild constipation, fatigue, and generalized malaise but otherwise ROS-. MoCA score 24. which of the following is the most likely diagnosis?

pseudodementia

71yo M routine exam. since death of wife, unable to drive, got lost, can't remember like he used to. moved to assistive living after water/electric shut off due to nonpayment. refuses group activities. used to enjoy painting. says hates painting. hx OA, stage IV CKD, CAD with quad bypass, father died of PD, mother of stroke. fine tremor with writing. walks slowly. married for 40yrs before wife died of breast cancer.. forgetfulness, mild constipation, fatigue, and generalized malaise but otherwise ROS-. MoCA score 24. started on sertraline. lab unremarkable. mri wnl. phq9 improved. still some diff with memory. forgets names, to take pills unless pillbox, 2/3 3 word recall. what is the most likely diagnosis?

mild cognitive impairment | no impaired daily functioning

liver function tests | right upper quadrant ultrasound

42yo F c/o int epigastric and RUQ pain after eating, occasionally at night. within 1-2hrs after meal, dull. sometimes radiates to R shoulder/back. takes H2 blocker for GERD. no pmhx. BP 146/92. no melena/hematochezia. no tenderness, -Murphy's. labs wnl. u/s distended stone-filled gallbladder w wall thick 2mm, no pericholecystic fluid, normal CBD. has to wait 2mo for surg. occ chest tight worse w spicy foods. had some while watching tv. ok exercise. no smoke. which of the following tests would be indicated?

EKG

acute viral hepatitis ascending cholangitis choledocholithiasis

blood cultures chest x-ray lactic acid liver enzymes

MRI total spine with contrast

IV cefepime | IV vancomycin

44yoM ED x2d gen wk, abd pain, diff urinating. diff initiating stream. no hx prostate. chronic back pain after constr accident, worsening over 2wks (ibuprofen). nightly alcohol, +tobacco, +heroin. +full suprapubic w pain. R/L patellar reflex 0, R biceps 1+. upgoing toes. mild arm weakness, dc grip strength, L foot clonus post-void residual 580cc. insert foley. temp 101.1, hr 104. started on abx w vanc + cefepime. MRI +abscess, osteomyelitis/discitis what is the most important next step in management?

consult neurosurgery for decompressive surgery and abscess drainage

44yoM ED x2d gen wk, abd pain, diff urinating. diff initiating stream. no hx prostate. chronic back pain after constr accident, worsening over 2wks (ibuprofen). nightly alcohol, +tobacco, +heroin. +full suprapubic w pain. R/L patellar reflex 0, R biceps 1+. upgoing toes. mild arm weakness, dc grip strength, L foot clonus post-void residual 580cc. insert foley. temp 101.1, hr 104. started on abx w vanc + cefepime. MRI +abscess, osteomyelitis/discitis surg decompression. blood clx +ORSA. what are the next best steps in management?

obtain an echocardiogram | repeat blood cultures

44yoM ED x2d gen wk, abd pain, diff urinating. diff initiating stream. no hx prostate. chronic back pain after constr accident, worsening over 2wks (ibuprofen). nightly alcohol, +tobacco, +heroin. +full suprapubic w pain. R/L patellar reflex 0, R biceps 1+. upgoing toes. mild arm weakness, dc grip strength, L foot clonus post-void residual 580cc. insert foley. temp 101.1, hr 104. started on abx w vanc + cefepime. MRI +abscess, osteomyelitis/discitis surg decompression. blood clx +ORSA. TEE +23mm vegetation on tricuspid valve w severe regurg. after 7d, blood clx still pos. dev progr resp failure req 4L o2. cxr b/l pulm infiltrates w cavitary lesions. what is the most important step in management?

surgical valve replacement

5yo M c/o ear pain and fatigue. less active and more fussy at daycare. tugging ear. uncertain if utd on vax. mom and dad divorced. T 100.7. without yet performing an eye, ears, nose, and throat examination, what conditions are highest on your differential diagnosis?

acute otitis media otitis externa upper respiratory infection

5yo M c/o ear pain and fatigue. less active and more fussy at daycare. tugging ear. uncertain if utd on vax. mom and dad divorced. T 100.7. red bulging TM w no motility. conservative tx. mom unlikely to f/u if sx do not improve. prescribe an abx. no allergies. what antibiotic is most appropriate?

amoxicillin

temporal bone

28yoM. x5d runny nose, cong, sinus pressure +cough. no fever. bro similar sx a month ago. every year gets it, prescribes 2x abx in spring and fall, sometimes 3x. suggests zpack. no pmhx. married. given this patient's initial complaints and current level of information, which of the following should be considered on the differential diagnosis?

``` acute rhinocinusitis bacterial rhinosinusitis complicated rhinosinusitis uncomplicated rhinosinusitis viral rhinosinusitis ```

acetaminophen or ibuprofen | fluticasone nasal spray

28yoM. x5d runny nose, cong, sinus pressure +cough. no fever. bro similar sx a month ago. every year gets it, prescribes 2x abx in spring and fall, sometimes 3x. suggests zpack. no pmhx. married. mild frontal HA, tender sinuses b/l. purulent d/c, edematous nasal turbinates. initially improves over the past 2d with worsening facial pain,, purulent d/c, fever. maxillary tooth pain. what is the appropriate treatment for this patient's condition?

oral amoxicillin/clavulanic acid

28yoM. x5d runny nose, cong, sinus pressure +cough. no fever. bro similar sx a month ago. every year gets it, prescribes 2x abx in spring and fall, sometimes 3x. suggests zpack. no pmhx. married. mild frontal HA, tender sinuses b/l. purulent d/c, edematous nasal turbinates. initially improves over the past 2d with worsening facial pain,, purulent d/c, fever. maxillary tooth pain. within 24hrs, worse facial pain and R eye swelling. hurts to look to sides, dec vision, diplopia. +fever. advise to go to ED. +proptosis, reduced EOM CN VI palsy. what are the next best steps?

CT head and face with contrast IV ceftriaxone OR IV ampicillin/sulbactam IV vancomycin ophthalmology consultation IV metronidazole OR IV ampicillin/sulbactam

25yo M MVA. restrained driver. unresponsive on scene, supraglottic airway. withdraws to pain, no open eyes. no limb deformities. diminished breath sounds b/l what is the most appropriate next step?

establish definitive airway

25yo M MVA. restrained driver. unresponsive on scene, supraglottic airway. withdraws to pain, no open eyes. no limb deformities. pulses 2+. est IV access. 2L crystalloids given w blood products. what imaging studies should be obtained as adjuncts to the primary survey?

AP chest radiograph | FAST exam

25yo M MVA. restrained driver. unresponsive on scene, supraglottic airway. withdraws to pain, no open eyes. no limb deformities. pulses 2+. est IV access. 2L crystalloids given w blood products. FAST +fluid in pelvis. AP chest wnl. AP pelvis +open book fx. 3u pRBCs. CT head/cervical spine once stabilized. what are the immediate next steps in management of patient's pelvic fx?

apply pelvic binder consult interventional radiology laparotomy

cervical motion tenderness Murphy sign rebound tenderness with palpation

``` basic metabolic panel complete blood count lactic acid pregnancy test urinalysis ```

18yo F. gen abd pain, woke from sleep. +vomiting. worsening. ROS +anorexia. nl 2d ago. menses in 2wks. sexually active with new partner. on OCPs, but occasionally misses doses. T 100.4 TTP worse near umbilicus & RLQ. no CVA. TTP in R adnexa, physiologic vaginal discharge. labs wbc 16, 14% bands; plt 550k, bicarb 19, beta-hCG neg, lactate 3.8 based on above, what imaging would you request?

CT of abdomen and pelvis with IV contrast

good peripheral IV access IV opioid pain medication resuscitation with IV fluid boluses followed by maintenance

41yoM w/o chest pain. non-radiating, substernal, burning, worse at night. wake from sleep. which of the following additional questions in the patient's history would most assist you in obtaining an accurate diagnosis?

alleviating and aggravating factors previous cardiac history smoking history timing

electrocardiogram

41yoM w/o chest pain. non-radiating, substernal, burning, worse at night. wake from sleep. always at night, between 30min -4hrs. +nausea. 2x/wk. worse w coffee and spicy. eats 1hr or less before bed. divorced, not with activity. restarted smoking. father died of MI at 53. TTP epigastrium. ekg NSR w/o ST changes. discuss tx options and lifestyle mods. interested in lifestyle alone. which of the following would you recommend as most appropriate lifestyle modifications for this patient?

avoid caffeine and spicy foods elevate the head of the bed weight loss

41yoM w/o chest pain. non-radiating, substernal, burning, worse at night. wake from sleep. always at night, between 30min -4hrs. +nausea. 2x/wk. worse w coffee and spicy. eats 1hr or less before bed. divorced, not with activity. restarted smoking. father died of MI at 53. TTP epigastrium. ekg NSR w/o ST changes. discuss tx options and lifestyle mods. interested in lifestyle alone. returns w mild improvement. ready to add medication. which of the following are the most appropriate recommendations for this patient?

oral omeprazole

41yoM w/o chest pain. non-radiating, substernal, burning, worse at night. wake from sleep. always at night, between 30min -4hrs. +nausea. 2x/wk. worse w coffee and spicy. eats 1hr or less before bed. divorced, not with activity. restarted smoking. father died of MI at 53. TTP epigastrium. ekg NSR w/o ST changes. discuss tx options and lifestyle mods. interested in lifestyle alone. returns w mild improvement. ready to add medication. inquire about screening for vascular condition often affecting males with hx of smoking, but would not generally be screened until 65. which specific medical condition are you thinking of?

abdominal aortic aneurysm.

41yoM w/o chest pain. non-radiating, substernal, burning, worse at night. wake from sleep. always at night, between 30min -4hrs. +nausea. 2x/wk. worse w coffee and spicy. eats 1hr or less before bed. divorced, not with activity. restarted smoking. father died of MI at 53. TTP epigastrium. ekg NSR w/o ST changes. discuss tx options and lifestyle mods. interested in lifestyle alone. returns w mild improvement. ready to add medication. inquire about screening for vascular condition often affecting males with hx of smoking, but would not generally be screened until 65. which imaging modality is recommended in males 65-75 in order to screen for this condition?

ultrasound

chest x-ray basic metabolic panel complete blood count brain natriuretic peptide

76yoM ED progr SOB. x4mo DOE, abd fullness after meals. used to be active. +orthopnea, decr exercise tolerance. hx DM (metformin, insulin glargine), aspirin. +tobacco, quit 9yrs ago. SOB to get to bedside commode. +systolic murmur at apex. split S2, decr w inspiration. +JVD. abd fullness, +hepatojugular reflux, +peripheral edema. placed on 3L O2. Na 129; Cr 1.8; BNP 9840. Bili 1.6. cxr b/l infiltrates with central venous congestion and mod b/l pleural effusions w enlarged heart border. what are the next most appropriate steps in management?

echocardiogram | IV furosemide

76yoM ED progr SOB. x4mo DOE, abd fullness after meals. used to be active. +orthopnea, decr exercise tolerance. hx DM (metformin, insulin glargine), aspirin. +tobacco, quit 9yrs ago. SOB to get to bedside commode. +systolic murmur at apex. split S2, decr w inspiration. +JVD. abd fullness, +hepatojugular reflux, +peripheral edema. placed on 3L O2. Na 129; Cr 1.8; BNP 9840. Bili 1.6. cxr b/l infiltrates with central venous congestion and mod b/l pleural effusions w enlarged heart border. removes 8L fluid x3d. EF 25%. cardiac cath, severe triple vessel dz w >90% stenosis of LAD, RCA, and L circumflex, no stents. what additional medications should be added for this patient before discharge?

``` po carvedilol (or metoprolol) po lisinopril (any ACEi or ARB) po atorvastatin (or rosuvastatin) ```

76yoM ED progr SOB. x4mo DOE, abd fullness after meals. used to be active. +orthopnea, decr exercise tolerance. hx DM (metformin, insulin glargine), aspirin. +tobacco, quit 9yrs ago. SOB to get to bedside commode. +systolic murmur at apex. split S2, decr w inspiration. +JVD. abd fullness, +hepatojugular reflux, +peripheral edema. placed on 3L O2. Na 129; Cr 1.8; BNP 9840. Bili 1.6. cxr b/l infiltrates with central venous congestion and mod b/l pleural effusions w enlarged heart border. removes 8L fluid x3d. EF 25%. cardiac cath, severe triple vessel dz w >90% stenosis of LAD, RCA, and L circumflex, no stents. f/u with cards. still mild dyspnea with strenuous exertion. no side effects from meds. which of the following would you recommend for this patient?

coronary artery bypass grafting (CABG)

32yo F. severe L pelvic pain xhrs +n/v, +diaphoresis. home pregnancy + 2wks ago. LMP 6wks ago. +chlamydia recently. trace blood in vaginal vault +adnexal tenderness. LLQ tender which tests would you like to order?

pelvic ultrasound with transvaginal imaging if needed | quantitative HCG

32yo F. severe L pelvic pain xhrs +n/v, +diaphoresis. home pregnancy + 2wks ago. LMP 6wks ago. +chlamydia recently. trace blood in vaginal vault +adnexal tenderness. LLQ tender TVUS -> no intrauterine gestation, L adnexal mass. beta-hCG 2000. +diaphoretic, pale, worsening pain. 74/36. 137/min, 28/min. PIV placed, IVF. blood type A+. FAST -> pelvic free fluid. serum lactate 5.1. what are the next most important steps in management?

consult OB/GYN for emergent surgery | blood transfusion

32yo F. severe L pelvic pain xhrs +n/v, +diaphoresis. home pregnancy + 2wks ago. LMP 6wks ago. +chlamydia recently. trace blood in vaginal vault +adnexal tenderness. LLQ tender TVUS -> no intrauterine gestation, L adnexal mass. beta-hCG 2000. +diaphoretic, pale, worsening pain. 74/36. 137/min, 28/min. PIV placed, IVF. blood type A+. FAST -> pelvic free fluid. serum lactate 5.1. which of the following factors have the highest increased risk for ectopic pregnancy?

history of tubal surgery history of pelvic inflammatory disease previous ectopic pregnancy

33yoM. new lump in L groin. after working out, gets larger sometimes. admits to heavy lifting. sometimes feels like it pops. reducible lump in L groin no erythema. what is the most likely diagnosis of this patient

left inguinal hernia

33yoM. new lump in L groin. after working out, gets larger sometimes. admits to heavy lifting. sometimes feels like it pops. reducible lump in L groin no erythema. dx with reducible inguinal hernia. 2wks later intermittent sharp pain at site x3d. relieves by changing position. no pain at site, now cant push back in. new redness on skin surface. no n/v. not sig tender, but erythematous. abd soft nontender. serum lactate wnl. which of the following are the most appropriate initial steps in management?

attempt manual reduction

basic metabolic panel complete blood count with differential HIV testing rapid plasma reagin

acute HIV infection

HIV RNA levels OR HIV viral load | HIV antigen/antibody testing OR HIV antibody testing

immediately

33yoM new onset, nonpruritic full body rash assoc w low grade fever, joint pains, sore throat x5d. +watery diarrhea w/o blood xfew weeks, lost 5kg. rash 6d ago on chest little red dots -> neck/back,arms. no IVDA. +maculopapular rash, worse over upper thorax/shoulders, some extension into palms. no target lesions, some mucocutaneous ulceration, between 5-10mm through mouth/pharynx. denies IVDA, +marijuana and MDMA, polygamy w/o barriers. UTD on vax. wbc 1.35, plt 93k, heterophile+ HIV RNA 130,000 copies/mL, CD4 640. resolution of acute sx. lost to follow-up. 6yrs later worse exert dysp, fever, cough, weight loss x5wks. tachyp. white plaques on tongue and roof of mouth that scrape easily. cxr diffuse b/l interstitial infiltrates. in addition to general treatment for sepsis and suspected respiratory infection, which of the following additional tests is indicateD?

arterial blood gas LDH 1-3-beta-D-glucan (pneumocystis)

33yoM new onset, nonpruritic full body rash assoc w low grade fever, joint pains, sore throat x5d. +watery diarrhea w/o blood xfew weeks, lost 5kg. rash 6d ago on chest little red dots -> neck/back,arms. no IVDA. +maculopapular rash, worse over upper thorax/shoulders, some extension into palms. no target lesions, some mucocutaneous ulceration, between 5-10mm through mouth/pharynx. denies IVDA, +marijuana and MDMA, polygamy w/o barriers. UTD on vax. wbc 1.35, plt 93k, heterophile+ HIV RNA 130,000 copies/mL, CD4 640. resolution of acute sx. lost to follow-up. 6yrs later worse exert dysp, fever, cough, weight loss x5wks. tachyp. white plaques on tongue and roof of mouth that scrape easily. cxr diffuse b/l interstitial infiltrates. improves with abx. cd4 at dc is 38. for which of the following organisms or infections should this patient receive prophylaxis?

mycobacterium avium complex (MAC) pneumocystis pneumonia toxoplasma gondii

electrocardiogram

66yoF abd pain. intermittent x2d. epigastric. +n, +diaphoresis. pmhx hypothyroid, htn,, gerd, dm. stroke. meds low dose aspirin, levothyroxine, lisinopril, metformin, glyburide. 176/86. uncomfortable, shifting. RRR. soft minimall tender in epigastrium. no guarding. ekg 2mm ST depr in inferior leads. pain improves with bp control and nitroglycerin drip. trops elevated. uncomplicated cardiac catheterization and drug-eluting stent placement in RCA which medications would you start/continue?

aspirin atorvastatin clopidogrel metoprolol

disequilibrium non-specific dizziness presyncope vertigo

71yoF hx CAD, afib, htn, copd c/o dizziness x2d. feels unsteady like she's going to fall over. unsure if she feels like she will lose consciousness. happens all the time. bumping into walls at home, holding onto objects. meds: aspirin, atorvastatin, metoprolol, amlodipine, lisinopril, rivaroxaban, and albuterol. bed, chair, walking. unsteady. room is tilting. sometimes feels like bein gpushed over. worse with turning head. +n/v. continuous. you want to ask a few more questions to help delineate the cause of this patient's vertigo, what are other important details to ask regarding her HPI?

``` hearing loss any recent infections any headaches tinnitus any focal neurological symptoms ```

71yoF hx CAD, afib, htn, copd c/o dizziness x2d. feels unsteady like she's going to fall over. unsure if she feels like she will lose consciousness. happens all the time. bumping into walls at home, holding onto objects. meds: aspirin, atorvastatin, metoprolol, amlodipine, lisinopril, rivaroxaban, and albuterol. bed, chair, walking. unsteady. room is tilting. sometimes feels like bein gpushed over. worse with turning head. +n/v. continuous. no FND, 168/74. what other physical exam maneuver or maneuvers should be performed to help determine the cause of this patient's vertigo?

Dix-Hallpike Maneuver HEENT examination including visualizing the ear drums with dedicated ocular testing Head-Impulse-Nystagmus-Test-of-Skew (HINTS)

71yoF hx CAD, afib, htn, copd c/o dizziness x2d. feels unsteady like she's going to fall over. unsure if she feels like she will lose consciousness. happens all the time. bumping into walls at home, holding onto objects. meds: aspirin, atorvastatin, metoprolol, amlodipine, lisinopril, rivaroxaban, and albuterol. bed, chair, walking. unsteady. room is tilting. sometimes feels like bein gpushed over. worse with turning head. +n/v. continuous. no FND, 168/74. Dix-Hallpike: immediate nystagmus w no delay, L beating, torsional, lasting 2mins. after sitting up, nystagmus is L beating on nystagmus testing. head impulse test wnl. test of skew and R eye takes 1 second to realign after uncovering. remainder of FND wnl. what are the next best steps in management?

MRI brain hospital admission CT head without contrast

have you ever had a mammogram? do you have any family history of cancer? do you have a history of cancer?

63yo F c/o R hip pain for 3wks which has been worsening. dull, radiates to the groin to the knee. worse w weight bearing. bothers at night and sitting in chair. lost 10lbs x6mo. former smoker. TTP femur below greater trochanter. xray shows multiple lytic lesions of proximal femur and pelvis. mother died of breast cancer at 76. colonoscopy @61 wnl. mammogram 6y ago wnl, no follow up. UTD cervical screen. what are the body areas/systems that you would like to focus on during your physical exam to help you determine etiology of suspected underlying malignancy?

``` breast exam pulmonary exam thyroid exam abdominal exam hip exam neurological exam cardiac exam lymphatic exam skin exam ``` at least 6 of the above systems

63yo F c/o R hip pain for 3wks which has been worsening. dull, radiates to the groin to the knee. worse w weight bearing. bothers at night and sitting in chair. lost 10lbs x6mo. former smoker. TTP femur below greater trochanter. xray shows multiple lytic lesions of proximal femur and pelvis. mother died of breast cancer at 76. colonoscopy @61 wnl. mammogram 6y ago wnl, no follow up. UTD cervical screen. no lymphadenopathy. no thyroid/breast pathology. what further imaging or labs would be most important initial steps to help determine source of patient's malignancy?

complete metabolic panel CT chest, abdomen, pelvis with positron emission tomography (PET) if available serum and urine immunoelectrophoresis (SPEP, UPEP)

26yoF c/o HA x48hrs. similar headaches for 2yrs, 1-2x/month. sometimes 7/10, throbbing, right side. n/v. photophobia. +smoke +obese. mom hx migraines, dad hx colon cancer. no FND. what are the next best steps in the workup of this patient?

none complete blood count basic metabolic panel

26yoF c/o HA x48hrs. similar headaches for 2yrs, 1-2x/month. sometimes 7/10, throbbing, right side. n/v. photophobia. +smoke +obese. mom hx migraines, dad hx colon cancer. no FND. which of the following medications is appropriate to help manage her headaches at home?

acetaminophen orally ibuprofen orally sumatriptan orally

26yoF c/o HA x48hrs. similar headaches for 2yrs, 1-2x/month. sometimes 7/10, throbbing, right side. n/v. photophobia. +smoke +obese. mom hx migraines, dad hx colon cancer. no FND. does well w sumatriptan/naproxen x2y. getting worse and more frequent. MRI neg. labs wnl. what is the next best step in the management of this patient?

``` start oral propranolol start subcutaneous erenumab cranial OMM start oral amitriptyline lifestyle modification start oral verapamil start oral venlafaxine start oral valproate start oral topiramate ``` *start a preventative tx

bolus of IV normal saline creatine kinase CT scan of head without contrast once stable CT cervical spine without contrast once stable EKG

84yoF found on bathroom floor with AMS and inability to stand. mom lives alone, but daughter checks on her every other day. pmhx htn (furosemide), afib (metoprolol + apixaban), "prediabetes." 1step commands, symmetric pupils, confused. shortened L leg and bruising of L hip w palpable hematoma. no FND. in cervical collar. gluc 87. feels foggy. stuck on L side for a day. no head/neck pain. mild dysuria for a few days. dec po intake, mild nausea, generalized fatigue. Na 128, K 5.4, CK 17k. u/a hyaline casts + elev wbc. what are the most appropriate next steps in management of this patient?

admission to the hospital ceftriaxone IV continued fluid administration xray of the L hip

84yoF found on bathroom floor with AMS and inability to stand. mom lives alone, but daughter checks on her every other day. pmhx htn (furosemide), afib (metoprolol + apixaban), "prediabetes." 1step commands, symmetric pupils, confused. shortened L leg and bruising of L hip w palpable hematoma. no FND. in cervical collar. gluc 87. feels foggy. stuck on L side for a day. no head/neck pain. mild dysuria for a few days. dec po intake, mild nausea, generalized fatigue. Na 128, K 5.4, CK 17k. u/a hyaline casts + elev wbc. femoral neck fx. defer restarting apixaban. f/u 4wks later in clinic. what are the next best steps in the management of this patient?

bisphosphonate administration | vitamin D level

3yoM +SOB, +runny nose for a few days. vomited. diapers more wet, urinating into clothes. slightly premature, no sick contacts. dry mucus membranes. mild abd tenderness, tachypnea. which tests would you like to order as part of initial workup?

basic metabolic panel complete blood count urinalysis

3yoM +SOB, +runny nose for a few days. vomited. diapers more wet, urinating into clothes. slightly premature, no sick contacts. dry mucus membranes. mild abd tenderness, tachypnea. gluc 450. Na 128, bicarb 8, Cr 1.4. AG 28. u/a +gluc, +ketones what are the next best steps in management?

admission to the hospital under pediatrics service intravenous fluid bolus intravenous insulin

21yoM rash. pruritic on elbows/forearms began a few weeks ago. 2nd time in last year. no sick contacts, no pmhx. T97.6. what tests, if any, will you order for this patient at his time?

complete blood count direct immunofluorescence microscopy enzyme-linked immunosorbent assay for IgA tissue transglutaminase antibodies

21yoM rash. pruritic on elbows/forearms began a few weeks ago. 2nd time in last year. no sick contacts, no pmhx. T97.6. IF microscopy -> granular IgA deposits at the dermal papillae. ELISA for IgA TTA +. what additional diagnostic testing, if any, will you order at this time?

esophagogastroduodenoscopy | small bowel biopsy

21yoM rash. pruritic on elbows/forearms began a few weeks ago. 2nd time in last year. no sick contacts, no pmhx. T97.6. IF microscopy -> granular IgA deposits at the dermal papillae. ELISA for IgA TTA +. EGD -> scalloped duodenal folds. biopsy revealed absent villi and presence of intraepithelial lymphocytes. how will you manage this patient at this time?

gluten-free diet | dapsone

12yoF wcc. last seen 2y ago. missed 11yo wcc. what screening evaluations, if any, will you perform at this time?

screening for depression | screening for tobacco, alcohol, and drug use (CRAFFT or HEADSS screening)

12yoF wcc. last seen 2y ago. missed 11yo wcc. tobacco, alcohol, drug neg. usually happy. wears seatbelt. what immunizations, if any, will you order at this time?

meningococcal vaccine | human papillomavirus vaccine

amoxicillin treatment or amoxicillin course for 10d | ibuprofen or acetaminophen for pain control

8mo M irritability x2d. not sleeping well, crying every time she tries to settle for a nap. pulling L ear. T102.5. bulging L TM opaque and erythematous. R opaque & mildly erythematous. no perfs. completes amox. wcc 1mo later persisent left middle ear effusion. 6mo later fever, irrit, bulging L TM. 5th visit since initial. c/o language development. f/u 2wks later after amox/clav +mild conductive hearing loss what actions will you take for this patient at this time?

refer to otolaryngologist for tympanostomy tubes

8mo M irritability x2d. not sleeping well, crying every time she tries to settle for a nap. pulling L ear. T102.5. bulging L TM opaque and erythematous. R opaque & mildly erythematous. no perfs. completes amox. wcc 1mo later persisent left middle ear effusion. 6mo later fever, irrit, bulging L TM. 5th visit since initial. c/o language development. f/u 2wks later after amox/clav +mild conductive hearing loss referred to ENT for tubes. 3mo later foul-smelling drainage from L ear. afebrile. purulent. what actions would you take at this time?

topical antibiotics with ofloxacin ear drops or ciprofloxacin-dexamethasone ear drops

36yoF in ED diff breathing. SOB x24hr, mild chest pain w deep inspiration or coughing, no fever. +diaphoretic. +fine bibasilar rales. what actions should be taken for this patient at this time?

D-dimer

CT pulmonary angiography

36yoF in ED diff breathing. SOB x24hr, mild chest pain w deep inspiration or coughing, no fever. +diaphoretic. +fine bibasilar rales. ABG pH 7.45, pO2 90, pCO2 30. cxr: elev diaphragm. EKG -> ; D-dimer 1.4 CT pulm angio -> filling defects in R interlobar pulmonary arteries consistent with pulmonary emboli. what action, if any, should be taken at this time?

treatment with enoxaparin

electrocardiogram | exercise electrocardiogram

``` beta blocker nitroglycerin as needed for pain aspirin smoking cessation statin ```

57yoM c/o intermittent chest pain. several weeks of tightness during daily evening walk. stops to rest and resolves within 5mins. when severe, radiates to L shoulder and jaw. pmhx untx HLD and smoking. trop 0.005. exercise ekg 2mm depressions of ST in V4, V5, V6 during treadmill. which correlate with pain. BP stable, EF 55%. sx resolve after tx. 3yrs later, in ED for acute chest pain. at rest and exertion, relieved by sublingual nitroglycerin. squeezing, radiating x1hr. +diaphoretic, distressed. ekg no changes. the most appropriate next steps in management are:

``` aspirin atenolol nitroglycerin percutaneous coronary intervention heparin ```

discontinue piperacillin-tazobactam | discontinue ibuprofen/NSAIDs

renal biopsy

81yoF hosp for CAP x12d. initially tx ceftriaxone and azithromycin. deter over 3d, switched to vanc and pip/taz. pmhx t2dm and htn. insulin, acetaminophen/ibuprofen. held anti-htn. preparing for d/c. temp 101 for first time in 6d. no change in exam. u/a microscopic hematuria and wbcs incl eosinophils. renal u/s: echogenic, normal sized kidneys and no obstructions. all nsaids and abx d/c. fever resolves but Cr remains elevated. renal biopsy: interstitial infiltrate w lymphocytes and eosinophils and localized sites of interstitial fibrosis. histo -> acute interstitial nephritis. 6wks prednisone given. est GFR 25. which actions, if any, will you take for this patient at this time?

discuss patient's goals and preferences for renal replacement options education of patient and family regarding renal replacement therapy

36yo G2P2 w dysuria. burning x5d, urgency, inc frequency. new sex partner. no other pmhx. daily ocp. abd exam -> mild tenderness to palpation above the pubis. no CVA tenderness. what tests, if any, will you order for this patient at this time?

pregnancy testing urine dipstick for urinalysis chlamydia trachomatis screen neisseria gonorrhea screen

36yo G2P2 w dysuria. burning x5d, urgency, inc frequency. new sex partner. no other pmhx. daily ocp. abd exam -> mild tenderness to palpation above the pubis. no CVA tenderness. u/a nitrites and leuks positive, trace prot. full resolution. 3wks later, return for recurrent sx x6d. dysuria, frequency, and urgency. T101.4. abd exam mod TTP in suprapubic area what additional testing, if any, will you order for this patient at this time?

urine culture with susceptibility urinalysis renal ultrasonography repeat pregnancy test

36yo G2P2 w dysuria. burning x5d, urgency, inc frequency. new sex partner. no other pmhx. daily ocp. abd exam -> mild tenderness to palpation above the pubis. no CVA tenderness. u/a nitrites and leuks positive, trace prot. full resolution. 3wks later, return for recurrent sx x6d. dysuria, frequency, and urgency. T101.4. abd exam mod TTP in suprapubic area. u/a nitrites, wbcs, prot, rbcs, beta-hCG pos. gram neg bacilli. renal u/s no anatomic abn. after antibiotics x3d, returns with n/v, fevers, chills, 102.4, stable. inc suprapubic tednerness and R CVA tenderness how will you manage this patient?

hospital admission IV antibiotics (ceftriaxone or cefepime) prophylactic oral antibiotics to prevent recurrence - cephalexin or nitrofurantoin

49yoF c/o lump in breast. famhx pos sister w breast cancer at 52. mammo 4mo ago. firm, immobile mass about 2-3mm in upper outer at 2oclock. no dimpling. what tests if any will you order for this patient at this time

mammography needle biopsy of the mass ultrasonography of the breast

49yoF c/o lump in breast. famhx pos sister w breast cancer at 52. mammo 4mo ago. firm, immobile mass about 2-3mm in upper outer at 2oclock. no dimpling. mammo -> discrete density in upper outer of L breast with spiculated borders measuring 3mm. needle bx -> invasive ductal carcinoma what additional testing if any will you order for this patient at this time?

``` HER2 overexpression ER expression PR expression complete blood count alanine aminotransferase aspartate aminotransferase alkaline phosphatase sentinel lymph node biopsy ```

49yoF c/o lump in breast. famhx pos sister w breast cancer at 52. mammo 4mo ago. firm, immobile mass about 2-3mm in upper outer at 2oclock. no dimpling. mammo -> discrete density in upper outer of L breast with spiculated borders measuring 3mm. needle bx -> invasive ductal carcinoma. ALT and AST elev. AlkPhos elev. HER2, ER, PR positive. sentinel lymph node -> nests and cords of cells with occasional glandular formation what additional testing, if any, will you order for this patient at this time?

computed tomography scan of the abdomen | bone scan

basic metabolic panel complete blood count hemoccult stool evaluation thyroid stimulating hormone

``` peripheral blood smear reticulocyte count serum ferritin level serum iron level total iron binding capacity ```

72yoM fatigue worsening x3mo. no pmhx. avid bicyclist, but fatigue impacting exercise tolerance. remote smoking >20yrs ago. sleeps well. no snore. HR 111. new systolic ejection murmur, +pallor. Hgb 9, MCV 76, TSH 3.5. hemoccult stool pending. retic 0.2. ferritin 9, iron 32, TIBC 490. peripheral smear -> microcytic hypochromic rbcs with central pallor. hemoccult stool positive. what additional testing, if any, will you order at this time?

colonoscopy | endoscopy

72yoM fatigue worsening x3mo. no pmhx. avid bicyclist, but fatigue impacting exercise tolerance. remote smoking >20yrs ago. sleeps well. no snore. HR 111. new systolic ejection murmur, +pallor. Hgb 9, MCV 76, TSH 3.5. hemoccult stool pending. retic 0.2. ferritin 9, iron 32, TIBC 490. peripheral smear -> microcytic hypochromic rbcs with central pallor. hemoccult stool positive. colonoscopy -> 2cm ulcerating mass in R colon. bx -> colonic adenocarcinoma. some risk factors associated with this disease are:

``` alcohol use insulin resistance obesity red meat consumption tobacco use ```

72yoM fatigue worsening x3mo. no pmhx. avid bicyclist, but fatigue impacting exercise tolerance. remote smoking >20yrs ago. sleeps well. no snore. HR 111. new systolic ejection murmur, +pallor. Hgb 9, MCV 76, TSH 3.5. hemoccult stool pending. retic 0.2. ferritin 9, iron 32, TIBC 490. peripheral smear -> microcytic hypochromic rbcs with central pallor. hemoccult stool positive. colonoscopy -> 2cm ulcerating mass in R colon. bx -> colonic adenocarcinoma. most appropriate next steps in management are:

surgical resection abdominal CT scan serum CEA levels

counsel patient on lifestyle modifications (diet and exercise) oral diclofenac refer patient to dietician for weight loss counseling

intraarticular glucocorticoid injection of the left knee | referral to physical therapy

63yoM routine. c/o chronic L knee pain. was active in youth. deep, throbbing medial joint pain worse after active days. avoiding exercise and "feels old and worthless." knee stiff in AM x15mins. interferes with sleep 3-4x/wk. partial relief ibuprofen. no hx PUD. PE -> crepitus of L knee w passive movement, dec F ROM, mild knee swelling, ESR 12. x-ray -> joint space narrowing + osteophytes. encourage exercise. loses 20lbs, takes oral diclofenac. wakes up 2x/wk with nocturnal pain. daughter's wedding in 3wks. 4yrs later returns, healthy otherwise. s/p 3x steroid injections with resolution for 4wks. obtained hydrocodone to help him sleep. increasingly despondent, inability to help with chores what is the best option for this patient at this time?

referral to orthopedics for total knee arthroplasty

63yoM routine. c/o chronic L knee pain. was active in youth. deep, throbbing medial joint pain worse after active days. avoiding exercise and "feels old and worthless." knee stiff in AM x15mins. interferes with sleep 3-4x/wk. partial relief ibuprofen. no hx PUD. PE -> crepitus of L knee w passive movement, dec F ROM, mild knee swelling, ESR 12. x-ray -> joint space narrowing + osteophytes. encourage exercise. loses 20lbs, takes oral diclofenac. wakes up 2x/wk with nocturnal pain. daughter's wedding in 3wks. 4yrs later returns, healthy otherwise. s/p 3x steroid injections with resolution for 4wks. obtained hydrocodone to help him sleep. increasingly despondent, inability to help with chores referred for TKA. preop eval clear, has surgery. what are the essential postoperative orders for this patient?

knee movement exercise (physical therapy) pain management thromboembolism prophylaxis

screening for depression

34yoF urgent care 7th visit in last year. ongoing pain of abd, arms, legs, back. daily persists most of day. previous testing negative. referred to PCP but didn't keep appt. 4 jobs in 3 years. ROS +daily fatigue, dif concentrating, 30lb wt gain in 18mo. diff falling asleep. PE wnl. TSH 2mo ago 1.3. feels hopeless most days and no interest in doing any activities. few friends or family support. tearful. what focused questions if any will you ask her at this time?

thoughts of suicide or suicidal ideation; thoughts of death or killing herself are acceptable alternatives

34yoF urgent care 7th visit in last year. ongoing pain of abd, arms, legs, back. daily persists most of day. previous testing negative. referred to PCP but didn't keep appt. 4 jobs in 3 years. ROS +daily fatigue, dif concentrating, 30lb wt gain in 18mo. diff falling asleep. PE wnl. TSH 2mo ago 1.3. feels hopeless most days and no interest in doing any activities. few friends or family support. tearful. frequent thoughts of harming herself, possibility of own death daily. bought a gun. takes gun out and looks at it and considers whether she's brave enough how will you manage this patient at this time?

referral for immediate inpatient psychiatric treatment

35yoF routine. feels well, no complaints. no pmhx. social drinking, unmarried, sexually active. recent began work as social work, specializes in adoption from other countries. famhx sig MI at 60, breast cancer at 63. last exam 3yrs ago. pap neg at that time. last tetanus was 3yrs ago, unsure childhood. what tests, if any, are recommended for this patient at this time?

``` CAGE questionnaire chlamydia screening gonorrhea screening human immunodeficiency virus screening screening for intimate partner violence syphilis screening ```

35yoF routine. feels well, no complaints. no pmhx. social drinking, unmarried, sexually active. recent began work as social work, specializes in adoption from other countries. famhx sig MI at 60, breast cancer at 63. last exam 3yrs ago. pap neg at that time. last tetanus was 3yrs ago, unsure childhood. immunizations to which, if any, of the following are recommended for this patient?

hepatitis B | influenza

35yoF routine. feels well, no complaints. no pmhx. social drinking, unmarried, sexually active. recent began work as social work, specializes in adoption from other countries. famhx sig MI at 60, breast cancer at 63. last exam 3yrs ago. pap neg at that time. last tetanus was 3yrs ago, unsure childhood. labs no evidence of STI, no intimate partner violence, no CAGE. what is the appropriate interval at which the patient should return to the clinic for a full screening, papanicolau smear, and HPV evaluation?

2 years

chest radiograph | spirometry

continued short acting beta agonists systemic glucocorticoids avoidance of triggers asthma education

23yoF with diff breathing. dyspnea on exertion for last few weeks. last couple days, breathing worsening and now associated with chest wall pain and dry cough, especially at night. no pmhx. exam -> b/l expiratory wheezing with poor air movement PFT -> reduced FEV1 and FEV1/FVC, reverses with bronchodilators. cxr neg. cbc elev eosinophils.. .after 2x albuterol, pt sx return in 4hrs. after 1wk therapy w systemic glucocorticoids and int shortacting beta agonists, pt rerturns much improved. scheduled 3mo for repeat assessment. dyspnea and cough 3x/wk, takes albuterol with relief. four nights in past month waking from sleep the most appropriate management at this time is

continue short acting beta agonist (albuterol) add a daily inhaled glucocorticoid (fluticasone) OR add an inhaled glucocorticoid plus a short acting beta agonist concomitantly as needed OR low dose ICS-formoterol as needed

``` pregnancy test TSH prolactin level FSH level coagulation studies androgen levels hemoglobin A1c transvaginal ultrasound ferritin ```

38yoF hx prediabetes, inc menstrual bleeding q2-6wks, sometiems heavy. prev regular. weight gain. dec general energy w worsening fatigue. more sedentary. easy bruising. adult acne. thick terminal hair growth. previous pap wnl. returns 4wks later. mild anemia hgb 9.3, hgbA1c 8.9, ferritin 10. gluc 232, nl Cr. freq waxing, issues w body hair most of life, worse since gaining weight. less sex drive. no children planned. on OCPs, iron, metformin. returns 6mo later, menstration normalized, sig body hair. what are the next best steps in management of this patient?

``` start oral antiandrogens recheck iron stores recheck A1c check renal function and electrolytes complete blood count ```

deep vein thrombosis

58yoF f/u w orthopedist 2wks after L TKA. pain/swelling initially improved, but x5d pain in L calf. +tenderness, erytheam, swelling of L calf, +pitting edema. neurovasc intact. HCTZ, levothyroxine, conj estrogen pill. venous duplex +DVT L ant tibial v, popliteal v, and superficial femoral v. no hx, no anticoagulants. d/c on rivaroxaban. unable to fill med d/t insurance, presents w chest discomfort, SOB, small hemoptysis. best test to confirm her diagnosis?

thoracic CT angiography OR CT pulmonary angiography

pap smear | pulmonary function testing

26yoF new pt. pmhx asthma and eczema. pshx nasal polyp excision and wisdom teeth extraction. no meds except rescue inhaler, using more frequently last few months. nonsmoker. grad student. sexually active in long term monogomous relationship. copper IUD 4yrs ago. last physical exam was >3yrs ago. order spirometry and perform a Pap smear. notified sample was adequate for eval and some atypical squamous cells of undetermined significants (ASC-US). reflex HPV was not ordered. notify pt. se asks what is the most appropriate next step. you recommend which of the following?

repeat Pap smear in 1 year