Exam 1 Flashcards
34 yo waitress ptc w/productive cough started 14 weeks ago, feels tired and has chest discomfort from coughing. Had similar cough last year for 4 months, no night sweats or wt loss. Hx of smoking half pack of cigs for 16 yrs, vitals unremarkable, chest symmetric, no use of accessory Mm’s. PPD test = Neg., no imaging ordered.
Most likely Dx?
Also consider?
Case 40, Q1:
Chronic Bronchitis: Chronic prod. cough for 3 month in 2 consecutive yrs. Smokers at greater risk.
Consider:
Emphysema, bronchiectasis, small cell lung cancer
34 yo waitress ptc w/productive cough started 14 weeks ago, feels tired and has chest discomfort from coughing. Had similar cough last year for 4 months, no night sweats or wt loss. Hx of smoking half pack of cigs for 16 yrs, vitals unremarkable, chest symmetric, no use of accessory Mm’s. PPD test = Neg., no imaging ordered.
Which test is most indicated to order 1st?
- Plain Chest xray
- Spirometry
- Alpha 1 antitrypsin levels
- Sputum culture
Case 40, Q2:
Spirometry
34 yo waitress ptc w/productive cough started 14 weeks ago, feels tired and has chest discomfort from coughing. Had similar cough last year for 4 months, no night sweats or wt loss. Hx of smoking half pack of cigs for 16 yrs, vitals unremarkable, chest symmetric, no use of accessory Mm’s. PPD test = Neg., no imaging ordered.
Which drug is most indicated?
- Mometasone
- Amoxicillin
- Tamsulosin
- Tiotropium
Case 40, Q3:
Tiotropium - Long acting anticholinergic bronchodilator & antisecretory agent used in maintenance tx of bronchospasm in COPD.
- Mometasone - used in seasonal allergies
- Amoxicillin - Antibiotic used to tx upper respiratory infections
- Tamsulosin - Alpha 1 blocker used to relax smooth Mm’s in tx for BPH, bladder outlet obstruction & kidney stones (Ureteral Calculi).
34 yo waitress ptc w/productive cough started 14 weeks ago, feels tired and has chest discomfort from coughing. Had similar cough last year for 4 months, no night sweats or wt loss. Hx of smoking half pack of cigs for 16 yrs, vitals unremarkable, chest symmetric, no use of accessory Mm’s. PPD test = Neg., no imaging ordered.
Rx’d Boswellia serrata, ephedra Sinica, Glazzhiraza glabra, inula helenium to tx (1:1:1:1) 1 tbs tid but is fearing nauseated & having HA’s, what do you do?
- Continue dosage & f/u in 1 wk
- Reduce to 1 tbs BID
- Increase to 1 tbs QID
- Remake and use (5:1:5:5) 1 tbs TID
Case 40, Q4:
- Remake and use (5:1:5:5) 1 tbs TID
Reduce Ephedra Sinica but continue to used for its Bronchodilating, antitussive and antisecretory actions.
34 yo waitress ptc w/productive cough started 14 weeks ago, feels tired and has chest discomfort from coughing. Had similar cough last year for 4 months, no night sweats or wt loss. Hx of smoking half pack of cigs for 16 yrs, vitals unremarkable, chest symmetric, no use of accessory Mm’s. PPD test = Neg., no imaging ordered.
Which of the following supplements is indicated?
- 500mg Quercetin daily
- 1000 IU Vit. D daily
- 500mg N-Acetylcysteine BID
- 300mg Bromelain tid away from meals
Case 40, Q5
- 500mg N-Acetylcysteine BID
31 yo F smoker ptc w/vaginal dryness and mild pain w/intercourse. Pap reveals High grade squamous intraepithelial lesion (HSIL) & is HPV (+) for high risk strain.
What is the next most appropriate step given her Pap smear results?
Repeat Pap in 3 yrs
Colposcopy w/biopsy
Repeat PAP in 6 months
Repeat PAP in 12 months
Case 50 - Q1
Colposcopy w/biopsy
31 yo F smoker ptc w/vaginal dryness and mild pain w/intercourse. Pap reveals High grade squamous intraepithelial lesion (HSIL) & is HPV (+) for high risk strain.
Most common tx for condition?
Loop electrosurgical excision procedure
HPV Vaccination
Hysterectomy
Acyclovir
Case 50 - Q2
Loop electrosurgical excision procedure
HPV Vaccination - only for 13-26yo, not indicated for cervical dysplasia
Hysterectomy - Indicated for some cervical carcinoma
Acyclovir - Antiviral not indicated for HPV
31 yo F smoker ptc w/vaginal dryness and mild pain w/intercourse. Pap reveals High grade squamous intraepithelial lesion (HSIL) & is HPV (+) for high risk strain.
Which supplement is indicated?
- Beta- carotene
- Folic acid
- Vitamin D
- Genistein
Case 50 - Q3
2. Folic acid (B9) - folate def is linked to cervical dysplasia & has been shown to improve or normalize cytologic smears in pts w/cervical dysplasia.
It is CONTRAINDICATED for her as she is a smoker, may increase chances on dev. lung CA
- Beta-Carotine: Carotiniods & retinoids improve the integrity & fxn of epithelial tissue, are antioxidants, and improve immune system fxn.
- Vitamin D: USED FOR INFLAMMATORY & Immune conditions.
- Genistein: Phytoestrogenic used in menopause and endometriosis not used in Cervical dysplasia.
31 yo F smoker ptc w/vaginal dryness and mild pain w/intercourse. Pap reveals High grade squamous intraepithelial lesion (HSIL) & is HPV (+) for high risk strain.
You give her Astralagus membranaceus, Mahonia Aqualifolium, Ganoderma Lucidum (1:1:1) 1 tsp TID, but is now pregnant, what should she do with this formula?
- Continue it
- Discontinue immediately
- Discontinue at 3rd trimester
- Discontinue immediately but continue after 2nd trimester
Case 50 - Q4
- Discontinue immediately
Mahonia contains Burberine which crosses placenta & inhibits bilirubin metabolism in newborns which may cause bilirubin encephalopathy.
Astralagus is safe in preg.
Ganoderma may need more research but may be safe.
31 yo F smoker ptc w/vaginal dryness and mild pain w/intercourse. Pap reveals High grade squamous intraepithelial lesion (HSIL) & is HPV (+) for high risk strain.
She is now pregnant and having morning sickness, nauseous w/smell of food, irritable and craving pickles. Which Homeopathic remedy is indicated?
Sepia
Nox Vomica
Pulsatilla
Arsenicum
Case 50 - Q5
Sepia- Used to treat morning sickness - craving acid foods, nauseated and irritable
- Nox Vomica - used to tx nausea -same indication but want Spicy foods
- Pulsitilla- tx nausea - are emotional but want FATTY foods
- Arsenicum - used for food poisoning vomitting
60 yo M ptc w/complaints of freq. infections & reports increased susceptible to cold & flu’s over the past few months. Experiencing bladder discomfort and frequency of urination. Recently dx’d w/T2diabetes, refuses meds & is treating through diet & exercise. Labs pending, which lab would be most indicated to evaluate Glucose control?
- CMP
- Oral Glucose
- HA1C
- All of the above
Case 34 - Q1
- HA1C - for glycemic control
- CMP: Fasting glucose, Kidney fxn, liver damage, electrolyte imbalance
- NOT commonly performed in known diabetic pts
- Additional labs: Lipid panel, fasting insulin levels, cystitis-C, Urinary micro-albumin levels
60 yo M ptc w/complaints of freq. infections & reports increased susceptible to cold & flu’s over the past few months. Experiencing bladder discomfort and frequency of urination. Recently dx’d w/T2diabetes, refuses meds & is treating through diet & exercise. What are possible sequelae of poorly managed diabetes w/hyperglycemia?
CKD
CVD - stoke, MI
Limb amputation
all of the above
Case 34 - Q2
all of the above
60 yo M ptc w/complaints of freq. infections & reports increased susceptible to cold & flu’s over the past few months. Experiencing bladder discomfort and frequency of urination. Recently dx’d w/T2diabetes, refuses meds & is treating through diet & exercise.
Which herbal supplements would help him to tx diabetes?
- Vaccinium spp
- Momordica Charantia
- Berberus Vulgaris
- All of the above
Case 34 - Q3
- All of the above
- Vaccinium spp - potent antioxidant, microvascular protection
- Momordica Charantia - hypoglycemic & hypolipidimic agents often used to tx diabetes
- Berberus Vulgaris - hypoglycemic agent
60 yo M ptc w/complaints of freq. infections & reports increased susceptible to cold & flu’s over the past few months. Experiencing bladder discomfort and frequency of urination. Recently dx’d w/T2diabetes, refuses meds & is treating through diet & exercise.
Which pharmaceutical would be best indicated?
- Erythrocyacin
- Metformin
- Januvia
- Tetracycline
Case 34 - Q4
- Metformin-a biguanide that decreasing inhibiting gluconeogenesis in liver increasing insulin sensitivity in peripheral tissues. May also cause mod. reduction in appetite and body wt.
- Erythrocyacin
- Januvia
- Tetracycline
60 yo M ptc w/complaints of freq. infections & reports increased susceptible to cold & flu’s over the past few months. Experiencing bladder discomfort and frequency of urination. Recently dx’d w/T2diabetes, refuses meds & is treating through diet & exercise.
Which supplement is most appropriate when taking metformin?
Multivitmin & mineral
cholecalciferol
Chromium Picolinate
Methylcobalamin
Case 34 - Q5
Methylcobalamin (B12) - Metfomin may cause B12 deficiency which may worsen neuropathy.
42 yo F ppc w/diff. breathing, dull & increasing chest pain when pushed on ( w/palpation) w/o referral pain. Last week, she was on antibiotics for a Salmonella infection which has now resolved & has no more diarrhea but the next day she felt pressure on her chest & had difficulty breathing. PMHX & vitals unremarkable, Labs show elevated Sed rate of 40mm/hr (0-29 norm) & C-reactive protein of 8.6mg/L (<3 mg/L).
Any pt who experiences a new sx of difficulty breathing should be:
Referred to pulmonologist
Referred to Cardiologist
Referred to ER
Instructed on proper breathing
Case 10, Q1/5
Referred to ER
42 yo F ppc w/diff. breathing, dull & increasing chest pain when pushed on ( w/palpation) w/o referral pain. Last week, she was on antibiotics for a Salmonella infection which has now resolved & has no more diarrhea but the next day she felt pressure on her chest & had difficulty breathing. PMHX & vitals unremarkable, Labs show elevated Sed rate of 40mm/hr (0-29 norm) & C-reactive protein of 8.6mg/L (<3 mg/L).
While at ER an EKG was performed resulting in diffused PR depression on ante lateral leads w/o ischemia. Her clinical presentation suggests;
Amyotrophic lateral sclerosis
Acute pericarditis
Q fever
Oropharyngeal Pericarditis
Case 10, Q2/5
Acute pericarditis
42 yo F ppc w/diff. breathing, dull & increasing chest pain when pushed on ( w/palpation) w/o referral pain. Last week, she was on antibiotics for a Salmonella infection which has now resolved & has no more diarrhea but the next day she felt pressure on her chest & had difficulty breathing. PMHX & vitals unremarkable, Labs show elevated Sed rate of 40mm/hr (0-29 norm) & C-reactive protein of 8.6mg/L (<3 mg/L).While at ER an EKG was performed resulting in diffused PR depression on ante lateral leads w/o ischemia. Her clinical presentation suggests Acute pericarditis.
You send her out for additional testing to r/o neoplastic processing, w/o hx of CVD, what do think the causative agent is?
St. Johns wort
Salmonella infection
Anbiotic use
FXH of HTN
Case 10, Q3/5
Salmonella infection
42 yo F ppc w/diff. breathing, dull & increasing chest pain when pushed on ( w/palpation) w/o referral pain. Last week, she was on antibiotics for a Salmonella infection which has now resolved & has no more diarrhea but the next day she felt pressure on her chest & had difficulty breathing. PMHX & vitals unremarkable, Labs show elevated Sed rate of 40mm/hr (0-29 norm) & C-reactive protein of 8.6mg/L (<3 mg/L).While at ER an EKG was performed resulting in diffused PR depression on ante lateral leads w/o ischemia. Her clinical presentation suggests Acute pericarditis.
Her condition is self-limiting & will resolve over time, typical tx approach is:
Anti-inflammatories
Rest & exercise
Anti-microbial agents
Antihypertensives
Case 10, Q4/5
Anti-inflammatories
42 yo F ppc w/diff. breathing, dull & increasing chest pain when pushed on ( w/palpation) w/o referral pain. Last week, she was on antibiotics for a Salmonella infection which has now resolved & has no more diarrhea but the next day she felt pressure on her chest & had difficulty breathing. PMHX & vitals unremarkable, Labs show elevated Sed rate of 40mm/hr (0-29 norm) & C-reactive protein of 8.6mg/L (<3 mg/L).While at ER an EKG was performed resulting in diffused PR depression on ante lateral leads w/o ischemia. Her clinical presentation suggests Acute pericarditis.
Giver her condition a conservative approach is warranted, so you suggest the following:
Simple diet, Vit. C & D
Simple diet, Mg & Calcium
Simple diet, Boswellia serrata & Angelica archangelica
Simple diet, Boswellia serrata & Curcuma longa
Case 10, Q5/5
Simple diet, Boswellia serrata & Curcuma longa
40 lbs 5 yo asthmatic F ptc w/a wound in her rt arm from a dog bite which occurred 3 hrs ago. Grandma explains that she complains her arm is very painful & throbbing. Takes salbutamol q4hrs prn, PMhx & FHX unremarkable.
Allergies: Cat dander, Eggs, peanuts, Sulfa drugs, Pasteraceae plant family
Vitals: Temp. 99.6F, Pulse 114bpm, resp 26/min
PE: 4 deep Rt lateral puncture wound, minimal bleeding, distal pulses equal b/l, Hrt/Lungs unremarkable.
What is the most appropriate next step?
- Apply topical bacitracin, neomycin, polymyxin B ointment, cover the area w/clean guaze & allow it to heal as a 2nd intention.
- Apply lidocaine, epinephrine, tetracaine gel. Clean the wound with iodine solution & irrigate w/saline. cover the area w/clean guaze & allow it to heal as a 2nd intention.
- Apply liposomal lidocaine, suture w/4-0 nylon in vertical mattress stitch to repair wound.
- Apply lidocaine, epinephrine, tetracaine gel, suture w/6-0 vycril in simple interrupted stitch to repair wound.
Case 43 1/5
- Apply lidocaine, epinephrine, tetracaine gel. Clean the wound with iodine solution & irrigate w/saline. cover the area w/clean guaze & allow it to heal as a 2nd intention.
* salbutamol - short-acting, selective beta2-adrenergic receptor agonist used in the treatment of asthma and COPD.
40 lbs 5 yo asthmatic F ptc w/a wound in her rt arm from a dog bite which occurred 3 hrs ago. Grandma explains that she complains her arm is very painful & throbbing. Takes salbutamol q4hrs prn, PMhx & FHX unremarkable.
Allergies: Cat dander, Eggs, peanuts, Sulfa drugs, Pasteraceae plant family
Vitals: Temp. 99.6F, Pulse 114bpm, resp 26/min
PE: 4 deep Rt lateral puncture wound, minimal bleeding, distal pulses equal b/l, Hrt/Lungs unremarkable.
Which pharmaceutical is appropriate?
Amoxicillin-clavulanate
Doxycycline
Trimethoprim-Sulfamethoxazole
Ciprofloxacine
Case 43 2/5
Amoxicillin-clavulanate - 1st line for prophylactic a/b therapy in animal bites.
- **Trimethoprim-Sulfamethoxazole - also 1st line for prophylactic a/b therapy in animal bites but is a sulfa drug.
- **Ciprofloxacine (fluroquinolones) - should be avoided in kids d/t irreversible arthropathies & Cartilage destruction.
40 lbs 5 yo asthmatic F ptc w/a wound in her rt arm from a dog bite which occurred 3 hrs ago. Grandma explains that she complains her arm is very painful & throbbing. Takes salbutamol q4hrs prn, PMhx & FHX unremarkable.
Allergies: Cat dander, Eggs, peanuts, Sulfa drugs, Pasteraceae plant family
Vitals: Temp. 99.6F, Pulse 114bpm, resp 26/min
PE: 4 deep Rt lateral puncture wound, minimal bleeding, distal pulses equal b/l, Hrt/Lungs unremarkable.
Which intervention is most appropriate?
- DTap vaccine
- Rabbies immune globulin
- Rabbies vaccine
- Call child protective services
Case 43 3/5
- DTap vaccine - puncture wounds & animal bites are more at risk for tetanus infx so kids so get DTaP & adults TDaP.
- Rabbies immune globulin & Rabbies vaccine should also be considered but low risk d/t canine vaccinations in the USA.
- Animal control should be called as it is mandatory dog bite reporting when animal’s teeth break skin. Dog can be quarantined & observed for 10 days.
40 lbs 5 yo asthmatic F ptc w/a wound in her rt arm from a dog bite which occurred 3 hrs ago. Grandma explains that she complains her arm is very painful & throbbing. Takes salbutamol q4hrs prn, PMhx & FHX unremarkable.
Allergies: Cat dander, Eggs, peanuts, Sulfa drugs, Pasteraceae plant family
Vitals: Temp. 99.6F, Pulse 114bpm, resp 26/min
PE: 4 deep Rt lateral puncture wound, minimal bleeding, distal pulses equal b/l, Hrt/Lungs unremarkable.
You decide to RX Arnica Montana, Symphytum Off, Calendula off & Capsella bursa-partoris. Which is true?
- Indicated & would be safe
- Indicated & would NOT be safe
- NOT Indicated & would be safe
- NOT Indicated & would NOT be safe
Case 43 4/5
- NOT Indicated & would NOT be safe
- Both Calendula & Arnica are in the Pasteraceae plant family.
- Symphytum Off is avoided w/infections as it may close wound too early & trap infection
- Capsella bursa-partoris - indicated for hemorrhages not for this case
40 lbs 5 yo asthmatic F ptc w/a wound in her rt arm from a dog bite which occurred 3 hrs ago. Grandma explains that she complains her arm is very painful & throbbing. Takes salbutamol q4hrs prn, PMhx & FHX unremarkable.
Allergies: Cat dander, Eggs, peanuts, Sulfa drugs, Pasteraceae plant family
Vitals: Temp. 99.6F, Pulse 114bpm, resp 26/min
PE: 4 deep Rt lateral puncture wound, minimal bleeding, distal pulses equal b/l, Hrt/Lungs unremarkable.
Child is clingy to GM, pupil are slightly dilated, flushed faced, chilly hands & whispers she’d like lemonade to GM on the way home. Which homeopathic remedy is best fit?
Apis
Aconite
Belladonna
Bryonia
Case 43 Q5/5
Belladonna - acute remedy for throbbing pain worse w/motion, fright, flushed face w/cold extremities and craving lemonade.
27 yo white M ptc w/abd pain worse on LRQ, daily watery diarrhea, up to 6 BM’s/day in the last 5 Mo w/sig blasting & discomfort. Mucus stools w/ occ. blood & unintentional 10 lbs wt loss in last 3 months & low grade fever at night.
PMHX: Multiple Rx of antibiotics d/t Chr sinus congestion, hernia repair surgery & bronchitis.
Allergies: Erythromycin, clyndamicin & penicillin cause diarrhea & vertigo.
Fmhx: MI & lung cancer
PE: Hyperactive bowel sounds w/ttp all 4 quads, 2 Superficial shallow anal fissures,
LABS: Elevated hsCRP & ESR
Imaging: “Cobblestoning” & multiple linear ulcerations
What is the most like dx is & def. dx is made how?
- UC, Biopsy
- UC, stool test
- Crohn’s dz, Bx
- Crohn’s dz, stool test
Case 2 Q1/5
- Crohn’s dz, Bx - Colonoscopy shows Aphthous, linear or stellate ulcers: Strictures, “Cobblestoning”, “Skip lesions” (wound or inflammation that is clearly patchy, typical form of intestinal damage in Crohn’s disease),
Clinically, Crohn’s disease tends to present more frequently with abdominal pain & perianal dz, whereas ulcerative colitis is more often characterized by GI bleeding.
Cobblestoning mucosa & aphthous or linear ulcers characterize the endoscopic appearance of Crohn’s disease.
Ulcerative colitis presents w/diffuse continuous involvement of the mucosa.
Radiographic studies of pts w/Crohn’s dz characteristically show fistulae, asymmetry, and ileal involvement. In contrast, radiographic studies of ts w/ulcerative colitis show continuous disease without fistulizing or ileal disease.
Pathologically, Crohn’s disease features mucosal discontinuity, transmural involvement, and granulomas, whereas ulcerative colitis does not. Crypt abscesses and granulomas are present only in Crohn’s disease.
27 yo white M ptc w/abd pain worse on LRQ, daily watery diarrhea, up to 6 BM’s/day in the last 5 Mo w/sig blasting & discomfort. Mucus stools w/ occ. blood & unintentional 10 lbs wt loss in last 3 months & low grade fever at night.
PMHX: Multiple Rx of antibiotics d/t Chr sinus congestion, hernia repair surgery & bronchitis.
Allergies: Erythromycin, clyndamicin & penicillin cause diarrhea & vertigo.
Fmhx: MI & lung cancer
PE: Hyperactive bowel sounds w/ttp all 4 quads, 2 Superficial shallow anal fissures,
LABS: Elevated hsCRP & ESR
Imaging: “Cobblestoning” & multiple linear ulcerations
______ is used in mild/Mod UC & Crohn’s dz w/ ileitis & colitis but contraindicated w/pts with allergies to _____ & _____?
- Sulfasalazine, sulfa drugs & salicylate
- Sulfasalazine, penicillin, acetaminophen
- Celecoxib, sulfa drugs & salicylate
- Celecoxib, penicillin, acetaminophen
Case 2 Q2/5
- Sulfasalazine, sulfa drugs & salicylate
***Requires Folic acid (B9) supplementation
27 yo white M ptc w/abd pain worse on LRQ, daily watery diarrhea, up to 6 BM’s/day in the last 5 Mo w/sig blasting & discomfort. Mucus stools w/ occ. blood & unintentional 10 lbs wt loss in last 3 months & low grade fever at night.
PMHX: Multiple Rx of antibiotics d/t Chr sinus congestion, hernia repair surgery & bronchitis.
Allergies: Erythromycin, clyndamicin & penicillin cause diarrhea & vertigo.
Fmhx: MI & lung cancer
PE: Hyperactive bowel sounds w/ttp all 4 quads, 2 Superficial shallow anal fissures,
LABS: Elevated hsCRP & ESR
Imaging: “Cobblestoning” & multiple linear ulcerations
Based on his hx, which supplement would be indicated?
- Quercitin, potent antibacterial
- Quercitin, potent anti-inflammatory
- Althea off, potent antibacterial
- Althea off, potent anti-inflammatory
Case 2 Q3/5
- Quercitin, potent anti-inflammatory - (down regs.
27 yo white M ptc w/abd pain worse on LRQ, daily watery diarrhea, up to 6 BM’s/day in the last 5 Mo w/sig blasting & discomfort. Mucus stools w/ occ. blood & unintentional 10 lbs wt loss in last 3 months & low grade fever at night.
PMHX: Multiple Rx of antibiotics d/t Chr sinus congestion, hernia repair surgery & bronchitis.
Allergies: Erythromycin, clyndamicin & penicillin cause diarrhea & vertigo.
Fmhx: MI & lung cancer
PE: Hyperactive bowel sounds w/ttp all 4 quads, 2 Superficial shallow anal fissures,
LABS: Elevated hsCRP & ESR
Imaging: “Cobblestoning” & multiple linear ulcerations
He also says he feels full after a few bites & then hungry right after. Increased flatulence, worse w/tight clothes & at night, better w/window open, nervous in front of crowds but is a teacher. Which homeopathic remedy is best?
- Sulphur
- Lycopodium
- Arsenicum Album
- Chamomile
Case 2 Q4/5
- Lycopodium - common for GI complaints (Bloating, flatulence & day satiety). Worse w/tight clothes, aggravation 4-8pm, anticipatory anxiety. (Craves sweets adverse to cold beverage, milk, beans, cabbage, oysters) - better in open air.
- Suphurs: Diarrhea worse in the mornings, craves sweet but overindulges in food & alcohol,
- Arsenicum Album - GI remedy, anxious & controlling worse 12-2am, very chilly & worse if exposed to cold.
- Chamomile - Diarrhea remedy, extreme irritability after 9am & green stools.
27 yo white M ptc w/abd pain worse on LRQ, daily watery diarrhea, up to 6 BM’s/day in the last 5 Mo w/sig blasting & discomfort. Mucus stools w/ occ. blood & unintentional 10 lbs wt loss in last 3 months & low grade fever at night.
PMHX: Multiple Rx of antibiotics d/t Chr sinus congestion, hernia repair surgery & bronchitis.
Allergies: Erythromycin, clyndamicin & penicillin cause diarrhea & vertigo.
Fmhx: MI & lung cancer
PE: Hyperactive bowel sounds w/ttp all 4 quads, 2 Superficial shallow anal fissures,
LABS: Elevated hsCRP & ESR
Imaging: “Cobblestoning” & multiple linear ulcerations
Sulfasalazine which is used in mild/Mod UC & Crohn’s dz w/ ileitis & colitis but it impairs the absorption of ____ and what would be dose indicated?
- B12, 8ooomcg
- B12, 800mcg
- Folic acid, 8000mcg
4 Folic acid, 800mcg
Case 2 Q5/5
- Folic acid, 800mcg - ASA component of Sulfasalazine impairs absorption of Folic acid transport decreasing absorption. Deficiency may cause extra intestinal complications such as Hyperhomocysteinemia (risk factor for DVT). 800mcg is common dosage.
53 yo F ptc w/weakness, fatigue and depression. Dev. Abd pain over the last few weeks w/nausea & few episodes of vomiting. Had intense abd & back a week ago and urinated multiple blood clots, went to ER & was dx’d with kidney stones. She complaints of more aches & pains in her joints recently.
PMXH: Major depressive d/o 5 MO ago.
MEDS: Calcium, Vit. D, MultiVIT., Fluoxitine 20mg qd
Vitals: BP 146/88, pulse 96, resp. 18
PE: Diffuse ttp w/o mass, rigidity & guarding
Labs: CMP - High glucose 120 (60-100), Low Phorphorus, HIGH Calcium, LOW GFR 43 (<60), high creatine
What further lab work is needed?
- AM Cortisol
- TSH
- ParaThyroid Hormone
- Adrenocorticotropic Hormone
Case 15, Q1/5
- ParaThyroid Hormone
53 yo F ptc w/weakness, fatigue and depression. Dev. Abd pain over the last few weeks w/nausea & few episodes of vomiting. Had intense abd & back a week ago and urinated multiple blood clots, went to ER & was dx’d with kidney stones. She complaints of more aches & pains in her joints recently.
PMXH: Major depressive d/o 5 MO ago.
MEDS: Calcium, Vit. D, MultiVIT., Fluoxitine 20mg qd
Vitals: BP 146/88, pulse 96, resp. 18
PE: Diffuse ttp w/o mass, rigidity & guarding
Labs: CMP - High glucose 120 (60-100), Low Phorphorus, HIGH Calcium, LOW GFR 43 (<60), high creatine
What is most likely DX?
- Hypoparathyroidism
- Hyperparathyroidism
- Adrenal Insufficiency
- Carcinoid S/d
Case 15, Q2/5
- Hyperparathyroidism
53 yo F ptc w/weakness, fatigue and depression. Dev. Abd pain over the last few weeks w/nausea & few episodes of vomiting. Had intense abd & back a week ago and urinated multiple blood clots, went to ER & was dx’d with kidney stones. She complaints of more aches & pains in her joints recently.
PMXH: Major depressive d/o 5 MO ago.
MEDS: Calcium, Vit. D, MultiVIT., Fluoxitine 20mg qd
Vitals: BP 146/88, pulse 96, resp. 18
PE: Diffuse ttp w/o mass, rigidity & guarding
Labs: CMP - High glucose 120 (60-100), Low Phorphorus, HIGH Calcium, LOW GFR 43 (<60), high creatine
She is dx’d w/Hyperparathyroidism but what condition all needs to r/o?
Parathryroid Carcinoma
Small cell lung Ca
Osteoporosis
Type 2 DM
Case 15, Q3/5
Parathryroid Carcinoma
53 yo F ptc w/weakness, fatigue and depression. Dev. Abd pain over the last few weeks w/nausea & few episodes of vomiting. Had intense abd & back a week ago and urinated multiple blood clots, went to ER & was dx’d with kidney stones. She complaints of more aches & pains in her joints recently.
PMXH: Major depressive d/o 5 MO ago.
MEDS: Calcium, Vit. D, MultiVIT., Fluoxitine 20mg qd
Vitals: BP 146/88, pulse 96, resp. 18
PE: Diffuse ttp w/o mass, rigidity & guarding
Labs: CMP - High glucose 120 (60-100), Low Phorphorus, HIGH Calcium, LOW GFR 43 (<60), high creatine
She is dx’d w/Hyperparathyroidism, what imagine must be ordered?
U/S check of the neck
Radiograph of the chest
MRI of the head
Both A & C
Case 15, Q4/5
U/S check of the neck - Parathyroid adenoma & Parathyroid hyperplasia are the most common causes of Hyperparathyroidism which are dx’d by U/S check of the neck.
*MEN 1 s/d which may includes Parathyroid adenoma, Parathyroid hyperplasia, Pituitary adenoma, Pancreatic islet cell adenomas, GI adenomas & Zollinger-Ellison s/d.
53 yo F ptc w/weakness, fatigue and depression. Dev. Abd pain over the last few weeks w/nausea & few episodes of vomiting. Had intense abd & back a week ago and urinated multiple blood clots, went to ER & was dx’d with kidney stones. She complaints of more aches & pains in her joints recently.
PMXH: Major depressive d/o 5 MO ago.
MEDS: Calcium, Vit. D, MultiVIT., Fluoxitine 20mg qd
Vitals: BP 146/88, pulse 96, resp. 18
PE: Diffuse ttp w/o mass, rigidity & guarding
Labs: CMP - High glucose 120 (60-100), Low Phorphorus, HIGH Calcium, LOW GFR 43 (<60), high creatine
She is dx’d w/Hyperparathyroidism, what is the tx?
Reduce Vitamin D
Estradiol therapy
Surgical resection of Parathyroid Glands
All of the above
Case 15, Q5/5
All of the above - Depending on the severity of the Hyperparathyroidism
30 yo F w/SOB & cough that began this morning which is worsening with chest pain. Broke ankle a week ago, is a 1 pack/day smoker, tased Ibuprofen for cramps & takes Oral contraceptives (Ethinyl estradiol & progestin).
Vitals: TEMP 99, BP 98/62, HRT rate 106, resp 22
PE: Lungs- rales w/diminished breath sounds on Right lung field.
What is most like dx? Pulmonary Embolism MI Panic Attack Esophagitis
Case 42 Q1/5
Pulmonary Embolism
30 yo F w/SOB & cough that began this morning which is worsening with chest pain. Broke ankle a week ago, is a 1 pack/day smoker, tased Ibuprofen for cramps & takes Oral contraceptives (Ethinyl estradiol & progestin).
Vitals: TEMP 99, BP 98/62, HRT rate 106, resp 22
PE: Lungs- rales w/diminished breath sounds on Right lung field.
Possible dx is Pulmonary Embolism, what is needed to confirm dx?
- CT Pulmonary angiogram
- Plain Chest xray
- D-Dimer
- Pulmonary fxn test
Case 42 Q2/5
CT Pulmonary angiogram
- Plain Chest xray
- D-Dimer - Non-specific screening for blot clots in PE & DVT I pts that dx is questionable but not good for clinical probable PE such as this.
- Pulmonary fxn test - for obstructive or restrictive lung dz (Lung volume, capacity & expiratory flow)
30 yo F w/SOB & cough that began this morning which is worsening with chest pain. Broke ankle a week ago, is a 1 pack/day smoker, tased Ibuprofen for cramps & takes Oral contraceptives (Ethinyl estradiol & progestin).
Vitals: TEMP 99, BP 98/62, HRT rate 106, resp 22
PE: Lungs- rales w/diminished breath sounds on Right lung field.
Possible dx is Pulmonary Embolism, WHICH PHARMACEUTICAL IS INDICATED?
- Aspirin
- Salbutamol
- Heparin
- Alprazolam
Case 42 Q3/5
- Heparin - an anti-coagulant
- Aspirin - anti-platelet activity
- Salbutamol- Short acting bronchodilator for asthma
- Alprazolam- Benzodiazepine for anxiety & Panic d/o
30 yo F w/SOB & cough that began this morning which is worsening with chest pain. Broke ankle a week ago, is a 1 pack/day smoker, tased Ibuprofen for cramps & takes Oral contraceptives (Ethinyl estradiol & progestin).
Vitals: TEMP 99, BP 98/62, HRT rate 106, resp 22
PE: Lungs- rales w/diminished breath sounds on Right lung field.
Possible dx is Pulmonary Embolism, after tx began she rtc & says she is worried this may return and can’t sleep at night or fxn during the day. You give her botanical of Avena Sativa, Hypericum perforatum, Passiflora incarnata, sculltelaria lateliflora (1:1:1:1) 1 tsp tid, which statement is true about this formula?
- It would be safe and indicated for this pt.
- It would be safe and but NOT indicated for this pt.
- It would be contraindicated for this pt but indicated for this pt. w/these sx’s.
- It would be contraindicated for this pt & NOT indicated for this pt. w/these sx’s.
Case 42 Q4/5
- It would be contraindicated for this pt but indicated for this pt. w/these sx’s.
(All are used for worry & anxiety)
- Hypericum perforatum is a CYP450 3A4 enzyme which effects clearance of warfarin, decreasing its effectiveness.
- *Also Contradicted in pts using Oral contraceptives- may lead to pregnancy.
30 yo F w/SOB & cough that began this morning which is worsening with chest pain. Broke ankle a week ago, is a 1 pack/day smoker, tased Ibuprofen for cramps & takes Oral contraceptives (Ethinyl estradiol & progestin).
Vitals: TEMP 99, BP 98/62, HRT rate 106, resp 22
PE: Lungs- rales w/diminished breath sounds on Right lung field.
Possible dx is Pulmonary Embolism, which of the following is most indicated recommendation for her condition?
Discontinue oral contraceptive
Increase dark leafy greens
Reduce cigarette intake
Start supplementing Vit. K 90mcg daily
Case 42 Q5/5
Discontinue oral contraceptive - increases risk of blood clots
46 yo biracial F (AA/White) ptc w/acne, flushed cheeks & increased fatigue. Acne & flushed cheeks have worsened in the past yr and half, also has unilateral pulsing HA’s (Lt temporal) preceded by bright light & floaters in her eyes & have also become progressively worse & more frequent. She report dry, peeling skin on her face better after periods but odd sx’s with periods like pain on her left shin that wakes her at night.
PMhx: Tx for HA’s w/small white pill, facial lipoma removal surgery, recurrent strep throat & otitis media infxns., has eliminated dairy from her diet.
PE: Skin is dusky, papulopustular across both cheeks & forehead, prominent sebaceous glands noted w/greasy/yellow crusts on erythematous base. Dry scaling fissures noted on angles of mouth b/l. NEURO: B/L loss of vibratory sensation to lower ext.
LABS: CBC: (HIGH Lymphocytes, Eosinophils, MCV, RDW), (Low RBC’s, HGB, HCT)
Which of the following Vitamin deficiencies are assoc. w/cheilosis & paresthesia?
- Vitamin D & B12
- Riboflavin & B12
- B12 & Vit. A
- Thiamin & Riboflavin
Case 72/Q1
- Riboflavin (B2) & B12
* Riboflavin def. rarely is alone, usually presents w/cheilosis & B12 deficiency causing paresthesias.
46 yo biracial F (AA/White) ptc w/acne, flushed cheeks & increased fatigue. Acne & flushed cheeks have worsened in the past yr and half, also has unilateral pulsing HA’s (Lt temporal) preceded by bright light & floaters in her eyes & have also become progressively worse & more frequent. She report dry, peeling skin on her face better after periods but odd sx’s with periods like pain on her left shin that wakes her at night.
PMhx: Tx for HA’s w/small white pill, facial lipoma removal surgery, recurrent strep throat & otitis media infxns., has eliminated dairy from her diet.
PE: Skin is dusky, papulopustular across both cheeks & forehead, prominent sebaceous glands noted w/greasy/yellow crusts on erythematous base. Dry scaling fissures noted on angles of mouth b/l. NEURO: B/L loss of vibratory sensation to lower ext.
LABS: CBC: (HIGH Lymphocytes, Eosinophils, MCV, RDW), (Low RBC’s, HGB, HCT), Normal MCH
CBC shows possibility of _____ & can be tx by supplementing _____.
- Megaloblastic/Macrocytic anemia - B12 & Folate
- Pancytopenia - packed rbc & platelet transfusion
- Spherocytosis - corticosteroids & retuximab
- Hypochromic, microcytic anemia, iron & lead chelation therapy/disodium calcium versanate or CaNA2-EDTA.
Case 72/Q2
- Megaloblastic/Macrocytic anemia - B12 & Folate
- Megaloblastic = High MCV
- Microcytic/hypochromic r/o by MCV & Normal MCH
46 yo biracial F (AA/White) ptc w/acne, flushed cheeks & increased fatigue. Acne & flushed cheeks have worsened in the past yr and half, also has unilateral pulsing HA’s (Lt temporal) preceded by bright light & floaters in her eyes & have also become progressively worse & more frequent. She report dry, peeling skin on her face better after periods but odd sx’s with periods like pain on her left shin that wakes her at night.
PMhx: Tx for HA’s w/small white pill, facial lipoma removal surgery, recurrent strep throat & otitis media infxns., has eliminated dairy from her diet.
PE: Skin is dusky, papulopustular across both cheeks & forehead, prominent sebaceous glands noted w/greasy/yellow crusts on erythematous base. Dry scaling fissures noted on angles of mouth b/l. NEURO: B/L loss of vibratory sensation to lower ext.
LABS: CBC: (HIGH Lymphocytes, Eosinophils, MCV, RDW), (Low RBC’s, HGB, HCT), Normal MCH
Which are included in DDX?
- Rheumetoid arthritis, dermatitis herpetiforis
- Migraines, rosaceae, megaloblastic anemia
- Agne vulgaris, MS
- CLuster HA’s, menopause
Case 72/Q3
- Migraines, rosaceae, megaloblastic anemia
46 yo biracial F (AA/White) ptc w/acne, flushed cheeks & increased fatigue. Acne & flushed cheeks have worsened in the past yr and half, also has unilateral pulsing HA’s (Lt temporal) preceded by bright light & floaters in her eyes & have also become progressively worse & more frequent. She report dry, peeling skin on her face better after periods but odd sx’s with periods like pain on her left shin that wakes her at night.
PMhx: Tx for HA’s w/small white pill, facial lipoma removal surgery, recurrent strep throat & otitis media infxns., has eliminated dairy from her diet.
PE: Skin is dusky, papulopustular across both cheeks & forehead, prominent sebaceous glands noted w/greasy/yellow crusts on erythematous base. Dry scaling fissures noted on angles of mouth b/l. NEURO: B/L loss of vibratory sensation to lower ext.
LABS: CBC: (HIGH Lymphocytes, Eosinophils, MCV, RDW), (Low RBC’s, HGB, HCT), Normal MCH
Which of the following recommendations should help her?
- B12, folate, riboflavin, B-complex, MG, HTP supplementing, diet dairy to exclude triggers.
- Vit. C, digestive enzymes, Vit E & anti-inflammatory cream w/calendula
- Biofeedback w/elimination of gluten & dairy
- Zinc & botanical w/Gymnema, Momordica, Trigonella
Case 72/Q4
- B12, folate, riboflavin, B-complex, MG, HTP supplementing, diet dairy to exclude triggers.
46 yo biracial F (AA/White) ptc w/acne, flushed cheeks & increased fatigue. Acne & flushed cheeks have worsened in the past yr and half, also has unilateral pulsing HA’s (Lt temporal) preceded by bright light & floaters in her eyes & have also become progressively worse & more frequent. She report dry, peeling skin on her face better after periods but odd sx’s with periods like pain on her left shin that wakes her at night.
PMhx: Tx for HA’s w/small white pill, facial lipoma removal surgery, recurrent strep throat & otitis media infxns., has eliminated dairy from her diet.
PE: Skin is dusky, papulopustular across both cheeks & forehead, prominent sebaceous glands noted w/greasy/yellow crusts on erythematous base. Dry scaling fissures noted on angles of mouth b/l. NEURO: B/L loss of vibratory sensation to lower ext.
LABS: CBC: (HIGH Lymphocytes, Eosinophils, MCV, RDW), (Low RBC’s, HGB, HCT), Normal MCH
Which homeopathic is indicated to help?
- Calcarea Carbonica
- Rhus tux
- Lachesis
- Byonia
Case 72/Q5
- Lachesis
**(GO BACK * WRITE INDICATIONS**
52 yo F ppc w/irritability & Lathargy w/bouts of hysteria & anxiety which has worsened over the past few weeks. She has felt “warm & Flushed” waking up drenched in sweat at night. Her BM’s are inconsistent & fluctuate b/t constipation & Diarrhea.
PMHX: HTN, Hyperlipidimia, Anemia during pregnancy.
Meds: Melatonin 3mg po qhs (bedtime)
FMHX: Both parents HTN, Hyperlipidimia
LABS: HIGH FSH 100 mlU/ml (4.7-21.5) {Menopausal Female 25.8-134.8}
What Conditions are in your Ddx?
- Hasimoto’s
- Menopause
- Generalized anxiety
- All of the Above
Case 37 Q1
- All of the Above
52 yo F ppc w/irritability & Lathargy w/bouts of hysteria & anxiety which has worsened over the past few weeks. She has felt “warm & Flushed” waking up drenched in sweat at night. Her BM’s are inconsistent & fluctuate b/t constipation & Diarrhea.
PMHX: HTN, Hyperlipidimia, Anemia during pregnancy.
Meds: Melatonin 3mg po qhs (bedtime)
FMHX: Both parents HTN, Hyperlipidimia
LABS: HIGH FSH 100 mlU/ml (4.7-21.5) {Menopausal Female 25.8-134.8}
Which labs are indicated? A. Estrogen, Progesterone, TSH, Free T3, Free T4, Anti-TPO, Anti-TG ab's B. TSH only C. Lipid panel D. CMP
Case 37 Q2
A. Estrogen, Progesterone, TSH, Free T3, Free T4, Anti-TPO, Anti-TG ab’s
52 yo F ppc w/irritability & Lathargy w/bouts of hysteria & anxiety which has worsened over the past few weeks. She has felt “warm & Flushed” waking up drenched in sweat at night. Her BM’s are inconsistent & fluctuate b/t constipation & Diarrhea.
PMHX: HTN, Hyperlipidimia, Anemia during pregnancy.
Meds: Melatonin 3mg po qhs (bedtime)
FMHX: Both parents HTN, Hyperlipidimia
LABS: HIGH FSH 100 mlU/ml (4.7-21.5) {Menopausal Female 25.8-134.8}
What is the correct workup for Post-menopausal uterine bleed.
A. TVUS, Cervical Cytology, Endometrial bx
B. TVUS, Complete Blood Count
C. Thyroid Panel, Endometrial bx
D. CBC, Cervical Cytology
Case 37 Q3
A. TVUS, Cervical Cytology, Endometrial bx
52 yo F ppc w/irritability & Lathargy w/bouts of hysteria & anxiety which has worsened over the past few weeks. She has felt “warm & Flushed” waking up drenched in sweat at night. Her BM’s are inconsistent & fluctuate b/t constipation & Diarrhea.
PMHX: HTN, Hyperlipidimia, Anemia during pregnancy.
Meds: Melatonin 3mg po qhs (bedtime)
FMHX: Both parents HTN, Hyperlipidimia
LABS: HIGH FSH 100 mlU/ml (4.7-21.5) {Menopausal Female 25.8-134.8}
What Botanical is best indicated for sx of Perimenopause? A. Arctium Lappa B. Actaea racemosa C. Pisidia erythrina D. Piper methysticum
Case 37 Q4
B. Actaea racemosa