Final Flashcards by Daniel Coquyt

Patient with dilated cardiomyopathy + alcohol abuse

(1) Diagnosis?

(2)

Alcoholic cardiomyopathy

Abstinence from alcohol

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Woman w/ fever 103 F

Chemo + indwelling catheter
Pneumonia 1 month ago
Diarrhea 2 days ago

Vitals:

↓ BP 92/52

Exam:

No surrounding erythema
(1) Empiric antibiotic therapy = ceftazidime + _____ ?

Vancomycin

(sepsis from indwelling catheter - need to cover MRSA)

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45 y.o. woman

Weakness right hand x 4 months
Weakness left leg x 2 months
Twitching all 4 extremities

Exam

R hand atrophy
Left foot drop
↑ DTR’s (markedly)
(+) Babinksi right
Slurred speech

Labs:

↑ Creatine kinase (350)

Nerve conduction studies:

No abnormalities
(1) Diagnosis?

Amyotrophic lateral sclerosis

UPPER motor neuron lesion = babinksi + reflexes

LOWER motor neuron lesions = muscle wasting, twitching, ↑ CK

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74 y.o. w/ burning, aching pain in distal extremities x 3 weeks

Worse w/ lowering extremities
Relieved w/ elevation

Exam:

Tenderness + swelling fingers, wrists, knee, ankle
Overlying skin is warm + erythematous
Clubbing fingers + toes

(1) Diagnosis?
(2) Which would be abnormal?

XR of chest
XR abdomen
Serum protein electrophoresis
Serum creatinine

Hypertrophic osteoarthropathy

(also known as hypertrophic pulmonary osteoarthropathy, Bamberger–Marie syndrome or Osteoarthropathia hypertrophicans)

XR of the chest

(associated with non-small cell lung carcinoma. These patients often get clubbing and increased bone deposition on long bones. Their presenting symptoms are sometimes only clubbing and painful ankles.)

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A 55 y.o. woman w/ epigastric pain + vomiting for a 1-day

Exam:

scleral icterus
tender epigastrium

Ultrasound:

dilation of intrahepatic ducts

(1) Diagnosis?

Alcoholism
Pancreatic carcinoma
Choledocholithiasis

Choledocholithiasis

(a gallstone pancreatitis due to billiary tract obstruction)

(Most likely from cholesterol stone - note elevated TGs)

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56 y.o. w/ fatigue

Tooth procedure 5 weeks ago
Has had heart murmur since age 18

Exam:

Systolic murmur @ 2nd right intercostal
S4
Ejection click

(1) Diagnosis?

Calcification of bicuspid aortic valve
Calcified mitral annulus
Myxomatous degeneration of the aortic valve
Myxomatous degeneration of the mitral valve

Calcification of bicuspid aortic valve

Systolic murmur from 2nd intercostal = MUST be aortic valve

Systolic = stenosis

( Myxomatous degeneration of a valve = cause regurgitation which would produce a diastolic murmur rather than a systolic murmur)

Given this patient’s age, the location of the murmur (in the aortic region - right 2nd ICS) and the systolic murmur with ejection click we can deduce that this is AORTIC and it is STENOTIC.

Myxomatous degeneration of a valve would cause regurgitation which would produce a diastolic murmur rather than a systolic murmur. That eliminates C-D-E. Mitral valve murmurs are generally heard best at the left mid-clavicular line. That eliminates F. Tricuspid murmurs are generally best heard at the left sternal border. That gets rid of G. Don’t get caught up in the root canal distractor.

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65 y.o. w/ acute onset bilateral leg weakness + urinary incontinence (2 days ago)

Hx prostate cancer + bone mets to pelvis

Exam:

Tenderness over lumbosacral spine @ S1
Unable to lift legs
DTR’s absent @ knees + ankles

(1) Next step?

CT head
MRI of lumbosacral spine

MRI of lumbosacral spine

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28 y.o. w/ aching right shoulder pain @ deltoid muscle

Worse w/ reaching overhead
Also at night in bed

Exam:

Pain w/ shoulder abduction (against resistance)

(1) Where is the problem?

Deltoid
Proximal humerus
Supraspinatus tendon

Supraspinatus tendon

(Patients with rotator cuff tendinopathy complain of shoulder pain with overhead activity.

Patients may localize the pain to the lateral deltoid and often describe pain at night, especially when lying on the affected shoulder.)

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Chart shows disease history with time

Which group has the worst 1-year survival rate?

Group A at Time 0-1
Group B at Time 0-1
Group A at Time 3-4
Group B at Time 4-5

Group B at Year 3-4

This is a tricky question. Pay close attention to the wording. “Rate” is the key word here. So, group B is about 80% at Year 3 and about 40% at year 4 and 35% at year 5. So survival RATE between years 4 and 5 are 35/40 = 87.5% whereas survival rate between years 3 and 4 is 40/80= 50%. Clearly this is the poorest 1-year survival RATE. If the question had instead asked, “What is the year in which there were the least overall survivors?” then the answer would have been E.

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22 y.o. with red, skaly rash @ groin

Tx’d previously with clotrimazole, resolved –> recurred 2 days ago
Sexually active

Exam:

Erythematous, excoritated rash over groin + instep of foot

KOH stain:

Displays hyphae

(1) Diagnosis?

(2) Cause?

Autoinfection
Medication resistance
Impaired cellular immunity
Impaired humoral immunity
Reinfection (from sex)

Tinea cruris

(jock itch + athletes foot)

Autoinfection

Tinea cruris is a contagious infection transmitted by fomites, such as contaminated towels or hotel bedroom sheets, or by autoinoculation from a reservoir on the hands or feet (tinea manuum, tinea pedis, tinea unguium). Tthis condition is also called Jock itch.

For tinea cruris or jock itch the treatment is topical antifungal:

ketoconazole
clotrimazole
selenium sulfide
But always make sure the patient is also being treated for tinea pedis (athlete’s foot).

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40 y.o. man w/ greasy, diffuse scalp scaling + itching

Gradual over the last year

Exam:

Yellowish, red scaling papules along hairline + ears
No hair loss

(1) Diagnosis?

Exfoliative dermatitis
Lichen simplex chronicus
Pediculosis capitis
Psoriasis
Seborrheic dermatitis

Seborrheic dermatitis

Seborrheic dermatitis, also known as seborrheic eczema or simply as seborrhea, is a chronic, relapsing and usually mild dermatitis.

In infants seborrheic dermatitis is called cradle cap.

Dandruff is a type of seborrhoeic dermatitis where inflammation is not present.

Seborrheic dermatitis is a skin disorder affecting the scalp, face, and torso.

Typically, seborrheic dermatitis presents with scaly, flaky, itchy, and red skin. I

t particularly affects the sebaceous-gland-rich areas of skin.

In adolescents and adults, seborrhoeic dermatitis usually presents as scalp scaling or as redness of the nasolabial fold. There is no associated hair loss.

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53 y.o. suddenly collapsed + now in coma (in hospital)

Hx: recent CABG for CAD

EKG:

Wide QRS
Ventricular rate = 170
Atrial rate = 110

(1) What rhythm is this?

(2) Treatment?

A) Digitalis

B) Verapamil

C) Carotid sinus massage

D) Direct current countershock

E) External pacing

V-fib

Direct current countershock

(to defibrillate)

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35 y.o. patient

Immunizations:

Diptheria tetanus
23 val pneumococal vaccine (3 yrs ago)
Influenza (12 m.o. ago)

Serum Hep B:

surface antibody assay (+)

(1) What do you give her today?

A) Diphtheria-tetanus toxoid

B) Hepatitis B

C) Influenza virus

D) Meningococcal

Influenza virus

(due every year)

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30 y.o. lady w/ epigastric pain + vomiting x 8 hours

Radiates to back
2 similar things last 2 months
No EtOH

Ultrasound gallbladder

Normal

CT abdomen:

Image

(1) What next?

A) HIDA scan

B) Endoscopic retrograde cholangiopancreatography

C) Esophagogastroduodenoscopy

D) Mesenteric angiography

E) Percutaneous transhepatic cholangiography

Endoscopic retrograde cholangiopancreatography

lesions obstructing the ampulla of vater or pancreatic duct should be excluded by ERCP.

This is most likely a pseudocyst.

A HIDA scan is for cholecystitis.

If nonsurgical drainage is contemplated, it is important to elucidate the anatomy of the pancreatic duct beforehand. This may be done via endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance imaging (MRI)

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50 y.o. man w/ fatigue

HTN
Chronic renal insufficiency x2 years

Labs:

Low iron
Elevated ferritin

(1) What supplement couldve helped?

Erythropoetin

The kidney produces EPO

In chronic renal failure anemia must be monitored and EPO can be administered as needed to keep RBC production going.

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40 guy w/ sudden severe headache + left side weakness (x1 hour)

Smoker
BMI 31

Exam:

Weakness left lower face
Weakness Left arm + leg

Fundoscopic:

Arteriovenous ratio = 1
Mild focal spasm
arterioles

Labs:

↑ cholesterol

CT head:

hyperdensity in right putamen + lucency around it

(1) If hyperdensity, then what type of stroke is this?

Occlusive
Hemorrhagic

(2) Then, which is greatest risk factor?

Hypercholesterol
HTN
DM

(3) What will make less risk for future event?

stop Alcohol
stop Smoking
Lose Weight
Atorvastatin
Clopidogrel
Lisinopril

Hemorrhagic stroke

↑ BP

Lisinopril

This is a lucanar infarct which is associated with HTN and DM

This type of hemorrhagic stroke can be best prevented by lowering BP. Weight loss is the best lifestyle modification to lower BP but at this point, Lisinopril will help lower is BP right away whereas even a successful weight loss routing will take a long time to have an effect.

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60 y.o. guy w/ sudden SOB

Cyanotic + respiratory distress
Given 100% O2 via EMS

Hx:

COPD
Smoker

Exam:

↓ mental status
↓ breath sounds + bad air movement + prolonged expir

(1) In COPD guy, will the O2 slow or increase respir drive?

(2) Then, will more CO2 be retained or blowed off?

(3) Then, what caused his mental status change?

Hypercarbia
Hypoxemia
Metabolic acidosis
Oxygen toxicity
Respiratory alkalosis

Slow respiratory drive

More CO2 retained

Hypercarbia

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90 y.o. lady found down for 8 hours

UA:

3+ blood
No RBC’s

(1) Diagnosis?

Rhabdo

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30 y.o. w/ irregular periods (x3 years)

Gets them every 30-60 days (were consistent + normal before)
LMP 1.5 months ago

Exam:

↑ BMI
↑ hair

(1) What med is best?

Contraceptive
Leuprolide

Oral contraceptive

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39 yo w/ SOB for a year

Wheezing + cough
Family member smokes
Dad died early of liver disease

CXR:

↑ lucency + bullous @ both lungs (bases)

(1) Diagnosis?

alpha-1 antitrypsin deficiency

α₁-Antitrypsin deficienc always involves lung bases.

End expiratory wheezes are classic for COPD. Fibrosis would present with end inspiratory crackles but not end expiratory wheezes.

I say “Fire Crackles” = Fibrosis has crackles a

COPD/Emphysema has Wheezes.

Xray showing bullous changes also point toward A1AT def induced emphysema.

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49 yo guy w/ acute R knee pain

Similar thing in the past (2 yrs ago, 2 mo ago)
Both got better
HTN + smoker + EtOH
↑ BMI

Exam:

Pain + swelling in knee
less ROM

(1) Dx?

Gout

(Risk factors = alcoholism, obesity, HTN, and smoking)

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39 yo w/ fever + headache + musk/joint pain

Recently Tx’d for hyperthyroid
Given 2 unknown meds

Exam:

Lid lag
Exopthalmos
Goiter

Labs:

↓↓↓ Leukocytes (WBC)

(1) What 2 meds are commonly given for hyperthyroid?

(2) What is a common side effect of these?

(3) Dx?

Autoimmune neutropenia
Cyclic neutropenia
Drug-induced neutropenia
Radioactive iodine-induced neutropenia
Thyroid storm

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Propylthiouracil + methimazole

(don’t use propylthiouracil w/ pregnancy)

Neutropenia

(+ joint pain, rash, liver probs)

69 yo w/ hematemesis

Hx: Esophageal Cancer (currently on chemo)
HTN + DM II + CAD
Osteoarth

Surg:

artificial aort valve

Others:

Naps several hours a day from chemo

(1) Why is this guy on a blood thinner?

Hx cancer
CAD
↓ activity
chemo

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B/c of his artificial valve

49 yo lady w/ abd pain + vomiting yellow liquid

Hx:

Recent mouth surgery –> now taking tylenol + opioid for pain

Surg:

Hysterectomy for uterus bleeding (a few days ago)

Exam:

abdom. distension + tympanic
No stool in vault

XR:

distended loops of small intestine + air/fluid levels
rectum empty

(1) Dx? Why?

volvulus
ileus
small intestine obstruction
Pseudo–obstruction

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small intestine obstruction

(recent abdominal surgery - adhesions)

22 yo w/ dysuria + watery/white penis discharge Gram stain: * Segmented neutrophils * No intracellular bugs **(1) What STD does guy have?** *(which would present this way + not be seen on stain)* * Chlamydia * Neiss. gonorrhea * Treponem. palladium * Herpes

Chlamydia

69 yo lady worried about ↑ BP * Normal a few m.o. ago, taking her thiazide meds * Now acutely recently 205/110 @ market * Still high today Exam: * Fundoscope w/ aterio-venous nicking * Carotid bruiet (**1) Dx?**

**Renal artery stenosis** Any patient (especially elderly) w/ an acute rise in normal or well controlled BP, **RAS** should be very high on the differential. This can happen quite suddenly. And patients with atherlosclerotic disease are at particularly high risk of this complication.

College student w/ fever + sore throat + _dry_ cough x 1 week Exam: * Crackles in low left lobe CXR: * Patchy alveolar infiltrates + ↑ interstitial markings Labs: * WBC 11,000 + ↑ segmented neutrophils + bands (1) Organism?

**Mycoplasma pneumoniae** Atypical Pneumonia involves interstitial markings + a dry cough while lobar has productive cough. Eight days no production also suggestive of atypical pneumonia.

55 yo lady w/ fever + abdom. cramps + watery diarrhea * Then dry cough x 1 day Hx: * Smoker Exam: * 102 F * crackles @ both lungs Labs: * ↑ leukocytes + segmented neutrophils CXR: * Alveolar infiltrate R. up + low lobes + L. lower lobs Sputum gram stain: * Seg. neutrophils * No bugs (1) Bug? * A) Cytomegalovirus B) Haemophilus influenzae C) Klebsiella pneumoniae D) Legionella pneumophila E) Mycoplasma pneumoniae F) Pneumocystis jiroveci (formerly P. carinii) G) Pseudomonas aeruginosa H) Respiratory syncytial virus I) Streptococcus pyogenes (group A)

**Legionella pneumophila** Pneumonia + watery diarrhea + recent travel = Think of Legionella

25 yo w/ HIV + no symptoms (just checkup) Labs: * Hct: 43% * Leukocytes = 4,000 * CD4+ T-cells = 545 (normal is \>= 500) * Plasma HIV viral load = 2000 copies **(1) Next?** * Nothing, just F/U in 6 m.o. * 2 anti-retrovirus drugs * 3 anti-retrovirus drugs * Pneumocystis Ppx drugs

**3 anti-retrovirus drugs (?)** | (treat all regardless of CD4+ count)

30's y.o. woman w/ gradually worsening sensory loss * Feet * Then went up to belly button * ↑ Urinary frequency + urgency * "tight band" around abdomen Exam: * Right eye aduction during saccadic movement (of both eyes) to the left * ↑ Hyper-reflexia * ↓ sensation around belly button **(1) Dx?** **(2) Which involves the eye problem?** A) Left cerebral hemisphere B) Left medial longitudinal fasciculus C) Left paramedian pontine reticular formation D) Right cerebellar hemisphere E) Right sixth cranial nerve nucleus

Multiple sclerosis **Left medial longitudinal fasciculus** *Ascending paralysis most likely due to MS*

Mid 60's w/ **heartburn** + **dysphagia** (solids) x 1 month * Burning @ night after meals * No help with H2 blocker No other symptoms Exam normal All labs normal **(1) What next?** A) Add metoclopramide B) Add omeprazole C) Switch to famotidine D) Switch to omeprazole E) Upper endoscopy(EDG)

**Upper endoscopy** (b/c she has DYSPHAGIA - this is a bad symptom)

Mid 50's woman w/ acute tearing neck pain * Radiates to back * has HTN EKG: * tachy + LVH CXR: * wide mediastinum **(1) Dx?** **(2) What medication to give 1st?**

Aortic dissection ## Footnote **Labetalol**

70's lady w/ confusion * Gradually worse over few days * Osteoarth Exam: * Cannot reply to Q's * DTR's 1+ Labs: * ↑↑↑ Glucose 600 * Cr 2.5 * BUN 54 **(1) Dx?**

**Nonketotic hyperosmolar state** or **Hyperosmolar hyperglycemic state (HHS)** Usually seen in older individuals with DM II Usuall glucose\>600. Serum pH is usually \> 7.2 and there are few ketones present. This is less common than DKA but can be just as lethal.

60's man in ICU for a week with pneumonia * Now become weak, cannot walk on his own * Tx'd with Abx --\> improved --\> No fever for a couple days * DM II Exam: * Rhonchi in LUL Labs: * ↓ platelets from 340,000 to 90,000 in last 2 days **(1) Dx?** **(2) What next?** A) Add epoetin alfa to the medication regimen B) Stop ceftriaxone + Start PT C) Switch ceftriaxone to Pip/Tazo D) Switch heparin to direct thrombin inhibitor E) Switch heparin to LMWH (low mole. weight)

**This looks like _HIT_ (Heparin Induced Thrombocytopenia)** When the platelets drop more than 1/2 of baseline (even if still within normal range) a high clinical suspicion for HIT should be present. **\*\* Switch heparin to _direct thrombin inhibitor_ \*\***

40's lady w/ DM II c/b End-stage renal dysfunction Labs: * Normal Blood glucose * Normal BP **(1) Which will help reduce worsening of diabetic nephrop.?** * Diet change * Reduce Hgb A1c * Add Lisinopril

**Add Lisinopril** | (renally protective)

40's lady with thyroid lump (tender) * Hysterectomy 1yr ago * Now on estrogen Exam: * Tender lump on R side of thyroid Labs: * TSH normal * Free thyroxine normal **(1) Next step?** * Recheck later * Measure iodine uptake * CT neck * Fine needle aspiration

**Fine needle aspiration** A low TSH would require RAIU to differentiate whether the nodule is hyperfunctioning or that the gland is hyperthyroid. If the RAIU then shows a decreased uptake, go for FNAC. But this patient has regular levels.....so FNAC.

Scuba diver w/ sudden SOB + chest pain **(1) Next step?** * EKG * CXR * CT

**Chest x-ray** (pneumomediastinum, pneumothorax) Pulmonary barotrauma — Following drowning, pulmonary barotrauma is the second leading cause of death among scuba divers. As a diver ascends and transalveolar pressure exceeds 20 to 80 mmHg, overexpansion injury in the form of alveolar rupture can occur. Pneumomediastinum — Following alveolar rupture, gas can dissect along the perivascular sheath into the mediastinum to produce pneumomediastinum. Symptoms of pneumomediastinum include a sensation of fullness in the chest, pleuritic chest pain that may radiate to the shoulders, dyspnea, coughing, hoarseness, and dysphagia. Crepitation in the neck due to associated subcutaneous emphysema may be present, and a crackling sound heard over the heart during systole (Hamman's sign) may be appreciated upon auscultation. The diagnosis can be confirmed on the basis of chest and neck radiographs. Typically, a radiolucent band is seen along the cardiac border on the posteroanterior film and retrosternally on the lateral view. No specific treatment is required, but inhalation of 100 percent oxygen is recommended to hasten resorption of extraalveolar gas. Rarely, mediastinotomy may be required to relieve a tension pneumomediastinum. Pneumothorax, arteria or venus gas emboli are rare sequelae that might also be seen.

50's lady w/ non-small cell lung cancer * 2 days SOB * 102 F Diagnosis: * Post-obstructive pneumonia Family meeting: * Patient wants to d/c chemo, and requests DNR/DNI Next: * Must sign advanced-directive + power-of-attorney **(1) What else should happen?** * Send home w/ hospice care * Send home w/ PT * Send to nursing home

Send home w/ **hospice care** (likely less than 6 months to live --\> hospice)

90 y.o. man w/ right hemiplegia s/p stroke * Bed rest for sevaral years * Now has new, large pressure ulcer @ hip + eschar + erythema * Grade III * 6 x 8 cm (1) Next step? * Silver sulfadiazine * Wet/dry dressing * Debridement * Skin graft

**Debridement** Debridement of the ulcer Stage 1 - The skin is intact with non-blanchable redness in a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage 2 - Partial thickness loss of dermis, which presents as a shallow open ulcer with a red-pink wound bed, without sloughing. Stage 2 ulcers may also present as an intact or ruptured serum-filled blister. Stage 3 - Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscles are not exposed. Sloughing may be present but does not obscure the depth of tissue loss. There may be undermining and tunneling. Stage 4 - Full thickness skin loss with exposed bone, tendon or muscle. Sloughing or eschar may be present on some parts of the wound bed. These ulcers often include undermining and tunneling. ~~This woman has stage 3 as stated in the stem~~ Stage 1 treatment — Stage 1 ulcers may be dressed with transparent films for protection. Stage 2 pressure ulcers usually require an occlusive or semipermeable dressing to maintain a moist wound environment. Wet-to-dry dressings are avoided since these wounds generally require little debridement. Stages 3 and 4 — Treatment of wound infections, debridement of necrotic tissue, and appropriate dressings will accelerate healing of Stage 3 and 4 pressure ulcers. Surgery is necessary for some full thickness pressure ulcers.

College-age girl w/ check up appt Exam: * S2 fixed, split * Systolic murmur @ 3rd intercostal space **(1) Dx?**

ASD | (atrial septal defect)

60's man w/ confusion + weakness + constipation Hx: * Dx'd w/ SCC lung cancer (squamous) Exam: * ↓ skin turgor * ↓ breath sounds @ left apex EKG: * Short QT Labs: * ↑ Ca+ = 14.8 * ↓ Phos = 1.1 **(1) What hormone can these lung cancers secrete?** **(2) What med best?** * A) Allopurinol B) Cisplatin C) Cryoprecipitate D) Demeclocycline E) Doxycycline F) Fresh frozen plasma G) Heparin H) Hydroxyurea I) Pamidronate J) Tamoxifen

**PTH-rp** (Parathyroid Hormone - related peptide) seen in lung cancer can cause rapid and dramatic increase in Calcium **Pamidronate**

70's lady w/ palps + weight loss Exam: * Non tender enlargement of left thyroid lobe Labs: * ↓ TSH * ↑ T4 (thyroxine) A131 iodine: * Uptake in single area of left lobe * Less uptake elsewhere (1) What is happening? * A) Autoimmune destruction of thyroid cells * B) Focal granulomatous inflammation * C) Parafollicular cell cytokine overproduction * D) Production of thyroid-stimulating immunoglobulin * E) Autonomous T4 production

**Autonomous T4 production** this is a hot nodule. Low TSH + high T4 and an increased ¹³¹I uptake of the nodule points to autonomous T4 production.

20's male with: * Neck swelling x 1 month * Fever + night sweats + pruritis (all over) Exam: * A few cm left anterior node * Sytolic mumur @ right (upper) sternal border * Hyperactive bowel sounds Labs: * Leukocytes = 6,100 * Segmented neutrophils = 62% * Bands = 3% **(1) Dx?** A) Acute lymphocytic leukemia C) Chronic lymphocytic leukemia G) Hodgkin disease H) Infectious mononucleosis

Hodgkin disease

25 y.o. lady for check up * Smoker * EtOH * Sedentary * ↑ BMI 33 * ↑ BP (151/94) **(1) How best to lower risk for osteoarthritis?** A) Abstinence from alcohol B) Regular aerobic exercise C) Weight loss D) Calcium supplementation E) Estrogen replacement therapy at the onset of menopause

**Weight loss** Epidemiologic studies suggest that obesity is strongly associated with the development of OA and that the amount of weight lost and the decrease in incidence of OA has a linear relationship.

70's lady w/ abd. pain + hematochezia Hx: * Alzheimer dementia * Constipation (tx'd w/ psyllium + docusate) Exam: * Temp 102.4 F * LLQ tend + distension * Rectal w/ blood * Oriented only x 1 (not to place/time) **(1) Dx?** * **Campylobacter** * **Celiac** * **C-diff** * **Diverticulosis** * **Colon cancer** * **Diverticulitis**

**Diverticulitis**

50's lady @ ED after found laying in the street Hx: * EtOH abuse Exam: * No response to pain (noxious) stimulus * Temp 100.7 F * HR 124 * BP 92/58 * Poor skin turgor * Dry mmm Blood: * Hct: 42% * BUN: 60 * Cr: 3.4 Urine: * Reddish * Spec. Grav: 1.03 * Blood = 3+ * Protein = 1+ * No RBC's or WBC's * Hyaline casts = 1/hpf **(1) What diagnosis do you think of when anybody is found down for a period of time?** **(2) _Hyaline casts_ = what diagnosis?** **(1) Dx?** A) Acute glomerulonephritis B) Acute tubular necrosis C) Allergic interstitial nephritis D) Glomerulosclerosis E) Pyelonephritis

**Rhabdo** **ATN** **Acute tubular necrosis** (Whenever we see Bun:Cr\<20 and blood in the urine with no RBCs… think Rhabdo. There are all kinds of things that could have caused rhabdomyolysis in this woman…. Immobility, possible EtOH related seizure, etc. Either way… all this with the presence of hyaline casts and we have ourselves some ATN.)

\*\*\* 70's lady w/ fever + cough (1 day) Hx: * Pneumococcus pneumonia ~1 yr ago Exam: * Temp 102.3 F * Bronchial breath sounds @ R lung base + dullness + egophony Labs: * ↑ Leukocytes (89,000) * 16% segmented neutrophils * 82% lymphocytes * 4% monocytes Gram stain: * Gram (+) lancet-shaped diplococci **(1) What cancer has these lab findings?** **(2) What the the most common immune defect in these patients?** **(1) Which below will tell us about this patients deficiency in immune defence?** A) Assessment of segmented neutrophil function B) Measurement of CD4+ T-lymphocyte count C) Measurement of serum lgE concentration D) Measurement of T-lymphocyte count E) Quantitative immunoglobulin assay

CLL Hypogammaglobulinemia (subtypes ***IgG3 + IgG4*** affected most) **_Quantitative immunoglobulin assay_**

60's man w/ concerns about his BP * Gradual ↑ in systolic + diastolic BP (over last ~5 years) * BP now = 162/88 **(1) What is causing the ↑ in this old man's BP?** A) ↓ diameter of the vascular lumen B) ↓ vascular compliance C) ↑ deposition of lipids in arterial smooth muscle D) ↑ deposition of lipofuscin in cardiac myocytes E) ↑ intimal thickening of the arteries

↓ **vascular compliance (decreased)** As we age our vessels become less compliant _Stiffening of the arteries_ due to **calcium** and **lipid depositions** cause an increase on both systolic and diastolic BP.

20's girl @ ED w/ bad sore throat + hoarse voice + dysphagia x 9 hrs Exam: * Looks sick (toxic) * 102 F * Stridor Labs: * Leukocytosis **(1) What next?** A) Assay for diphtheria toxin B) Culture + Gram stain of sputum C) XR of the chest D) Barium swallow E) Laryngoscopy + endotracheal intubation

Laryngoscopy + endotracheal intubation abrupt ***less than 24 hour*** resp distress + dysphagia and toxic picture so most likely **_epiglotitis_**… get your tubes ready

20's guy w/ loose stools + fatigue x 4 months * Weight loss (normal PO) * Hx of diarrhea as a child + some trouble gaining weight, resolved Stool: * ↑↑↑ fecal fat (72hr) D-xylose absorption test: * ↓ concentration of 5 (normal is 25-40) **(1) Dx?** **(2) Which matches?** A) Bacterial overgrowth in the small bowel B) Exocrine pancreatic insufficiency C) Failure of bile acid excretion D) Failure of bile acid reabsorption E) Lactase deficiency F) Villous atrophy in the small bowel

Celiac sprue ## Footnote **Villous atrophy in the small bowel**

**\*\*\*** 60's male hospitalized for CAP (pneumonia) * Started Ceftriax * on Thiazide for HTN * on glyburide for DM II * on Acetaminoph. for osteoarthr. 2 days being in hospital, labs are: * BUN: 52 * Cr: 2.5 Urine: * Na: \<10 * FeNa: \<1 * Protein: trace **(1) Dx?** A) Acute glomerulonephritis B) Acute tubular necrosis C) Diabetic nephropathy D) Interstitial nephritis E) Prerenal azotemia F) Urethral obstruction

**_Prerenal azotemia_** **FeNa \<1 (low) = body is trying to conserve Na+ = trying to bring up volume =** **body is low on volume =** **Prerenal azotemia** Prerenal azotemia is caused by a decrease in blood flow (hypoperfusion) to the kidneys. The BUN:Cr in prerenal azotemia = greater than 20. In this patient the ratio is \>20. This patient might have volume depletion. However, there is no inherent kidney disease. It can occur following hemorrhage, shock, volume depletion, congestive heart failure, adrenal insufficiency, and narrowing of the renal artery among other things.

40's lady for check up * Dx'd w/ HTN ~6 months ago --\> started hydrochlorothiazide * Active, healthy, normal BMI 2 months ago: * BP = 175/95 * Added Lisinopril Today: * BP = 165/95 Labs: * 1+ urine protein **(1) What would help lower chances of renal failure?** * A) Less protein in diet B) 24-Hour urine protein level C) ↑↑ Up the dose of lisinopril D) Use furosemide instead of hydrochlorothiazide

**↑↑ Up the dose of Lisinopril** - Target BP \<140/90. If uncontrolled on 2-drug therapy guidelines say to add a 3rd medication of increase the dose.

\*\*\* 50's male @ ED after 3 min of LOC * Watching TV --\> felt ill --\> confused + fell to ground * Spontaneously recovered to 100% within a few minutes * No incontinence Hx: * Hx HTN (managed well w/ hydrochlorothiazide) * MI 4 yrs ago EKG: * Q waves in II, III, aVF **(1) Dx?** * A) Hypoglycemia * B) Paroxysmal ventricular tachycardia * C) Pulmonary embolus * D) Seizure * E) Transient ischemic attack

**Paroxysmal ventricular tachycardia** prior MI = ↑ risk for arrhythmia No focal neuro deficits = not TIA No post ictal period = not seizure hypoglycemia doesn't resolve spontaneously PE would have other findings (prior hx of surgery, tachypnea, hypoxia, sinus tachycardia on ecg). Plus a prior MI can leave you at risk for arrhythmia.

Final Flashcards

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