Final Flashcards
Patient with dilated cardiomyopathy + alcohol abuse
(1) Diagnosis?
(2)
Alcoholic cardiomyopathy
Abstinence from alcohol
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)
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
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.)
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)
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.
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
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.)
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.
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).
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.
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)
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)
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)
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.
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.
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
90 y.o. lady found down for 8 hours
UA:
- 3+ blood
- No RBC’s
(1) Diagnosis?
Rhabdo
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
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.
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)
