Firecracker Flashcards
A 43-year-old man with a history of orthotopic liver transplantation on maintenance tacrolimus presents to the emergency department complaining of blurred vision for two days. On arrival, his temperature is 36.9°C (98.4°F), heart rate is 88 beats/minute, blood pressure is 216/112 mmHg, and SpO2 is 98 % on room air. While in the emergency room, he suffers a generalized tonic-clonic seizure. An MRI of the brain is obtained that demonstrates non-enhancing patchy bilateral asymmetric T2/FLAIR hyperintensities throughout the posterior parietal and occipital lobes. What is the most likely diagnosis?
Multiple Sclerosis Subarachnoid hemorrhage Glioblastoma Posterior Reversible Infarct Syndrome Ischemic Infarct
This patient has posterior reversible encephalopathy syndrome (PRES). Though the precise pathophysiology is unclear, most cases of PRES are seen in the setting of either profound hypertension or immunosuppressant therapy (in particular tacrolimus and cyclosporin). Often both are present. On MRI there is increased T2 signal intensity in the white matter of the posterior parietal and occipital lobes consistent with vasogenic edema. Clinical manifestations include headache, altered mental status, visual symptoms, and seizures. Treatment involves the correction of the hypertension, often with IV antihypertensives, and the cessation of the offending agent if possible.
A 18-year-old male presents with moderate-to-severe pain in his left lower extremity. The pain has been worse at night for the past two weeks. There is also some swelling associated with this lesion in the area of his distal femur. He is an avid distance runner and wonders if his symptoms could be related to overtraining. Plain radiographs are obtained that demonstrate an intense periosteal reaction associated with an area of local bone destruction in the region of the epiphysis. What is the most likely etiology of this patient’s bone pain?
The patient has an osteosarcoma. It is the most common primary bone cancer. (However, it should be noted that multiple myeloma is also considered a bone cancer, although it is a hematologic malignancy). Metastatic cancer is the most common malignant bone lesion overall.
The demographic for osteosarcoma is typically a 10-30 year old male. It presents with pain and swelling. The radiographic findings are characteristic: there is an intense periosteal reaction associated with an area of local bone destruction. This produces the characteristic “Codman’s triangle” that is sometimes used to describe its appearance. It affects the metaphyseal region of long bones, rather than the epiphysis (characteristic of giant cell tumor of bone).
Risk factors for osteosarcoma include Paget’s disease (rare), radiation treatment/exposure, and familial retinoblastoma. The retinoblastoma tumor suppressor gene is located on chromosome 13. Biopsy is necessary for definitive diagnosis. The lung is the most common site of metastasis.
While providing medical care at a refugee camp in Rwanda, a 3-year-old girl presents with a diffuse, dark red maculopapular rash with areas of marked desquamation. Her mother says she had a cough, runny nose, and red eyes and felt very hot about 1 week ago. On physical examination, in addition to the rash, you note wasting of the child’s limbs, abdominal distension, and sparse, brittle hair. Administration of which of the following vitamins is recommended for treatment of this patient’s disease? Vitamin A B9 B6 Vitamin C Vitamin D
The patient’s recent history of cough, coryza (rhinitis), conjunctivitis, and fever together with the dark red, maculopapular, desquamating rash and other physical findings are consistent with measles (rubeola) in the setting of malnutrition. The measles rash in malnourished children tends to be more confluent and to progress to a dark red and then violet color. Desquamation occurs in large scales. Malnutrition is associated with greater severity and increased complications of measles, with the degree of malnutrition correlated with mortality rates. Supplementation with vitamin A (retinol), in particular, has been shown to reduce complications and mortality. Vitamin A can act as an immune modulator that increases antibody responses to measles. In the United States, the Centers for Disease Control and Prevention recommends considering vitamin A supplementation for measles in populations at higher risk for complications, such as hospitalized children 6 months to 2 years of age and those with immunodeficiencies, malabsorption, or malnutrition.
A 3-year-old boy presents to the emergency department with a five-day history of fever and irritability. He has no other significant past medical history and his immunizations are up-to-date. He is eating less than usual and has been less active. On physical examination his vital signs are: temperature 40°C (104°F), heart rate 112 beats per minute, blood pressure 104/58 mmHg, respiratory rate 16 breaths per minute, and oxygen saturation 99% on room air. He is a well-developed child in a moderate amount of distress. He has bilateral conjunctivitis and cracked red lips. He has a 2 cm nontender lymph node in the right cervical chain. His heart is tachycardic with a regular rhythm and no murmur. His lungs are clear to auscultation bilaterally and his abdomen is soft, nontender, nondistended, with no hepatosplenomegaly. The dorsal surfaces of his hands and feet are both swollen. A point of care urine dipstick is positive for leukocyte esterase and negative for nitrites. Routine labs include complete blood count, blood culture, erythrocyte sedimentation rate, C-reactive protein, urinalysis, and urine culture have been sent and the results are pending. What is the most appropriate treatment for this patient?
Intravenous immune globulin (IVIG) and high-dose aspirin.
The child in the vignette has Kawasaki Disease (KD), which is a systemic medium-sized vessel vasculitis that typically occurs in children less than five years of age. The diagnostic criteria for KD disease requires ≥5 days of fever as well as four out of five of the following: bilateral nonsuppurative conjunctivitis; one or more changes in the mucous membranes of the upper respiratory tract such as pharyngeal injection, dry fissured lips, injected lips, or strawberry tongue; one or more changes of the extremities including peripheral erythema, peripheral edema, periungual desquamation, or generalized desquamation; polymorphous rash, primarily truncal; and cervical lymphadenopathy >1.5 cm. Intravenous immune globulin (IVIG) and high-dose aspirin is the standard treatment for KD and is given to prevent coronary artery aneurysms. IVIG is given in a high dose (2 gm) over 12 hours and is repeated if the fever does not resolve within 24 hours. High-dose aspirin is given until the fever resolves and then continues at a low dose for 6 to 8 weeks as an antiplatelet agent.
A 38-year-old woman presents to the primary care physician for a routine physical. She had no specific complaints at this time. She takes glyburide for diabetes and vitamin B12 supplements. Her vitals are: temperature 37°C(98.6°F), heart rate 70, blood pressure 118/79, respiratory rate 12, O2 saturation 100% on room air. On exam, a midsystolic click is heard followed by a late systolic crescendo murmur best heard at the apex. Which of the following will increase the intensity of this murmur? Inspiration Rapid squatting Lying down Fluid bolus Valsalva maneuver
Valsalva maneuver
This patient has mitral valve prolapse (MVP), characterized by a midsystolic click followed by a late systolic crescendo murmur. These sounds are the result of inability of the chordae tendineae to fully tether the valve, allowing it to prolapse back into the left atrium (the click) with late systolic mitral regurgitation (the murmur). The mitral valve prolapse murmur is one of two murmurs, the other being that of hypertrophic cardiomyopathy, that increases with Valsalva. The Valsalva maneuver decreases venous return to the heart, which results in decreased blood in the left ventricle. In this state, the prolapse occurs earlier and to a greater extent, augmenting the murmur. Increasing left ventricular volume will aid tension on the chordae tendineae to keep the valve shut.
A 53-year-old man presents with several hours of severe right toe pain. He denies injuring his foot. He has a past medical history of coronary artery disease, hypertension, and hyperlipidemia. His medications include aspirin, hydrochlorothiazide, and rosuvastatin. His vital signs are within normal limits. On exam, there is redness, swelling, and severe pain with light touch in his right great toe. Joint aspiration shows negatively birefringent needle-like crystals. What is the best initial step in therapy? Febuxostat Anakinra Colchicine Indomethacin Prednisone Allopurinol
This patient has a red, swollen, painful toe and multiple risk factors for acute gout. In particular, aspirin and hydrochlorothiazide both increase serum uric acid levels. Nonsteroidal antiinflammatory drugs such as indomethacin are first-line treatment for acute gout. Treatment should be initiated as soon as possible following the onset of pain and continued until complete resolution of symptoms.
A 26-year-old female presents to her gynecologist because she had a positive pregnancy test at home the day before. The first day of her last menstrual period was 42 days ago. She has been in a monogamous relationship for the past 5 years and is not using birth control. She has never been pregnant before. Menarche was at age 11. Menses currently occur every 35-90 days and last 5-6 days. She has never had a pap smear or mammogram. She denies any history of STDs. She has no ongoing medical conditions. She has no known drug allergies. Her mother has type II diabetes. She denies use of alcohol, tobacco, or illicit drugs. On exam, her vital signs are within normal limits. Her BMI is 34.6 kg/m2, and urine beta-hCG is positive. Which of the following should be performed at this visit?
- Pelvic exam, pap smear, transvaginal ultrasound, 1-hour glucose challenge test
- Pelvic exam, transabdominal ultrasound, CBC, urine gonorrhea test
- CBC, urine chlamydia test, parvovirus IgG, transvaginal ultrasound
- Hematocrit, RPR, indirect Coombs’ test, 3-hour glucose tolerance test
-Pelvic exam, pap smear, transvaginal ultrasound, 1-hour glucose challenge test
All new obstetric patients should undergo the following at their first visit:
Full physical exam Pelvic exam (speculum and bimanual) Pap smear if no current pap smear is available
The following testing should be ordered:
CBC Blood type, Rh factor, and antibody screen Syphilis screening test (RPR or VDRL) Chlamydia HIV Hepatitis B Gonorrhea, hepatitis C in high-risk patients
This patient has irregular menstrual periods, so her dating should be verified by early ultrasound. Early ultrasound also confirms viability and location of the pregnancy (intrauterine vs ectopic). This ultrasound should be performed as early in pregnancy as possible, preferably before 14 weeks’ gestation. She is also at increased risk for pre-gestational diabetes due to her obesity (BMI >30) and family history of diabetes, so she should undergo a one-hour glucose challenge test at her first visit. (Remember that patients do not need to fast before the one-hour glucose challenge test!)
A 54-year-old man is evaluated in the coronary care unit three days after suffering a myocardial infarction. His mentation has worsened compared to prior assessment and he is unable to answer basic questions. The nurse reports that his discomfort increased suddenly over the past hour. The telemetry monitor shows that he remains in sinus rhythm. His vitals are temperature 37.3°C (99.1°F), blood pressure 98/62, heart rate 112, SpO2 92% on room air. On exam, he appears to be in mild respiratory distress. Cardiac auscultation reveals a 4/6 holosystolic murmur, heard loudest at the apex, with radiation to the axilla. Pulses are reduced peripherally. Crackles are heard at the lung bases bilaterally. A 12-lead ECG demonstrates findings consistent with the evolving myocardial infarction. A bedside echocardiogram shows a hyperdynamic left ventricle, with an ejection fraction of 65% and severe regurgitant flow through the mitral valve. Which of the following is the best next step in management? Antiplatelet therapy Broad-spectrum antibiotics Preparation for surgery Percutaneous reperfusion Diuretic therapy
Preparation for surgery
This patient is experiencing hemodynamically unstable mitral regurgitation (MR) due to papillary muscle rupture, a classic complication of myocardial infarction (MI). If MR is severe, patients may develop a picture consistent with cardiogenic shock, as is the case in this scenario. The patient does not appear to be experiencing re-infarction based on absent ECG findings, though trending troponins would be appropriate. The patient’s echocardiogram paradoxically demonstrates normal ejection fraction, but this inaccurately reflects peripheral perfusion status, as a large portion of the stroke volume is being pumped retrograde through the mitral valve. In cases of severe MR in the post-MI setting, mitral valve repair is the appropriate treatment approach. Therefore, this patient should be prepared for urgent surgery.
An elderly woman with an extensive history of ischemic heart disease presents with a 2-month history of dyspnea on exertion which seemed to have an abrupt onset and has persisted since. She is found to have atrial fibrillation on ECG. What is the best next step in management?
Start Warfarin
start daily aspirin
start verapamil
This patient’s dyspnea was likely precipitated by loss of atrial “kick” due to atrial fibrillation 2 months ago when her symptoms began. As a general rule, one should only look for a reason not to give anticoagulation in atrial fibrillation; aspirin is only appropriate for stroke prevention in the uncommon case of “lone atrial fibrillation”, in which no underlying cardiac disease is present. This patient should receive a trial of electrical cardioversion, but not before at least 3-4 weeks of warfarin to prevent embolization of a thrombus that could have formed while she has been in atrial fibrillation. If atrial fibrillation has a known onset of <48 hours prior to presentation, this course of warfarin may not be necessary. But since we don’t know the precise start of her atrial fibrillation, anticoagulation for 3 weeks must be completed prior to cardioversion. Additionally, this patient should undergo an evaluation for possible causes of her atrial fibrillation including an transthoracic echocardiogram to look for evidence of structural heart disease and a thyroid-stimulating hormone level to detect hyperthyroidism. If attempts to electrically cardiovert this patient are unsuccessful, long-term management strategies include rate control (e.g. β-blockers, calcium channel blockers) or rhythm control (e.g. antiarrhythmics) and warfarin.
A 9-month-old female presents in the clinic with a rash. She has no other past medical history and her immunizations are up-to-date. She lives with her mother and two older siblings in a shelter. The older siblings do not have a rash, but they do have some itchy bumps on their hands. On physical exam, the child appears uncomfortable and has numerous small, erythematous papules on the hands, wrists, abdomen, ankles, and feet. There is evidence of excoriation. The rest of her physical exam is unremarkable. What is the best treatment for this patient? Benzyl alcohol lotion Lindane lotion Petrolatum ointment Hydrocortisone cream Calamine lotion Permethrin cream
The child in this vignette has scabies which is caused by Sarcoptes scabiei. The mite burrows under the skin where it lays its eggs. The rash is characterized by small papules overlying the mite bite as well as thin brown, gray, or red lines where the mites tunnel under the skin. The latter, referred to as burrows, are pathognomonic but often absent or obscured by excoriation. Typical locations for scabies lesions include the interdigital web spaces, wrist folds, elbows, axilla, buttocks, and belt line. Scabies is spread by skin-to-skin contact and through fomites. The mites can survive up to two days away from the human body. All of the family members should be treated simultaneously and all of the clothing and linens must be washed. Permethrin cream is the preferred treatment since it is poorly absorbed and rapidly metabolized by tissue esterases limiting its toxicity. It should not be applied near the mouth or eyes and the hands should be covered after application to present ingestion.
a. Benzyl alcohol lotion
Benzoyl benzoate is a treatment option for head lice that works via asphyxiation of the parasite.
b. Lindane lotion
Lindane is an effective treatment for scabies, however it is considered a second line therapy given significant side-effects. It is systemically absorbed and the toxic effects are greater in young children. It causes a rash and rarely aplastic anemia and seizures.
c. Petrolatum ointment
Petrolatum ointmentis not an effective treatment for scabies.
d. Hydrocortisone cream
Hydrocortisoneis not an effective treatment for scabies.
e. Calamine lotion
Calamine lotion is an anti-itch cream that is not an effective treatment for scabies.
