IM 4 Flashcards
CF 18. 27yo W @ ER complaining of retrosternal chest pain for past 2 days. Constant pain, not associated with exertion, worsens when she takes a deep breath, and is relieved by sitting up and leaning forward. Denies any shortness of breath, nausea, or diaphoresis. On examination, her temp 99.4, heart rate 104, blood press 118/72. She is sitting forward on the stretcher, with shallow respirations. Her conjunctivae are clear and her oral musoca is pink, w/ 2 aphthous ulcers. Her neck veins are not distended, her chest is clear to auscultation and is mildly tender to palpation. Her heart rhythm is regular, w/ a harsh leathery sound over the apex heard during systole and diastole. Her abdominal examination is benign, and her extremities show warmth and swlling of the proximal interphalangeal (PIP) joints of both hands. Lab studies: WBC 2100, hemoglobin conc 10.4 with MCV 94, and platelet count 78k. Her blood urea nitrogen (BUN) and creatinine levels are normal. Urinalysis shows 10 to 20 WBCs and 5 to 10 RBCs per hpf. A urine drug test is neg. Chest x-ray is read as normal, with a normal cardiac silhouette and no pulmonary infiltrates or effusions. The ECG is shown in fig 18-1. Dx?
Acute pericarditis as a consequence of SLE
68yo M w history of end-stage renal disease is admitted to hospital for chest pain. On exam, a pericardial friction rub is noted. His ECG shows diffuse ST-segment elevation. Treatment?
Dialysis. Uremic pericarditis is considered a medical emergency and an indication for urgent dialysis.
Patient described in 18.1 (previous) is hosp, but there is a dealy in initiating treatment. You’re called to the bedside b/c he has become hypotensive with systolic blood pressure of 85/68, a heart rate of 122, and you note pulsus paradoxus. A repeat ECG is unchanged from admission. Intervention?
Echocardiographic-guided pericardiocentesis. Clinical picture suggests the patient has developed pericardial tamponade.
25 yo W compl of pain in her PIP and MCP joints and reports recent pos ANA lab test. Which of the following clinical features would not be consistent with a diagnosis of SLE?
Sclerodactyly, which is thickened and tight skin of the fingers and toes is a classic features of patients with scleroderma (who may also have a positive ANA test), but it not seen in SLE
CF 19. 27 yo M presents to the outpatient clinic compl of 2 days of facial and hand swelling. He first noticed swelling around his eyes 2 days ago, along with diff putting on his wedding ring bc of swollen fingers. Additionally, he noticed that his urine appears reddish-brown and that he has had less urine output over the last several days. He has no significant medical history. His only medication is ibuprofen that he took 2 wks ago for fever and a sore throat, which have since resolved. On exam, he is afebrile, w heart r8 85 and bld press 172/110. He has periorbital edema; his funduscopic exam is normal w/o arteriovenous nicking or papilledema. His chest is clear to auscultation, his heart rhythm is regular with a nondisplaced point of maximal impulse (PMI), and has not abdominal masses or bruits. He does have edema of his feet, hands, and face. A dipstick urinalysis in the clinic shows specific gravity of 1.025 with 3+ blood and 2+ protein, but it is otherwise neg. Dx? Nxt dx step?
Acute glomerulonephritis (GN)/examine a fresh spun urine specimen to look for RBC casts or dysmorphic RBCs.
19.1// 18yo M. marathon runner has been training during the summer. He is brought into ER disoriented after collapsing on the track. His temp is 102F. A Foley catheter is placed and reveals reddish urine w/ 3+ blood on dipstick and no cells seen microscopically. Which of the following is the most likely explanation for his urine?
Myoglobinuria. Individual suffering from heat exhaustion, which can lead to the rhabdomyolysis and release of myoglobin.
19.2// Which of the following lab findings is most consistent with poststreptococcal glomerulonephritis?
Elevated ASO titers. The antristreptolysin-O titers typically are elevated and serum complement levels are decreased in poststreptococcal GN.
19.3// A 22yo M compls of acute hemoptysis over the past week. He denies smoking or pulmonary disease. His blood pressure is 130/70, and his physical examination is normal. His urinalysis also shows microscopic hematuria and RBC casts. Which of the following is the most likely etiology?
Goodpasture disease (antiglomerular basement membrane). This disease typically affects young males, who present with hemoptysis and hematuria.
CF 20// 48yo Hispanic W presents to office compl of persistent swelling of her feet and ankles, so much so that she cannot put on her shoes. She first noted mild ankle swelling approximately 2 to 3 months ago. She borrowed a few diuretic pills from a friend; the pills seemed to help, but now she has run out. She also reports that she has gained 20 to 25 lb over the last few months, despite regular exercise and trying to adhere to a healthy diet. Her med history is significant for type 2 diabetes, for which she takes a sulfonylurea agent. She neither sees a doctor regularly nor monitors her blood glucose at home. She denies dysuria, urinary frequency, or urgency, but she does report that her urine has appeared foamy. She had no fevers, joint pain, skin rashes, or gastrointestinal (GI) symptons. Her physical exam is significant for mild periodbital edema, multiple hard exudes, and dot hemorrhages on fundoscopic examination, and pitting edema of her hands, feet, and legs. Her chest is clear, her heart rhythm is regular w/o murmurs, and her abdominal exam is benign. She has diminished sensation to light touch in her feet and legs to mid-calf. A urine dipstick performed in the office shows 2+ glucose, 3+ prot, and neg leukocyte esterase, nitrates, and blood. Dx? Intervention to slow disease progression?
Nephrotic syndrome as a consequence of diabetic nephropathy// Angiotensin-converting enzyme (ACE) inhibitors
20.1/ 49yo W w/ type II diab presents to your office for new onset swelling in her legs and face. She has not other medical problems and says that at her last ophthalmologic appointment she was told that the diabetes had started to affect her eyes. She takes glyburide daily for her diabetes. Physical examination is normal except for pitting edema of bilateral upper and lower extremities, hard exudates and dot hemorrhages on funduscopic examination, and diminished sensation to the mid-shin bilaterally. Urine analysis shows 3+ prot and 2+ glucose (otherwise neg). Best treatment?
Start lisinopril. Beta blockers are a good first-choice agent for a patient with hypertension and no comorbidities.
20.2/ 19yo M was seen at univ health center a week ago compl of pharyngitis, and now returns because he has noted discoloration of his urine. He is noted to have elevated blood press 178/110 and urinalysis reveal RBC casts, dysmorphic RBCs and 1+ proteinura. Dx?
Post-streptococcal glomerulonephritis. The patient has hypertension, and a urinary sediment consistent with nephritic rather than nephrotic syndrome (RBC casts, mild degree of proteinuria).
20.3/ Which of the following is the best screening test for early diabetic nephropathy?
Urine microalbuminaria. Although a 24-hr urine collection for creatinine may be useful in assessing declining GFR, it is not the best screeing test for the diagnosis of early diabetic nephropathy.
20.4 / 58yo M with type 2 diab is normotensive but has a persistent urine albumin/creatinine ratio of 100, but no proteinuria on urine dipstick. Best mgmt fr patient?
Start ACE inhibitor. The albumin/creatinine ratio of 100 is indicative of microalbuminuria.
CF 21// 48yo M comes compl of severe right knee pain for 8 hrs. He states that pain, which started abruptly at 2AM and woke him from sleep, was quite severe, so painful that even the weight of the bed sheets on his knee was unbearable. By the morning, the knee had become warm, swollen, and tender. He explains that he prefers to keep his knee bent, and extending his leg to straighten the knee causes the pain to worsen. He has never had pain, surgery, or injury to his knees. A yr ago, he did have some pain and swelling at the base of his great toe on the left foot, which was not as severe as this episode, and resolved in 2 or 3 days after taking ibuprofen. His only medical history is hypertension, which is controlled with hyddrochlorothiazide. He works as a financial analyst; he is married and does not smoke, but he does consume one or two drinks after work one to two times per week. On exam, his temp is 100.6F, hear rate 104bpm, and blood press 136/78. His head and neck exams are unremarkable, his chest is clear, and his heart is tachycardic, but regular, with no gallops nor murmurs. His right knee is swollen, with a moderate effusion, and appears erythematous, warm, and very tender to palpation. He is unable to fully extend the knee because of pain. He has no other joint swelling, pain, or deformity, and no skin rashes. Dx? Nxt step? Best initial treatment?
Acute monoarticular arthritis, likely crystalline or infectious, most likely gout because of history// Aspiration of the knee joint to send fluid for cell count, culture, and crystal analysis// If the joing fluid analysis is consistent with infection, he needs drainage of the infected fluid by aspiration and administration of antibiotics. If analysis is suggestive of crystal-induced arthritis, he can be treated with colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), or corticosteroids.
21.1/ A previously healthy 18yo F (college freshman) presents to health clinic compl of pain on the dorsum of her left wrist and in her right ankle, fever, and a pustular rash on the extensor surfaces of both her forearms. She has mild swelling and erythema of her ankle, and pain on passive flexion of her wrist. Less than 1mL of joint fluid is aspirated from her ankle, which shows 8000 polymorphonuclear (PMN) cells per high-power field but no organisms on Gram stain. Best initial treatment?
Intravenous ceftriaxone. The patient described best fits the picture of disseminated gonococcal infection.
21.2/ Which of the following dx tests is most likely to give the dx for the case in Question 21.1?
Synovial fluid cultures usually are sterile on gonococcal arthritis (in fact, the arthritis is more likely caused by immune complex deposition than by actual joint infection), and blood cultures are positive less than 50% of the time.
21.3/ 30 yo M is noted to have an acutely swollen and red knee. Joint aspirate reveals numerous leukocytes and polymorphonuclear leukocytes, but no organisms on Gram stain. Analysis shows few neg biregringent crystals. Which of the following is the best initial treatment?
Intravenous antibiotic therapy. Corticosteroids should not be used until infection is ruled out.
