medicine nbme Flashcards
young healthy pt SOB x 6 weeks. Fixed split S2 2/6 systolic ejection murmur heard at the heart base
CXR - RV enlargement, Pul a. dilation
EKG - RBB block
What caused this?
Chronic volume overload of the RV
Pt on chemo meets SIRS. Start ceftazidime and what other abx? PMN count 2K
No other abx
If PMN count was <1000 add imipenem
50ish man w/ pain at mutliple sites through out his body x 1month
Bone scna - lots of dark spots in the femur
Bone mets
SOB
4/6 systolic murmur at LSB
Echo - LV thickening, calcified aortic valve area 0.8cm2
Next step?
AV replacement
Cause of dehydration in DKA?
Osmotic diuresis
New onset HTN after starting albuteral INH
hypo K+, Mag
Mineralcorticoid excess
Steatorrhea
+ Enomysial IgA Ab
Gluten-sensitive enteropathy (Celiac)
adult is treated with LABA nebulizer has 50% improvement in FEV1. What meds does he need for the next week?
po Corticosteroids
Tx for herpetic whitlow
po acyclovir
30 year old. No significant medical hx at first appointment. What screening do you need?
Serum cholesterol
Tx for prostatitis
Ciprofloxacin
sudden dyspnea after femur fx, petechia over chest
fat embolism
PE finding during hypotensive episodes in pericardial effusion?
Pulses paradoxes
Best way to prevent OA?
Weight reduction
Tx for acute gout attack
Indomethacin
Best way to prevent CVA in afib?
Warfarin
PT has SOB, JVD, S3, respiratory alkalosis.
CXR - b/l puffy infiltrates. Why does she have dyspnea?
Alveolar-arteriolar mismatch
Couple wants screening for SCD. Wife has Hgb A.
0%, mom does not have a copy of sickle cell trait so worse case scenario kid will have sickle cell trait
Hets have HgbS
Adult has frequent asthma, URI, OM, diarrhea since childhood. Anaphylactic reaction to transfusion
Obstructive lung patern
IgA deficiency?
After surgery pt has jaundice
High total bili, low direct
Gilbert syndrome
Recent viral illness Fatigue, jaundice Hepatomegaly High indict bili, alk phos AST - 350 ALT - 280 Lactate - 410
Hepatitis?
T1DM pt collapses while jogging
50% dextrose in water. he is more likely to be hypoglycemic
2 wks s/p colectomy pt develops fever while on abx therapy. CT is clrea Why?
Drug allergy/reaction
2 weeks s/p wonder drug
After an MI pt has wide QRS complexes, where in the heart?
Ventricles
Elderly pt 2 month hx of fatigue weight loss Na+ 128 K+ 6 BUN 30 Cr 1.6 What is the next step?
ACTH stimulation test
Regurgitating undigested food x 4 months. Sensation of food sticking to his throat.
Gurgling when swallowing
Order a?
Barium swallow
Older lady abdominal pain x 2 weeks, pruritis x 1 wk gallbladder out years ago Jaundice Total bili - 11.9 Alk Phose 305 AST 34 ALT 42 Amylase 56 U/S - dilation of common bile duct and pancreatic duct. What next?
Need to r/o mass at head of pancreas - get a CT
Untx HIV pt has fever, B syx,
CXR - mass in LUL posterior
What do you need to confirm dx?
Bx and culture of the lung mass
Mole x 15 yrs, has not changed
PE -raised, round, brown, symmetric, smooth, moveable ingluinal LN
What do you need to do?
Just observe
Don’t need to bx lesion or LN
Older lady was found down in her home x 2days. She’s very dry, Na+ 155. Start her on?
Normal saline
Young pt with new assymetrical weakness x months
Fasiculations
UMN and LMN signs
elevated creatine kinase
ALS
SOB x 6 months edema, bibasilar crackles CXR - cardiomegaly Echo - dilated L and R ventricles Dx?
Cardiomyopathy
19 y/o
Never had a menstrual period
Not able to differentiate smells
Hypogonadotropic hypogonadism (Kallman syndrome)
Sudden chest pain radiating to arm and back hypotensive diastolic murmur at USB Non specific ST wave changes CXR - small pleural effusion
Aortic dissection
Health care worker has a + annual PPD
CXR - NL
Whats the next step?
Isoniazide + vit b 6
Difficult to control HTN + abdominal bruit
Why do they have worsening of HTN?
RAAS activation
Leg pain x 4 months NO trauma Warm/tender over L ant tibia Pulses 1+ Xray - increased cortical thickness along the tibia with slight anterior bowing. Alk Phos - 100 Bone scan - several areas of increased uptake What's the cause?
Paget’s
Increased bone turnover
Painless hematuria in a smaker is caused by?
Bladder cancer
Malignant transformation of epithelial cells
30ish guy intermittent fever, nonproductive cough x 3 months 30lb weight loss Treated for L anterior uveitis 2 months ago AST - 100 Alk Phos - 200 CXR - hilar adenopathy DLCO 70% PPD negative Dx?
Sarcoidosis
pt on vent x weeks
febrile, tachy, hypotensive
CO is increased, CVP increased
Give IVF. What else does he need?
Systemic broad spectrum abx?
What lab is likely to be elevated in a pt with shock?
Lactate
Elderly pt with AMS becomes comatose and family is not availble to be a proxy. What do you do?
Get CT w/o consent
Peripheral edema, DOE x months
V/P lung scan - two subsegmental perfusion defects but no ventilation abnormalities
echo - mitral annular calcifications
What’s causing the dyspnea?
Recurrent Pulmonary emboli
30 y/o female low grade fever and rash x days On cefazolin therapy for osteomyelitis Faint diffuse maculopapular rash Urine sediment has esoinophils What is this?
Interstital nephritis
52 y/o alcoholic male
Unable to move lower extremities x 4 hours
Oliguria
Catheterization yields only a small volume of urine that’s + for blood. Dx?
Rhabdomyolisis
60 y/o man progressive pain and stiffness of the hands x 8 months Worse at the end of the day Fatigue, polyuria x 1 year Dark brown skin hyperglycemia How do you confirm dx?
Hemochromatosis
“bronzed diabetes”
Dx - measure serum ferritin
Tx - phlebotomy
67 y/o female
12 watery stools/day x 2 days
abx in hospital 2 wks ago for PNA
Flexible sigmoidoscopy - pseudomembranes. Dx?
C. diff
From ingested spores
52 y/o female 2 day hx of rash on her abdomen
Receiving chemo for non hodgkin lymphoma
febrile, vesicular rash over L and R lower quadrants and on her back
Tx?
IV acyclovir
Pt is brought by her son for stroke. Son insists on receiving tpase but this is contraindictated d/t size of the stroke. Son insists. What do you do?
Do not administer tpase despite son’s insistence because it is medically contraindicated
DM pt w/ SOB and peripheral edema x 3 wks
Orthopnea, S3
What would be found in the pleural fluid?
Glucose concentration about the same as the serum glucose concentration
52 F R knee pain after falling x 1 wk Worsening, cannot bear weight, effusion, limited ROM Xray - degenerative dz, no fx What next?
Need a joint tap
27F
Fe deficiency anemia d/t excessive menstration
Changes on CBC?
Decreased Mean red cell volume
NOT decreased RDW, TIBC or Increased ret count, ferritin
62F Pt needs surgery. PMH signficant for: HTN CABG x 3 yrs ago MI x 5 months ago Smoker PVC's on EKG Greatest predictor for perioperative MI?
MI w/in past 6 months
NOT Age, ECG, CABG, HTN, or Smoking
37M GI bleed after NSAID use
HCT 18%
Next step?
pRBCs
NOT NS, FFP, H2 blocker, octreotide
32 F gardener
Rash x 1 day
Bright red papules, vesicles, bullae, some in a linear pattern w/ oozing versicles
Contact dermatitis
18F febrile, tonsils with exudate
+ ant and post cervical lymphadenopathy
spleen tip 1 cm below L costal margin
Monospot test
57M COPD w/ ipratropium
4 days SOB, yellow sputum
CXR - hyperinflation
Dx?
Bronchitis
52F
polyuria, polydypsia x 7 days
Water deprivation - urine and serum increase in osmolality
She is given desmopressin and her Urine Osmo doubles
Why?
Idiopathic central DI
65M smoker
Hypertensive w/ retinopathy
What test is needed?
Serum Cr
NOT renin, aldosterone, metaneprhine, BUN:Cr
57 M admitted for unexplained fever develops renal failure
Meds: acetazolamide, lisinopril, heparin, amikacin, naproxen
2+ pitting edema
UA - WBCs, epithelial cells, muddy brown casts.
Which med caused the ARF?
Amikacin (abx, aminoglycoside)
Side effects are similar to other aminoglycosides -> kidney damange and ototoxicity
37M watery diarrhea x 8 weeks
New onset Patchy alopecia on the scalp, hyperkeratotic lesions on the elbows and knees
He has a deficiency in?
Zinc
67M
PNA
Thoracentesis yields yellow fluid w/ low glucose, triglycerides, LDH 1.5x that of serum, acidic
What is the dx?
Empyema
Low glucose, high LDH, acidic
27M Jaundice x weeks, hepatomegaly HBS sAg - AntiHBVc Ag + Anti HBV sAg - What could have prevented this?
HBV vaccine
20M w/ gynocommastria, rare erections, sparse facial hair, tanner 3 FSH 2x NL LH 2x NL Testerone 1/2 of NL What would confirm dx?
Karyotype
90F pruritis, weight loss, BMI 14 Anemic hyponatremic hyperkalemic BUN 45 Cr 3 Why is she anorexic?
Renal failure
25M gets sudden onset HA, dizziness, n/v while picking peaches
Hypotensive, weak, diaphoretic, pinpoint pupils
What is the mechanism?
Decreased synaptic activity of cholinesterase
32 F Burning substernal chest pain x 2 weeks Wakens her from sleep, relieved with sitting up Smoker Murmur Next step?
Give po H2 receptor blocker
15F
Intermittent fleeting pain under breast
midsystolic click
ECG NL
Reassure
37F non radiating chest pain during sleep. Lasts 20 min resolves spontaneously
no heart burn, diaphoresis
ST changes on EKG but they resolve by the time she arrives to ER
Dx?
Variant angina pectoris
Older pt w/ pyelo grouped clusters of vesicles. They look dark but that seems weird
Varicella-zoster virus
62F
DOE x 3 months
Slow rising sustained carotid pulse
Apical beat is sustained inferiorly and laterally
4/6 harsh systolic ejection murmur peaking late in systole
Dx?
Bicuspid aortic valve
47F T2DM 148/88mmHg A1C 5.8% LDL < 95 Next step?
Add enalapril
goal <140/80
27M HIV CD4 count 110 on 2xstrength Bactrim \+ Ab's against toxo and HBV What is needed to asses the pts risk for opportunisitic infection?
PPD
NOT sputum cytology, urine CMV, Stool mycobacterium, CXR
62F SOB x 3 mo
COPD no meds
Overall looks well
Next step?
Start ipratropium
37F Puffy eyes, peripheral edema x 6 weeks heavy menses weight gain Hyponatremic high CK What should be measured next?
TSH
47 F non smoker w/ cough
CXR - 3 cm peripheral lesion
Dx?
Adenocarcinoma
37M weight loss, early stiety, splenomegaly WBC 23,600 PLT 500,000 Lots of blasts on smear Dx?
CML
52F SOB x 1 hr Orthopnea JVD B/l lung crackles Pitting edema Nest step in management?
IV furosemide
22M Closed head injury Oriented UO = 50mL/24hr Na+ = 120 Urine Osmo = 340 Next step?
Fluid restriction
37F 1 yr hx of: resistant GERD Diarrhea Raynaud Dx?
Systemic sclerosis (scleroderma)
42F
new dx PKD
What are the odds her kids will have PKD?
50% (AD)
47M alcoholic
2 wk hx of productive brown foul sputum
Foul breath, poor dentition
Which abx?
Clindamycin
57F Confusion, drowsy x 4 hrs On tamoxifen Dry Sr Ca2+ 16 What is the next step?
IV NS
42F
RA x 10 yrs, no meds
Splenomegaly
neutropenia
Felty syndrome
Tx the RA or splenectomy
76M collapses at home after 6 hrs of chest pain SBP 80mmHg pulse 103 Ashy Why hypotensive?
Decreased myocardial contractility
42M progressive SOB x 1 mo Non smoker Younger Brother has COPD CXR - hyperinflation Whats the cause?
Abn of antiprotease resulting in destruction of alveolar supporting structures
72F CAP waxing and waning alertness Seems lucid right now Wants to leave AMA What do you do?
Asses her decision-making capacity
73M syncopal episodes x months
Whats the next step in dx?
Ambulatory EKG monitor
NOT CXR, CT, Carotid doppler, LP
48M alcoholic upper abd pain, n/v x 2 days Tachy, hypotensive FBOT + Ca2+ - 7.6 Sr Alb - 3.5
Pancreatitis
If you increase the upper limit of serum creatine kinase from less than 5% to less than 8% What would this do to sens and spec?
Decreased sensitivity (SNOUT) Increased specificity (SPIN)
62M w/ hemochromatosis
in shock
Abd distention
What is the next step in dx
Paracentesis
62M sudden L hemiparesis resolving in 2 hours
Carotid bruit heard
Next step?
Duplex U/s of carotids
NOT EKG, echo, carotid arteriography, MRI
20M long car ride
Eythematous fluctuant area of edem in the intergluteal cleft above the sacrum at midline. Small purulent discharge from small opening
What is the next step?
Surgical drainage
NOT wide excision
62F urinary incontinence x 3 weeks
Can’t reach bathroom quickly enough after feeling need to void
What is appropriate tx?
Oxybutynin
47M hip pain x 1 month
HD x 6yrs for hypertensive nephropathy
CXR - nondisplaced fx of the femoral neck
What is the underlying cause?
Deficient mineralization of osteoid
62F confusion x 2 days HCT 24%, WBC 3.4 Ca2+ 13 Cr 2 Protein 9.5 Albumin 4.5 What is next?
IV NS
NOT CT of the head, Cefepime, LP, HD
32 F low grade fever, joint pain, weight loss x months RF - ANA + 1:320 Anti smith + Next step?
Prednisone
67F fever, hypotension, ARDS In shock Increased PCWPs, b/l crackles Why does she have respiratory failure?
Increased vascular permeability
NOT Decreased pulmonary vascular flow
27F hip pain x 2 months
methylprednisolone for SLE
Xray - one femur is less dense
Dx?
Osteonecrosis
New lesion that has dark spots, x 6 months
Needs surgical excision
74 F
MI -> cardiogenic shock. What is the acid base disturbance?
Primary metabolic acidosis (lactate)
23 M african american swelling above knee x 2 months Retinoblastoma in infancy Alk Phos - 1350 Xray - lytic lesion w/ periosteal new bone @ the margins Dx?
Osteosarcoma
deletion of 13q14 -> inactivation of Rb
40M cold syx, weight loss, weight count
CXR - large cavitary lesion a/ an air-fluid level in the superior segment of the RLL
Lung abscess
27 F Fever unilateral knee pain x 2 days Erythematous papules on both palms Joint tap: WBC 45000, - gram stain, no crystals Dx?
disseminated gonorrhea
65 F, macrocytic anemia. What is the primary pathophysiologic mechanism causing her anemia?
Impaired DNA synthesis
22F febrile, flank pain x 2 days Septic RBC, WBC on UA Tx with?
IV Ceftriaxone
30 F PMH SLE
severe chest pain x 2 hours, increases with respiration
Most likely dx?
Pulmonary embolus
52 F, pain and swelling in knees x 2 months
Stiffness worse in the morning
Xray - osteopenia, subcartilaginous cysts around the joints, joint space intact
What tx?
Intra articular injection of methylprenisolone
50M massive hematemesis, hypotensive
Tx?
Rapid NS IV
75 F s/p hip replacement rapid onset chest pain, dyxpnes, confusion pH 7.46 PCO2 28 PO2 62 What would prevent this?
Administering oxygen
57 M has acromegaly. How do you confirm dx?
Serum insulin like growth factor 1
57 M
SOB wheezing x 2 ddays
JVD, crackles in the lungs, S3, ankle edema
CXR - cardiomegaly and cephalization of the pulmonary vessels
Dx?
Pulmonary edema
48M alcoholic. Confused and drowsy, wide based gait. What does he need?
Vitamin B1 (thiamine)
21 M post tussive vomitting x 2 weeks
Pertusis
82M COPD exacerbation
no urine x 12 hours
on IV methylprenisolone. albuterol, ipratropium, fluticasone
Dx?
Urethral obstruction
55F riping substernal chest pain x 30 min
CXR - widened aortic root and dilated ascending aorta.
What is the cause?
Medial degeneration of the aorta
27 M Hemophilia A pt
No longer responding to supplemental factor VIII
PLT 125k
aPTT 120s
Whats the best study to dx the increased bleeding?
Test for Factor VIII inhibitor
64F exertional chest pain x 3 weeks
No ECG changes. Now what?
Antianginal drug therapy now and exercise stress test in 5 days
