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
Most likely cause of acidosis in DKA/HOH?
Accumulation of B-hydroxybutic acid
27 F, health
lots of swelling x weeks
Sr albumin 2.5
why?
Nephrotic syndrome
87 M forgetful with names
MMSE 27/30
dx?
Mild cognitive impairment
32F, dilation of achlasia
contrast is leaking into her chest.
Now what?
OPerative repair of the esophageal injury
47M w/ travelers diarrhea (water x several days) occ green diarrhea
Enterotoxigenic E. coli
77 F shortness of breath climbing stairs x 3 months
Relieved with rest
No chest pain
EKG - LBB, no T wave changes. Unchanged in a year
Next step in dx?
Exercise stress echo
NOT EKG stress test
52M is interested in an investigational drug. What is the best study design?
RTC drg vs standard therapy
68M substernal chest pain and SOB x 2 hours
JVD, crackles, S3, S4
CXR - b/l perihilar infiltrates, cardiomegaly
EKG ST elevetation, T wave inversion V2-V5.
Dx?
MI
77F brought in for confusion and sleepiness x 12 hours Na - 146 K+ 5 Ca2+ 15 BUN 40 Glucose 105 Cr 1.8 Albumin 3.1 Next step?
IV NS
Uptodate - volume expand w/ isotonic saline at 200-300 mL/hr, calcitonin, zoledronic acid
NS corrects hypercalcemia due to osmotic diuresis or salt wasting
67 M nocturnal incontinence x 2 months
Taking amitryptiline
UA is bland
Dx?
BPH
57 F MVA
Can extend DIP, PIP but not MCP or wrist
midshaft humoral fx
Dx?
Radial n. injury
67M pain at the fingertips x 1 mo Plethora and splenomegaly Hgb 20.2 NL Labs, ABG Next step?
Phlebotomy
42 F dizziness, difficulty with balance x 3 days
TM dull b/l, distorted light reflex
No other signs of illness.
Dx?
Labyrinthitis (AKA vestibular neuritis)
Self limitied
vertigo, n/v gait impairment
34 M fever, rahs x 2 days
just completed 6 wk course of naf
maculopapular rash
What is this finding on UA?
AIN 1.005 SF trace flucose 2+ protein WBC 30 RBC 3 Rare WBC casts eosinophils
47 M fatigue SOB x 6 months Told he had a murmur as a teen 2/6 systolic murmur RUSB EKG - LVH Dx?
Congenital bicuspic aortic valve
65M
FOBT +
Next?
Colonoscopy
72M worked in the shipyrad non productive cough, SOB x 2 months dull to percussion of LLL CXR - calcified pleural plaques and L pleural effusion Toracentesis - glucose 4 dz is caused by exposure to?
Asbestos
27 F african america chest tightness, SOB x 1 wk former smoker cough worse during sleep end expiratory wheezing b/l What is causing her syx?
Activation of mast cells (asthma)
35 F suddenly collapses
Shes in shock
Dx?
Anaphylactic shock
42 F SOB, cough x years
reactive airway dz
Multiple URI’s
Whats next step in dx?
Measure serum Ig concentrations
72 F, SOB x 1 month
EKG non specifc ST segment changes
EF 70%
Pulmonary congestion
High output HF
19 F wants isoretinoin for acnes tx
What is a contraindication?
Sexually active w/o contraception
57 M with headaches
Glucose 265
Most likely cause of high glucose?
T2DM
73 M SOB, CP x 1 hr diaphoretic, cardiogenic shock EKG - wide complex tachycardia Tx?
synchronized cardioversion
27 M with IDD
Regurgitating food instantly
alopecia
Gastric bezoar
46 F ill for a while pleural fluid: WBC 50,000 pH 7.11 Glucose 20 protein 4 lactate 400 Next step?
Chest tube
27 M cholesterol 190
Recommend diet changes
Next step?
check again in 5 years
27 F HIV
cold syx
Sputum gram stain - GP diplococci
Tx?
Ceftriaxone
36 M fever, chills, abd pain, dark urine x 1 day PMH ulcerative colitis ING 1.8 Cholesterol 320 Alk Phos 300 ALT 120 viral serologies negative dx?
Sclerosing cholangitis
65 M fatigue x 2 months blood transfussion 1985 HCV + HBV + consistent with vax/prior infection (HBsAg , Anti HBs +, Anti HBc +) Dx?
Chronic hep C
19 M, watery urethral discharge and high risk sex
Chlamydia
67 M, Hematemesis x 2 days
PMH cancer treated w/ radiation (current), prosthetic mechanical heart valve
What is the greatest reason for why he needs anticoagulation?
Prosthetic heart valve
22M swelling of the neck x 1 month
Malaise, fever, fatigue, night sweets, pruritis x 2 weeks
NL WBC count but 33% lymphocytes
Dx?
Hodgkin dz
58 M fatigue and malaise x 3 weeks Root canal 5 weeks ago Told he had a murmur at 19 y/o 2/6 systolic ejection murmur head best at the right second intercostal space, S4, ejection click. Dx of cardiac abnormality?
Calcification of a bicuspid aortic valve
72 M burning, aching pain in distal extremities x 3 weeks
exacerbated by lowering the extremities, relieved by elevation
edema and clubbing
What is likely to be abnormal?
CXR - lung cancer
24F wants advice on best way to prevent OA
Weight loss
62M hospital for PNA
HD 2 BUN 50, Cr 2.4
Urine: Na<10, FNa <1%, trace protein
What is causing the RF?
Prerenal azotemia (BUN:Cr > 20)
57M in ER after LOC x 3 minutes
Impending sense of feeling ill while at rest
No incontinence during episode, no post ictal state
PMH sig for MI 4 years ago
Vitals WNL
EKG - Q waves in II, III, aVF
What caused this?
Paroxysmal ventricular tachycardia
NOT hypoglycemia, Pulm embolus, Seizure, TIA (basically nothing else made any sense)
32F nulligravid, irregular menses x years
All PCOS syx (overweight, 30-60day intervals, hirtuism).
You recommend weight loss and?
OCPs
42 F GERD x 4mo, dysphagia to solids x 1 month
Ranitidine ineffective
next step?
EGD
87 M resident of nursing home
Pressure ulcer on leg
Exchar w/ small rim or erythema
Next step?
Debridement
NOT: air bed, wet to dry dressings, silver sulfadiazine cream w/ sterile dressing, skin graft
32 F progressive sensory loss x 1 wk
Initially just feet were numb but has ascended to umbilicus
+ urinary urgency, frequency, nocturia, tight band like sensation around mid abdomen
Left eye adduction when looking to the R
hyperreflexia
What is causing slowing of the left eye adduction d/t a lesion where?
L Medial longitudinal fasciculus
72 F with malignant HTN (200/105) Previously controlled with thiazide Funduscopic exam - AV nicking R carotid bruit Most likely cause?
Renal a. stenosis
NOT: cushing, Hyperaldosterone, Pheo
56 F epigastric pain and vomitting x 1 day Scleral icterus Total Bili - 4.4 D Bili 3.3 Amylase - 1350 Alk Phos - 320 U/s - dilation of intrahepatic ducts Dx?
Choledocholithiasis
67 M slowly increasing BP
Very health w/ low cholesterol diet
What is the most critical factor in the etiology of this pts HTN?
Decreased vascular compliance (arteriolsclerosis?)
21 F sore throat fever x 8 days Crackels over LL fields CXR - pathy, Lower R alveolar infiltrates w/ increased interstitial marking High WBC with L shift Etiology?
Mycoplasma PNA (walking PNA)
57 F fever, abd cramps, watery diarrhea, cough x 5 days right after returning from a conferrence
Smoking x 20 yrs
Febrile
WBC count w/ L shift
CXR - alvelolar infiltrates in the RU and lower lobes, LLL.
Gram stain - semented PMN’s but no organism
Etiology?
Legionella PNA
55 M in a coma following a sudden collapse.
Recent CABG
EKG - wide QRS, vent rate 170bpm, atrial rate 110 bpm
Initial step?
Direct current countershock
NOT digitalis, verapamil, carotid massage, external pacing
47 F poorly controlled T2DM w/ metformin
Best way to prevent progression of DM nephropathy?
Add lisinopril
42 F tender bump on her neck x 2 days
10 pyr smoking hx
TSH - 1.5, T4 - 1.4
Next step?
FNA
NOT radioactive thyroid uptake (I think thyroid hormone levels would have to be more abnormal)
32F epigastric pain, n/v/ x 8 hrs Amylase 1450 CT c/w pancreatitis U/S of gallbladder WNL Next step in dx?
ERCP
47 F sever abd pain, n/v x 24 hrs Imprves with vomiting Last BM 24hrs ago dental procedure and taking opioid Dry MM distended and tympanic abdomen, high pitched bowel sounds Benign labs Xray - distended loops of small bowel with air fluid levels. Dx?
SBO
57 F stage IV non small cell lung cancer. Does not want anymore testing, dNR. What is her best option moving forward?
D/c home w/ home hospice care, advance directives, durable POA
42 M gradual onset of greasy, diffuse scaling of the scalp w/ itching x 1 year
Yellowish red scaling papules along the hairline and behind the ears
No hair loss
Dx?
Seborrheic dermatitis
20 F
Split fixed S2
2/6 systolic murmur heard over third intercostal space
Dx?
ASD
Fixed split S2
72M abd pain, bloody stool x 3 days
Febrile
LLQ tenderness and distention
Dx?
Diverticulitis
62M sudden onset SOB
PMH COPD on home oxyge
80 pyhx
He develops AMS, why?
Hypercarbia
57 F, EtOH abuse found down Meets SIRS BUN 58, Cr 3.4 Urine - reddish, 3+ blood, 1+ protein, hyaline casts Dx?
ATN d/t rhabdo
NOT Acute GN, AIN, glomerulosclerosis, or pyelo
27 M loose stools and weight loss x 3 months
+ fecal fat
d-xylose absorption test shows 4 mg D-xylose 2 hours s/p administration of 25 mg of d-xylose
Why does he have malabsorption?
Villous atrophy in the small bowel (Celiac)
27 M sudden onset of SOB while scuba diving. He ascended repaidly
PaO2 88% on RA, cannot complete sentences, accessory muscle use
Decreased breath sounds, hyperrosonance on L
Next step?
CXR
The bends can make pt prone to PTX
20 F sore throat, hoarse, dysphagis x 8 hours Toxic appearing Febrile, pharyngitis, stridor leukocytosis Next step?
Laryngoscopy and intubation
Do it before you lose her airway
52 M fatigue x 4 months
Chronic renal insufficiency
Normocytic anemia w/ NL ferritin, Iron
Supplement with?
Erythropoietin
30M R shouldr pain initiated by reaching overhead
Occurs during sleep
Pain most prominent over deltoid
Reproduced by abduction of the shoulder against resistance
Which tendon is damaged?
Supraspinatous
37 M progressive SOB x 1 year Non smoker, but wife does smoke Dad died from alcoholic cirrhosis SPO2 90% on RA, end expiratory wheezes CXR - increased lucency and bullous changes at lung bases What is the Dx?
alpha1 antitrypsin deficiency
62M weakness, inability to walk x 2d, but was admitted for PNA 7 days ago
Platelet count severely decreased
NExt step?
Stop heparin, start DOAC
62 M lethargy, weakness, confussion, constipation x 3 days
SCC
Ca2+ 15.2
EKG - short QT interval
IV NS is started, what is an appropriate pharmacotherapy?
Pamidronate (bisphosphonate to reduce calcium and stabilize bone)
42 M Sudden onset of HA and L sided weakness x 1 hour
smoker, drinker
BP 180/120
Cholesterol - 400
CT - hyperintensity at R putamen
What would have decreased his risk of stroke?
Linsinopril
NOT Etoh/smoking cessation, weight loss, statin, clopi
37 F
CRF d/t polycystic kidney dz, on HD
Vax - Td, pneumovax 3 years ago, flu vax 1 yr ago, AbHBVSag +
What does she need?
Flu vax
72 F w/ multiple episodes of S. pneumo PNA. What would be the best way to confirm her deficit in host defenses?
Quantitative Ig assay
42 F fever/c, HA, joint/muscle pain x 1 day
recent hospitalization for overactive thyroid and d/c’d on 2 meds
Lid lag, exophthalmos, goiter
WBC 1400, 5% PMN
Dx?
Drug induced neutropenia (agranulocytosis)
77F palpitations x 2 days weight loss Goiter TSH <0.05, T4 30ug Increased uptake in the leeft lobe and suppressed uptake everywhere else. What is the mechanism?
Autonomous T4 production
42 F Dx w/ HTN 6 months ago and started on HCTZ Lisinopril added 8wks ago BP 160/98 today 1+ Urine protein how can she prevent renal failure?
Increase lisinopril dosing
24 M HIV + on no meds
CD4+ count - 550
HIV viral load - 2k
What do you recommend?
3 drug therapy
24 M Two months ago tx w/ clotrimazole for a red scaly rash over his groin Recurred 2 days ago Similar rash on his foot How is he getting this?
Autoinfection
67M b/l weakness of lower extremities and urinary incontinence x 2 days PMH prostate cancer w/ bone mets TTP at S1 Unable to lift legs, DTRs absent Next step?
MRI of the lumbosacral spine
85F found down x 7hrs
UA: 2+ blood
Dx?
Rhabdo
47 M sudden onset of pain/swelling L knee similar episodes x 2 No trauma smoker, drinking Dx?
Gout
52F HTN w/ tearing pain at base of neck radiating to the back
BP 190/110
CXR - wide mediastinum
Next step?
Labetolol
NOT Morphine, nitroglycerin, phenylephrine, sodium nitroprusside
72 F AMS x 3 days
Glucose 602
DTR’s 1+
Dx?
Nonketotic hyperosmolar state
16 M
Painless mass in scrotum, decreases while supine
Bag of worms sensation
Varicocele
42M Essential HTN x 1 month
Smokes, Drinks, BMI33
Best non pharma way to decrease his BP?
Weight loss (approx 20lb, 10%)
27F healthy, asyx T4 - 14 (H) T3 - 250 (H) TSH - 0.01 (L) Dx?
Hyperthyroidism
15 F admits she uses MJ - you counsel on AE’s of MJ
What next?
Schedule a follow up
Don’t tell her parents or work up for substance abuse
56 F Itchy vesicular rash on one half of face x days
tx?
po valcyclovir
52F 2wks w/p inferior MI, EF 33%
Best way to prolong her life?
Lisinopril (prevent ventricular remodeling)
42M
Smoker, travels, drinker
AST 1.5x aLT
Why?
Alcohol use
Recommend abstinence
42F T2DM lesion on perineum x 3 months Ulcerated plaque Bx - invasive Squamous cell carcinoma What is the cause?
HPV
37 F Cholesterol last year - 260, diet controlled Last Pap - 1 yr NL Mom has T2DM Dad had CRC at 62 BMI 31 Next step in management?
Repeat cholesterol
NOT Colonoscopy, mammo, pap, or OGTT
72F calls w/ concerns about her husbands ability to drive and wants you to revoke his license and his appointment tomorrow. What do you advise?
That she joins him at the appointment so everyone can talk about it
25 F + PPD NL CXR
What is the next step?
Tx for latent TB
22F primigravid @ 34wks has burning pain in R thumb, index, and middle fingers x 1 wk
Why?
Median n. entrapment (CTS d/t edema)
12 M has problem with bed wetting
Doesn’t wake up when bed wetting occurs
Management?
Maybe water deprivation after 5pm?
NOT Desmopressin
72M HTN, HLD pt on ramipril, atorvastatin, ASA
R carotid bruit
Carotid U/s - 30% stenosis R, 10% stenosis L
Next step?
Continue current regimen (on ASA)
Does NOT need clopi
45 M gout
Cannot tolerate colchicine in acute attack.
Next option?
Indomethacin
67 M wants nicotine patch for smoking cessation. PMH significant for angina. Quit for a few months with nicotine gum in the past.
NExt?
Prescribe transdermal nicotine and recommend behavior modificiation
82F feels her memory isn’t great
MMSE 29/30
Cannot recall polysyllabic words but uses shorter words to describe the same concept
Reassure
55F fatigue x months Takes naproxen QD colonoscopy - hyperplastic polyps 5 yrs ago HGB - 10.4 MCV 80 What would you measure next?
Ferritin
55F takes naproxen and has a low serum ferritin. Told to stop naproxen and start Fe supplement. One month later, labs are about the same. Now what?
Colonoscopy
67F backpain x 3 days
Long term prednisone use
Point tenderness of L2
Dx?
Compression fx
47M severe HA x 2 months
Wakes up at night, retroorbital stabbing pain, left pupil is smaller than right and eyelid droops during episodes
dx?
Cluster HA
37 M epigastric pain x 6 weeks, relieved by OTC antiacids
Next step?
Serum H. pylori Ab assay
15F L ear pain x 2days Avid swimmer, often in the ocean PE - erythema/edema of auditory canal, small amount of white discharge She is treated Next step to prevent recurrence?
QD alcohol-acetic acid ott
45 M T2DM, HTN, smoker A1C - 7.8% Glucose - 135 Cholesterol - 214 LDL - 120 What would be most beneficial?
Smoking cessation
100 pts participate in health education program about diet
Best way to asses if they learned something?
Change in knowledge and dietary habits of each pt
27 M visits in April
Received childhood vax
5pyhx smoker
What vaccines does he need?
None
Flu - not indicated in spring
Pneumovax - only indicated in the setting of lung dz
H. flu - only indicated if missed in childhood
47M sore throat, cough x 2 days
afebrile, no exudate
Next step?
Warm saline gargle
Don’t test for mono, strep, or start abx
77 M w/ CAD s/p CABG
BP has been creeaping up for 2 years (130/80 to 180/110)
Dorsalis pedis, post tib pulses not palpable b/l
BUN 20, Cr 1.1
why the increase in BP?
Renal a. stenosis
47 F is tearful and stressed because her two boys stress her out Drinks wine to help her sleep (1 glass a few times a week) Other SIGECAP things What next?
“sometimes when people are as upset as you are, they think about suicide. Have you thought about ending your life”
11M nasal congestion and sore throat x 2 days
sneezing with green mucos
afebrile, TM NL, no tonsilar exudate
Next step?
Symptomatic care only
57 M intermittent chest pain with eating x 3 months
Food gets stuck in chest, relieved by drinking water
GERD x 20 years, PPI
NExt step?
EGD
47F back pain radiating to buttock and lateral aspect of L leg x 1 wk after moving furniture
TTP over paraspinal m. in lumbosacral area
Next step?
po IBU
NO bed rest, steroid inj, CT, prednisone
37 F PMH rheumatic fever
Left parasternal lift palpated, diastolic murmur at apex, LLSB
S4
What is the cause of this?
Mitral valve stenosis
14M reactive airway dz exacerbated by exercise has atopy FEV1 has 16% improvement w/ bronchodilator has nebulized albuterol
Add INH corticosteroid therapy
NOT INH LABA
47 F R wrist pain after FOOSH x 2 days
TTP over anatomical snuff box
XRAY WNL
NExt step?
Cast immobilization
47 F pain, swelling L knee x 1 week
No trauma
knee is tender, swollen, warm, erythematous
severe pain with ROM
Xray - periarticular osteopenia, joint space narrowing medially
NExt step?
Aspiration of knee joint
42 M severe leg pain qhs x 2 months poor control of T1DM decreases sensation in stocking glove distribution A1C 10.2% Recommend tighter glucose control and?
po amitriptyline
NOT Top capsaicin, po aceta + codeine, po ibu, po morphine
62 M DOE x 2 months
paroxysmal nocturnal dyspnea, orthopnea
S3
CXR - cardiomegaly, cephalization of blood flow, Kerly B lines
Which med will improve his chances for survival?
ACEI
NOT CCB, Dig, diuretic, nitrates
6M scaling of the scalp
Bald spot
Tx?
po griseofulvin for the pt Itinea capitis)
other contacts do not need tx
82 F with dementia
Daughter is concerned about driving restrictions
pt wants to drive but hasn’t been able to in 2 years
MMSE - sad mood, reactive affect
Impaired recall, cannot copy rectangle, intersecting pentagons
NExt?
Pt should not have access to her car keys until driving skills are formally assessed
62M dysphagia x 4 months. Initial solids, no liquids
Results from barium swallow arenot in his record
Radiology said they mailed it and showed esophageal carcinoma
What would have prevented his delay in care?
Keep a log of ordered tests that require follow up by the office
NOT - ask the radiology office to fax instead of mail, encourage pt to have routine follow up, refer all GI pts to GI, retrain office staff
16 F decides to go vegan. What supplement does she need?
Calcium
62 F w/ concern about risk for T2DM Fhx is + Her A1C - 8.4% BUN - 30 Cr - 1.8 Which med would be contraindicated?
Metformin
Contra in in renal insufficiency d/t risk of lactic acidosis
62 F SOB, Peripheral edema x 6m
S3
Secondary hyponatremia, why?
Baroreceptor-mediated ADH (vasopressin) secretion
14 M, healthy
Black, but over 1 week has lost skiin pigmentation over his neck, back, chext
Tx?
po griseofulvin
Tinea multicolor
25 F neck pain, palpitation, sweating x 2 wks Goiter T4 - 15 (H) Thyroid scan reveals decreased uptake Dx?
subacute thyroiditis
82M progressive urinary frequency, decreased stream x 8 months TURP 11 years ago for BPH PE today - moderate prostate enlargement Sr Cr 1.3 10 months ago, 2.4 today Best initial step?
Measure post void residual volume
77F decreased appetitie, n/v x 1wk
Last BM x 5 days ago
Rectal exam - stool in vault
Most likely dx?
Fecal impaction
57 M cough with light sputusm, DOE, wheezing x 6 months 50+pyhx polycythemia CXR - flat diaphragms Next step in management
Recommend participation in smoking cessation program
82F weakness, sore tongue x 1 month diet of tea and homemade bread x 6 months Pallor, jaundice, smooth, red tongue Macrocytic anemia Which nutritional deficiency?
Folate (homemade bread)
Recurrent UTI in a teen needs?
Post-coital nitrofurantonin
NOT delay post coital urination
42 M PMH HTN non smoker, drinker Sedentary BMI 39 hypercholesterolemia Greatest RF for infarct?
HTN
42 F w/ new HTN and migraines
Next pharma?
B block - tx HTN and migraine
NOT ACEI
67F PMH T2DM, HTN x 3 years Meds - glyburide, metoprolol, amlodipine, fluoxetine 2+ peripheral edema b/l renal fxn looks good What's causing the edema?
adverse effect of medication
42F swollen red knee x 1 day, right after kickboxing workout
Next step?
Reassure or Tap
NOT RICE
82M memory problems
MMSE 22/30
FHx of Alzheimer
Tx?
Add donepezil for Alzheimer
82M painful tinging in feet x 2yrs, failed gaba and carbamazepine
Tx?
Nortryptiline
32F acute SOB, sweating, chest discomfort at a concert
Has been anxious since she had a similar episode 1 month ago again in a crowded place
Tachy, systolic click on PE
Panic disorder
9 y/o has a lump in her breast under the areola
Next step?
REexamin in 6 months
Do NOT bx
42F persistant R heel pain x wks after a big walk
Started naproxen
foot swellign x 4 days w/ 1+ peripheral edema. why?
Impaired renal excretion of sodium d/t intrarenal dz.
67F has worsening of constipation. Last BM 4 days ago. Cannot tolerate laxative. No acute abdomen, decreased bowel sounds. NExt?
Try fiber supplement
NO abd Xray
Conservative tx for lateral epicondylitis?
Forearm strap
27M pregger at 26 wks Random brusies PLT 280K Bleeding time 6 min (NL) Dx?
Domestic abuse
Check yo labs
23 F pain at L ankle after twisting injury with moderate edema
able to bear weight
Recommend ice and?
Soft brace and early ROM exercises
NO Xray to r/o fx
32 M Painful penile ulcers Lymphadenopathy Vesicular ulcers Tx?
Acyclovir
55 M Smoker, drinker BMI 34 Most appropriate screening test? Also what is his strongest RF for mortality?
Serum lipid studies
RF for mortality - smoking
2 y/o hoarse cough, difficulty breathing x 1 day that got worse o/n Immunized 100.4, Sat 86% inspiratory stridor Dx?
Laryngotracheobronchitis (croup)
NOT bronchiolitis. Stridor is not RSV
82 F frequent falls x 6 months Feeling of imbalance No other red flags Next?
Physical therapy
77F
GERD, dysphagia x 1wk
Meds: chlortalidone, KCl, alendronate, ASA, lovastatin
EGD - 2 shallow ulcers in distal esophagus
Dx?
Drug induced esophagitis
19M cough x 3 months worse in afternoon/evening, exacerbated by cold weather Does not wake him CXR - NL Dx?
Asthma
Mom of 16 y/o wants her son to be screened for drugs. She has not discussed this with her son.
How do you handle it?
Do not agree to the testing unless her son agrees to it
18F w/ pruritic facial rash x 2 days
hx of asthma
exam - vesicular rash and eczematous lichenified palques on flexor surfaces
Dx?
Atopic dermatitis w/ eczema herpeticum
30F fever, cough, L sided chest pain x 5 days
started after a hike, friend also got this
Dx?
Mycoplasma pneumoniae
6M itchy rash on arm x 1 wk
Round rash with central clearing
Tx?
TOP clotrimazole
16M is started on retinoid for acne. What do you advise?
Avoid sun
82F w/ difficulty sleeping Weight loss Slowed responses Loss of interest poor concentration What do you do?
Start sertaline
22F with clue cells
Tx with?
Metronidazole (or clinda) for Gardenella
27 M IVDU with jaundice x 1 week
Negative hepatits seroligies 6 months ago
Dx?
HCV
57F Former smoker; 20pyhx sedentary BMI 23 high cholesterol, LDL Next step?
Recommend exercise program
NOT weight loss, repeat lipids study in 1 year
52 F general muscle pain and difficulty sleeping x 14m
12 areas of muscle tenderness
Recommend exercise and?
Antidepressant (SNRI for fibromyalgia)
62 M
T2DM
high cholesterol, LDL, triglycerides.
What is the goal for this guy?
Lipid lowering therapy to decrease LDL to < 100
77M mod severe ach and stiffness in his shoulders and hips
ESR 70
Tx?
Prednisone tx
37M intermittent chest pain x 2 days. Started after a cold
Serum Creatine kinase 500
Dx?
Pleurodynia (“Bornhom dz” caused by coxsackie B. Attacks of severe pain in the chest, often on one side. Associated w/ movement. Attacks can be unpredictable and occur out of the blue)
Tx - NSAIDs
56F wants to decline flu vax because her friends get flu despite vax. Response?
pts who are incubating flu when they receive the vax mistakenly attribute their syx to the vax. You should get the vax
whatever
11 y/o M
Passes out while playing this stupid hyperventilation game. Why did he black out?
Cerebral hypoperfusion (d/t hypocapnia)
37F w/ anemia and diarrhea, especially after pasta
Microcytic anemia
What test would confirm dx?
Assay for anti-transglutaminase ab
47F hand pain over palmer surface of thumbs, middle, index fingers
Next step?
Wrist splints
37F prison CO cough w/ blood tinged sputum x 2 months
Smoker
CXR - RUL infiltrate
Dx?
TB
47F struggled with weight loss
T2DM
BMI 38
Most effective weight loss plan?
Gastric bypass
14 y/o is smoking. What do you do?
Ask her about her attitude towards smoking and health
52F asks about her risk for developing thyroid cancer. Her dad was just dx’d with papillary carcinoma.
What is an appropriate screening test?
Palpation of thyroid gland
66F DOE x 4 months
orthopnea, S3
Next step in Dx?
Measure LV ejection fraction
16F has gotten withdrawn and has all the SIGECAPS. Says her modd is “ok”
Next step?
Asses her SI risk
4F tests negative for strep but culture grows strep. Why did the rapid strep give a false negative?
Low Sensitivity (Low SNOUT)
42M with PCKD on HCTZ Blood pressure is 156/94 on 3 visits Sr Cr 1 UA: 2+ protein, 5-10 RBCS Next step?
Start lisinopril
27M depression d/t divorce x 5 weeks.
Tx?
CBT
Not other weird therapies
62F swelling and pain in her fingers x 9m Pain increases with activity Enlarged PIP and DIP joints She takes no meds Management?
Acetaminophen
Don’t start methotrexate, Prednisone. This is OA not RA
Microcytic anemia
Next step?
Measure Sr iron, ferritin
9m/o
Viral gastroenteritis 2 wks ago
Started back on cows milk and has a lot of gas and watery stools
Why?
Lactose intolerance.
