medicine nbme Flashcards by Halley Flammer

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

How well did you know this?

Not at all

Perfectly

Pt on chemo meets SIRS. Start ceftazidime and what other abx? PMN count 2K

No other abx

If PMN count was <1000 add imipenem

How well did you know this?

Not at all

Perfectly

50ish man w/ pain at mutliple sites through out his body x 1month
Bone scna - lots of dark spots in the femur

Bone mets

How well did you know this?

Not at all

Perfectly

SOB
4/6 systolic murmur at LSB
Echo - LV thickening, calcified aortic valve area 0.8cm2
Next step?

AV replacement

How well did you know this?

Not at all

Perfectly

Cause of dehydration in DKA?

Osmotic diuresis

How well did you know this?

Not at all

Perfectly

New onset HTN after starting albuteral INH

hypo K+, Mag

Mineralcorticoid excess

How well did you know this?

Not at all

Perfectly

Steatorrhea

+ Enomysial IgA Ab

Gluten-sensitive enteropathy (Celiac)

How well did you know this?

Not at all

Perfectly

adult is treated with LABA nebulizer has 50% improvement in FEV1. What meds does he need for the next week?

po Corticosteroids

How well did you know this?

Not at all

Perfectly

Tx for herpetic whitlow

po acyclovir

How well did you know this?

Not at all

Perfectly

30 year old. No significant medical hx at first appointment. What screening do you need?

Serum cholesterol

How well did you know this?

Not at all

Perfectly

Tx for prostatitis

Ciprofloxacin

How well did you know this?

Not at all

Perfectly

sudden dyspnea after femur fx, petechia over chest

fat embolism

How well did you know this?

Not at all

Perfectly

PE finding during hypotensive episodes in pericardial effusion?

Pulses paradoxes

How well did you know this?

Not at all

Perfectly

Best way to prevent OA?

Weight reduction

How well did you know this?

Not at all

Perfectly

Tx for acute gout attack

Indomethacin

How well did you know this?

Not at all

Perfectly

Best way to prevent CVA in afib?

Warfarin

How well did you know this?

Not at all

Perfectly

PT has SOB, JVD, S3, respiratory alkalosis.

CXR - b/l puffy infiltrates. Why does she have dyspnea?

Alveolar-arteriolar mismatch

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

Adult has frequent asthma, URI, OM, diarrhea since childhood. Anaphylactic reaction to transfusion
Obstructive lung patern

IgA deficiency?

How well did you know this?

Not at all

Perfectly

After surgery pt has jaundice

High total bili, low direct

Gilbert syndrome

How well did you know this?

Not at all

Perfectly

Recent viral illness
Fatigue, jaundice
Hepatomegaly
High indict bili, alk phos
AST - 350
ALT - 280
Lactate - 410

Hepatitis?

How well did you know this?

Not at all

Perfectly

T1DM pt collapses while jogging

50% dextrose in water. he is more likely to be hypoglycemic

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

After an MI pt has wide QRS complexes, where in the heart?

Ventricles

How well did you know this?

Not at all

Perfectly

``` 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?

``` 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?

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.