Mehl. Risk factors 4 intox/electrolytes/GI 04-06 (1) Flashcards
(48) 42F + long-standing history of rheumatoid arthritis managed with prednisone + undergoes appendectomy + experiences drop of BP to 80/40 during surgery; risk factor for this precipitous drop in BP?
chronic prednisone use causing adrenal suppression –> can’t mount stress response in setting of stressor (i.e., surgery, trauma, infection) –> can cause BP to fall precipitously -> after IV fluids, give hydrocortisone.
(48) adrenal suppression due to presdnisolone -> surgery -> low BP. Tx?
after IV fluids, give hydrocortisone.
(48) Normally, cortisol (i.e., glucocorticoid) from the adrenals helps maintain BP by upregulating alpha-1 receptors on arterioles; NE and E (catecholamines) agonize alpha-1 to maintain BP; this is called permissive effects of glucocorticoids on catecholamines. Patients with suppressed adrenals have insufficient cortisol after exogenous prednisone is consumed in setting of stressor -> insufficient alpha-1 expression on arterioles -> drop in BP; hydrocortisone is Tx because without the glucocorticoid, NE and E can’t do their job.
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(49) 42F + long-standing rheumatoid arthritis managed with multiple medications + 6-month Hx of dry cough + CXR shows reticular pattern; what’s the risk factor for this condition?-> answer =?
methotrexate-induced pulmonary fibrosis + rheumatoid lung (the autoimmune disease itself, independent of methotrexate, can cause pulmonary fibrosis, so patients will have restrictive lung disease due to both methotrexate and the RA).
(50) 39F + rheumatoid arthritis + low RBCs, WBCs and platelets + splenomegaly; Q wants risk factor for this condition?
Dx?
rheumatoid arthritis;
diagnosis is Felty syndrome (RA + neutropenia + splenomegaly); sometimes RBCs and platelets can be down as well.
!!!!!! super Hy (51) 50F + BMI 40 + smoker + HTN; Q asks #1 way to decrease risk of osteoarthritis in this patient?
weight loss (exceedingly HY).
(52) 62F + has peripheral edema + using high doses of naproxen for past 6 weeks to manage her osteoarthritis; Q wants to know #1 way to minimize risk for this patient’s condition?
avoidance of NSAIDs; patient has fluid retention due to NSAIDs (decreased renal blood flow causes kidney to reabsorb fluid to compensate).
(53) 50M + 6-month history of declining mental function + microcytic anemia + drinks home-distilled liquor + smoker; Q wants to know biggest risk factor for this patient’s condition?
Dx?
home- distilled alcohol
diagnosis is lead poisoning; in this case, you need to be aware old-school home distillation equipment is a cause of lead poisoning, which can cause microcytic anemia.
(54) 50M + swollen big toe + smoker + works on farm in California + drinks home-distilled liquor; Q wants to know biggest risk factor for this patient’s condition?
answer = home-distilled liquor; patient has podagra (gout of big toe) from alcohol; the fact that it’s home-distilled doesn’t mean lead poisoning in this context, but this is on NBME. Smoking doesn’t cause gout; farming can be risk factor for organophosphate poisoning.
(55) 70M + high creatinine + taking amitriptyline; Q wants to know best way to prevent this patient’s condition?
answer = avoidance of anticholinergic medications; patient has high creatinine due to post-renal obstruction -> BPH in the setting of a TCA, which is anticholinergic (urinary retention).
!!! (56) In elderly, be very cautious administering TCAs, anti-psychotics, or 1st-generation H1-blockers (i.e., diphenhydramine). They can cause delirium, worsening of dementia, and in old men in particular, exacerbation of BPH.
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(57) 23F + works on fruit farm + doesn’t wear mask + doesn’t wear gloves + develops pinpoint pupils and salivation; Q wants to know what would most likely have prevented this patient’s condition?
= wearing gloves; wrong answer = face mask; organophosphate poisoning occurs through the skin, not inhalation (on NBME).
(58) 16F + consumed pills + now has tinnitus + low bicarb, low CO2, and high anion-gap; risk factor?
aspirin (salicylate) causing high anion-gap mixed metabolic acidosis / respiratory alkalosis.
(59) 25M + uses a variety of illicit drugs + develops Parkinsonism; risk factor?
MPTP use (synthetic heroin) can cause Parkinsonism.
(60) 16F + consumed bottle of pills in suicide attempt + now has severe elevation in ALT and AST; what is risk factor for this presentation?
acetaminophen toxicity; antidote = N-acetylcysteine.
(61) 55M + high BMI + high blood lipids + does not drink or smoke + ALT and AST very slightly elevated; Q asks #1 way to have prevented this condition?
answer = weight loss; non-alcoholic steatohepatitis (NASH) occurs in patients with metabolic syndrome / high BMI -> it’s assumed most chronically overweight patients will have some degree of fatty liver.
(61) NASH.
Patients will start out with no change in their hepatic enzymes; this is very important.
There are a couple of NBME Qs for 2CK where they give patient with metabolic syndrome and normal liver enzymes, and then the answer is just NASH (you can eliminate other answers as obviously wrong); student will ask how this makes sense if labs are all normal; my response is, once again, that labs start out normal in NASH, but it assumed that most people with obesity have some degree of ensuing steatosis.
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(62) 55M + drinks 2 beers a day + smokes a pack a day + all laboratory findings normal except slight elevation in both AST and ALT (AST slightly higher than ALT); Q asks what is most likely to have prevented the findings in this patient?
cessation of alcohol; students should know smoking isn’t a significant risk factor for hepatic disease; alcoholic liver disease need not present with significant alcohol intake or with prominent elevations in transaminases where AST/ALT is 2:1.
(63) 55M + obese + gurgling sounds when swallowing + sometimes regurgitates undigested food + halitosis; Dx + risk factor?
Zenker;
risk factor is obesity; can also be seen in setting of dysphagia (e.g., from stroke Hx) due to increased oropharyngeal pressure -> increased risk of outpouching.
(64) 28F + spoon-shaped nails + chapped lips + trouble swallowing; Dx + risk factor?
Plummer-Vinson syndrome;
risk factor is iron deficiency anemia.
PV syndrome is triad of 1) iron deficiency anemia (can present as koilonychia), 2) angular cheilitis, and 3) esophageal webs (dysphagia).
(65) 28F + eating clay, starch, and ice; Dx + risk factor?
pica due to iron deficiency.
(66) 40M + dysphagia to solids and liquids + barium swallow shows birds beak appearance; Dx + risk
factor?
achalasia; loss of myenteric plexus; often idiopathic; can be due to Trypanosoma cruzi
(Chagas disease) as risk factor; latter can also cause dilated cardiomyopathy.
(67) 40M + Hx of heavy smoking/alcohol + new-onset dysphagia; Dx + risk factor?
squamous cell
carcinoma of esophagus; heavy smoking/alcohol are major risk factors; do immediate endoscopy.
(68) 40M + Hx of GERD + new-onset dysphagia; Dx + risk factor?
adenocarcinoma of esophagus;
GERD / Barrett is major risk factor; do immediate endoscopy.
(68) adenocarcinoma of esophagus;
In short, do immediate endoscopy on USMLE to look for esophageal cancer in any patient with new-onset dysphagia who has Hx of GERD or heavy smoking/alcohol.
Progression of dysphagia from solids only to solids + liquids is HY for cancer.
(68) adenocarcinoma of esophagus; Dysphagia to solids + liquids from the start suggests neurogenic etiology (achalasia).
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