Mehl. Risk factors 5: GI/reproductive Flashcards
(69) 45M + abdo pain an hour after meals + no other PMHx; Dx + risk factor?
duodenal ulcer due to H.
pylori; can also be gastrinoma.
If they give you no information apart from duodenal ulcer presentation, H. pylori is answer. Gastrinoma is patient who has recurrent duodenal ulcers despite H. pylori Tx. Gastrinoma can also be part of MEN 1.
(70) 67M + abdo pain an hour after meals + Hx of CABG four years ago + intermittent claudication; Dx + risk factor?
chronic mesenteric ischemia due to atherosclerosis of SMA/IMA;
don’t confuse with duodenal ulcers; will sound like duodenal ulcer except will be an older patient with extensive cardiovascular history. The abdo pain is angina of the bowel ( oxygen demand during digestion).
!!(71) 65M + long-standing diabetes + diarrhea; Dx + risk factor?
diabetic neuropathy to bowel affecting hypogastric nerves (loss of anti-peristalsis sympathetic nerves -> causes too much peristalsis).
!!(72) 65M + long-standing diabetes + constipation; Dx + risk factor?
diabetic neuropathy to bowel affecting pelvic splanchnic nerves (loss of pro-peristalsis parasympathetic nerves).
(73) 65M + long-standing diabetes + new-onset GERD; Dx + risk factor?
diabetic gastroparesis;
do endoscopy first to rule out physical obstruction, followed by gastric-emptying scintigraphy to diagnose; can give metoclopramide and/or erythromycin (motilin receptor agonist) to Tx.
(74) 27F + exophthalmos + tachycardia + diarrhea; Dx + risk factor for GIT symptoms?
“motility disorder” due to hyperthyroid state (in this case, Graves); “motility disorder” is also answer for hypothyroidism causing constipation, as well as for the diabetes conditions above.
(75) 44M + alcoholic + low calcium; following administration of calcium, serum levels do not rise appreciably; what is risk factor/cause?
alcoholism causing hypomagnesemia; latter can cause hypocalcemia and/or hypokalemia refractory to supplementation
(76) 23M + lost in woods for 3 weeks without food + given big meal following rescue + develops arrhythmia; Q wants Dx + risk factor?
refeeding syndrome; presents as hypophosphatemia causing arrhythmia; patient can have normal BMI; being given food after a long time without can cause a surge production of glycolytic intermediates that trap phosphate within the liver.
(77) 27F + painful thyroid + low uptake of radioiodine on scan; Dx + risk factor?
subacute granulomatous thyroiditis (aka deQuervain); risk factor is viral infection; answer on USMLE for tender/painful thyroid.
(78) 27F + gave birth 4 weeks ago + non-tender thyroid + hypothyroid state; Dx + risk factor?
post- partum thyroiditis; risk factor is recent pregnancy (makes sense).
(79) 55F + started on new medication regimen + now has hypothyroidism; Dx + risk factor?
drug- induced thyroiditis; lithium and amiodarone are HY causes.
(80) 55F + started on new medication regimen + now has mouth ulcers; Dx + risk factor?
drug-induced neutropenia (agranulocytosis); HY drugs are clozapine, methimazole, PTU, ganciclovir, methotrexate.
(81) 44M + ataxia + confusion + ophthalmoplegia + confabulations; what is risk factor for this condition?
alcoholism causing thiamine deficiency, resulting in Wernicke-Korsakoff syndrome (WKS). ACOW -> Ataxia, Confusion, Ophthalmoplegia = Wernicke. If we add confabulations (Korsakoff psychosis) on top of ACOW, we now call it WKS.
(82) 60M + had gastrectomy performed 6 months ago + now has neuropathy; Dx + risk factor?
B12 deficiency due to gastrectomy (loss of parietal cells which produce intrinsic factor).
(83) 60M + had gastrectomy performed 6 months ago + now has neuropathy and confusion; Dx + risk factor?
thiamine (B1) deficiency due to gastrectomy; if confusion is present, this is suggestive of Wernicke; the neuropathy can be dry beri beri. Absolutely asinine question, but asked twice on 2CK NBME material. In other words, just be vigilant for B1 deficiency after gastrectomy, not just B12.
(84) 24F + vegan + high MCV + hyper-segmented neutrophil on smear; Dx + risk factor?
B12 deficiency due to veganism (can also be strict vegetarianism).
(85) 40F + moving around legs in bed aimlessly at night; Dx + risk factor?
restless leg syndrome; risk factor is iron deficiency anemia (always check iron and ferritin first); otherwise, patient is at risk for developing Parkinson disease later; Tx with gabapentin or D2 agonist (e.g., pramipexole / ropinirole).
(86) 44M + fever 103F + diffuse abdominal pain with fluid wave; Dx + risk factor?
spontaneous bacterial peritonitis (SBP);
major risk factors are cirrhosis, recent peritoneal dialysis, or nephrotic syndrome (any cause of ascites, but those are the ones I’ve seen on NBME forms); next best step is paracentesis; in terms of what we look for, choose “white cell count and differential” before “gram stain and culture of the fluid” if both are listed. That sequence is assessed on 2CK NBMEs.
(87) 36F + new-onset shortness of breath and tachycardia; patient has 5-pack-year Hx of smoking + recently prescribed combined oral contraceptive pill; Q asks which of the following would have prevented this patient’s acute presentation?
answer = avoidance of combined contraceptives; diagnosis is pulmonary embolism; combined contraceptives (i.e., containing estrogen in addition to progesterone in order to minimize breakthrough bleeding) are contraindicated in women 35+ who are smokers. They are also contraindicated in women who have migraines with aura, active breast cancer, or Hx of thromboembolic disease. This is because estrogen-containing contraception (and HRT) increases risk of thromboembolic events (estrogen upregulates fibrinogen and factors V and VIII).
(88) 55F + perimenopausal + family Hx of osteoporosis + severe vasomotor symptoms; Q wants to know which aspect of patient’s history makes HRT a consideration; answer?
severe vasomotor symptoms (i.e., hot flashes, vaginal dryness, urge incontinence); this is the only approved indication for HRT; preservation of bone density is not an indication; this is because the increased risk of breast cancer and thromboemboli (i.e., DVT, stroke, MI) negatively outweigh the bone-preserving effects in most circumstances.
(89) 55F + perimenopausal + severe hot flashes + started on HRT a few months ago + stopped taking the progesterone component because of effects on her moods; Q asks what is most likely to be seen in this patient?
answer = endometrial hyperplasia; unopposed estrogen is risk factor for endometrial hyperplasia, which in turn can lead to endometrial cancer (incr. cell proliferation = incr. risk of mutation)
(90) 55F + started taking HRT three months ago + has appearance of new breast cyst + mammogram prior to HRT showed no such cyst; Q asks next best step in management?
answer = biopsy of the cyst; HRT is risk factor for breast cancer, even when it is combined with progesterone (the only role progesterone has as part of HRT is to prevent endometrial cancer); 2CK CMS form has vignette of new-onset simple (i.e., clear; hypoechoic) cyst following HRT where biopsy is answer.
(91) 50F + BMI of 30 + irregular menses for many years + new-onset heavier vaginal bleeding; Q asks what is most likely risk factor for this patient’s condition?
anovulation;
diagnosis is endometrial cancer due to history of anovulation/PCOS.
(91) anovulation; diagnosis is endometrial cancer due to history of anovulation/PCOS.
Mechanism: high BMI -> insulin resistance -> abnormal GnRH pulsation -> high LH/FSH ratio -> high LH over-stimulates theca interna cells (hirsutism);
low FSH leads to poor follicular development (anovulation / retention of follicles as cysts) -> lack of ovulation means no formation of corpus luteum -> since corpus luteum normally secretes progesterone, there is no progesterone production -> unopposed estrogen -> endometrial hyperplasia and increased risk of endometrial cancer (progesterone normally limits growth of endometrium; estrogen stimulates it).
(92) 65F + started on tamoxifen as part of her breast cancer chemotherapy regimen; Q asks what aspect of her history makes her best candidate for this treatment?
answer = history of hysterectomy; tamoxifen is risk factor for endometrial cancer due to its partial agonist effects at endometrium. Raloxifene is the classic SERM used in most patients who still have a uterus, as it is not a partial agonist at endometrium; both agents are antagonists at breast and partial agonists at bone.
(93) 16F + concerned about risk for ovarian cancer because her great aunt was diagnosed with it; there is no family Hx of BRCA mutations; Q asks next best step in management for this patient?
answer = oral contraceptive pills (any type); random factoid you need to know is that OCPs decrease risk of ovarian cancer by ~50%, presumably due to synchronization of cycles.
In summary regarding OCPs in relation to cancer risk: decr. (2 arrows down) ovarian cancer (~50%); ̄decr. endometrial cancer; incr. cervical cancer (not direct effect; cause is incr. HPV exposure due to decr. condom use); no change breast cancer (some studies have suggested a possible increased risk, but there is no significance across meta-analyses).
