nbme 7 Flashcards by Loïc Thomas

47 F

Why does she have postural hypotension?

Intravascular volume depletion

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52 F
Personality changes since the death of her friend x 2 weeks
hx of depressive episodes
presenting with flight of ideas and pressured speech

Bipolar

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9 y/o M
low back pain x 4 months
Most severe in the morning
tenderness over SI joint
Decreased waist flexion
Elevated ESR
ABN lumbar Xray

Ankylosing spondylitis

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15 y/o F
low back pain x 2 months
dull ache present all day and night
Has required prolonged course of po prednisone for asthma
Cushingoid and hirsute
TTP over T11-L2

Compression fx

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42 y/o M
severe flank pain x 6hr
CVA tenderness
Pain responds to morphine
How do you manage him?

Discharge to home and encourage po fluid intake

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26 M
SOB x 3wk, bumps on legs x 1 wk
Red tender nodules over anterior leg
CXR - b/l hilar fullness
What sr abn would you expect?

Increased calcium

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42 F
Weakness, lethargy, double vision x 2wks
CXR - upper anterior mediastinal mass
Dx?

Thymoma

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82 F
Metastatic breast cancer on home care
Severe back pain that responds to 5 mg Morphine q4h
However, pain returns after 2-3 hours
How do you manage her pain?

Increase morphine frequency to q3h

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66 M
Homeless
jaundice x 1 wk
20 lb weight loss
Alcoholic
Wasting, scleral icterus
Signs of cirrhosis
Mag - 0.8
Other sr abnormality?

Decreased calcium

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23 M
PPD 16mm
CXR - WNL
Negative sputum
Management?

Tx latent TB

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27 M
unable to conceive with his wife who has kids from a previous relationship
Exam - ill-defined soft masses palpated b/l high in the scrotum
Dx?

B/l varicoceles

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24 M
SOB 2 days s/p reduction of a femoral fx
Petechial hemorrhage over the chest and UE

Fat embolism

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4 M
fever, cough, runny nose x 3 days
Heart murmur
Dx?

URI

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24 F
amenorrhea x 7 years
anorexia x 8 years
Compared to other women her age, she is at increased risk for?

Osteoperosis

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22 F
Presents in labor at term
Why did she have frequent UTIs during pregnancy?

Urinary stasis

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foodborne illness
n/v 3-4 hrs after eating egg salad
How does the food become contaminated?

Inadequate refrigeration

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17 F
severe acne x 4 months
What structure is involved?

pilosebaceous follicles

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62 M
6hr s/p CABG
SBP drops to 100mmHg
decreased UO
Wide mediastinum
What is the next step?

Surgical exploration of the mediastinum

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37 F
Malaise, muscle aches, painful vulval blisters, vaginal discharge, dysuria x 3 days
New sexual partner 7 days ago
Vesicles and ulcers over labia, perineum, vulva, mons
How do you dx?

Culture for herpes simplex

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4 F
Cough, 5lb weight loss x 2 months
Crackles over RML
PPD -
Gastric aspirate has M. TB
How?

She has T lymphocyte dysfunction

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82 F
Visual loss in the L eye on awakening
PMH HTN
Fundoscopy - dilated retinal v. and widespread retinal hemorrhages intermixed w/ patches of white exudate
Dx?

Central retinal v. occlusion

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62 F
difficulty swallowing solids, liquids x 3 months
Foul smelling breath
Next step in dx?

Barium swallow

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14 M
BP 150/90
Never been high before
Next step?

Repeat BP in 4 wks

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50 F
SOB x 8 hrs
JVD, distant heart sounds
EKG alternating amplitude of QRS
Next?

Pericardial window

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``` 42 F 1 day s/p removal of meningioma now comatose Na - 155 Dx? ```

Diabetes insipidus

32 F abdominal pain, n/v x 6 hrs Amylase - 1022 Next step in identifying the cause?

Measure Triglycerides

52 M excruciating pain in the great toe, 10 days s/o LCC Tx?

Indomethacin

``` 14m M WCC Not walking on his own Stands for several seconds unassisted before falling to the floor Next step? ```

Reassurance

``` 4m seizure poor feeding, sleep x 2 days tense anterior fontanele b/l retinal hemorrhages dx? ```

Child abuse

16 F Mom wants contraception for daughter Daughter has been staying out late and texting boys daughter admits she doesn't know why she is behaving the way she is. Next step?

Family therapy

6 M Cramping abdominal pain and R scrotal pain x 4 hours R hemiscrotum is discolored with tenderness and swelling Next step?

Operative procedure | NOT u/s

24 F Intermittent double vision, ptosis x 3 wks Difficulty chewing, swallowing x 1 week pathophys?

Decreased Acetylcholine receptors

``` 37 M Progressive weakness x 5 days Started at ankles and has migrated to proximal muscles URI 2 weeks ago pathophys ```

Demyelination of axons

62 F SOB x 12 hrs She is treated for PNA and 4 days later her Sr Cr 3.6 What would have prevented her acute renal failure

IVF

``` 4 M Fatigue after viral illness 3wks ago Pale x 1 wk Gums bled when he brushed his teeth Pancytopenic Next step in management? ```

Bone marrow aspiration

72 M difficulty climbing stairs, rising from chair, combing hair x 3 months Where is the abnormality?

Muscle

``` 27 F HA, diffuse abdominal pain, n/v x 5 days Worse with eating, relieved by vomiting Febrile Abdomen distended, diffusely tender, tympanitic Decreased bowel sounds NL amylase lipase Dx? ```

SBO

18 F Fatigue and jaundice x 3 days Spherocytes on blood smear Best way to prevent her syx?

Splenectomy

6m M diaper rash x 3 days 2 cm honey crysted papular lesion Tx?

Mupirocin ointment

47 F ACTH therapy for MS x 2 days Angry, irritated, pulling out lines, walking around Tx?

Haloperidol

``` 18 F 37 wks gestation Outbreak of Herpes 6 wks ago No syx since No ulcers on exam Management? ```

Amniotomy and vag delivery NOT c-section, intrapartum acyclovir

``` 47 F MVA Slightly widened mediastinum C5 fx What structure has the most threatening injury? ```

Thoracic aorta

19 M Found standing in his neighbors house in the middle of the night b/l nystagmus, constricted pupils, hypertonia, decreased sensation What's he on?

PCP

67 M rectal bleeding x 1 mo Colonoscopy - large ulcerating rectal mass Bx - rectal cancer what is the best research to find his treatment options?

RCT

``` 47 F fever, n/v, severe HA x 24 hrs T - 102.2 Weak RUE, nystagmus, Kernig sign Next step? ```

Head CT

``` 72 F Indigestion while walking uphill or briskly Improves with rest Does not respond to anti acids Next step? ```

Exercise stress test

22 F Concerned about her risk for ovarian cancer d/t family hx What is the best recommendation?

OCP's

``` 57 M Flank pain, hematuria x 3days CVA tenderness Ca - 10.9 Phos - 2.3 PTH - 1020 What is the most likely cause of his renal stone? ```

Increased urinary excretion of calcium

``` 25 F 27 wks gestation in labor 2 cm dilated, 70% effaced GBS + Next step? ```

IM betamethasone

32M MDD, sensation of insects under his skin x 2wks Exoriations all over his body Tox screen would show?

Meth

``` 75 F 2hrs s/p perforated gastric ulcer reapir Multifocal premature ventricular contractions Meds - dig and diuretics What electrolyte abnormality? ```

Decreased K

``` 55 F metastatic breast cancer Confused, obtunded Barely arousable Electrolyte abn? ```

Increase Ca | NOT Na

``` 17 F MVA Facial trauma, fx maxilla and mandible Gurgling when she breathes Next step? ```

Cricotyrotomy NOT elevate head of bed ETT was not an option

24 M | New sexual partner, painful ulcers on his penis

Genital Herpes

``` 67 F 4 days s/p R hemicolectomy Serosanguineous fluid leakage from her incision afebrile Dx? ```

Wound dehiscence

``` 12m M 105 F x 4 hours In the last 8 months: pneumococcal bacteremia, periorbital cellulitis (H. Flu) Immunizied Strep meningitis on LP today He has an abn in which immune cell type? ```

B lymph

``` 12m M 3 major lifetime infections: skin abscesses d/t Staph aureus PNA and empyema Today skin abscess w/ Staph aureus Likely has a defect in which immune cell? ```

PMN's

57 F n/v diarrhea, abd pain, weakness x 8 hours 32 hrs ago she was at a party with pork, shrimp, rice, canned jam PE - muscle weakness Dx?

Botulism

``` 37 F, EtOH severe alcohol pancreatitis Required intubation CI WNL, elevated CVP CXR - b/l diffuse hazy densities w/ cephalization of the pulm vasculature and perihilar fullness Dx? ```

ARDS

``` 57 F Pain in left groin and thigh over past year 20 degree hip flexion contracture ROM intact but produces pain Xray - narrowing of joint space Dx? ```

``` 43 M PNA syx x 3 days smoker Increased tactile fremitus and dullness to percusion over L lung base CXR consistent with LLL consolidation Sputum - Small Gram - bacilli Etiology? ```

Haemophilus influenza

``` 42 F Intermittent loss of urine x 3 weeks Only occurs after voiding 3cm midline cystic tender mass in the midthird of the vagina UA - WNL post void volume - 50 mL Dx? ```

Urethral diverticulum NOT Vesicovaginal fistula, urethral syndrome, incontinence, neurogenic bladder

15 M changes in behavior since transfering to a new school 4 months ago withdrawn, sleeping poorly, 10lb weight loss, failing classes Cooperative, flat affect. Dx?

Major depressive disorder

``` 32 F 16 wks gestation fever, waxing/waning consciousness x 6hrs HCT 11% PLT 52K Cr - 3.5 Blood smear - schistocytes ```

Thrombotic thrombocytopenic purpura ADAMTS-13, defieciency in vWF cleaving enzyme platelet microthrombi -> fragmented RBC's -> microangiopathic hemolytic anemia Five syx: 1. Low platelet count 2. Microangiopathic hemolytic anemia (schistocytes) 3. Neurologic changes (AMS) 4. Impaired renal fxn 5. Fever Tx - plasma exchange

50 F Megaloblastic anemia Giving IF corrects her anemia What caused her syx?

atrophic gastritis

32 F PCOS, unable to conceive x 3 years Appropriate pharma?

Clomiphene

``` 52F abd pain, nausea, decreased appetite x 5 days 10 days s/p LCC Jaundice, RUQ pain Alk Phos - 251 NL U/s Next step? ```

ERCP

``` 8hr M Jaundice, respiratory distress hepatosplenomegaly, petechiae Hgb - 4 T bili - 15 Direct bili - 0.3 Dx? ```

Rh incompatibility

7 M about to have a dental cleaning Aortic valve replacement 1 year ago At risk for bacterial endocarditis d/t?

Viridians streptococcus

32 M burning substernal chest pain and sour taste x 3 months Next step?

Trial of omeprazole

``` 47 M Progressive weakness x 6 months Mild dysphagia atrophy of quads, deltoid fasciculations Babinsky + b/l EMG and NCS likely to reveal? ```

fibrillation potentials in multiple muscles of multiple extremities

32 F abd pain, watery diarrhea x 4 days Most likely Etiology?

ETEC

11 F new onset of body odor, irritibility Tanner 2 Next step?

Education about puberty for kid and parents

22 M exposed to unk gas vomitting/diarrhea, miosis, copisous oral secretions, rhinorrhea, fasiculations Clothing is being removed and skin washed. Next step?

Atropine

``` 32 F HA, joint pain, fatigue, fever x 2 weeks Rash on calf 3 weeks ago Serology + for berrelia burgodrferi Next step? ```

Amoxicillin Doxy was not a choice (ASA, metronidazole, prednisone, propanolol)

57 F Factor XI and IgA deficiency Receives pRBCs and develops SOB, uticaria Why?

Anaphylactic transfusion rxn

``` 62 F s/p resection of ovarian tumor BUN -80 Cr - 5.7 Next step in identifying cause of ARF? ```

Renal U/S

``` 27 F, HIV + Wants to know about immunizations Had childhood vax MMR vax - 4 yrs ago Tetanus - 6 yrs ago HBV Ab + CD4 count is 450 What is appropriate for her to receive today? ```

Pneumococcal vax | HAV vax, HBV vax, MMR vax, Td vax, None necessary

``` 75 M confusion, lethargy x 2 days Gardening in 100F weather prior to syx onset T - 106.7 Creatine kinase - 8000 AST - 400 Dx? ```

Heat stroke

``` 32 M syncope while jogging 3/6 systolic murmur at LSB Intensity increases when he stands from squatting position Dx? ```

Hypertrophic obstructive cardiomyopathy

54 M 90% stenosis of R ICA Next step to prevent stroke?

Carotid endartectomy

``` 36 F postpartum hemorrhage after placental delivery Fundus - 3 cm above umbilicus placenta is torn but intact Dx? ```

Uterine atony

17 M Unresponsive after using heroine at a party rr - 6 Next step?

Naloxone

``` 72 M SOB x 3 days PMH - HTN, CAD b/l crackles and wheezes CI - 2 pulm a. occlusion pressure - 28 pH - 7.49 PCO2 - 30 PO2 - 58 Next step? ```

Diuretics

``` 67 M difficulty walking 25 py smoker 3EtOH's QD wide based gait, reel from side to side No more than 3 steps heel to toe What could have prevented this? ```

EtOH abstinence

``` 27 M doc stuck by a needle on pt + for HBV doc was vax for HBV 2 years ago serology shows adequate levels of antiHBV Ab Next step? ```

No tx necessary | NO revax, NO IVIG, etc

``` 67 M uncontrollable nosebleed x 6 hours 220/120 w/ abdominal bruit Given ACEI to drop BP Why did he respond? ```

No cleaving of C term peptide on angiotensin I

``` 37 M SOB, fatigue x 6 m sleep apnea syx, BMI 59 pH - 7.32 PCO2 - 56 PO2 - 70 What explains his hypoxemia? ```

Alveolar hypoventilation

4 M Not using his L arm Holds his LUE with elbow flexed, forearm pronated Next step?

Supination of the forearm with elbow in slight flexion | dont image

``` 10d M 6h s/p L toracotomy restless while on vent Given sedative Next step? ```

Analgesic therapy

``` 27 M LOC x 1 min, pulse 45 occurred while at the morgue ID'ing his brother that died in a MVA Seems fine now Dx? ```

Vasovagal syncope

``` 37 M end stage Duchenne MD Requests DNR with no further abx Mental status seems fine Next step? ```

Ask if the patient wants to discuss his decision with anyone else (NO ethics committee, scheduling family meeting, transfer to SNF, or psych assessment)

67 M aching in his calves while walking this is caused by significant narrowing of which vessels?

Femoropopliteal a.

``` 25 F 20 wk gestation severe epigastric pain radiating to the back x 12 hours Vitals are stable T - 100 Next step? ```

Measure Sr amylase

``` 21 F 37 wk gestation mild epigastric pain, HA x 24 hrs 150/98 DTR 3+ Urine protein 3+ Next step? ```

Measure PLT count

37 F progressive dysphagia x 6 months Esophageal manometry - achlasia (Bird beak) What does this mean for esophageal peristalsis and Lower esophageal sphincter tone

Peristalsis - decreased | Lower Esophageal sphincter tone - increased

23 M auditory hallucinations since his wife was killed x 1 wk Keeps hearing his brothers voice even though he lives in another state Dx?

Brief psychotic disorder | NOT Bereavement, PTSD, Schizoaffective disorder, Schizophrenia

32 M admitted for EtOH w/d Day 2 - unable to move eyes laterally, wide based ataxic gate, b/l rectus palsies, horizontal nystagmus Received dextrose and chlordiazepoxide during hospitalization What is causing his syx?

Vitamin B1 (Thiamine) Always B1 before glucose

21 F hospitalized for Guillain-Barre Develops PNA w/ Gram + cocci, Gram - coccie, and Gram - bacilli What could have prevented this?

Elevation of the head of the bed

``` 14 M L knee pain x 6 mo exacerbated by jumping Recent growth spurt TTP over L tibial tubercle Underlying mechanism? ```

Repeated microfracture of the tendon insertion

``` 62 M painless rectal bleeding Anoscopy - 5 cm ulcerated mass bx - adenocarcinoma Next step? ```

Colonoscopy to cecum NOT radiation or resection

``` 62 M tearing sensation in midchest BP 180/100, 104 bpm CXR - wide mediastinum Next step? ```

IV labetalol

``` 18 F fever, obtunded x 12 hours at summer camp Meets SIRS WBC elevated w/ L shift Skin lesions over legs, chest abdomen big macular patches Dx? ```

Meningococcemia

37 M hand/foot numbness x 10 months Renovates houses Pale MM PE - weakness of dorsiflexion and loss of sensation in a stocking/glove pattern Early tx with ? could have prevented this?

Calcium disodium edetate

``` 34 F L hemithorax pain x 2 days after movign heavy furniture Worse w/ inspiration TTP Lateral to the sternum on the L Dx? ```

Costochondritis NOT 10th rib fx

``` 37 F Sicle Cell Dz RUQ pain, post prandial nausea Scleral icterus T - 100.8 U/s - cholelithiasis, pericholecystic fluid, NL CBD Dx? ```

Acute cholecystitis NOT cholangitis

``` 67 M fatigue, weakness x 3 mo Sr Ur electrophoresis - monoclonal spike Bx of Bone marrow - >50% plasma cells CXR - radiolucency of ribs More susceptible to infection with which organisms? ```

Strep pneumo NOT Aspergillus, E. coli, HZV, M tb, PCP

18 F B syx x 5 weeks exudative pharyngitis, splenomegaly Dx?

EBV infection

63 F 3 days s/p fixation of femoral fx TTP over L calf Next step?

Duplex scan

72 F increasing abdominal girth, 8lb weight gain x 2 months Abd exam - fluid wave Pelvic exam - 8 cm fixed nontender mass in cul-de-sac Next step?

Exp Lap NOT Therapeutic paracentesis

``` 72 M 4 wks s/p 10 day course of quinolone therapy for UTI PMH - schizoaffective disorder Drinks 12-15 glasses of water/day Dry MM NA 122 Ur OsMo - 200 Why is he hyponatremic? ```

Psychogenic polydipsia NOT SIADH

``` 42 M Pruritic rash on his back x 4 days plumber, crawls under houses a lot multiple erythematous serpinginous tracks on his back Elevated WBC Dx? ```

Cutaneous larva migrans

``` 37 F irregular menses x 1 yr BMI 24 Visual field testing shows outer field deficits b/l MRI - pituitary micradenoma Next step? ```

Bromocriptine

``` 72 F 3hrs s/p AAA repair CI - 1.2 MAP - 55 (L) PCWP - 30 (H) CVP - 28 (HH) Pul a. pressure - 55/35 (H) Dx? ```

Cardiogenic shock

``` 27 M Rash on neck, face, torse x 2 months Flesh colored papules w/ central umbilication over the face etc Molluscum conatgiosum In addition to tx, Next step? ```

HIV testing NO CBC, syphilis serology, viral culture

47 M constipation x 9 mo Blood in stool x 2mo Next step?

Colonoscopy

37 F 3cm nontender fluctuant mass on L posterior vulva underlying the mucosa of the vestibule and external hymenal ring Dx?

Bartholin duct cyst

``` 8 M sudden onset facial swelliing + FHx of same voice is hoarse vitals stable edema of lips and tongue, stridor What is likely to be abnormal? ```

C1 esterase inhibitor

``` 57 F 5 days s/p splenectomy for ITP sudden SOB Breath sounds decreased at L lung base Next step? ```

CXR

``` 50 M 3 days s/p hip replacement Unable to move legs and is incontinent Started right after removal of epidural catheter Dx? ```

Epidural hematoma

``` 32 M Behavioral changes x 2 wks Saw his friend die vivid dreams difficulty concentrating Dx? ```

Acute stress disorder

42 M scheduled for MRI Freaks out, SOB, tunnel vision during MRI Next step

Lorazepam

``` 82 F Concerns for parkinsons Difficult w/ word finding Difficult to distinguish smells Slowed in postural changes Rotary nystagmus High frequency hearing loss What is the most concerning finding? ```

Brisk rotary nystagmus on lateral gaze

``` 77 M Progressive forgetfulness x 2 yrs 2+ pitting edema DTRs 1+ Na - 130 Uninterested, responds slowly MMSE 20/30 Most likely dx? ```

Hypothyroidism DTR's, hyponatremia

``` 72 M 2 days s/p tx for cholecystitis UO -15mL/3hr Gram - bacteremia, DIC Tx - cefoxitin, gentamicin BP 90/64, 110 bpm Sr Cr - 3 Most likely to have? ```

Brown muddy casts ATN Low BP makes ATN more likely than AIN

``` 15 F finger pain, swelling x 6 months Erythema over cheeks Low C3 ANA + Urine: 1+ RBC, 4+ protein Dx? ```

SLE

``` 32 F Progressive cough x 3 months Occasionally tinged with sputum PMH - asthma Meds - albuterol, budesonide End expiratory wheezing Serum IgE - 1250 CXR - linear atelectasis at lung bases and thickened airways, irregular cystic opacities primarily in central distribution Dx? ```

Allergic bronchopulmonary aspergillosis

``` 72 M progressive SOB x 4 days JVD 6cm b.l crackles diminised carotid upsrokes 4/6 systolic murmur throughout the precordium w/ radiation to carotids liver span 13 cm Dx ```

Aortic stenosis

``` 16 F Suicide attempt Dolls eye reflex present AG - 20 pH - 7.32 PCO2 - 12 PO2 - 92 What is the substance? ```

Aspirin

``` 27 F 39 wks gestation 3cm dilated, vertex -1 FHR - 130, late decels Next step? ```

Cesarean delivery

70 F Peeling, scaling, cracking of R nipple x 2 mo Dx?

Paget dz of the breast

40 F yellow discharge from L nipple Can be expressed, no spontaneous d/c Dx?

Physiologic discharge

``` 14 M Sickle cell trait severe pain in L thigh and knee x 1 day Unable to bear weight NO joint line tenderness, effusion L hip ROM limited by pain NL knee xray 6 days ago Next step? ```

Xray of the hip

``` 42 F Lift eye red on awakening Like a burst blood vessel No trauma No change in vision Next step? ```

Reassurance

For a screening test 2 questions are considered a +ve | If it were changed so that 1 question was required What would happen to sensitivity and specificity?

Sensitivity would increase | Specificity would decrease

72 M Dyspnea x 6 wks PMH DVT, PE/JVD, ascites, pitting edema LE CXR - mild cardiomegaly, no pulmonary edema What is the cause of his worsening condition?

Cor pulmonale NOT ischemic heart dz, AS, MR, viral cardiomyopathy

``` 19 M African American 6-12 hr episodes of watery diarrhea x 9 mo abd cramps, bloating diarrhea after meals since the age of 12 Dx? ```

Digestive enzyme deficiency

``` 24F 38 wks gestation Tx for GBS at 20 wks 2cm dilated, 80% effaced, vertex -1 What is the best way to prevent GBS for this pt? ```

IV penicillin G

``` 17 M severe pain on swallowing x 4d IBU intermittently x 3 mo smoker no GERD syx Dx? ```

Pill induced esophagitis

``` 10 F Fever, joint pain x 5 d T 103F Cardiac exam - gallop, 3/6 holosystolic murmur in 4th intercostal space and mid clavicular line Throat swab grows step pyogenes What explains her cardiac findings? ```

Mitral valve incompetence

``` 42 F Fatigue, palpitations, anxiety x 3 mo 7lb weight loss, heat intolerance, increased BM's lid lag, exophtalmos TSH 0.1 T4 - 16 Diffuse uptake on thyroid scan Next step? ```

po propythiouracil

``` 72 F hyponatremia x 3 days admitted for cerebral infarction On appropriate IVF Na+ - 120 Sr Osmo - 255 Urine: Na - 50, Osmo - 358 Dx? ```

SIADH

60 M 2 mo f/u for upper GI bleeding EGD shows a sliding hiatal hernia (type 1) Next step?

Observe

``` 2mo F born at 34 weeks Development is appropriate for corrected age Has a cough, snot T 100F today What is the plan for her vax? ```

Give all recommended immunizations for age Do NOT delay until URI resolves

``` 37 M low back pain x 3 mo pain increases w/ hyperextension strength 5/5 Xray shows anterior displacement Dx? ```

Spondylolithiasis

18 F Lump in neck x 1 month 3cm LN, spleen palpable Abn lab finding?

Increased serum lactate dehydrogenase Not decreased K, increased RBC, Increased Ca, Increased TSH

82 M CHF on f/u exam meds - furosemide, lisinopril BUN/Cr have increased since increasing furosemide at his appt 1 month ago. Why?

Decreased renal blood flow NOT interstitial inflammation, ATN, or obstruction

``` 57 M Joint pain x 1 mo purple rash on legs x 3 days ALT - 156 Cryoglobulins + HCV + Tx? ```

Interferon - alpha

``` 27 M MVA remains tachy, hypotensive after 3 L of crystalloid LOC Next? ```

Transfuse O- pRBCs

65 M episodes where he could not speak and transient blindess of the L eye R handed Where is the arterial stenosis?

ICA

``` 20 M auditory hallucinations, odd behaviors x 12 mo secluding himself flat affect Dx? ```

Schizophrenia

4 M gets chickenpox 8 hrs after visiting a newborn nursery all the moms had chickenpox prior to pregnancy Next step?

No intervention needed

``` 32 F vomiting, diarrhea, R sided pelvic pain x 2 days T - 102.2 RLQ tenderness WBC - 15K w/ L shift US - no adnexal masses Dx? ```

Appendicitis

56 F PMH - short bowel syndrome Maculopapular rash, hair loss after hospital stay requiring TPN What is the deficiency?

Zinc

study compares outcomes for hip fx at 2 horpitals pts matched based on age and gender Physicial fxn at 1 yr s/p much worse at one hospital What is concerning?

Results are not adjusted for comorbidities

``` 67 M burning/achin in lower extremities x 3 wks exacerbated by walking improved with feet elevation finger clubbing Dx? ```

Bronchogenic carcinoma

62 F Increasingly sever upper back pain x 4 days progressive leg weakness, tinging, urinary incontinence 6 mo s/p radical b/l mastectomy Babinski b/l Next step?

Radiation therapy

47 M n/v burning epigastric pain x 3 days 90/50, 128 bpm What is causing his vitals?

Hypovolemia

``` M newborn b/l clubfoot did not move lower extremities or cry during needle stick bladder is full Dx? ```

Spinal dysraphism

``` 21 F sudden R sided chest pain x 1 day worse with deep inspiration Recent travel to the Andes T - 100.4 Faint erythematous macular non pruritic rash over cheeks and trunk dullness to percussion at RL base w/ inspiratory rub Dx? ```

Viral pleurisy

``` 27 F African American 34 wks gestation lower abd pain x 6 hr, vag bleeding x 1 hr FHR - 160 U/s - anterior placenta Dx? ```

Abruptio placentae

``` 25 F tremulousness, fatigue x 1 mo Thyroid detectable by palp and nontender Iodine uptake is decreased Dx? ```

Surreptitious administration of thyroxine

``` 55 M fever, neck pain, fatigue x 2wks 7lb weight loss began 4 days s/p viral URI Thyroid is diffusely enlarged and exquisitely TTP ESR 110 Dx? ```

Viral infection

``` 87 M difficulty starting urinary stream, post void dribble x 1 yr Enlarged prostate on exam Orthostatic hypotension Tx? ```

Finasteride doxazosin would be contra d/t bp

52 F T2DM controlled with metformin A1C 6.9 best way to prevent nephropathy?

Add lisinopril

``` 52 F progressive DOE x 2 wks PMH - breast cancer s/p mastectomy x 8yrs dullness to percusion over R lung base Dx? ```

Pleural metastasis

6w M Forceps delivery Head is rotated to the L with chin deviated to the R 2cm hard nontender oval mass on R side of neck dx?

Fibrosis of the SCM (torticolis)

``` 32 F 28 wks gestation contractions x 4 hrs cervix partially effaced Tx? ```

Magnesium sulfate NOT desmopressin, egonovine, mifepristone, misoprostal, oxytocin

68 M sudden onset of chest pain radiating to the arm x 3 hrs ST elevations V2-V5 Dx?

Acute MI

70 F chest pain and weakness Vtach on EKG

Vtach

``` 16 F abdominal pain x 2 days RLQ, high risk sex Cervical motion tenderness, L sided adnexal tenderness Dx? ```

PID

``` 7m M persistnet fever x 4 days prolonged bleeding after cicumcision eczema, frequent thrus, OM, pneumococcal bacteriemia Plt - 35 k IGA - 100 IgG - 400 IgM - 15 IgE - 60 ```

Wiskott-Aldrich syndrome Xlinked recessive Characterized by 1. eczema, 2. thrombocytopenia, 3. immune difficiency, 4. bloody diarrhea

Study is designed to include prison population who will be rewarded with consideration for early parole. What is the problem?

Coercion of a vulnerable population

``` 51 F acute R sided chest pain, SOB x 15m after placement of subclavian catheter CXR - 10% apical PTX Vitals stable Next step? ```

Obs NO chest tube

62 M fever, general muscle pain x 12 hours On chemo with subclavian catheter in place SIRS criteria gram stain of blood - gram + cocci in clusters Remove the catheter and give which abx?

Vanco

``` 22 M difficulty sleeping, paranoia x 1 month Odd paranoias Utox - Tx? ```

Olanzapine (only antipsychotic option)

77 M cough productive of blood tinged sputum x 15 m Tachycardic, but vitals stable Broncophony R lung CXR - thin walled cystic spaces in RLL with some air fluid levels Explanation?

Destruction and dilation of distal airways

``` 3 F father found her unconcious in gargae running space heater all day, peeling paint On arrival - cyanotic, diaphoretic, unresponsive T - 99F, 100/60, 80, rr 48 rhinorrhea and drooling Poor air entry, diffuse wheezing DTR's absent What was she exposed to? ```

Organophosphate NOT CO, ethylene glycol, hydrocarbon, lead

27 F Pap - high grade squamous intraepithelial lesion no previous hx Next step?

Coloposcopy

``` 42 F L eye pain, decreasing vision x 2 days severe vertigo, L arm clumsiness, difficulty walking 4 years ago that resolved spontaneously after 3 wks Decreased visual acuity on L Central scotoma and afferent pupillary defect, pallor L optic disc Finger nose testing shows dysmetria R pronator drift, R ankle clonus Babinski b/l What's causing her visual syx? ```

Optic neuritis

``` 32 M sudden onset confusion, agitation Started new medication for schizoaffective disorder 5 days ago d/t auditory hallucinations T 103.1, 160/100, 110, 28 Muscle rigidity WBC - 15k pCreatinine kinase - 950 Which NT is responsible? ```

DA (NMS)

10 F mild itchy rash spread from face to arms x 2 days URI 1 wk ago Rash - symmetric, maculopapular, reticular, erythematous, nonconfluent on face, arms and legs Next step?

No tx is needed (Parvo)

22 M 10 min tonic clonic seizure while running a marathon T - 105 Foley yields red brown urine, 4+ hemoglobin, 4+ myoglibin, 2+ RBCs Next step?

IV NS

``` 67 M Ulcer on anterior surface of leg x 2 wks PMH - CHF, T2DM 5 cm ulcer w/ 3 mm red border moderate edema from toes to midcalf b/l lung crackles dx? ```

Stasis dermatitis w/ ulcer