nbme 8 Flashcards
25 M non radiating chest pain smoked cocaine 30 min ago Hemodynamically stable EKG - 4mm STEMI V1-V4 Start nitroglycerine and?
Aspirin
NOT clopi
2 mo M
going to the beach for 2 weeks
Advise avoidance of sun advise what other protective measure?
Use of protective clothing
NOT sunscreen, contraindicated in kids under 6 mo
37 F increasing mentral pain x 1 yr regular 28 day cycles uterue is soft, tender, consistent with 8 week gestation and no adnexal masses Dx?
Adenomyosis
67 F Preop consult for lung surgery SOB climbing 1 flight of stairs x 4mo MI complicated by DVT 2 years ago 40 py hx FEV1 25% of predicted Venous u/s consistent with chronic DVTs Stress test - no reversible ischemia EF 40% Significant contraindication for surgery?
PFTs
Gold’s criteria
EF < 35%
MI in last 6 months
DKA
52 M fever x 3 days fatigue weakness x 2 months Diffuse LN, palpable spleen HCT 26% WBC 22K, 25% lymph PLT 68K What is the mechanism of his illness?
Proliferatin of hematopoietic progenitor cells
NOT failure of pluripotent stem cells, EBV, BM fibrosis
87 M problems w/ memory x 6 months misplaces house keys, forgets items on grocery list no neuro findings MSE - aox3, 3 item recall intact Dx?
Normal aging
42 M SOB x 3 wks Breath sounds decrease over L hemithorax CXR - LUL mass Bx - uniform small round cells w/ darkly staining nuclei Tx?
Chemotherapy
Small cell - chemo
For lung masses, if they are large enough resect. Not likely to do radiation on the lung
9 M
recurrent cough x 4 months
Teachers say he is disruptive in class
Blinks frequently, facial grimacing, clears his throat frequently
Mom comments he started doing this 3 years ago and doesn’t do it all the time
Dx?
Tourette disorder
37 F irregular heavy vaginal bleeding x 6 months LMP 3 wks BMI 32 Uterus NL size, no adnexal masses TSH, prolactin WNL Next step?
Endometrial bx
NOT OCP’s, dx is still unclear
32 M
Severe throbbing HA x 3 months
6-12 hr, n/v, photophobia
Most appropriate prophylaxis?
Propanolol
7 Mpain and itching of the R ear x 2 days
Forward flexion of pinna = severe pain
Ear canal = erythematous, TM cannot be seen d/t purulent discharge in the ear canal
Next step?
Top abx
22 F nausea, diarrhea x 2 days T bili - 3.2 Indirect bili - 2.8 Why does she have hyper bili?
Deficiency of serum glucoronosyltransferase
52 M severe constant back pain while bowling 220/120, 102 Femoral pulses decreased WBC - 13.5K Pain does not resolve with SL nitro Does improve with IV morphine, lobetalol Dx?
Thoracoabdominal aortic dissection
37 F
12 days s/p orthotopic liver transplant d/t HBV
WBC - 8.5k, 75% PMNs
Alk Phos - 432
AST - 306
bx - mononuclear infiltrate w/ a significant number of eos in the hepatic triads
Dx?
Allograft rejection
9 F strange behavior x 6 mo taps feet 3 times when she has bad thoughts turns lights on and off habitually Tx?
Sertaline (SSRI)
19 M tonic clonic seizure x 20 min excessive thirst, urination x 6 months Na - 121 Sr Osmo - 250 Ur Osmo - 50 Dx?
Psychogenic polydipsia
57 F severe diarrhea x 6 d dx'd with diverticulitis x 2 wks levofloxacin x 10 days Why diarrhea?
Toxin-induced inflammation of the colonic mucosa
52 F T1DM painless lesion on foot x 1 wk No ankle reflexes, sensation to pain and touch absent to the knee How did this happen?
Abn pressure distribution caused by sensory neuropathy
37 F PMH - asthmas 40 py smoking hx Meds - NSAIDs, inhaled isoetharine, OCPs BMI 22 Best recommendation to prevent a stroke?
D/c OCP’s
F >35 w/ smoking hx
37 F bloody discharge from L breast x 2 mo bloody dc can be expressed from the L nipple Mammo - WNL Dx?
Intraductal papilloma
37 F
intermittent pens and needles in R hand x 6 months
resolve after shaking her hand
Becoming more frequent
Pain, temp decreased over R thumb, index, middle fingers
Next step?
Use of wrist splint
Study demonstrates a 50% reducting in fx with drug X vs placebo. Which piece of data are they referring to?
Relative risk reduction
NOT absolute risk reduction
72 M DOE x 6 mo 96 p yr hx, coal miner digital clubbing SPO2 88% CXR - b/l upper lobe masses and areas of consolidation Dx?
Pneumoconiosis
77M
PPD > 15 mm
CXR - WNL
Next step
Isoniazid, vitamin B6
72 M Leg weakness x 2 months Dry mouth, constipation, hand tingling Receiving radiation for lung cancer b/l ptosis that worsens w/ upward gaze He can rise from a chair with his arms folded DTRs absent, sensation is intact What test would establish Dx?
Repetitive nerve stimulation (Lambert Eatton)
27 M
Unable to see x 3 hrs
Went to the ER for auditory hallucinations and was given haloperidol
Reg meds - IM fluphenazine q3wks
afebrile, UE held rigidly, neck is rigid, eyes are rotated and fixed superiorly
What is the cause ofh is visual problems?
Adverse effects of haloperidol
27 M CMV - HBV Ab - HCV Ab - Toxo - What vax's should they get?
Influenza virus
23 pneumo vax
HBV
32 F
1 yr hx of LL abd cramps 2-3 wkly
BM relieves the pain
Dx?
IBS
72 F 6wks s/p L MCA infarction frequent dribbling Palpable mass in suprapubic area Why incontinent?
Flaccid neurogenic bladder
25 F to discuss risk of Alzheimer’s
strongest predispoosing fact?
FHx
72 F
COPD, worsening SOB x 3 mo
Why?
constriction of vessels in the lungs
42 F BMI 39 Alk Phos - 110 AST - 84 ALT - 69 Dx?
NASH
37 M chest pain x 1 day URI 1 wk ago febrile 2/6 crescendo-descrendo at LSB Troponin I < 0.04 Dx?
Echo
37 F SOB x 2 days now occuring at rest rad/chemo for breast cnacer 75/48, 140 SBP decreaes 15mmHg with deep inspiration Crackles at lung bases CXR - cardiomegaly Dx?
Cardiac temponade
62 M
Undergoing TKR
Does he need prophylactic abx?
Parenteral cefazolin
29 F becomes agitated while on vent hypotensive, tachy Breasth sounds diminished Dx?
PTX
23 M fever, malaise, HA x 5 days Febrile nonpruitic, painless, pigmented, maculopapular rash over the palms and soles How to prevent?
Syphilis
Use condoms bro
27 M cough, sob x 2 months weight loss HBV dx 3 years ago white plaques on buccal mucosa What should he be tested for?
HIV/AIDs
weight loss and thrush suspicious especially in a pt with a hx of HBV
25 M Weakness of both legs, urinary retnetion x 6 hours Fever, midthoracic back pain x 2 days febrile TTP on spinous process T1DM Next step?
MRI of thoracolumbar spine
52 M chest heaviness, L arm pain x 1 hr occured while lifting blocks CK - 130 Myoglobin, trop elevated EKG - PR intervals get longer until QRS is dropped Dx?
Second degree AV block
72 M vomitting/diarrhea x 3 days PMH a fib controlled with dig hypotensive abd exam - distention, diffuse TTP w/ guarding WBC - 20K Surgery finds black omentum What caused this?
Arterial emboli
from his a fib
3 F coughing, SOB x 30 min hx of eczema Unvax coughing, drooling, difficulty speaking 90% sat RA edema of the face, hands retractions, stridor, expiratory wheezes CXR - subglottic narrowing Next step?
IM epi
42 F
difficulty urinating x 6 mo
sudden urge to void but can only void a small volume
unable to reach a bothroom quickly enough sometimes
PMH - MS
No postvoid residual volume
Dx?
Detrusor hyperactivity
NOT MS neuropathy
47 M pins and needles, weakness in R leg 1 hour after confusion scuba diving earlier today Diffuse lung crackles S4 gallop 2/6 systolic ejection murmur over LSB strength 4/5 Dx?
Air embolism (Bends)
12 M
PMH - Marfan
found a new murmur
3/6 late systolic murmur following a click
Fainter w/ shorter duration with squatting
Dx?
MVP
A study selects pts 55-75 in New york. What is problematic for their conclusion?
Selection bias
32 F
2 days s/p fixation of femoral fx
agitated, petechiae over upper thorax
Fat embolism
Study evaluates if A1C >15% predicts diabetic retinopathy. 88% of pts with A1C > 15% have DR
What does this suggest?
Positive predictive value is 88%
Study of efficacy of ELISA in dx'in pneumococcal PNA 100 PNA pts 100 asyx controls 81 of PNA and 5 asyx have positive ELISA What is the specificity
95%
3day M difficulty breathing x 1hr 64/40 UE, 36/20 LE, 160, 84 rr Pale cold extremities w/ mottling respiratory acidosis CXR - cardiomegaly, edema What caused him to crash?
PDA closure
20 M MVA pelvic pain, crepitus Large scrotal hematoma Xray - b/l fx of the superior and inferior rami Next step?
Retrograde urethrography
Kiddo has perioral rash with honey crust
Tx?
TOP mupirocin
47 F progressive SOB, cough x 1 wk 66 py hx breathing w/ pursed lips, using accessory m. Diffuse wheezes Dx?
COPD
16 M
Organophosphate poisoning
Which receptor is most responsible?
Peripheral muscarinic receptors
32 F sever back pain raditing the outer aspect of the leg to the foot Worse with bending and pooping started after lifting her kid straight leg test + Dx?
Lumbar radiculopathy
NOT low back straing
47 F
pain in R heel worse with ambulation x 3 mo
No trauma
BMI 35
TTP on plantar surface of the heel and medial surface fo the foot
Dorsiflexion produces pain
Xray - bone spur on plantar surface of calcaneus
Dx?
Plantar fascitis
57 M small cell carcinoma of the lung declining chemo Na+ - 128 Osmo appropriate Next step?
Fluid restrict
11month M Werdnig-Hoffman muscular atrophy sore on the back of the head x 4 days ulcerative lesion w/ a crusted base and slightly raised erythematous edge Dx?
Decubitus ulcer
37 M
chest pain x 30 min
cowrer says the guy has been crankly lately
Vitals fine
Diaphoretic, aox3, hypervigilant. Speech rapid, pressured
ST semgment elevation across precordum
dx?
Substance induced psychotic disorder
18 M n/v abd pain x 24 hr 10lb weight loss x 1 month 95/58, 118, dry RUQ tenderness Glucose - 250 ABG pH - 7.32 PCO2 - 30 PO2 - 105 Dx?
DKA
17 M stab wound at the base of his neck (L) 70/50, 140 Breath sounds diminished on L Tense pulsatile hematoma Where is the cardiovascular injury?
Subclavian a.
4 F Progressive unsteadiness x 1 month tips over, clumsy when reaching for toys normal developmental milestones height 60%, head 95% Nystagmus on lateral gaze, dysarthria gait is broad, ataxic DTR 3+ in LE Dx?
Medulloblastoma
52 F T2DM, vomiting x 24hrs AMS Na - 127 Glucose - 890 pH - 7.35 PCO2 - 37 PO2 - 100 What AMS?
Hyperosmolality
32 F
fever , swelling redness of R forearm x 2 days
noticed red streaking from forearm to elbow 6hours ago
Epitrochlear LN are enlarged
PE - warm erythematous area of edema that is TTP. Warm tender red streak extending from this area to the elbow
No ulcer, fluctuance or palpable cord
Dx?
Lymphangitis
30 F
PMH SLE
34 wks gestation
How could her dz affect her baby?
Complete AV block
17 F SOB, chest pain x 12 hours recent hospitalization for femoral fx 100/80, 90, rr 30, 88% RA CXR - pleural effusion Next step?
Spiral CT scan of the chest
2 hour F
Fever
Mom received intrapartum ampicillin d/t uterine tnderness, fever, hx of HSV but no lesions at time of delivery
Next step for baby?
IV ampicillin + gentamicin
32 F fatigue, fever, red bumps, x 2 days IVDU, sex worker PE - scattered, erythematous, maculopapular rash over trunk and extremities including palms and soles general LN Perlvic exam WNL Next step?
Penicillin G benzathine
1 day M
bilious vomiting x 4 hours
Not passed meconium
sister has CF
Abd Xray - big dilated loops of bowl, no air near rectum
Barium enema - small, empty colon and multiple filling defects in distal ileum
Laparotomy - inspissated tar-like meconium removed from the ileum
How do you manage for future feedings?
Pancreatic enzyme
NOT prokinetic agent
9 M
non productive cough exacerbated by exercise, worse at night
What would be his FEV1, FVC, TLC?
FEV1 - decreased
FVC - WNL
TLC - increase
72 F increasing difficulty w/ vision cars have halos at night PE - yellowing of lenses, optic disc WNL Dx?
Cataracts
52 M severe retching, vomitting x 20 min after eating large meal
L hemithorax is dull to percussion
CXR - effusion on the L
Dx?
Perforation of the esophagus
32 F 27 wk gest
painless vaginal bleeding x 6 hours, new pad q2h
16 wk u/s - WNL, posterior fundal placenta
hemodynamically stable
2cm friable ulcer on the cervix
external os - 1cm. internal is closed
Dx?
Cervical cancer
NOT abortion/fetal demise, previa
20 M
painful urination and urethral discharge x 1 wk
unprotected sex
Tx?
Ceftriaxone + azithromycin
newborn F severe respiratory distress 2 hrs s/p meconium aspiration APGAR at delivery 7, 8 rr 80, grunting, subcostal retractions Next step?
supplemental O2
TTN
32 F weakness in leg x 1 wk tingling in hands/electic like visual loss in R eye, pain with movement, scotoma DTRs 3+, Babinski MRI - bright spots randomly Tx?
Interferon beta
NOT dexamethasone
2 AA F numerous water stools x 1 month adopted 3 wks ago diet was mostly corn in Africa skin is thick and rough especially in sun exposed parts ulcerations of the tongue/mucosa Blunted affect She has a deficiency in?
Niacin
3 month M Delayed growth feeds poorly, turns blue around his lips during geedings turns blue when crying pink at rest 3/6 systolic ejection murmur at LSB Dx?
Tetralogy of Fallot
37 M
sever abdominal crambs x 24 hr
vomiting and small bowel movements x 2 weeks, constipated x 2 days
PMH Crohn dz
High pitched bowel shounds
upright Xray - multiple air fluid levels, no free air.
Dx?
Small bowel stricture
16 F T1DM A1C 8% has microalbuminuria How do we protect her kidneys?
ACEI
To protect kidneys
- BP control
- Glycemic control
18 M rash, stuporous x 24 hr fever/chills HA x 4 days recently went camping and had all of the exposures T- 104.9, 80/40, 130, 24 Diffuse erythematous maculopapular rash on trunk, extremities, palms, soles petechiae, purpura LE Inspiratory crackles, S3 HCT 32% WBC - 5.5K PLT - 20K Dx?
Rocky Mountain spotted fever
27 M found uncious does not improve with naloxone or glucose Na - 142 Cl - 102 HCO3 - 12 pH - 7.27 PCO2 - 27 PO2 - 99 Why is he acidodic?
Ingested organophosphate (Just looked for the MUDPILE that made sense)
19 F
fever, back pain, dysuria x 2 days
febrile, CVA tenderness
UA findings?
Key - WBC clump
Blood - trace protein 1+ RBC 0-5 WBC > 50 no casts Other - WBC clumps
doubly blind RCT has primary endpoint dependent on ER docs subjectively scoring severity of respiratory distress.
What is the flaw?
Variability among observes (observer bias)
27 F 8hrs s/p TAH for endometriosis no urine output 1500mL hemorrhage during surgery Foley is places and flushes easily Cr has doubled U/s - b/l hydronephrosis and no urine in the bladder What happened?
Ureteral ligation
5 M knee/ankle sweling x 12 hrs after a fall on the playground FHX + hemophelia BT - 6 min PT - 12 PTT - 55, corrects after 1:1 mixing Dx?
Factor VIII deficiency
Factor IX was not an option. Remember if it corrects w/ mixing the defect is d/t deficiency not an inhibitor
62 M pain at the base of thumbs and knees x 6 months Exacerbated w/ exertion Heberden nodes at DIP Dx?
Degenerative joint dz
25 F Nurse s/ needle stick pt has jaundice d/t HBV nurse had declined HBV vax during employee workup Next step?
HBV IG and HBV vax
15 M
chest and L arm pain while sitting in class
SOB, tingling around his mouth, light headed
PMH - asthma
kiddo is struggling in school
O2 Sat 100% RA, CTAB, RRR
Next step?
Breathe into a paper bag
NO lorazepam
52 M HIV+
severe rectal pain, bleeding w/ defecation x 6 wks
on HAART
illicit drug abuse
DRE - palpable mass in the anal canal
Anoscopy - 1.5 cm mass at anal verge w/ central ulceration and oozing blood
Dx?
Squamous cell carcinoma
NOT Anal fissure
21 F fever, sore throat, fatigue x 3 days LN, pharyngeal exudate WBC 11K, 46% PMNs 44% lymphocytes AST - 87 ALt - 64 Strep - Dx?
EBV
17mo M PMH - SCD T 105 x 1 day Takes penicillin ppx, UTD on vax spleen palp Hgb - 9.8 WBC - 18.7 K, 65% PMNs Tx?
IV ceftriaxone
bacterimia in SCD - s. pneumo or H. flu
37 F T1DM L ear pain, drainage x 4days recent swimming while camping T - 101.3 ear canal is erythematous, swollen w/ purulent fluid draining from the canl. TM cannot be visualized etiology?
Pseudamonas infection
10 M pale recently Nec enterocolitis as a baby and resected part of ileum Macrocytic anemia What is the deficiency?
Vit B12
DJI
FeFBro
Newborn w/ ambiguous genitalia
no palp gonads
46, XX karyotype
Serum 17 hydroxyprogesterone is increased
virilization is d/t which enzyme deficiency?
21-hydroxylase
47 F
increasing eye pain and bulging of eyes x 2 months
exophtalmost
sclera are injected
MRI - enlargement of EOM but not the tendinous insertions
Dx?
Graves dz
23 F urinary frequency, dysuria x 3 days frequent UTIs x 6 months uses diaphragm for contraceptive, post coital voiding, increased fluid intake How can she decrease future URI risk?
Switch to a different contraceptive method
12 M vommiting, abd pain w/ sudden onset Exacerbated by eating afebrile, stable epigastric tenderness Decreased Bowel sounds on IV morphine d/t femoral fx d/t MVA Next step?
CT scan
suspicious for SBO, appendicitis, ileus etc
42 F increased dysphagia d/t dry mouth x 1 yr swelling of cheeks, increased cavities slightly red eyes chapped lips Next step?
Serum ANA
57 F increasing joint pain, especially in knees x 4 yrs worse w/ walking, mornign stiffness nodules over DIP joints crepitus What would be seen on xray?
Osteophytes
NOT erosions
3 F
Intermittent progressive knee pain x 6wks
afebrile
ESR - 55
ANA +, RF -
Greatest risk for developing what in the next 2 years?
Uveitis
NOT CHF, fibrosis, scoliosis, sub Q nodules
32 M 12 yr hx of productive cough with occasional hemoptysis Nasal polyps experiatory wheezes clubbing FEV1/FVC 59% CXR - hyperinflation sputum culture - Pseudomonas Pathophys?
ABN Cl channel in airway epithelium
37 F vaginal bleeding 2 hrs s/p forcep delivery Uterine fundus at umbilicus placenta was delivered intact Why is she bleeding?
Genital tract laceration
42 F low grade fever, HA, facial swelling x 3 days T1DM T-102 TTP ovr maxillary sinus CT scan of sinus - opacity of the R sinus Mild ketoacidosis Next step?
Bx and culture of sinus mucosa for fungus
3 F fever, irritability x 7 days T - 101.7 b/l LN, injected sclera w/o exudate erythematous papular rash over perineum Hgb - 10.2 PLT - 285K Ua - 50 WBC Tx?
IVIG
Kawasaki
72 M constipation x 6 wks PMH - stage III Squamous cell carcinoma Ca - 12.8 Why is his calcium so high?
Increased parathyroid hormone related peptide concentration
67 F excessive fatigue x 6 months RA treated w/ MTX, NSAIDs HCt - 32% MCV - 72 Iron - 20 TIBC 200 (NL 250-400) Transferrin Sat 10% (NL 20-50%) most likely cause of her anemia?
Chronic inflammation
RCT
40 participants, 20 into each arm
Despite promising data p=0.1
Why did the study fail?
Low statistical power
37 F
intermittent HA, palpitations, sweating x 6 mo
180/104
why is she HTN?
increased catecholamine production
22F RLQ pain x 12 hours LMP 8 wks ago Bhcg - 2430 TVUS - 3cm complex R adnexal mass, no gestational sac in the uterus or fluid in the cul-de-sac Next step?
MTX therapy
25 M low back pain x 6 mo trouble getting going in the morning ROM limited to 30 degress, straigh leg -ve strength DTR's intact Initial step in diagnosis?
Xray of SI joint
NOT measure ESR
18 F
dysphagia x 3 mo, weight loss
Barium swallow - dilated esophagus w/ narrowing at GE junction
Dx?
Achlasia
52F
intermittent abd cramps, diarrhea x 2 months
increased milk intake to prevent osteoperosis
Lactose hydrogen breath test +
Pathophys?
Decreased lactose activity in the brush border
42 M
facial grimicing, poor articulation of speech x 3 months
irrational behavior, chronic fidgeting x 1 yr
disjointed, poorly coordinated gait
MSE - 19
Pathophys?
Atrophy of the caudate nucleus
Huntington’s
27 M Palpitations, heat intolerance x 1 wk Enlarged tender thyroid gland TSH - 0.02 T4 - 15 T3 - 210 Uptake is less than 1 wk Pathophys?
Release of preformed thyroid hormone
Nurse
PPD > 12mm
CXR NL
Next step?
Isoniazid therapy only
NOT I + R
23 F SOB, fatigue, light headed x 10 days URI 6 wks ago lungs CTAB CXR - hilar opacifications b/l Echo - NL valves but general hypokinesis CI = 1.4 Dx?
Post viral myocarditis
13 M decreased hearing at high frequencies b/l during school screening test multiple OM's, uses headphones Exam - WNL What caused his hearing loss/
Exposure to high decibel sounds
19 M
believes his internal organs have been replaced with a womans organs
hallucinations
Dysregulation of which NT?
Dopamine
77 M decreased appetite x 10 wks weight loss interview consistent with depression What do you need to ask?
SI
12 M
CRF d/t GN x 2 yrs
Takes a ACEI
How can mom minimize complications of his renal failure?
Restrict intake of phosphorus
14 M
obese w/ new limp
SCFE on Xray
How do you manage?
Pin fixation
4month M
What is the strongest predisposing factor for asthma?
FamHx
82 F sudden onset constant pain in her foot x 2 hours A fib, S3 L foot is cold, pulses absent Next step?
Heparin therapy
no pulses = arterial
13 M concerns for delayed puberty 25th % growth charts show linear growth since birth genitalia T2, pubes T1 Next step?
Reassurance that his pubertal development is normal
57 F tenderness and swelling of her calf x 2 days Pain increases w/ weight bearing 40pyhx PE - superficial varicosities b/l tenderness induration erythema and thickening in a linear distribution along medial aspect just below the L knee to ankle pulses 2+ b/l Dx?
Superficial Thrombophlebitis
NOT varicose veins, thromboangiitis obliterans
21 M
New dx of Hodgkin lymphoma
He asks - what are my chances?
What do you say?
Tell me more about what you want to know
47 M
fever, cough, sputum x 6 days
first episode occured after exploring caves
CT - cavitory lesion in RUL, LN in the mediastinum b/l, several small scattered indeterminate nodules b/l. Some are calcified
Dx?
Histoplasmosis
22 F, 10 wks gest
vaginal bleeding x 4 hrs and fetal parts in the os
Given a paracervical block with lidocaine prior to D&C
5 min later - numbness of lips and twitching of hands
99% sat
What caused this?
Lidocaine therapy
54 M impotence, decreased libido, abd pain x 3 months increased thirst, nacturia, weight loss Feels he is more than lately spider angiomata Fasting glucose 350 AST 80 ALT 100 Gucosuria Bx would show?
Increased iron stores in the hepatocytes
RCT determines a new treatment has a 17% improvement in cure rate vs TAU
p = 0.0002
95% CI = 8, 26
How do you interpret this?
There is a 95% probability that the difference between the cure rates is between 8% and 26%
67 F
episode of blindness 2 days ago, lasted 15 min
vision loss began at the top and gradually involved the entire visual field
NL vision now
fundoscopic exam show NL fundus
Next step?
carotid duplex u/s
62 M cramping pain in his left calf while walking x 2 months
improves w/ rest
decreased pulses
next step?
ABI
23 F irregular mensus, facial hair x 18 months 35-60 day intervals BMI 33 She is a trisk of developing?
DM
87 F dypnes x 2 days aphashia since a cerebral infarction x 6 months RLL consolidaton on CXR Tx?
Clindamycin
Good choice in anaerobes
62 M
productive vough
84pyhx
hospitalized for PNA, improved with bronchodilators
What isthe next preventative measure that he needs?
Plyvalent influenza vax annually
NOT Tdap, H flu, HBV, polyvalent pneumovax annually
67 M lesion on his chest x 2 wks landscaper ulcerated base and a shiny slightly raised border Next step?
Excisional bx with narrow margin
NOT punch bx
22 F
pain at R wrist, worth with lifting 2mo son x 2 mo
ulanr deviation produces pain, TTP at radial styloid
Patho phys?
Inflammation w/ithin the first dorsal extensor tendon compartment
52 M Frequent HA's 170/104 abdominal bruit Cr - 1.6 Next step?
MR angio of the renal arteries
66 F lower abd pain, fulness x 1 wk dysuria, pneumaturia x 1 day TTP LLQ Dx?
Diverticulosis
42 F increasing thirst x 6 mo hx of bipolar, tx w/ lithium Na - 146 Sr osmo - 280 Ur osmo - 200
After 2 hr water deprivation
sr osmo - 295
Ur osmo - 250
Mechanism?
nephrogenic DI
Resistance of kidneys to ADH
2 hour deprivation ur osmo should be >600
52 M pain at the base of scrotum, pain, AMS x 2 day T2DM, poor control T - 102.5 bullae over scrotum and crepitus of perineum WBC - 16K w/ L shift glucose - 415 Started on insulin, abx What else does he need?
Surgical debridement
62 F f/u 3 wks after starting lisinopril SBP improved 30 mmHg Systoic bruit over abdomen Why is her BP improved?
Decreased circulating AgII
5 F fatigue, blood in urine x 1 day strep 2 weeks ago U/A 4+ protein, many RBCs Dx?
PSGN
4 M
fever, cough, runny nose x 3 days
Split S2
Dx?
URI
27 M bloody stools x 4 days; 8-10 QD x 1 month abdominal fullness T 101.2, 90/60 abdomen distended, TTP on upper quadrants BS decreased Xray shows dilation of transverse colon Dx?
Toxic megacolon
27 F, 6 wks gestation PMH T2DM, controlled with metformin BID Fasting glucose 100-115 2hr post prandial 150-180 Should her regiment change?
Yes, switch to insulin
1hr post prandial < 140
2hr post prandial < 120
57 M found unconcious PMH HTN, ACEI HCTZ 180/90 4mm pupil b/l CT - big bright spot What caused this?
HTN
NOT cerebral amyloid
52 F
Burning pain over her ribs x 2 days
Also a mild vesicular rash
Tx?
po acyclovir
82 F SOB x 6 hours 85/50, 90% RA 4cm JVD Crackles over lung base b/l S3 w/ 1/6 systolic murmur at LSB EKG - T wave elevations Dx?
Acute MI
37 F HA x 3 mo 190/105 Renal arteriography shows 80% obstructive lesion on the L L renal v. renin assays show 1.5:1 Dx?
Renovascular HTN
47 M
sedentary, BMI 23
150/94
Recommend dietary changes and?
Schedule a f/u in 1 mo
Check BP
NOT f/u in 12 months, weight loss, HCTZ, ACEI
32 F, 10 wks gest PMH HTN treated w/ labetolol 140/94 24 hr excretion - 342 mg protein She is at risk for which OB complication?
Abruptio placentae
52 M progressive fatigue x 4 months falls asleep randomly BMI 35 Hgb - 18.8 Next step?
polysomnography
32 M progressive fatigue x 2 mo urine is dark PMH UC, mesalamine mild jaundice, mild scleral icterus T bili - 3.2 Alk Phose - 432 AST - 65 ALT - 58 Dx?
Primary sclerosing cholangitis
Biliary is for bitches
2 M swallowed a liquid under the sink Crying ulcerations on the lips, mucosa, pharyns What did he drink?
Drain cleaner
19 F elevated serum alpha fetoprotein LMP 18 wks 2.8 x median Next step?
U/s to confirm gestational age
There wasn’t a great amnio option
57 M lethargy x 3 hrs PMH - myasthenia gravis s/p thymectomy but continues to have syx b/l ptosis, breath sounds decreased pH - 7.19 PCO2 - 70 PO2 - 70 HCO3 - 25 Why his acid base disorder?
Acute respiratory failure
d/t myasthanic crisis
52 F eats out every night protects her heat with 4-5 glasses of wine QD BMI 26 T cholesterol - 205 AST 65 HDL 70 DEXA osteoperosis What do you recommend?
Decrease alcohol intake
NOT decrease saturated fat, decrease Na, Take MV w/ Fe, Take K+
21 M sudden blindness in L eye Under a lot of stress at school Exam looks fine, but decreased sensation on L side Next step?
pysch assessment
16 M
wants to be circumcised
How do you answer?
Circumcision cannot be done w/o parental consent
62 M
Dx’d w/ pancreatic adenocarcinoma and several mets
also 7 cm AAA
What should you do about the aneurysm?
It should not be repaired because of the pt’s poor prognosis
22 F heavy menstrual bleeding, bruising x 2 months PLT 20k BM bx - megakaryocytes Tx w/ prednisone x 1 wk and not PLT 90K What is causing this?
antiplatelet IgG Ab’s
37 F
wants b/l tubal ligation
What will she be at increased risk for after the procedure?
Ectopic pregnancy
72 M
gradually increasing pain in hip and thighs x 2yrs
improves w/ leaning forward, worse with extending back
Dx?
Spinal stenosis
5M refuses to bear weight on R leg x 24 hrs T - 102.6 WBC 18K ESR 50 Dx?
Septic arthritis
febril febril febrile
67 M malaise, nausea, bloating, pruritis x 3wks suprapubic distention/tenderness enlarged, nontender prostate BUN - 93 Cr - 6.7 increased from studies 2 months ago What caused his renal findings?
Postrenal obstructive uropathy
82 F
AMS, T 102, 82/60, 108
Why is she hypotensive?
Peripheral vasodilatin (Septic shock)
20 M PMH Wilsons dz hair loss, decreased taste, poor healing pathcy alopecia, testicular atrophy He has a deficiency in?
Zinc
15 M
irritable mood since breaking up w/ girlfriend
All depressive syx
Tx?
Bupropion (only SSRI/SNRI option
57 F R sided abd pain x 8 hours On warfarin for hx of DVT 6 cm mass lateral to the umbilicus on the R Dx?
Rectus sheath hematoma
bleeding into her abdominal wall and on wafarin
2wk newborn fever cough x 3 days T 100, 104 She has a big sail shaped thing in her R lung field What is that?
Her thymus
Tots NL
15 M lesion on his R buttck growing in size wrestling team annular lesion with erythematous margins and well defined raised edges Etiology?
Trichophytun ruburm (only fungal option)
42 F 14 wks gest
cervic closed, uterus consistent w/ 6 wk gest size
U/s - gestational sac w/ no cardiac activity
Dx?
Blightened ovum
when a fertilized egg attaches to the endometrium but an embryo never develops
25 F urinary frequency, dysuris despite tx with bactrim and macrobid Sexually active mildly erythematous, tender urethra Purulent material can be expressed from the periurethral glands nontender cervix, uterus cervix is friable and bleeds easily Dx?
chlamydia trachomatis infection
no Cervical motion tenderness in acute infection
32 F 30 wks gest
bright red spotting x 6 hours
Her first two pregnancies resulted in c section.
What is she at increased risk for during this infection?
Placenta accreta
42 F
Nontender R sided neck lump x 1 month
What would establish the dx?
FNA
NOT thyroid fxn tests or scintography
These are helpful but doesn’t give the actual dx
52 F irregular menses 22 to 45 day intervals occasional vag dryness Next step?
Reassurance
no measuring estrogen, estrogen therapy, OCP, or endometrial bx
Newborn F
2/6 systolic murmur best heard over midback
redundant skin at nape of neck
edema of the dorsum of the hands and feet
Dx?
Gonadal dysgenesis (45,X; Turner syndrome)
8hr M regurg's first feeding drools constantly no urine or BM intercostal retraction How do you dx?
Insert radiopaque NG tube
newborn F cyanotic 1 hr after birth 60% sat does not improve with Oxygen 3/6 systolic ejection murmur best heard at apex Next step?
IV prostaglandin
Keep the DA open
38 F
n/v/d x 6 hrs
potluck 8 hrs ago
Most likely etiology?
Staph aureus
Preformed toxin = quick onset
67 F
L sided facial drooping, L hand weakness x 10 min
now asyx
has had episodes of 5-10 min vision loss x 2weeks
Next stop?
Carotid duplex U/s
