nbme 8 Flashcards by Shawn Chapman

25 M
non radiating chest pain 
smoked cocaine 30 min ago
Hemodynamically stable
EKG - 4mm STEMI V1-V4
Start nitroglycerine and?

Aspirin

NOT clopi

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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

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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

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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?

Pre-op eval:

Cardio- goldmans EF < 35% MI in last 6 months
Resp- PFT-
Liver- Childs Pugh
Nutrition- Prealbumin
Metabolic- Diabetes DKA

PFTs

Gold’s criteria

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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

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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

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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

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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

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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

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32 M
Severe throbbing HA x 3 months
6-12 hr, n/v, photophobia
Most appropriate prophylaxis?

Propanolol

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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

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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

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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

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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

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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)

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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

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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

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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

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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

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37 F
bloody discharge from L breast x 2 mo
bloody dc can be expressed from the L nipple
Mammo - WNL
Dx?

Intraductal papilloma

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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

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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

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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

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77M
PPD > 15 mm
CXR - WNL
Next step

Tuberculosis:
PPD
AFB+ RIPE
AFB- CXR+ Isoniazid B6

Isoniazid, vitamin B6

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``` 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? ```

Dilated myocarditis---> Cardiomyopathy 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 tamponade Hypotension, JVD, Pulsus paradoxus

62 M Undergoing TKR Does he need prophylactic abx?

Parenteral cefazolin

``` 29 F becomes agitated while on vent Ventilator- high pressure alarm hypotensive, tachy Breasth sounds diminished Dx? ```

Barotrauma- PTX Needle decompression

``` 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? ```

Pulmonary barotrauma 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? ```

Transposition great vessels: Two seperate circ. systems, PDA dependent Pt PDA closure--> hypoxemia--> Cyanotic Dx ECHO Tx Prostaglandin to keep open

``` 20 M MVA pelvic pain, crepitus Large scrotal hematoma Xray - b/l fx of the superior and inferior rami Next step? ```

Urethral involvement- 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 | -Pain bottom of foot. Hurts morning, gets better with use.

``` 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= pressure 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? ```

Fat embolism s/p ortho surg | 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?

Asthma PFT: 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? ```

Transient tachypnea of newborn Supplemental O2 PPV

``` 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 feedings 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 1. BP control 2. 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?

Reiters syndrom -Uveitis, urethritis, arthritis -Associated with connective tissue diseases (e.g., sarcoidosis, ankylosing spondylitis, Reiter syndrome, and IBD) 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 over maxillary sinus CT scan of sinus - opacity of the R sinus Mild ketoacidosis Next step? ```

Mucormycosis Bx and culture of sinus mucosa for fungus Surgical debridement, Amphotericin

``` 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? ```

Lung Squamous cell carcinoma Paraneoplastic: 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 Pt heart failure Dx ECHO, CXR Tx Supportice

``` 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? ```

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? ```

Acute Limb ischemia Dx US doppler, Arteriogram Tx 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 Virchow's triad 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?

Peripheral vascular disease- Claudication Dx ABI Tx Stent vs Surg vs meds vs amputation

``` 23 F irregular mensus, facial hair x 18 months 35-60 day intervals BMI 33 She is a trisk of developing? ```

``` 87 F dypnes x 2 days aphashia since a cerebral infarction x 6 months RLL consolidaton on CXR Tx? ```

Aspiration Pneumonia 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? ```

Mechanism of lisinoprol- ACE inhibitor | Decreased circulating Angiotensin II

``` 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 Juvenile RA- 6 weeks or more

``` 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 growindcg 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? ```

Esophageal atresia 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? ```

Transition of Great vessels 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