Practice test 3 Flashcards
a 3w female newborn is brought to the physician b/c of a 18d history of increasingly yellow skin and eyes. she was born at term to a 24yo woman, G2P2, following an uncomplicated pregnancy and delivery, her weight at birth was 3175g (7lb). she is exclusively breast-fed. today, she weighs 3345g (7lb 6oz). physical examination shows scleral icterus and generalized jaundice. the remainder of the examination shows no abnormalities. her serum total bilirubin concentration is 15mg/dL with a direct 13. which of the following is the most likely diagnosis/
a. ABO incompatibility
b. biliary atresia
c. breast milk jaundice
d. gilbert syndrome
e. hereditary spherocytosis
f. physiologic jaundice
B
adequate weight gain
direct = conjugated ==> more likely biliary atresia
if unconjugated ==> physiologic jaundice of infancy
57yo man comes to the physician b/c of a 3mo history of 5-6 loose stools daily and a 7.3kg (16lb) weight loss. he notes that he had 2-3 BM for 3w following at 10d course of tetracycline 2 months ago. he underwent antrectomy with Billroth II reconstruction for a perforated gastric ulcer 1y ago. he has not had any changes in his diet. he has osteoarthritis of the hips treated with ibuprofen. he is 185 cm (6’1”) tall and weighs 72kg (160lb). BMI is 21. Exam shows excess skinfolds over the abdomen. the abdomen is scaphoid with a well-healed surgical scar. which of the following is the most likely cause of this pt’s diarrhea?
a. bacterial overgrowth
b. bile reflux
c. cox-2 inhibition
d. dumping syndrome
e. efferent loop obstruction
A
hx of antrectomy = decreased gastric acids to kill the bacteria
hx of abx use = killing off some of the good bacteria.
8h after undergoing transurethral prostate resection, a 62yo man has a Hgb conc. of 7.5 a transfusion of heterologous packed RBCs is begun. 2 h later, he develops chills and fever. he has received 200mL of the transfusion. his temperature is 39C (102.2 F), pulse is 120, RR 18; BP is 120/70. which of the following is the most likely explanation for these findings?
a. ABO incompatibility
b. bacterial overgrwoth in transfused blood
c. IV catheter infection
d. preformed Abs to leukocyte antigens
E. Rh incompatibility
D
rapid rxn ==> preformed antibodies
2d after undergoing an aortic valve replacement for aortic stenosis, a 72yo woma develops ventricular fibrillation secondary to hypokalemia. the pt is a Jehovah’s Witness, and she and her family were adamant during preoperative consultation that no blood products be administered under any circumstances. her Hct is 18%. following successful resuscitation, she has severe abdominal pain. her temp is 38C (100.4F), pulse 100 and BP 100/70. she is being mechanically ventilated. abdominal examination shows rebound tenderness; BS are absent. her Hct is 15% and leukocyte count is 17,000. IV antibiotic therapy is begun. which of the following is the most appropriate next step.
a. sign a do-not-resuscitate order
b. administration of erythropoetin, IV
c. administration of Fe, IM
d. transfusion of pRBCs
e. exploratory laparotomy
E
can’t give her blood products b/c she has already said that she would refuse
likely a perforation / mesenteric ischemia ==> emergent surgery to repair and/or remove dead bowel
26yo woman with chronic alcoholism comes to the ED b/c of hematemesis 4x during the past 24h. she vomited small amts of clear material before vomiting blood and blood clots. she appears unkempt and tremulous. her pulse is 124, BP is 92/68. exam shows dry, blood-caked oral mucous membranes. there are no skin signs of chronic hepatic dz. the liver and spleen are not palpable. there is no evidence of ascites or peripheral edema. which of the following is the most appropriate next step in management?
a. measurement of arterial blood gases
b. IV administration o ffluids
c. IV infusion of ADH (vasopressin)
d. insertion fo nasogastric tube
e. upper gastroduodenal endoscopy
B
first - need to up her BP
1) fluids
2) endotracheal intubation to establish an airway
24yo woman comes to the ED b/c of diffuse pain after she fell asleep for 4h while sunbathing at a tropical resort. exam shows diffuse erythema and exquisite tenderness over 48% of her body. which of the following is the most appropriate next step in management?
A
1st degree sunburn (over lots of body) - but don’t do anything.
if anything - aloe
24h after undergoing surgical repair of an abd aortic aneurysm, a 77yo man has the onset of mild confusion . his urine output has been 10ml/h over the past 3h. he is diaphoretic. he is oriented to person but not to place or time. hiss temp is 38.2C (100.8F), pulse is 100, RR 20 and BP 80/60. the upper and lower extremities are cold and clammy. pulmonary artery catheterization shows a pulmonary capillary wedge pressure of 23mmHg (n=5-16). which of the following is the most likely explanation of these findings.
E
increased left atrial pressure, likely due to cardiogenic shock
SIRS Fever = temp > 100.4 tachycardia = HR > 90 tachypnic = RR > 20 WBC > 12,000 or <4,000
+ hypotension = SBP < 90
septic shock –> diffusely decrease systemic vascular pressure = hypotension
pt with bleeding d/o, most likely diagnosois? a. anticardiolipin antibodies b. antithrombin III deficiency c. fibrinogen abnormality d. hemophilia e. thrombasthenia f. thrombocytopenia g. thombocytosis h. von Willebrand disease A 64yo man is undergoing an elective surgical repair of an abd aortic aneurysm. during the operation, a retroaortic renal vein and lacerated, and the pt subsequently losees a large amt of blood. in addition ot 4L of blood retained byt eh cell-saver autotransfusion devision, 22U of pRBCs are replaced. the pt is hemodynamically stable, but blood is oozing from every surface in the operative field and from the VI and arterial catheter sites
F
–> DIC
consumption of all coagulation factors –> thrombocytopenia
pt with bleeding d/o, most likely diagnosois? a. anticardiolipin antibodies b. antithrombin III deficiency c. fibrinogen abnormality d. hemophilia e. thrombasthenia f. thrombocytopenia g. thombocytosis h. von Willebrand disease a 22yo man comes to teh ED b/c of a swollen, painful, and slightly plethoric R LE. he has had 2 episodes of superficial thrombophlebitis of the R LE; the first episode occurred 30 months ago and the second episode occurred 18mo ago. venous duplex scan cofirms DVT, involving the infrapopliteal veins.
B –> most likely a hypercoagulable disorder. a young man –> more likely to be an inherited disease
deficienct antithrombin III = more likely to have lots of clots .
now, if had someone with nephrogenic disorder - then more likely to be hypercoagulable, possibly with thrombocytosis
hypercoagulable disorder
A, B,G
bleeding d/o
D, F, H
46yo woman with immune thrombocytopenic purpura has been treated with prednisone (100mg daily) and immune globulin for 6w w/out relief. her plt count is 20,000. bleeding time is prolonged, clot retraction is poor, and plt life span is shortened. a bone marrow biopsy specimen shows a near-normal level of megalokaryocytes. which of the following is the most appropriate next step in management?
a. aspirin therapy
b. increase prednisone to 200mg daily.
c. doxorubicin therapy
d. granulocyte-macrophage colony stimulating factor therapy
e. splenectomy
E
low plts, but megakaryocytes are putting out enough
- normal production
- -> must be problem with destruction
28yo woman comes to the physician b/c of fatigue, increasing breast size and tenderness, and increased urinary freq over the past 8w. she has also had slight intermittent cramping in the midline. she is uncertain when her last menstrual period occurred. she is 152cm (5ft) tall and weighs 85kg (187lb). BMI is 37. U/S shows a viable pregnancy high in the uterus, consistent with a 8w gestation. 2w later, she has severe R sided abdominal pain associated with R shoulder pain. U/S of the pelvis shows a viable pregnancy in the R cornua area of the uterus. immediately after the U/S, the pt’s vital signs become unstable with a pulse of 140, RR 20, and BP of 90/40. which of the following is the most likelly diagnosis?
a. adenomyosis
b. corpus luteum cyst
c. ectopic pregnancy
d. endometrioa
e. endometriosis
f. follicular cyst
g. leiomyomata uteri
h. pelvic inflammatory disease
i. ruptured ovarian cyst
j. spontaneous abortion
C
“high in uterus” –> already scary sign
definitiely pregnancy-based
B, C, or J
60yo woman has had dysphagia for 3mo. she has a 10y history of heartburn. exam shows no abnormalities. barium swallow shows a 2cm tapered distal esophageal stricture with moderate dilation of the proximal esophagus. which of the following is the most appropriate initial step in management?
a. hydrostatic balloon dilatation
b. endoscopic placement of a silastic feeding tube
c. esophagoscopy and biopsy
d. antireflux operation
e. esphageal resection
C
have to rule out esophageal adenocarcinoma –> causing stricture (RF = GERD)
after so many years of GERD –> have to be concerned about what else has happened because of the damage
11month old girl is brought to the ED 1h after the onset of fever & passing purple, jelly-like stools. during the past 7h, she has had episodes of drawing up her knees and crying. she does not appear to be in distress or dehydrated. her temp is 37.8C (100F), pulse is 110, respirations are 16, and BP is 100/50. an elongated mass is palpated in the RUQ. which of the following is the most appropraite next step in management?
a. contrast enema
b. upper GI studies with small bowel follow through
c. CT scan of the abdomen
D. HIDA scan
e. colonoscopy
A. air-contrast barium enema
INTUSUSCEPTION
–> this will diagnose and treat it
a previously 62yo man comes to the physician 2d after an episode of blidnness in the R eye that lasted 5-10min. he has no history of similar episodes or other neurologic sxs. he has T2DM treated with an oral hypoglycemic agent. his pulse is 75, RR 12, BP 150/90. exam shoes intact motor and sensory function. the visual fields are full to confrontation. results of funduscopic examination are shown with funduscopy shows a pale, opaque fundus with a red fovea (cherry-red spot). Arteries are attenuated and may even appear bloodless. which of the following is the most likely underlying cause of these findings?
a. cardiomyopathy.
b. carotid stenosis
c. cataract
b. diabetic retinopathy
e. glaucoma
B
–> retinal artery occlusion = sudden, painless blindness
“cherry red spot”
86yo man with long-standing HTN comes for a follow-up exam. he has angina pectoris and mild COPD. meds include nitroglycerin and an albuterol inhaler. he has smoked 2 packs of cigarettes daily for 48y. he is 183cm (6ft) tall and weighs 70kg (154lb). BMI is 21. his pulse is 72, RR 14, and BP 165/105. exam shows no other abnormalities. serum studies show a urea nitrogen conc. of 36 and a creatinine conc. fo 1.9. renal ultrasonography shows a 14cm L kidney and a 7cm R kidney. which of the following is the most likely cause of this pt’s HTN and renal atrophy?
a. chronic glomerulonephritis
b. chronic interstitial nephritis
c. chronic vesicoureteral reflux
d. fibromuscular dysplasia of the renal artery
e. renal artery stenosis
E
” renal atrophy” –> normal must be the 14cm one. lack of perfusion –> renal artery stenosis
52yo man is brought to the ED b/c of respiratory distress after hitting his chest on the steering wheel in a motor vehicle collision. on arrival, his pulse is 110, RR 32, and BP 110/80. there is tenderness to palpation over the 3rd, 4th, and 5th ribs. x-rays show fractures of these ribs both anteriorly and laterally and an infiltrate in an underlying area suggestive of alveolar and insteritial edema. which of the following is the most likely diagnosis?
a. cardiac tamponade
b. hemothorax
c. open pneumothorax
d. pulmonary contusion
e. tension pneumothorax
f. traumatic diaphragmatic hernia.
D
= “infiltrate in an underlying area suggestive of alveolar and insteritial edema”
- -> something that looks like a pneumonia
- -> immediate hx of trauma
==> pulmonary contusion
52yo woman comes for a routine health maintenance examination. she has been receiving tamoxifen therapy for breast ca prophylaxis for 3y b/c of her family hx of breast ca. examination shows a palpable 3cm L ovary. the remainder of the exam shows no abnormalities. which of the following is the most appropriate next step in diagnosis?
a. measurement of serum estradiol concentration
b. xrays of the abdomen
c. barium enema
d. pelvic US
e. laparoscopy
D
could simply be a cyst
52yo man comes to the physician b/c of a 3d history of upper abdominal pain and blotaing and 1d history of N&V. bismuth preparations and antacids have not relieved the N&V. he has a history of a duodenal ulcer treated with omeprazole. he currently takes no prescription medications. his pulse is 90 and regular, BP is 130/88. cardiopulmonary examination shows no abnormalities. the abdomen is distended with borborygm in the epigastric area and a succcussion splash. there is no rebound tenderness or guarding. which of the following is the most likely explanation for these findings?
a. gasric mucosal irritation due to an enterovirus infection
b. mucosal action of ingested heat-stable enterotoxins
c. perforation of a duodenal diverticulum
d. scarring and fibrosis of a duodenal ulcer crater
e. thrombosis of the superior mesenteric artery
D
concerns about succusion splash
RF = chronic duodenal ulcer
borborygm = rumbling or gurgling noise produced by air in the bowels
+ succusion splash
==> gastric outlet obstruction = likely due to a duodenal crater / scarring from chronic ulcer
process of elimination
32yo woman comes to teh ED b/c of a 10h hx of increasingly severe, constant pain in her abdomen. she has nausea, but has not vomited. she has SLE well-controlled with prednisone. she takes no other medications. her temp is 38 (100.4F), pulse is 110, RR 16, BP is 115/85. examination shows no scleral icterus. the abdomen is soft and tender to palpation over the RUQ. there is mild guarding without rebound. lab studies show Hgb 14 Leuk 12000 Segmented neutrophils 75% Bands 10% lymphocytes 15% results of the LFTs are within the reference ranges. abd US shows a disteded gallbladder with a thickened wall and a gallstone lodged in the neck of the gallbladder. following administration of cefazolin and an IV infection of lactated ringer solution, the pt is taken to the OR for laparoscopic cholecystectomy. on induction with propofol, her BP abruptly decreases to 60/40 and remains constant despite adminisration of additional 500mL bolus of lactated Ringer solution which of teh followig is the most appropriate next step in pharmacotherapy? a. administer diphenhydramine b. administer pressors
B. Immediate rxn to propofol
Common side effects include an irregular heart rate, low blood pressure, burning sensation at the site of injection, and the stopping of breathing.
–> reversal: pressors (e.g. dopamine)
57yo man comes to the physician b/c of a 3mo hx of increasing pain in his calves when he walks >1/2 mile. the pain resolves after 5min of rest, and he can again walk 1/2 mile before the pain returns. he has smoked 1PPD for 40y. he has a 10y hx of HTN well-controlled on HCTZ and atenolol. his temperature is 37C (98.6F), pusle 84, RR 12 and BP 140/85. popliteal, dorsalis pedis, and posterior tibialis pulses are slighly decreased. femoral pulses are normal. measurement of ankle brachial indices shows a ratio of 0.8 (N>1). in addition to recommending smoking cessation, which of the following is the most appropriate next step in management>
a. recommend a walking program
b. CT scan of the lumbar spine
c. MRI fo the calf
d. aspirin therapy
e. aortic angiography
A
<1.0 –> claudication; peripheral artery disease
>1.3 –> calcified artery
treatment of peripheral artery disease
1) exercise program
2) ASA
3) angioplasty, stenting
4) arterial bypass
