Q15$

Question 1

PPH 1 week after delivery. Underwent prolonged induction of labor complicated by Intra amniotic infection and baby was 10lbs. Bleeding through pad every hour v with lots of closets

Diagnosis

Answer 1

retained POC

Secondary late PPH (Intra amniotic infection, large baby, prolonged labor )
- retained POC- D and c
- postpartum endometritis - uteri tonics
- placental site subinvolution- uterus doesn’t go back to size ; broad spectrum abx

Question 2

76 yo with 2 days of weakness and low energy . Pmh of hfpef. One week ago was admitted for recompensares hf. ECG shows long qt at segment depression and flattened t waves mZ

Most likely cause

Answer 2

Hypokalemia due to furosemide
- Potassium helps dilate arteriolas that supply skeletal muscles so if no k skeletal muscles have ischemia causing weakness

Question 3

Alcoholic gets leg laceration but the wound margins are poorly approximates. Gingiva is receded and bleeds easily to touch. BMI 18.8

Why does he have poor wound healing

Answer 3

Nutritional deficiency- vitamin c

Question 4

Patient wants to get pregnant and takes levothyroxine

What to recommend

Answer 4

Increase the dose when she gets pregnant
- estrogen stimulates tbg and HCg stimulates the tsh to make thyroid hormones so less thyroid hormones are free bc bounded

Question 5

Management of shingles

Answer 5

Systemic acyclovir therapy

Question 6

Management of stroke in scd

Answer 6

Plasmapheresis

Question 7

26 yo women monocular vision loss, pain with eye movement , washed out color vision. Aferente pupillary defect (swing light from good to bad bad eye dilated

Diagnosis
Diagnostic
Treatment t

Answer 7

Optic neuritis - hints at Ms
Dx- so hints at Ms do MRI of orbits and brain
Tx: IV corticosteroids

Question 8

Rosacea mama gent

Answer 8

Avoid triggers (sun etoh
Topical metronidazole for papulopustular
Laser or topical brimonidine alpha 2 agonist for erythematotelangiectactic type

Question 9

Recent spinal anesthesia and now has urinary retentionC diminished sensation in legs and weakness of right foot. Also back pain. On chronic antiplatelet therapy.

Diagnosis
Diagnostic
Treatment

Answer 9

Spinal epidural hematoma lead to casida equina
- seen in patients on anticoagulants

-dx: MRI OF SPine
TX: laminectomy

Question 10

Pregnant lady has pyelo and was started on IV ceftriaxone. 48 hours later doing better and is age tule . Urine culture grew ecoli and sensitive to cephalexin, fosfomycin, nitrofurantoin, bactrim

Most appropriate oral antibiotic

Answer 10

Cephalexin

Pyelo
start with iv broad then oral for 5-24 days to eliminate from kidney renal collecting duxts and lower urinary tract
- can’t use nitrofurantoin bc can’t achieve good concentration in the urine but it’s good for cystitis. bactrim is good for cystitis but can cause kernicterus in third trimester so avoid it

Question 11

Adverse effects of tamoxifen (raloxifene good adverse effect

Answer 11

Hot flashes - anti estrogenic in cns so can’t thermoregulate well

Endometrial hyperplasia/ cancer

Uterine sarcoma

Venous thromboembolism

R- osteoporosis

Question 12

Left lower quadrant abdominal pain with n/v, hasn’t pooped but passed gas. Positive leukocyte esterase negative moriré, urgency and frequency

Diagnosis

Answer 12

Diverticulitis - can irritate the bladder

Question 13

Admitted 10 days ago for his a creatures and Ct showed necrosis hence acute necrotizing pancreatitis. Now has fever AMS , shock . Flanks are tympanic

NBSIM
Treatment

Answer 13

Ct of abdomen - if negative aspirate and culture the necrotic pancreatic material

Acute necrotizing pancreatic - necrotic part is sterile originally and 7-10 days later bacteria like ecoli and pseudomonas can collect causing gas within the necrotic parts

Tx: IV antibiotic therapy debridment

Question 14

65 yo with fever productive cough and right love infiltrate has lymphadenopathy and severe leukocytosis (24,000) mostly lymphocytes plus anemia and thrombocytopenia

Blood cultures sent. NBSIM

Answer 14

Flow cytometry if the peripheral blood
- chronic lymphocytic leukemia and because of ineffective immunoglobulins have infections

Question 15

4 week old drinks cow milk formula has bloody streaked stools

Cause
Prognosis

Answer 15

Non I’ve mediated allergic reaction - food protein induced allergic proctocolitis
—-protein causes eosinophilic inflammation of the colon and rectum

• self limited and by age 1 can tolerate products that triggered them as a newborn

Question 16

Associated nutritional deficiency is itv breath holding spell

Answer 16

IDA

Question 17

3 hour old pulse ox is 75% and appears cyanotic . Breath sounds are normal . On 100% Pa02 is 43

NBSIM

Answer 17

Pa02 is 43 so think cyanotic congenital heart disease . If pa02 improved it would be a pulmonary pathology like meconium aspiration pulmonary hypoplasia

NBSIM- ECHO

Question 18

Interesting antibody seen in scleroderma

Answer 18

Anti rna polymerase III

Question 19

23 yo with intact dentition has prolonged severe sore throat, high fever , pain with swallowing , neck pain, swelling along the sternocleidomastoid muscle . Vs- hypotension tachy cardiac , febrile 104. CXR - lung nodules and some nodules with cavitation. Duplex is shows left internal jugular vein thrombosis

Organism

Answer 19

Lemierre syndrome
- gram negative anaerobe like Fusobacterium necrophorum. Starts with tonsillitis or complication from dental work or mastoiditis. And rhe. Can cause internal jugular thrombosis
-prolonged severe sore throat, high fever , pain with swallowing , neck pain, swelling along the sternocleidomastoid muscle .
-infects the internal jugular vein and thromboembolism can go other places like the lung leading to nodules and respiratory symptoms

Dx: culture form blood or pus
Tx: Supportive airway management with IV antibiotics and maybe surgery (ID) if no response to antibiotics

Question 20

Term newborn without prenatal care now has grunting nasal flaring and cyanosis of mucous membranes (82% satting) . CXR interpretation was air filled loops of bowel on left and heart shifting to the right . Scaphoid / flat abdomen and barrel shaped chest . Heart sounds loudest on right

Cause
Diagnostic
Treatment

Answer 20

Congenital diaphragmatic hernia
Dx: CXR but should be seen at prenatal visits
Tx: initial is intubation with cautious ventilation and gastric decompression
Correction Surgery urgently

Heart sounds loudest on right because heart is deviated

Question 21

Alcoholic tested for pancreatitis now says he can’t get enough air . A febrile but CXR shows bilateral diffuse alveolar opacities

Which treatment strategy decreases risk of in hospital mortality

Answer 21

Preventing alveolar overdistension
- ards caused by pancreatitis; low tidal volume ventilation to ventilate the non collapsed alveoli . Higher volume van stretch already damaged alveoli therefore further lung injury

Question 22

Food management. In burn victim

Answer 22

Enteral immediately - helps prevent sepsis etc