Q18@

Question 1

64 yo with Hodgkin treated with radiation and chemo (doxorubicin like drugs) now has sob, Peripheral edema, ascites, abdominal distention, hematomegaly,. Elevated JVP

CAUSE
Pathophysiology
Diagnostic
Treatment

Answer 1

INELASTIC PERICARDIUM
- constrictive pericarditis - can occur due to recurrent pericarditis, radiation, cardiac surgery, tb pericarditis
-pathophysiology: scarring an loss or elasticity of the pericardial sac so decreased venous return to the right heart during inspiration leading to right heart failure (hence Peripheral edema, ascites, abdominal distention, hematomegaly,. Elevated JVP) which can lead to cardiac cirrhosis
- physical exam- JVP, prominent x and y descent sand heparin uvular reflux, kussmaul sign lack of decrease or increase in JVP on inspiration, pericardial knock (mid diastolic sound)

Dx: echo : pericardial thickness, abnormal septal motion and biatrial enlargement
Ekg: low voltage qrs
Chest X-ray /Ct - pericardial calcification

Tx: diuretics
Pericardiectomy

Question 2

Patient with diminished food and water intake with confusion and shock vitals
WXG- wide qrs no p

NBSIM

Answer 2

Calcium gluconate
a- hypovolemic shock leads to hyponatremia/hypernatremia/ Hyperkalemia- can present with peaked t waves then loss of p then wide qrs then systole

Question 3

Patient over 65 received chemotherapy recently and now has watery diarrhea , abdominal cramps, low grade fever , and leukocytosis. No recent antibiotics use

NBSIM

Answer 3

Stool testing for c. Diff
- cliff can occur if you haven’t used antibiotics , RF: chemo, over 65

Question 4

Complication with associated symptoms wit upper extremity central catheter liKe PICC

Diagnostic
Treatment

Answer 4

DVT- pain, redness , swelling of unilateral arm

Duplex US
3 months of anticoagulant

Question 5

Kid swallowed fish bone and it’s in the esophagus . She has no symptoms

NBSIM

Answer 5

Immediate Endoscopy removal high risk features because its sharp object in esophagus stomach proximal duodenum , obstruction of esophagus with symptoms , symptoms of respiratory compromise, battery button on esophagus , magnets on esophagus or stomach

Question 6

Kid and cousin who spent the night have pared papule a in a liner line on neck and arm. Papule shave a central hemorrhagic puncture . Trick they said searched home in furniture and found webs

Diagnosis
Treatment

Answer 6

Bedbug not a spider bite( solitary papule not bitten numerous times

Tx: supportive (heat or freeze belongings; they can leave 1 year without food

Question 7

Mi heart failure with pulmonary edema. Patient is given aspirin, clopidogrel, statin and anticoagulant

NBSIM

Answer 7

Give furosemide

Question 8

Day 3 after hospitalization for pancreatitis has respiratory distress

Vent settings
RR 14
TV 420
FIO2 0.8 (80%)
PEEP 10

10 minutes after being intubares BP 110/70 and pulse is 90. ABG is
Ph 7.32 Pac02 48, Pa02 105

NBSIM

Answer 8

Had similar question
Pancreatitis lead to ards

ARDs improves oxygenation by increasing Fi02 and PEWP to prevent alveolar collapse. Ideal FI02 is <60% to keep Pa02 at 60-90 mmhg which corresponds to saturation of 82-96%.
Need to decrease Fi02 to decrease Pa02
ABG shows overly oxygenated

Question 9

Hemodynamic effects of congenital heart defects
OVERLOAD PRODUXED
VENTRICLE AFFECTED

ASD
VSD
PDA
AORTIC COARCTATION

Answer 9

ASD volume rV
VSD volume LV
PDA volume LV
AORTIC COARCTATION pressure LV

Question 10

Pregnant lady with elevated total t3 and T4 and low TSH. No symptoms

Cause

Answer 10

Normal physiologic changes

Question 11

Alcoholic has surgery . NPo since surgery and only received antibiotics. Bleeding from venipuncture sites

Labs - plt normal , PT AND PTT prolonged

Cause

Answer 11

Vitamin d deficiency
- alcoholic, npo

Question 12

Girl came and said my interstitial cystitis is worsening. Developed 6 months ago which amitriptyline helped but a week ago but last week worsening urinary urgency and pain with voiding . Recently started a new relationship and takes OCP (didn’t say condoms)

UA - leukocyte esterase pos
Nitrites neg
Bacteria none

NBSIM

Answer 12

Chlamydia and gonorrhea NAAT
- urethritis - dysuria and sterile pyuria

Question 13

50 yo boy with C diff infection and now has worsening abdominal pain , signs of peritonitis and severe colonic dilation (10cm- toxic megacolon), absence of bowel sounds , serum lactate elevated

NBSIM

Answer 13

Surgical exploration (laparotomy) if c diff not responded to treatment and is progressing

Question 14

30 yo man with headache and high HP multiple times (today 185/105) systolic continuous murmur
diagnosis

Answer 14

Coarction of aorta

Question 15

Signs of alcohol cerebellar degeneration
Pathophysiology

Answer 15

Degeneration of purkinje (vermis)

Wide based fair
Impaired tandem walking / heel knee shin
Preserved finger nose
Nystagmus
Pendular knee reflex- hit the patella limb swings
Postural temor of fingers and thighs at later stages

Question 16

Bow legged 15 month old with full rom, , legs are equal length , normal stature, no lateral thrust when walking

NBSIM

Answer 16

Reassurance - physiologic gent varum resolves by 2 yo

Question 17

35 yo female with episodes of dysphagia , regurgitation and chest pain relieved by nitroglycerins, ofynophagia for cold and hot food

Diagnosis
Diagnostic

Answer 17

Diffuse esophageal spasm
Dx: esophageal manómetry (motility studies)

Question 18

46 yo women with recurrent episodes of cellulitis , BMI of 34 complaining for chronic LLE swelling for 2 years. Can’t lift skin from the sprain of the toes of left foot

Cause

Answer 18

Disruption of lymphatics -lymphadema due to the obesity and inflammation. Caused by cellulitis

Question 19

When to use steroids with bactrim

Answer 19

Sat <92%, pa02 <=70, Aa gradient >=35

Question 20

Progressive sensorineural hearing mis, episodic vertido with nystagmus triggered by pressure change in the inner ear (Vasalva, elevator)

Cause

Answer 20

Perilymphatic fistula -rare due to head trauma or barotrauma where leakage of endolymph from the semicircular canals and cóchlea

Question 21

Postprandial pain and nausea, nsaid use for migraines , positive stool guiac test. For past several weeks. Now he’s severe abdominal tenderness with guarding and fever and tachycardia
NBSIM

Answer 21

Upright X-ray of chest and abdomen
- see air under diaphragm
- perforated viscus
- peptic ulcer which eroded through stomach and duodenum releasing air and gastric contents causing peritonitis(severe abdominal tenderness with guarding and fever and tachycardia)