Q6)

Question 1

17 year old girl recently broke up with bc, under stress at school and has been sleeping poorly. Mom heard her fall in shower , lates unconscious for 20 minutes . Transported to hospital and was drowsy and confused . FS 100

What would be seen in patient

Answer 1

Tongue biting

Stress and lack of sleep can trigger a generalized tonic clinic seizure

Question 2

12 year old boy had cough rhinorrhea and sore throat 2 weeks ago x past 2 days fever, worsening pain behind eyes which radiated to right forehead(tenderness when palapating right forehead) woke up this am and vomited. Green nasal discharge from right nose. Neuro wxam normal.

NBSIM

Answer 2

Ct scan of head (orbits and sinuses too?

Acute bacterial rhinosinusitis which bacteria spread to the brain leading to a brain abscess (fever and headache)
Headche and vomiting leans to ICP elevated

Question 3

How long should most antidepressant s be discontinued before beginning an MAOI to avoid serotonin syndrome? +exception

Answer 3

2 weeks but 5 weeks for Fluoxetine because it has a long half life

Question 4

Neonatal conjunctivitis’s
timeline symptoms and treatment
- chemical
- gonorrhea (diagnosis
- chlamydia

Answer 4

Chemical <day old - mild irritation after getting the silver nitrate prophylaxis- give eye lubricant

Gonorrhea 2-5 days - very bad eye swelling and ALOTTT of purulent discharge , corneal edema / ulceration
- one IM 3rd gen
- diagnosis (culture gram neg intracelular diplococci on Thayer Martin agar

Chlamydia 5-14 days of age - mild eye swelling , watery serosang or mucopurulent eye discharge
- oral erythromycin

Question 5

55 yo female with 1 day of worsening sob , blurred vision , dry mouth. Pupils dilated . Neck muscles are weak and muscle strength in UE 4/5. ABG- resp acidosis

Cause of th ABG findings

Answer 5

Impaired neuromuscular transmission
- botulinum poisoning- starts up then down , can affect the diaphragm hence the respiratory distress , descending motor paresis of cn 3,6, 9, 10, autonomic symptoms

Thought maybe MG. Spares pupils

Question 6

Teen girl with fever , enlarged erythematous tonsils, bilateral cervical lymphadenopathy with mild hepatospleenomegaly . Dad give left over amoxicillin(she’s taken it before) now has maculopapular rash all over body

Diagnosis

Answer 6

Mono

• people with mono who takes ampicillin or Amox can get a rash for unknown reasons

Question 7

Man with alcohol use disorder found unconscious in park on a cold winter day. VS- sinus Brady, QT 560, 77/38 and Hr 38.

NBSIM hemodynamic status

Answer 7

Active warming

Question 8

45 yo with recurrent sinusitis and otitis for the past 6 months, auditory canal or oral ulcers, fatigue, mild leukocytosis, anemia, microscopic hematuria (UA showed RBC 20-30) and protein and blood 2+ ) . HIV negative.

NBSIM (other unique symptoms)

Answer 8

Qualitative serum autoantibodies
- Wegner
- c-ANCa (proteinase 3-anca) —->HIV can give FP ANCA so it can be ruled out
- hearing loss, hemoptysis, lívido reticularis, non healing ulcers on skin

Question 9

36 week GA with Herpes but no lesions

NBSIM

Answer 9

Start her on acyclovir or valacyclovir until delivery (starts at 36 weeks) and if no lesions at time of delivery vaginal delivery

Question 10

55 yo female , non smoking with chronic copious thick mucus , streaky hemoptysis and 7 antibiotic responsive episodes of foul smelling purulent sputum. CXR shows increased bronchial markings and ring like shadows in middle and lower lung fields.

How to confirm the diagnosis ?

Answer 10

High res CT of chest

• bronchieectasis - mucus attracts bacteria leading to bronchial dilation

Question 11

33 yo female unable to conceive after 9 months of unprotected sexual with husband . Remote history of chlamydia 10 years ago. Travels 3-4 dates each week but sex around schedule. NBSIM

Answer 11

Timed Intercourse with ovulation predictor kits - LH surge 1 day/36 hours prior to ovulation and egg survives 12-24 hours after ovulation

I PICKED HYSTEROSALPINGOGRAM thinking possible PID but do this later if can’t get pregnant after 1 year

Question 12

chronic granulomatous disease
-Prophylaxis antibiotic and anti fungal
-what kind of infections

Answer 12

Bactrim
Itraconazole

Cutaneous and pulmonary infections with catalase positive (no cardia , s.aureus, burkholderia, serraría , aspergillosis

Question 13

Cervical screening guidelines for
Hysterectomy with cervix removed
HIV
Immunosuppressed
>65

Answer 13

Hysterectomy with cervix removed- no if negative other screens and low risk
HIV- onset of sexual intercourse or at time of HIV diagnosis, Q1y until > or = 3 normal
Immunosuppressed -onset of sexual intercourse, Q1y pap with HPV contesting
>65: no if at low risk and negative prior screens
If history of CIN2 or higher screen for 20 years after detection
Continue after 65- if cervical risk factors: a lot of high risk sexual activity, cig, DES, immunosuppressed

Question 14

76 year old man with chronic constipation and fecal incontinence.
NBSIM
Treatment t

Answer 14

Evaluate for fecal impaction

Tx- first manually break up Doo doo then use enema
Bowel regimen (laxatives and change in diet

Question 15

5 year old boy with chronic foul smelling purulent drainage from one ear. Tympanic membrane is scarred with large perforation . Transient improvement with oral antibiotics. Had cholesatoma which was removed

What organism cause the infection

Answer 15

Pseudomonas (s.aureus ) maybe fungal
- chronic suppuration (pus) Ottis media - can lead to choleas toma and Eustachian tube problems
- tx oto topical fluoroquinolone

Question 16

13 year old came from SE Asia recently . Recalls a time when she had febrile illness a year ago with pain and swelling in knees and wrists and was treated with NSAIDs and symptoms went away. No symptoms since. Also has a Holosystolic murmur at apex.

Most appropriate treatment and screening

Answer 16

IM Pen G and monitor for 6-12 months for signs of LV dysfunction due to the MR )

patients with a history of RF can get it again and it can progress to RHD so need antibiotic prophylaxis every 4 weeks to prevent recurrence
- timing depends on servity
Uncomplicated - Q4 weeks for 5 years or until 21 whichever is longer
CARDITIS - Q4 weeks for 10 years or until 21 whichever is longe
Carditis and valvular disease Q4 weeks for 10 years or until 40 whichever is longe

Question 17

32 yo with signs of MDD but craves salty pretzels or potato chips , post 33 pounds and has decreased axillary and pubic hair , loss of libido

How to establish diagnosis ?

Answer 17

Cosyntriphin stimulation test - low production of cortisol is a positive test

Primary adrenal insufficency due to AU destruction of the adrenal - low cortisol leads o psychiatric manifestations and androgen deficiency leads to low libido and suppressed secondary sexual characteristics

Question 18

Some 40 year old lady was just diagnosed weird adenomyosis last month. Period started yesterday , pain is more severe and radiates to the LLQ. On bimanual exam the left adnexa is tender.

NBSIM

Answer 18

Diagnostic laparoscopy immediately

Ovarian torsion is a clinixal diagnosis

Divine says do US then lap . Even if US is negative. That doesn’t rule out the torsion

Question 19

3 week old in NICU born premie was intubares now on nasal cannula has bilious emesis , distended abdomen with hupoacyive bowel sounds, leukocytosis and metabolic acidosis . Nasogastric feeds. Appears lethargic .TEMP 96. Yellow seedy stool

Imaging findings

Answer 19

Abdominal X-ray with air in the bowel wall and portal veins

• nEC —inflammation of the bowel wall and gas producing bacteria grows there’s . Hypothermic and lethargic may not see bloody stool yet

Question 20

Hydroxyurea
- when is it given to SCD patients
- complication
- what can it be given with

Answer 20

Recurrent vasoocculusive crises , history of ACÁ, severe symptomatic anemia
-give with penicillin until 5 yo, folate, vaccination
- myelosuppreasion (any of the pancytopenia labs

Question 21

Euthyroid sick syndrome
- pathophysiology
- labs for early and severe

T3
T4
TSH
Reverse T3

Answer 21

Decreased peripheral conversion. Of T4 to T3

Mild
T3 low
T4 normal
TSH normal
Reverse T3 high

Severe

T3 low
T4 low
TSH low
Reverse T3 high

Question 22

30 year old women with weakness in hands and can’t grip mug or open jaws. Bilateral upper extremities have impaired pain and temperature sensation. Moderate wasting of small muscles of hand

Diagnosis
Diagnostic
Treatment t

Answer 22

Syringomyelia
MRI
SURGERY

Question 23

5p year old man is a traffic controller in an underground parking garage complaining of occasional daytime headaches dizziness nausea. 2 pack daily smoker for past 25 years . Abnormal lab: HCT is elevated at 60%

What’s responsible for condition. V

Answer 23

Carb oxyhemoglobin- car exhaust and the cigarettes
-co poisoning
- co has higher o2 affinity therefor why hypoxia so inc production of epo

Question 24

3 days after laparoscopic cholecystectomy patient is hypoxix at 90%. Decreased breath sounds at base. ABG- resp alkalosis:

Why?
How to prevent this

Answer 24

Impaired cough and shallow breathing
- atelectasis - pain so shallow breathing and weak cough
- prevent by pain management , deep breathing, IS , mobilization

Question 25

Exercise induced bronchoconstriction
Diagnosis
Treatment

Answer 25

Dx: FEV1 decreases >15% after exercise
Tx: inhaled corticosteroids and beta agonist 10 minutes before exercise