STEP 2

Best initial test for evaluating PAD

ABMI

quick rule for CO2 expected in metabolic acidosis

expected CO2 should equal last 2 numbers of pH

gel phenomenon associated with what dz process?

osteoarthritis - stiffness <30 min - after being immobile (car rides) - accumulation of synovial fluid --> needs time to spread out after accumulating

Asymptomatic bacteriuria in pregnant women should be...

treated to reduce risk of preterm labor & pyelonephritis - oral antibiotics

TSC mutation

tuberous sclerosis

70 yo pediatrician develops headache of sudden onset, slurring speech, & confusion. He is brought to ED, where he arrives with Glasgow coma score of 8. Emergency CT scan of head reveals well-demarcated lobar bleeding involving left frontal lobe, centered in cortex & extending into underlying white matter. Pt's hx is negative for HT or vascular risk factors. Most probable underlying cause of pt's bleeding?

*Cerebral amyloid angiopathy* (CAA) - via deposition of alphabeta amyloid in small arteries & arterioles of leptomeninges & brain - intracerebral bleeding related to CAA occurs in neocortex in "lobar" distribution (frontal, parietal, temporal, occipital lobe) - hematoma readily identifiable with CT scan & is centered in cerebral cortex - most pts over 60 yo - blood usually absent from CSF

74 yo woman comes to doc bc of progressive itching & irritation on her vulva for past 2 years. She has seen several docs during this time & has been treated with antifungal creams & topical steroids without relief. She has HT & takes an ACEI. She had 2 cesarean deliveries in her 30s & no other surgeries. She has no known allergies. Pelvic exam shows numerous excoriations with scarring on patient's labia majora. Speculum exam reveals normal vaginal discharge. Microscopy of vaginal discharge shows no clue cells, trichomonads, or hyphae. Remainder of physical exam normal. Most appropriate next step in management?

*Vulvar biopsy* - consider in any woman who has persistent vulvar pruritus - even more essential in postmenopausal women (SCC)

Postinfectious glomerulonephritis

- infected few weeks ago - C3, C4 - dysmorphic RBCs

62 yo man has had GERD for several years. Diagnosis was originally made by endoscopy, & he was placed in hands of good gastroenterologist, who among other things put him on PPIs. He has been less than totally compliant with med management which he follows when pain is bad but discontinuous when he feels better. Endoscopy & biopsy specimens now show severe peptic esophagitis with Barrett esophagus & early dysplastic changes, but no overt carcinoma. Additional studies show good esophageal motility, with low pressure in lower esophageal sphincter and normal gastric emptying. Most appropriate treatment at this time?

*Laparoscopic Nissen fundoplication* - improves pt symptoms in 85-90% of pts - all pts with moderate to severe GERD should receive trial of PPI therapy - if PPIs ineffective or compliance is an issue, surgical intervention indicated...

48 yo woman with ho depression has been maintained on phenelzine for several years. She comes to doc complaining about worsening of her depression & insists on switching to newer med, such as SSRI. She is also tired of sticking to such a rigid diet. Doctor agrees to switch patient to an SSRI. What is correct concerning switching her from phenelzine to an SSRI?

*A 14-day washout period after discontinuing phenelzine is needed before an SSRI can be started* Serotonin syndrome can develop with concomitant use of MAO inhibitors such as phenelzine & SSRIs, of if there has been too short a period of washout in crossing over from one to another agent - at least 10 days after MAO discontinuation & 5 weeks after discontinuation of SSRI should pass to avoid this complication

31 yo man evaluated bc of exquisitely painful, recurring episodes of swelling in his left great toe & both ankles. He states that he has one acute episode per month. B/t episodes, he has no symptoms at all. He is asymptomatic now. Patient's BP is 120/80 mmHg, pulse rate is 80/min, & temp is 37 C (98.6 F). Physical exam is normal, including left first metatarsophalangeal joint & ankles. Lab evaluation shows sserum uric acid level of 10.5 mg/dL, serum creatinine level of 0.8 mg/dL, & BUN level of 23 mg/dL. Blood country, hepatic enzymes, & radiographs of affected joints are normal. What is the best course of action?

*A 24-hour urine for uric acid excretion* - asymptomatic right now

70 yo man evaluated in ED bc of SOB, cough, purulent sputum. His symptoms began week ago & have progressively worsened. He has never smoked. On physical exam, pt is alert & oriented & appears dyspneic. Temp is 104.4 F, BP 112/60 mmHg, pulse rate 100/min, RR 30/min, & O2 sat 89% on ambient air. Pulmonary exam shows right-sided crackles & dullness to percussion. Chest radiograph shows right-sided consolidation. Blood cultures obtained, & treatment with empiric antibiotics initiated. Most appropriate disposition for this patient?

*Admit to medical ward* - pt is at moderate risk considering his age & tachypnea --> needs to be admitted to hospital CURB-65 - identifies pts at risk for complications - confusion, BUN>19.6, RR>30/min, systolic BP <90 mmHg or diastolic <60 mmHg, age >65

Part of dermoid cyst that contains largest number of different tissues

*Rokitansky protuberance*

58 yo man undergoes liver transplantation. Procedure goes well, without any noted complications. Ten days later, however, pt's levels of GGT, alkaline phosphatase, & bilirubin begin to increase. Most appropriate next step in diagnosis?

*Ultrasound of biliary tract & Doppler studies of anastomosed vessels* Liver transplants... - tech probz with biliary & vascular anastomosis = most common cause of early functional deterioration --> first anomalies to be sought

Therapeutic range for lithium

0.6 - 1.2 mEq/L

Used to adequately hydrate patient in slowly developing severe hypernatremia

5% dextrose in 0.45% NaCl

interstitial pulmonary fibrosis usually results in respiratory failure within

5-10 years

Goal of oxygen therapy in COPD is admin of oxygen through Venturi mask with target PO2 of

60-65 mmHg (pulse oximetry reading of 90-92%) --> to avoid causing pulmonary vasodilation to poorly ventilated lung regions

good prognosis AML cytogenetics

8:21 15:17 inv 16

Rabies prophylaxis if animal becomes ill

Animal must be killed for brain biopsy. - negative biopsy = no treatment - positive biopsy = give prophylaxis

Rabies prophylais if anirmal can be observed

do so for 10 days; no treatement needed

FSGS slowly progresses to renal failure and has no effective treatments except for

ACEIs

Mainstay of medical treatment of infantile spasms

ACTH

Most common cause of acute intrinsic renal failure

ATN via prolonged renal ischemic via hypovolemia - ATN usually reversible but sometimes requires short term dialysis - presents with oliguria or anuria in most cases + elevated creatinine & BUN levels, normal BUN:creatinine ratio, low urine osmolality, elevated urine sodium, renal tubular epithelial cells, muddy brown granular casts on urinalysis

What can falsely elevate serum ferritin?

Acute Phase Reactants - chronic inflammation - infection - malignancy

muddy brown casts

Acute Tubular Necrosis

Caused by thrombosis of hepatic venous circulation and/or IVC resulting in acute pain, hepatomegaly, splenomegaly, & elevated transaminases.

Acute onset *Budd-Chiari syndrome*

Treatment of hyperuricemia in overproducers and most underexcretors

Allopurinol - 100-300 mg/dL - use lowest dose to keep uric acid level < 6.5 mg/dL - start 100 mg/dL in patients with renal insufficiency Febuxostat - 40-80 mg/dL - no renal dose adjustments - can be used in renal insufficiency

Arthropod vector: ehrlichiosis, tularemia, Southern tick-associated rash illness (STARI)

Amblyomma

Has been shown to provide greatest decrease in mortality in initial approach to acute coronary syndrome (ACS)

aspirin

Criteria for diagnosis of preeclampsia

BP > 140/90 mmHg after 20 weeks' gestation with proteinuria >300 mg/24 h or >1+ on urine dipstick Mild preeclampsia treatment - can be expectantly managed until 37 weeks' gestation provided they don't meet criteria for severe dz

What is a safe and effective practice within defibrillation sequence?

Be sure oxygen is not blowing over patient's chest during shock

Most frequently used treatment in children with enuresis

Behavioral therapy - dry nts recorded on calendar & rewarded with star as gift - buzzer & pad apparatus used for conditioning - should be tried first before starting meds

Best test to verify nasal or ear discharge in CSF

Beta-2-transferring

2 nodes of OA

Bouchard = nodes at PIP joints Heberden = nodes at DIP joints

Absolute requirement of oxygen for first 28 days of life

Bronchopulmonary dysplasia (BPD) - end result = obliterative fibroproliferative bronchiolitis with widespread bronchiolar and bronchial mucosal hyperplasia & metaplasia & interstitial edema - tachypneic, increased A-P chest diameter, intercostal retractions, baseline wheezing, fine crackles, poor growth - continued oxygen requirement - increased incidence of lower track obstruction - longer use of *furosemide* = less actual diuretic effect = volume depletion with increased loss of chloride in urine; hypochloremia, hypokalemia, metabolic alkalosis, hypocalcemia, hypercalciuria

hypercalcemia normal PTH

C-Christimas-25 PTH<25 = goal

Early treatment for cocaine-induced MI should include

benzodiazepines - for sedation and to reduce heart rate and blood pressure

Most common leukemia in western countries

CLL

Diagnosis for cryptococcagl meningitis is

CSF or *serum antigen testing*

GPA

Wegener's Granulomatosis - pulm-renal - *PR3* / c-ANCA

anti-EGFR Abs. Useful only if RAS-wt. Only for stage IV.

Cetuximab Panitumumab

Improve symptoms & survival of metastatic pancreatic cancer

Chemotherapy - sx contraindicated in pancreatic cancer with mets

Can lead to renal failure & ischemia distally, causing blue toe syndrome. Livedo reticularis (lacy erythematous rash) classically seen on physical exam.

Cholesterol emboli from catheterization procedures

Most common cause of brain abscess formation in meningitis

Citerobacter koseri or C freundii

potassium EKG changes....give

calcium

acute gout treatment

Colchicine Naproxen / NSAIDs Prednisone - try to use both colchicine & NSAIDs both in max doses Colchicine - available form = Colcrys - treatment of gout flares = 1.2 mg (2 tablets) at first sign of goutflare followed by 0.6 mg (1 tablet) one hour later - prophylaxis of gout flares = 0.6 mg once or twice daily in adults & adolescents older than 16 yo - max dose 1.2 mg/day

Findings of CHARGE association are:

Colobomas - anywhere from anterior structures to optic nerve Heart defects (mostly septal & conotruncal) Atresia choanae (unilateral or bilateral) Retardation (growth &/or mental) Genitourinary abnormalities &/or hypogonadism Ear anomalies

Complication of right-sided MI due to direct lesion of AV node

Complete heart block - manifests as hypotension & *bradycardia*

Only 3 beta blockers approved or HF

Coreg Metoprolol Succinate Bisoprolol

Dzes that result in thrombocytopenia/increased destruction

ITP - childhood - post-viral - adults = chronic dz - Ab-mediated = IgG TTP/HUS - pentad: fever, neuro, MAHA, thrombocytopenia, renal dysfunction (only need MAHA) - elevated reticulocyte count, LDH, total & indirect bilirubin DIC - increased PT & PTT - positive protamine - increased FDP - increased D dimer HIT

Post-operative fever classically attributed to etiology based on timing: Day 1-3 = Day 3-5 = Day 4-7 = Day 5-10 =

Day 1-3 = wind, atelectasis Day 3-5 = water, or *UTI* Day 4-7 = walking, or DVT Day 5-10 = wound infection

Arthropod vector: Rocky Mountain spotted fever, Colorado tick fever, tularemia

Dermacentor

Characterized by impaired ventricular filling during diastole. Most common cause is chronic HT leading to left ventricular hypertrophy.

Diastolic dysfunction

Diffuse esophageal spasm and nutcracker esophagus are clinically distinguishable, & require manometry to differentiate. Howso?

Diffuse esophageal spasm - normal resting lower esophageal pressure Nutcracker esophagus - increased resting lower esophageal pressure

Initial evaluation of suspected GERD

Esophagoscopy with biopsies

First-line treatment for hemodynamically stable ventricular tachycardia is

IV antiarrhythmic agent, such as *amiodarone* - procainamide & sotalol are also acceptable agents

Reversal of elevated INR best done with admin of

FFP - for acute setting - followed by Vit K for prolonged effects on clotting cascade

Most common inherited hypercoagulability

Factor V Leiden mutation - difficult for activated protein C to turn of factor 5 - increases risk of clot

First line treatment of symptomatic or severe hypercalcemia (serum >15 mg/dL)

IV normal saline - subsequent treatment = IV calcitonin & bisphosphonates

Indicated in treatment of severe BPH or of BPH that is unresponsive to monotherapy with alpha-adrenergic antagonists

Finasteride - inhibits 5alpha-reductase (responsible for conversion of testosterone to more active & potent form of dihydrotestosterone)

Treatment of choice for pts who have Wenicke encephalopathy

IV thiamine & magnesium, followed by glucose infusion

Treatment of Wernicke encephalopathy

IV thiamine BEFORE glucose

Acute bacterial prostatitis is most often caused by E coli or chlamydial infection. What covers both of these microorganisms and are therefore good choice for empiric treatment?

Fluoroquinolones (ofloxacin, levofloxacin,ciprofloxacin) - 4-6 wks of therapy required = ensures adequate drug levels in prostatic tissue

Leading cause of nephrotic syndrome worldwide

Focal segmental glomerulosclerosis (FSGS)

Most common causes of meningitis in neonatal period =

Group B Step / agalactiae E coli Listeria monocytogenes

Combo of hematuria & hemoptysis should always raise possibility of

Goodpasture syndrome - *Anti-glomerular basement membrane Abs* = pathognomonic - often upper resp tract infection precedes

PTCH mutation

Gorlin syndrome - AKA nevoid basal cell carcinoma syndrome - affects many areas of body - increases risk of developing various cancerous and noncancerous tumors - most ppl also develop benign tumors of jaw / keratocystic odontogenic tumors

Acidemia: - primary metabolic cause if: - primary respiratory cause if:

HCO3 < 22 pCO2 > 45

Alkalemia: - primary metabolic cause if: - primary respiratory cause if:

HCO3 > 28 pCO2 < 35

Characterized by platelet aggregation & destruction by induced Abs. *May present with episode of arterial thrombosis, which usually presents with cold, pulseless extremity that is extremely painful.*

HIT - usually occurs with unfractionated heparin but can be seen with LMWH

Shock: Low CVP + low cardiac output

Hypovolemic shock

Increased in acromegaly. Best initial test.

IGF-1 - AKA Somatomedin C - diagnosis confirmed by 100-gram oral glucose tolerance test (OGTT) that fails to suppress GH levels

Known complication of AAA repair second to occlusion of IMA.

Ischemic colitis - prompt recognition & diagnosis with *colonoscopy* allows for timely resection of colon with colostomy to prevent sepsis & death

1 of 3 molecular backgrounds for colon cancer. result of promoter hypermethylation. involves inactivation of BRAF.

Island methylator phenotype

Arthropod vector: babesiosis, ehrlichiosis, Lyme dz

Ixodes

Subtype of cholangiocarcinoma occurring at confluence of right and left hepatic bile ducts, with or without thickened wall. Results in intrahepatic ductal dilation with hyperbilirubinemia, caused by obstruction of outward biliary flow.

Klatskin tumor

Most common dysproteinemia

MGUS/Monoclonal Gammopathy of Unknown Significance - older pts - IgG protein mostly - may progress to MM - <5% marrow plasmacytosis - minimal M spike elevation - no bone lesions

Scan that uses radiotracer that binds to NE receptors. Will identify neuroblastomas & metastatic dz.

MIBG scan

What to do for suspected ankylosing spondylitis if x-ray negative

MRI of sacroiliac joints - may not see changes yet - HLA-B27 does not establish diagnosis = a lot of population actually has it

Characterized by precocious puberty, multiple cystic bone lesions, cafe au lait spots

McCune-Albright syndrome / *polyostotic fibrous dysplasia*

Unstable angina and NSTEMI have same pathophysiology except...

NSTEMI has biomarkers; unstable angina does not - same treatment

Most frequent and severe complication of CSF leak

Meningitis - most common pathogen = S pneumoniae

95% have abnormal protein on SPEP orUPEP

Multiple Myeloma - assess with metastatic bone survey, NOT bone scan = plain films

Shock: low CVP + low cardiac output

Neurogenic shock

Arthropod vector: recurrent fever, tick-born relapsing fever

Ornithodoros

Commonly employed to estimate amount of fluid needed in burn patients

Parkland formula - fluid resuscitation essential in treating burn pts - normal saline or Ringer's lactate = first-line fluids used in resuscitation

Causes slapped-cheek-appearing rash & constitutional symptoms. Rash may spread down to arms & legs in days after appearance of facial rash.

Parvovirus B19 - diagnosis may be confirmed with specific IgM Abs to parvovirus B19

What BEST strategy for performing high-quality CPR on patient with advanced airway in place?

Provide continuous chest compressions without pauses & 10 ventilations per minute

Most common causes of vaginal bleedign after 20 wks' gestation.

Placenta previa & Abruptio placentae - bleeding in placenta previa = painless - bleeding in placental abruptio = painful

Can be considered for reaccumulating pleural effusions

Pleurodesis - PleurX indwelling catheter

Differential Diagnosis Pre-renal causes of AKI

Poor blood flow to kidney: Dehydration - not enough blood volume Heart Failure - can't pump blood to kidney Liver failure/Nephrotic syndrome - volume not in arterial space Vascular problems - flow through vessel impeded but kidney otherwise ok - clinical signs = arterial bruit, weak pulses

Requires massive force of muscle contracture and is classically described in 2 scenarios: *seizures* & electrocutions. Classic = missed diagnosis on single-view, AP x-ray film. Axillary view x-ray films needed to make diagnosis.

Posterior shoulder dislocation

Significant hypotonia + almond-shaped palpebral fissures + hypogonadism

Prader-Willi syndrome - deletion of gene locus on chromosome region 15q11-13 Other common causes of hypotonia - Down syndrome, Turner syndrome, hypothryoidism, leukodystrophies, sepsis & perinatal trauma (central hypotonia), spinal mucular atrophy, botulism, myasthenia gravis, myasthenic syndrome (peripheral hypotonia)

Occurs in young women & presents with right heart failure.

Primary pulmonary HT - diagnosis via right heart cath with mean PA pressure >25 mmHg - echo useful to rule out cardiomyopathy

Antihypertensive used along with CCB

Raynaud syndrome

Arrest of labor may be due to inadequate contractions, malpresentation, or fetopelvix disproportion. When contractions are not adequate as evidenced by arrest of dilation with decreased frequency of contractions, the next step is to

administer IV oxytocin

Primary evaluation method for suspected urethral & bladder injury

Retrograde cystography

Occupational lung dz in pts who work in mining, quarrying, tunneling, glass & pottery making, sandblasting

Silicosis

Rare complication of pancreatitis. Isolated *gastric varices without any concomitant esophageal varices*

Splenic vein thrombosis

Med that should be used if tumor is estrogen receptor-positive.

Tamoxifen

Speech that never gets to point

Tangentiality

Criteria for brain death

Tests involving eye - pupils fixed, dilated, & *unreactive to light* - absent oculocephalic reflex - absent corneal reflex - absent vestibulo-ocular reflex: using 20 mL of ice cold water in each external auditory meatus Other nonocular tests - absence cough & tracheal reflexes: tested by passing suction cath down trachea - no localizing to pain: pin prick in anterior nares - no respiratory drive: no resp movements when disconnected from respirator for long enough for arterial PCO2 to increase to >50 mmHg

Initial US finding for IUGR is frequently...

abdominal circumference <10th percentile for gestational age

Nausea, constipation, & abdominal distention are consistent with small-bowel obstruction. Most common causes are adhesions from previous surgery, hernias, and intra-abdominal masses. Initial diagnosis clinical & is made with aid of

abdominal x-ray films - show dilated loops of bowel - conservative management = NPO orders & nasogastric decompression, with surgery reserved for severe or worsening obstructions that are worrisome for bowel ischemia

Major complication and major reason for morbidity in polycythemia vera

Thrombosis

RTA associated with nephrocalcinosis

Type 1

Consequence of amphotericin use & several toxins & rheumatologic diseases (Sjogren, RA, SLE) & should be suspected in any pt with non-anion gap metabolic acidosis, hypokalemia, & a urine pH >5.3.

Type 1 (distal) RTA - low plasma bicarb - high (>5.3) urine pH - mild to severe hypokalemia - nephrocalcinosis & nephrolithiasis - treatment = replacement of amphotericin B, alkali (oral bicarb) therapy

What can be measured directly with spirometer?

VC IC *ERV* VT (Tidal Volume)

Most common symptoms with vaginal candidiasis

Vulvar pruritus

Most common renal tumor of childhood

Wilms Tumor/Nephroblastoma - abdominal mass - HT, constipation, pain, hematuria via enlarging size & encroachment on other organs - WAGR association via deletion of chr 11 = Wilms tumor, aniridia, GU defects, retardation of growth &/or dev't

Indicated in evaluation of all nontraumatic neck pain in pts older than 50 yo

X-ray films of cervical spine

Accepted treatment of gonorrhea in pregnancy

a cephalosporin, & treatment of Chlamydia with erythromycin or azithromycin

First symptoms of penile cancer is

appearance of painless, ulcerated nodule, or flat ulcer that does not heal but enlarges progressively - diagnosis made via biopsy of lesion - 95% = SCC

ITP should be treated when platelet levels are dangerously low or if clinically significant bleeding is present. Otherwise, pts should...

be watchfully managed with regular follow-up

Hallmark of thalassemic syndromes

decreased or absent synthesis of normal alpha or beta chains alpha thalassemia - peripheral blood smear = target cells - normal hemoglobin electrophoresis = alpha-thalassemia trait = suggested by chronic microcytic anemia, target cells, normal serum iron studies, normal Hgb electrophoresis

Most common cause of hypercalcemia in hospitalized pts

dehydration - cancer --> cachexia

Widely used threshold for diagnosis of macrosomia

estimated weight of 4,500 g - fetus weighing 5,000 g (4,500 + diabetes) --> offered cesarean delivery bc of risk for shoulder dystocia

Risk factors for SCC of head & neck mucosa

excessive *alcohol* & nicotine use

Diagnose Hodgkin Lymphoma via

excisional lymph node biopsy - enlarged, painless, rubbery, non-erythematous, non-tender lymph nodes

Pure motor infarcts of brain most often occurs where?

genu or posterior limb of internal capsule - where descending corticostpinal & corticobulbar tracts are located

Rabies prophylaxis if bat is from wild animal

give prophylaxis = 5 doses of vaccine + 1 dose of immunoglobulin

IV/IO drug admin during CPR should be...

given rapidly during compressions

beta thalassemia on electrophoresis will show

hbg A2

Continuous RUQ bleeding despite Pringle maneuver is likely caused by injury to

hepatic vein or retrocaval inferior vena cava

Brown pigment stones are due to

infection

In pts with acute PE, we recommend

initial treatment with *LMWH*, UFH, or fondaparinux - for at least 5 days & until INR is >2 for at least 24 h

end-inspiratory crackles

interstitial lung disease

Management for uncomplicated cystic mass in epididymis, found by scrotal ultrasound in asymptomatic pt

needs no further workup or treatment

Findings specific for Graves dz

ophthalmopathy-exophthalmos (proptosis), periorbital edema, *pretibial myxedema*

-1 to -2.5

osteopenia

5 Ps of compartment syndrome

pain, pallor, paresthesia, poikilothermia, pulselessness - treatment = decompressive excharotomy

Ways to differentiate pseudodementia from true dementia

pseudodementia - pt often seems concerned or even frustrated about malfunctioning memory true dementia - tend to hide their memory-loss probz Management of the 2 is diff't

Diagnosis of FSGS confirmed by

renal biopsy

Needed to diagnose specific type of glomerulonephritis

renal biopsy nephritic syndrome - HT - hematuria - mild to moderate proteinuria

Corresponding coronary artery: ST elevation in leads II, III, aVF

right coronary artery - inferior wall

hyperkalemia + ACEI

stop ACEI

Treatment of choice for tularemia

streptomycin

myeloid leukemias stain with

sudan black - can see auer rods

Suspicion for ulcer in pt with pneumoperitoneum indicates perforation & mandates urgent...

surgical exploration

Estimated protein intake for a patient (equation) =

((Urine Urea Nitrogen/UUN + (weight(kg)*0.031))*6.25) - how many grams a day a person is eating

Mr. Plankton is complaining of difficulty in breathing and feels a rapid heart rate. His cardiac monitor reads rate of 179 bpm. What are examples of safe vagal maneuvers with consideration of Mr. Plankton's age of 89?

*Bearing down and holding his breathe; Coughing and pushing himself up in bed*

p53 mutation

Li-Fraumeni syndrome

May improve cognitive and gait impairment in pts with normal pressure hydrocephalus (NPH)

surgical treatment with CSF shunting

Definitive treatment that can lead to permanent cure of Graves disease

*Radioactive iodine ablation*

When a patient becomes unstable with a wide-complex tachycardia, what is the next treatment of choice?

*Synchronized Cardioversion at 100 joules* - press "SYNC" button each time, when there is a pulse

Best management of diabetic foot complications

*blood glucose control*

Most appropriate management of spinal cord compression

*corticosteroids followed by radiation therapy*

Preferred method to confirm diagnosis of nodular melanoma

*excisional biopsy*

Withdrawal from benzos =

*hallucinations* seizures anxiety tremors nausea

Prophylaxis against abdominal compartment syndrome

*leaving abdomen open with negative pressure therapy system* - protects visceral contents while allowing for normal intra-abdominal pressure & preventing comp't syndrome

Solitary pulmonary nodule: signs of malignancy

- older pt age - positive smoking history - large size - evidence of met dz - *stippled* or asymmetric calicifications - irregular spiculated borders - avid uptake of FDG

Recognize *1st degree av block*

- patients usually remain stable & recover - causes = MI or ischemia, cardiac & anesthetic medications

Target INR for mitral valve replacement with mechanical valve

2x greater than pt's basleine = 2.5-3.5 - target INR in most pts = 2 - 3 for warfarin anticoag

Iron Deficiency Anemia hints - RDW - platelet count - reticulocyte count

- elevated - elevated - decreased IDA - most common cause of anemia

C/I of using aldosterone antagonists for HF

- hyperkalemia (>5 at baseline) - sCr of 2.5 in men & 2 in women

Criteria for Classification of RA (ACR/EULAR 2010)

- synovitis in at least one joint - absence of alternative diagnosis - total score of at least 6 (of possible 10) from individual scores in 4 domains Domains - # of joints involved: 2-10 large joints = 1 pt; 1-3 small joints = 2 pts; 4-10 small joints (usually hands) = 3 pts; >10 joints (including at least 1 small joints) = 5 pts - serologic abnormality (rheumatoid factor or anti-CCP) - elevated acute phase response (ESR or CRP) - symptoms duration (at least 6 wks = 1 pt)

Cardiac conditions that warrant prophylaxis for infective endocarditis

- uncorrected cyanotic congenital heart disease - prosthetic valve - previous episode of infective endocarditis - repaired congenital heart disease with residual defect - valvulopathy in transplanted heart

How to preserve amputated digit

- wrap digit in moist gauze --> put in plastic bag --> place bag on bed of ice - digit must be kept form drying out & must not be injured with any chemical agents - digit must not be placed in direct contact with ice & must not be allowed to freeze

When patient presents with signs & symptoms suggestive of optic neuritis, what is the most appropriate diagnostic test?

*MRI of brain* - to exclude MS Optic neuritis = several days of loss of vision = eye pain with movement = central scotoma = loss of color vision = afferent pupillary defect = inflammation of optic nerve with flame hemorrhages

What drug and dose are recommended for the management of a patient in refractory ventricular fibrillation?

*Amiodarone 300 mg*

Clinicall presents with petechiae, gingival bleeding, epistaxis, easy bruising, & isolated decrease in platelet count without signs or symptoms of systemic toxicity. Normal PT & PTT.

*Idiopathic thrombocytopenic purpura*

Some patients who have IgG2 deficiency may also have deficiency of

*IgA* IgG subclass deficiency - may involve either or both IgG2 & IgG3 w/ or w/out IgG4 def

72 yo man with diabetes who had large bowel resection for acute GI hemorrhage earlier same day becomes confused at night. Pt was stable when nurse began her shift; however, he has become more confused as night has progressed. He is now danger to himself, as he is attempting to climb out of bed & will not listen to floor staff. Pt was administered patient-controlled anlagesia (PCA) pump after surgery. It will take doc appx 3 minutes to get to pt's bedside. Most important step in management for this pt before doc's arrival at bedside?

*Placing him on supplemental oxygen* Postoperative disorientation - most lethal = hypoxia - safest thing to do = assume pt is hypoxic --> treat

5 yo boy brought to doc by his mom bc he has refused to stand or walk for 2 days. He walked without assistance at 14 mos, he rode a tricycle at age 3 yrs, & he recently starting riding a bicycle with training wheels. He received his MMR immunization last wk. His temp is 99.3 F. Exam shows inability to bear weight. There is tenderness to palpation over the left hip joint. Remainder of exam shows no abnormalities. Lab studies show: HCt 43% WBCs 7500/mm^3 Platelets 439,000/mm^3 He receives ibuprofen. Pain resolves in 3 days. Most likely diagnosis?

*Postviral synovitis* - may occur 1-2 wks after resp infection or rubella vaccine - typically lasts less than 1 wk Hip pain preceding rubella vaccination = transient synovitis

32 yo female 6 days postpartum, has mental status changes, anemia, thrombocytopenia. Plt 3, Hct 19, LDH 3000, PT/INR wnl Helmet cells/Schistocytes shown. Gave her platelets & she got mentally worse.

*TTP* - MAHA - deficiency of ADAMSTS-13 - plasma exchange needed; fresh frozen plasma if not available

amyloidosis diagnosis made by

- fat pad biopsy - cMRI - native RV biopsy

Preferred diagnostic procedure for sarcoidosis

FOB/TBB

migratory polyarthralgia

disseminated gonorrhea - initial treatment = ceftriaxone - disseminated = pustules on skin - multiple joints swollen - tenosynovitis = inflammation at site of tendon sheath

54 yo lawyer presents to ED with diarrhea for past 2 months. He has associated fatigue, SOB, & weight loss. He has lost appx 10 lb over last few months, during which time symptoms have worsened. He has no past med history & does not smoke or drink. He takes no meds. On exam, his BP is 115/75 mmHg & pulse 108/min. His skin is pale. Neuro exam reveals loss of vibration sense, spasticity, & positive Babinski sing. Lab studies show: Hematocrit 26% WBC 2,700/mm^3 Platelets 110,000/mm^3 MCV 116 um^3 Reticulocyte count 0.5% Serum LDH 650 U/L Serum total bilirubin 2 mg/dL Most likely diagnosis?

*Vitamin B12 def* - macrocytosis, diarrhea, neuro symptoms - vit absorbed in terminal ileum - neuro findings may precede anemia

65 yo man evaluated in ED for painless bright red blood per rectum that began 6 hrs ago. He has no other medical problems & takes no meds. On physical exam, temp is 97.9 F, BP 130/78 mmHg, pulse rate 96/min, & RR 18/min. Abdominal exam is normal. Rectal exam discloses no external hemorrhoids; bright red blood is noted in rectal vault. Lab studies show hemoglobin level of 0.4 g/dL, leukocyte count of 6000/uL, & platelet count of 380,000. What is the most likely cause of this patient's bleeding?

*Diverticulosis* - severe hematochezie --> most common site of bleeding = colon (75%) - diverticula = 33% of colonic bleeding

2 yo boy shot in arm in drive-by shooting. His brachial artery is partially transected & there is copious bleeding. Emergency medical technicians able to control site of bleeding by local pressures & child stops losing blood, though he is hypotensive & tachycardic. IV fluid resuscitation urgently needed, but several attempts at starting peripheral IV lines are unsuccessful. Best alternative route in this situation?

*Intraosseous cannulation in proximal tibia* IV lines can't be established in very small children? --> preferred alternative route = IO cannulation - place trocar in bone marrow of long bone - site of choice in kids = proximal tibia - alternative sites = distal tibia & proximal femur

76 yo woman has experienced significant visual loss in left eye in past & now in right eye which has occurred over past 2 year. At her most recent exam, her ophthalmologist finds separation of neurosensory retina from retinal pigment epithelium in right eye. Left eye shows neovascularization from choroidal vessels. What treatments may delay onset of permanent visual loss?

*Laser photocoagulation of subretinal neovascular membranes* Age-related macular degeneration (ARMD) - leading cause of visual loss in elderly - incidence increases with each decade over age 50 - more common in whites, female, hx of cigarette smoking, positive fam hx - 2 types = dry & wet - dry = small, granular, subretinal deposits (drusen) - wet = abnormal growth of vessels from choroidal circulation

A 65-year-old man presents with an asymptomatic large brown patch on his cheek. It has been present for many years and is enlarging slowly. The patient is a retired farmer and received a significant amount of sun exposure over the course of his life. The lesion is shown (Plate 24). Which of the following is the most likely diagnosis?

*Lentigo maligna* - slow-growing type of melanoma most commonly seen on face of older fair-skinned ppl who have received substantial amounts of cumulative sun exposure with resultant evidence of skin damage - has prolonged radial growth phase - can present many years before developing invasive component (vertical growth phase)

56 yo man brought to ED bc of chest pain & SOB with exertion. He has no ho any major med illnesses & takes no meds. An exercise stress test reveals findings suggestive of CAD< & the pt undergoes cardiac cath. There is diffuse coronary artery dz but stent placement is not deemed possible. Pt is medically managed & remains in hospital for following 3 days. His pulse & BP readings are shown. Day 1 BP 146/96 mmHg, pulse 80/min Day 2 150/90 mmHg, pulse 86/min Day 3 140/96 mmHg, pulse 73/min Which of the following drugs is most appropriate for this pt?

*Metoprolol* - beta-blockers indicated in treatment of pts who have CAD - in addition to decreasing BP, they keep HR slow = decreases strain on heart & increases myocardial perfusion

55 yo woman falls in shower & hurts her right shoulder. She comes to ED with her arm held close to her body & forearm rotated outward as if she were going to shake hands. She is in pain & will not move the arm from that position. Her right shoulder looks "square" in comparison with the rounded, unhurt opposite side, & there is numbness in small area of right shoulder over deltoid muscle. Most likely diagnosis?

*Anterior dislocation of shoulder* = most common dislocation of that joint - classic: lack of rounded contour of humeral head - area of numbness = injury to axillary nerve = common complication of anterior dislocation of shoulder

Newborn + signs of bacterial meningitis + neutrophil-predominant pleocytosis + elevated protein + decreased glucose in CSF analysis + MRI of abscesses = microorganism?

*Citrobacter koseri* - abscess formation in 80% of pts - gram-negative enteric rod - resistant to ampicillin - vertical mode of transmission = mother to infant during delivery - treatment = 3rd-4th gen ceph & aminoglycoside for 4-6 wks - abscess area frequently drained

Mr. Plankton's vital signs are deteriorating due to supraventricular tachycardia, which did not respond to vagal maneuvers. Heart rate is up to 200/minute. Patient's BP is 110/48 mmHg. Pulse oximetry reading is 96%. He has a patent IV in his upper arm. Next recommended intervention?

*Adenosine 6 mg IV push* - Adenosine can be repeated in 2 minutes at 12 mg - short acting & fast acting = preferred med for SVT - has dramatic effects for 6 seconds - flat line on monitor, chest pain & SOB

31 yo man brought to ED by friend. Friend related that pt has been complaining that he is having auditory hallucinations & tremors, along with associated nausea & vomiting. Pt states that he feels very anxious. He appears to be obtunded &, on mini-mental status exam (MMSE), he scores 22 of 30. From what susbtances is this pt most likely to be withdrawing?

*Alprazolam* = benzo - *hallucinations* + insomnia + tremor + GI distress + anxiety - can be accompanied by generalized seizures = life-threatening

Patient in pulseless ventricular tachycardia. Two shocks & 1 dose of epinephrine have been given. Drugs that should be given next?

*Amiodarone 300 mg* Drug therapy for VF/Pulseless VT: Epinephrine IV/IO dose = 1 mg every 3-5 minutes Amiodarone IV/IO dose: first dose = 300 mg bolus second dose = 150 mg

Used to guide conversion from IV insulin to subcutaneous insulin

*Anion gap* - once anion gap closes, subcutaneous insulin should be overlapped with IV insulin --> IV insulin can gradually be discontinued

34 yo divorced man presents to outpatient clinic for consultation. He recently moved from another state where he was being treated with sertraline, 150 mg/d for major depressive episodes. He had no prior psychiatric hx. He has been on sertraline for 2 mos. He complains of occasional nausea that does not affect his life, but he is othewise doing well on the medication, with marked relief from his symptoms of depression. He is concerned about taking too much medication & asks your opinion. What is the most appropriate management of this pt's med?

*Continue sertraline for 6 more months* - man presents in middle of being treated for his first episode of major depression - adults who have uncomplicated major depression & good response to antidepressant med should continue on med for 6 mos after achieving full remission

AD condition. Typically causes conductive hearing loss in late teens or early 20s. Pregnancy may cause condition to progress rapidly.

*Otosclerosis*

Indicated for patient with renovascular HT secondary to fibromuscular dysplasia, a nonatherosclerotic, noninflammatory renovascular dz.

*Percutaneous transluminal kidney angioplasty*

Radiographic findings consistent with irregular, nonlobular opacification of pulmonary parenchyma

*Pulmonary contusion*

72 yo woman with diabetes, HT, CAD, & ho MI 2 yrs ago, is admitted to hospital after sustaining fall & injuring her hip. She is in excruciating pain & lies on stretcher with affected leg appearing shorter & externally rotated. X-ray shows displaced femoral neck fracture. Next best step in management?

*Replacement of femoral head with metal prosthesis* - chances of femoral head surviving displaced neck fracture = slim secondary to tenuous blood supply & dev't of avascular necrosis - quicker recovery expected if native bone discarded & replaced with prosthesis

Most appropriate management of pt's Barrett esophagus (BE)

*periodic upper endoscopy surveillance* BE - most common in white pts with long-standing & severe GERD - premalignant

Supraventricular tachycardia caused by...

*reentry or re-excitation of an impulse* - reentry can possibly cause heart rate to reach rate above 150 bpm

CJD manifests as rapidly progressive dementia with myoclonic jerking movements. It is prior-related spongy encephalopathy and the most common cause is

*sporadic* mutations in prior protein gene

Preferred diagnostic study of PUD

*upper endoscopy* - allows direct visualization of upper GI tract - H pylori testing of biopsy specimens as needed

Most common type of functioning pituitary adenoma

prolactinomas --> prolactin - prolactin levels must be measured in any pt suspected of having pituitary tumor - most common prolactinoma = microadenoma - macroadenomas --> bitemporal hemianopsia - MRI of brain = sensitive test

For immunocompromised pts, treatment for molluscum contagiosum is

ritonavir or cidofovir

Most common type of hemorrhagic cystitis (HC)

secondary to admin of *cyclophosphamide* - MESNA prophylactically given with cycloph. to prevent HC

Pyridoxine deficiency can be caused by

severe malnutrition, *malabsorption syndromes*, excessive alcohol ingestion, drugs (chloramphenicol, isoniazid, pyrazinamide) Clinical features - seborrheic dermatitis, glossitis, angular cheilitis, peripheral neuropathy, confusion, seizure - microcytic (sideroblastic) anemia common

Most common finding on physical exam of CML

splenomegaly

Felty syndrome

splenomegaly + anemia + neutropenia + thrombocytopenia + arthritis (rheumatoid)

Orthostatism is defnied as

variation in BP of 20 mmHg systolic or 10 mmHg diastolic during first 2-5 minutes after changing from supine position to standing up, or if symptoms of cerebral hypoperfusion occur - fluid management = normal saline

Bleeding time & PTT elevated in

von Willebrand dz - von Willebrand factor = factor VIII Ag = platelet glue = carrier of factor VIII

You are providing bag-mask ventilations to patient in respiratory arrest. How often should you provide ventilations?

*About every 5-6 seconds* - recheck pulse every 2 minutes - take at least 5 seconds but no more than 10 seconds for pulse check

59 yo man comes to doc for routine physical exam. He says he tries to exercise three times a week, but admittedly does not succeed. He has hx of type 2 diabetes & HT. His current meds are HCTZ & metformin. His BP is 147/85 mmHg & pulse 75/min. Physical exam shows no abnormalities. Next best step in pt care?

*Add lisinopril to his regimen* Combo of diabetes & HT - ACEI = first-line to prevent renal damage/remodeling in long-term - goal BP for this pop = 140/90 mmHg

Most common cause of menorrhagia in adolescent girls but is a diagnosis of exclusion.

*Dysfunctional uterine bleeding* - bleeding = painless

Following treatment with pyrimethamine & sulfadiazine and improvement of toxoplasmosis, what is the next step?

*Lower the doses of pyrimethamine & sulfadiazine* - can be decreased for secondary prophylaxis - chronic suppressive therapy

15 yo girl brought to pediatric cardiology clinic with complaint of chest pain. She states the pain has come & gone over past year but has increased in frequency over past few weeks. She describes it as a sharp pain over her left chest. Physical exam reveals healthy appearing 15 yo girl. Her temp is 99 F, pulse 90/min, & respirations 20/min. Lung exam is normal. Cardiac exam reveals late systolic murmur preceded by click at apex. No heave or rub present. ECG & chest radiograph unremarkable. Most likely diagnosis?

*Mitral valve prolapse* - apical click followed by late systolic murmur - can be source of subjective chest pain in kids - more common in females

Motiveless resistance to all attempts to be moved or to instruction. Sign of catatonia

*Negativism* - catatonic symptom

Contraindication to nitroglycerin administration in management of acute coronary syndrome

*Right ventricular infarction & dysfunction*

What action is likely to cause air to enter victim's stomach (gastric inflation) during bag-mask ventilation?

*Ventilating too quickly*

Antimicrosomal Ab associated with

Hashimoto thyroiditis

lymphoid leukemias stain with

PAS

Therapy for Type 1 second-degree heart block (Wenckebach phenomenon) / progressive lengthening of PR interval with successive heartbeats

benign/no therapy

fragility fracture

osteoporosis - -2.5 = cutoff

Therapeutic Hypothermia, at 32-36 C, often called "Code Chill" or Temperature Management has been used to treat patients' post-cardiac arrest. The ideal candidate for hypothermia protocol is what patient?

*A victim who is resuscitated, but won't wake up* - purpose of 24-hour hypothermia protocol in post cardiac arrest victim = improving survival by reducing free radicals & decreasing oxygen demand

Expected pCO2

(HCO3x1.5) + 8 - pCO2 lower than expected? --> presence of pathologic respiratory alkalosis - pCO2 higher than expected? --> presence of pathologic respiratory acidosis

Recommended dose of epinephrine for treatment of hypotension in post-cardiac arrest patient who achieves ROSC?

*0.1 - 0.5 mcg/kg per min IV infusion*

You diagnose unilateral, new-onset white reflex, which is retinoblastoma until proven otherwise. Next step?

provide *immediate ophthalmologic exam* with pupillary dilation under anesthesia to assess extent of dz

Mitral valve area less than 1.5cm^2 indicates need for

valvotomy - asymptomatic? --> watchful monitoring - symptomatic? --> diuretics

Recommended compression rate for high-quality CPR?

*100 to 120 compressions per minute*

All symptomatic stones that fail to pass with medical management should be removed using

lithotripsy (stones <1 cm) or open removal (stones >1cm)

GI malignancies typically metastasize to

liver and lungs

Follicular carcinoma of thyroid gland managed with

total thyroidectomy - adjuvant therapy with radioactive iodine indicate to destroy remaining malignant cells & normal functioning cells in thyroid gland, & microscopic met dz

Best diagnostic study of acromegaly

*insulin-like growth factor* = >5x upper limit of normal in acromegaly

Treat patient with breast cancer & small focal tumor with

*lumpectomy, sentinel node dissection, & radiation* Breast-conserving therapy - removal of primary tumor (lumpectomy) + radiation therapy to remainder of ipsilateral breast - high risk for local recurrence for lumpectomy alone - sentinel lymph node biopsy = accurate method for screening axillary lymph nodes for metastases in women with small breast tumors

First teeth to erupt

*mandibular central incisors* = 5-7 mos - maxillary central incisors = 6-8 mos - mandibular lateral incisors = 7-10 mos - maxillary lateral incisors = 8-11 mos - molars = 10-16 mos

Good technique for thoracentesis

*midaxillary line above the rib* - avoid neurovascular bundle

Treatment of cluster headache

oxygen &/or sumatriptan

All sexually active women age <25 should be offered routine screening for

gonorrhea, Chlamydia, & HIV

Jo-1

dermatomyositis

Most rapid way of reversing warfarin anticoagulant effect

transfusing fresh flozen plasma - anticoagulant effect of warfarin mediated through inhibition of vit K-dep gamma-carb of caogulation factors II, VII, IX, & X --> repalce these factors with FFP = INR level normalized quickly

Diagnosis of Prostate Cancer often made by

transrectal ultrasound (TRUS) with either directed or template biopsies (minimum of 12)

Patient with sinus bradycardia & heart rate of 42/min has diaphoresis & BP of 80/60 mmHg. Initial dose of atropine?

*0.5 mg* Bradycardia... Serious signs/symptoms due to bradycardia... Intervention sequence: - Atropine = 0.5 to 1 mg - Transcutaneous pacing if available - Dopamine = 5-20 ug/kg per minute - Epinephrine = 2-10 ug/min - Isoproterenol = 2-10 ug/min

What is the recommended IV fluid (normal saline or Ringer's lactate) bolus dose for a patient who achieves ROSC but is hypotensive during post-cardiac arrest period?

*1 to 2 L*

What is the recommended assisted ventilation rate for patients in respiratory arrest with a perfusing rhythm?

*10 to 12 breaths per minute*

How should a corneal abrasion be managed?

- inspection of eye, with topical anesthetic (*tetracaine*), if required & removal of foreign bodies - detailed exam of eye = fundoscopy & fluorescein slit-lamp exam - application of topical abx & patching eye for no more than 24 hrs

Best next step for new non-tender, palpable mass which most likely indicates a malignant process

*Excisional biopsy* - of suspicious lymph node --> allows evaluation of lymph node architecture & pattern of growth if malignant cells are present - superior to fine-needle aspiration in diagnosis

Pts with low outflow states often benefit from circulatory assist devices, including intra-aortic balloon pumps. What is the mechanism by which the IABP most likely helps the patient?

*Increasing coronary artery perfusion from balloon inflation* - during diastole the balloon expands --> creates counterpulsation --> increases diastolic pressures --> increases coronary artery & cerebral perfusion

Patient remains in ventricular fibrillation despite 1 shock & 2 minutes of continuous CPR. Next intervention is to

*administer a second shock*

Enzymatic degraders of uric acid

Pegloticase Rasburicase

Immunizations given at 6 mo old

final HBV third DTaP IPV PCV7

Close contact of pt with meningococcal meningitis should receive chemoprophylaxis with

*rifampin*, ciprofloxacin, third-gen cephalosporin/ceftriaxone

blood in urine but not RBC casts

rhabdomyolysis

Complication of acute pancreatitis. Usually manifests with high-grade fever & leukocytosis appx 10-14 days from onset of inflammation.

*Pancreatic abscess* - next step = locate collection with CT scan of abdomen, followed by drainage

What action should you take immediately after providing an AED shock?

*Resume chest compressions*

Dose-limiting side effects of zidovudine

*hematotoxicity* - others = myopathy, headache, GI symptoms, increase in transaminases

recognize *calcium oxalate*

- ethylene glycol

If no contraindications exist to a vacuum-assisted delivery, it is often preferred because...

the extractor *does not occupy space next to the fetal head* - results in less trauma to maternal tissues during delivery (in contrast to forceps)

Infectious organisms associated with Bell palsy

HSV, *Epstein-Barr virus*, Lyme dz - therapeutic intervention = early short-term oral glucocorticoids & eye lubricants to protect cornea from drying

Test of choice in pt who desires early knowledge of chromosomal defects or is at very high risk of having child with chromosomal anomaly

chorionic villus sampling (CVS) - performed b/t 10 & 12 wks of gestation

urine osmolality > 300...

think activated vasopressin - SIADH - hyponatr - euvolemic

Underlying mechanism of acidemia in multiple myeloma

*Reduced proximal tubular bicarbonate reabsorption* Renal tubular acidosis type 2 - associated with MM & carbonic anhydrase inhibitors (acetazolamide) - proximal tubule bicarb reabsorption impaired - mild nongap acidosis, hypokalemia, urine pH<5.3 - Fanconi syndrome (global proximal tubule dysfunction) usually accompanies it

Lung cancer most sensitive to chemotherapy

Small-cell lung cancer

Most common agents that cause NMS

haloperidol & fluphenazine NMS - can occur with all drugs that cause central dopamine type 2 receptor blockade - muscle rigidity, hyperthermia, cognitive changes, autonomic instability, diaphoresis, sialorrhea, seizures, cardiac arrhythmias, rhabdomyolysis within 2 wks after initiation of drug treatment - symptoms can persist longer if parenteral meds were given

Indicated by presence of hepatitis B surface antibody (anti-HBs) & hepatitis B core antibody (anti-HBc IgG).

hepatitis B infection in past

Hormone levels of Turner syndrome

high levels of FSH & LH low estrogen buccal smear = normal epithelial cells with no Brr bodies treatment = estrogen replacement therapy

Indicated to evaluate coronary artery disease (CAD) as a cause of newly diagnosed left ventricular systolic dysfunction.

*Coronary angiography* Indications for coronary angiography for evaluation of new-onset HF - angina - new-onset left ventricular dysfunction in setting of condition, such as diabetes, that may predispose to silent ischemia

Infertility workup for couple should alway start with

*semen analysis* Normal semen analysis - pH 7.2-7.8 - volume >1.5 mL - sperm density >15 million/mL - total motility >40% - morphology >4% normal forms - single abnormal semen analysis should be followed by repeat semen analysis 4-6 wks after first before other tests of infertility done - 2 semen analyses required before male factor fertility can be diagnosed

When faced with stressor such as surgery, pts who have severe hypothyroidism need to be treated with

*steroids* - prior to correction of hypothyroidism to address potential adrenal insufficiency

68 yo man comes for routine maintenance exam. He denies chest pain, dyspnea, cough, or shortness of breath. He has 5-year ho hypercholesterolemia controlled with atorvastatin. He recently retired from his job as a mail carrier. He has smoked one pack of cigarettes daily for 45 years. He drinks three to five beers on weekends. His mother had MI at age 52 years, & his brother had MI at 48 years. Complete blood count, metabolic panel, & lipid panel were within normal limits 8 months ago He had colonoscopy 3 years ago that showed no abnormalities. What is the most appropriate screening test for this patient?

*Abdominal ultrasound* USPSTF recommends screening in men who have ever smoked & are between age 65 & 75 years at least once for AAA by abdominal ultrasonography

15 yo gravida 1, para 0 girl comes to labor & delivery at 31 weeks' gestation bc she had large gush of fluid 2 hours ago while watching television. She does not have any uterine contractions. Her prenatal course is remarkable for smoking half-pack of cigarettes per day despite counseling on cessation. Pelvic exam with sterile speculum shows pooling of clear fluid in posterior fornix. Fluid causes nitrazine paper to turn blue. Exam under light microscope shows ferning pattern. Fetal heart tones are in 150s on external tocodynameter, & abdominal ultrasound reveals oligohydramnios with fetus in cephalic presentation. Pooled fluid is sent to lab for evaluation of fetal lung maturity, & it shows lecithin to sphingomyelin ratio of 1:5:1. What is the best next step in management?

*Administer IM betamethasone* Preterm Premature Rupture of Membranes + evidence of lack of fetal lung maturity - fetal lung maturity = lecithin:sphingomyelin ration > 2:1 - *in those with PPROM without documented maturity, 2 doses of intramuscular betamethasone administered 24 hours apart = drug of choice for inducing fetal lung maturity* - another accepted regimen = IM dexamethasone, 4 doses administered 12 hours apart = more frequent dosing

47 yo African-American woman + SOB, chest pain w/ respirations, & nonproductive cough that has been going on last 3-4 months. Med history positive for flu 1 week ago treated with amantadine, ventricular tachycardia treated with implantable cardioverter-defibrillator (ICD) & amiodarone, & OCP for last year since she began menopause. She drinks 2 glasses of wine a day & smoked cigarettes for 20 years but quit 10 years ago. She mentions that she has lost weight, even though her appetite is good. Vital signs are temp 37.6 C (99.6 F), BP 120/60 mmHg, pulse 98/min, & respirations 20/min. Physical exam reveals lung with diffuse crackles, decreased air movement, & pleural rub. Cardiac exam shows apical impulse, & no murmurs or gallops are appreciated. There is purple mottling of LEs noted. Lab studies: Hb = 12 g/dL Hct = 35% WBC = 12,000/mm^3 Neutrophils = 68% Bands = 3% Creatinine = 1.1 mg/dL Sodium = 136 mEq/L Potassium = 5 mEq/L Calcium = 9.6 mg/dL Amiodarone levels = 1.6 ug/mL (normal levels, 1-3 ug/mL) Chest radiograph shows patchy alveolar infiltrates. Pulmonary function tests taken & reveal normal FEV1/FVC & decreased FEV1. Most likely diagnosis?

*Amiodarone pulmonary toxicity* 3 forms: - organizing pneumonia - chronic interstitial pneumonitis - ARDs - also associated with hypo/hyperthyroidism & liver toxicity - *amiodarone levels are usually normal & should not be used to correlate toxicity* Amiodarone - used for treatment of atrial fibrillations & ventricular tachycardias - toxicity = dose-dependent (more common with VT bc doses to control VT are much higher)

70 yo woman comes to your office complaining of weakness & cold intolerance. Physical exam reveals diffusely enlarged, nontender thyroid gland & delayed ankle reflexes bilaterally. On lab testing, she hs elevated TSH & very low free T4 level. Only med is sertraline (Zoloft), & she has not ho heart dz. After discussing results with patient, you elect to start L-thyroxine. What is true regarding replacement thyroid hormone therapy?

*Because of long half-life of L-thyroxine, dosage titration should be done at 6-week intervals* - goal of therapy = normalize TSH - thyroxine will normalize much sooner than TSH = not an indication euthyroidism has been achieved

24 yo gravida 1, para 0 woman at 36 weeks' gestation comes to labor & delivery bc of decreased fetal movement over last 12 hours. She has ho chronic HT secondary to moderate SLE. Her HT has been controlled with alpha-methyldopa until this time. She takes no other meds. Her BP is 132/82 mmHg, pulse is 86/min, & respirations are 16/min. Non-stress test is performed & fails to reveal accelerations greater than 15/min twice within past 20 minutes. Vibroacoustic stimulation applied & there is still no change in results of fetal testing. Most appropriate next step in management?

*Biophysical profile* - 5 parameters = non-stress test, amniotic fluid volume, gross fetal movements, extremity tone of fetus, fetal breathing - each component = 0-2 score with max score of 10 - 4-6 = worrisome - >36 weeks = should deliver fetus - <36 weeks = repeat test in 12-24 hours to perform contraction stress test (CST) - 0-2 = fetal hypoxia = immediate delivery of fetus, regardless of gestational age - nonreassuring non-stress test after vibroacoustic stimulation has failed to increase variability = biophysical profile or contraction stress test

38 yo woman comes to her PCP with complaints of fatigue & insomnia. ROS reveals no medical symptoms, but patient does endorse several symptoms on psychiatric ROS. She describes feeling tired most of day, having difficulty falling asleep as well as waking up too early, poor appetite, frequent crying spells, poor concentration, & a recent loss of interest in her hobbies. Her past medical history is significant for a seizure disorder since childhood. Physical exam & routine lab studies, including TSH, are within normal limits. What pharmacologic interventions is contraindicated in this patient?

*Bupropion* - contraindicated in patients with seizure disorder (reduces threshold for seizure) = antidepressant that acts as dopamine reuptake inhibitor

Internist discussing risks of cardiovascular dz with one of his patients. Patient is a 40-year-old man with 20-pack-year history of cigarette smoking. He is 5 ft 10 in tall & weighs 190 lb. He has mild HT, which is being treated effectively with hydrochlorothiazide. His recent lipid profile is: Total cholesterol = 200 mg/dL LDL = 160 mg/dL HDL = 35 mg/dL What is the most important modifiable factor in this patient to reduce the morbidity & mortality related to cardiovascular dz?

*Cigarette smoking* = most important cause of preventable morbidity & early mortality

Recognize tinea versicolor, a product of *competitive inhibition of tyrosinase by azelaic acid* Case: "28 yo man comes to doc bc of skin rash his gf noticed on his chest & back 1 week ago. He has had occasional pruritis after exercising. He has had no fevers or weight loss. His med history is unremarkable. He has no allergies to meds. He works in a demanding job & exercises in gym 5 nights/week. His mother died of breast cancer at age 62 years. He is in no acute distress. Exam is shown. There are numerous hypopigmented patches with fine scale that is accentuated by rubbing over neck, anterior chest, shoulders, & upper back. Remainder of exam shows no abnormalities. What is most likely underlying mechanism for this pigmentary change?

*Competitive inhibition of tyrosinase by azelaic acid* = dicarboxylic acid produced by hyphal form of yeast Tinea versicolor - common in young adults - via hyphal form of nondermatophyte dimorphic fungus Malassezia globosa - promoted by exposure to warm, humid env'ts - common in strenuous physical activity

33 yo man brought to ED 30 minutes after fam witnessed him having seizure. He was eating dinner when he got blank look on his face. His arm started shaking, & then he fell to ground & had generalized convulsions. He was not arousable for several minutes after episode. His medical history is unremarkable & he takes no meds. He emigrated from Mexico 4 years ago. He is vegetarian. He does not drink alcohol or use illicit drugs. In ER he is alert & oriented. His temp is 36.8 C (98.2 F) & BP 118/76 mmHg. Head & neck exam show no abnormalities. Lungs are clear to auscultation. Cardiac exam shows normal S1 & S2; no murmurs heard. Lab studies show: Hematocrit = 44% Platelets = 189,000/mm^3 Leukocyte count = 6,700/mm^3 Serum studies show: Na+ = 138 mEq/L Cl- = 105 mEq/L K+ = 3.9 mEqL HCO3- = 24 mEq/L BUN = 11 mg/dL Creatinine = 0.8 mg/dL What is the most appropriate next step in diagnosis?

*Computed tomography of brain* Taenia solium: Neurocysticercosis - diagnosis confirmed with abnormal CT scan of head & positive enzyme-linked immunotransfer blot assay - lesion --> "burn outs" --> punctate calcifications leftover evidence of prior infection - treatment = albendazole & glucocorticoids

25 yo accountant with ho asthma brought to hospital from her office in severe respiratory distress. Coworker reports that patient had cold that day & inadvertently inhaled chemical fumes from nearby construction area on their floor, after which time she was unable to breathe. Her respiratory rate is 44/min, pulse 78/min, & oxygen saturation 97% on room air. At hospital she is unable to speak in full sentences & is markedly diaphoretic. She is using accessory muscles of respiration & there are suprasternal retractions. Pulmonary exam shows bilateral wheezes. She is given 2 successive albuterol nebulizer treatments & is started on IV corticosteroids. She has never been intubated in the past. She has had asthma symptoms for about 1 weeks & has never had night symptoms. Arterial blood gas after 2 treatments shows: pH = 7.39 mmHg pCO2 = 42 mmHg pO2 = 78 mmHg After treatment, she is now able to speak full sentence. Respiratory rate is 30/min, pulse 97, & oxygen saturation 98%. What is the most appropriate next step in management?

*Continued albuterol treatment* Acute exacerbation of asthma - woman's condition improving --> continue treatment to which she responded - should also be switched to oral steroids & continue course for 5-7 days

78 yo man with ho diabetes presents to outpatient department complaining of chest pain & SOB. Over past 6 months he has been experiencing dull chest pain & dyspnea every time he walks uphill to his home; pain & dyspnea relieved by rest. He denies chest pain at rest. He is 55-pack-year smoker. Vital signs: temp 37 C (98.6 F), pulse 60/min, BP 135/82 mmHg. On physical exam patient is comfortable. No JVD. Cardiovascular exam reveals normal heart sounds, regular rate & rhythm without murmurs. Breath sounds clear bilaterally. Current meds include NPH insulin & captopril. Patient undergoes stress test, which shows ST-segment depression of 1 mm in leads III & aVF. He is sent home on aspirin, nitrates, metoprolol, & atorvastatin for abnormal lipid profile. He is also advised on diet modification. Despite this treatment regimen, he continues to complain of symptoms. Patient undergoes coronary angiography, which reveals patchy disease in left circumflex coronary artery & right coronary artery. What is best next step in management?

*Coronary artery bypass grafting* Stable angina + persistent symptoms despite optical med therapy (aspirin, statin, ACEI, metoprolol with HR at goal (55-60)) - diabetic + 2-vessel disease revealed by coronary angiogram = eligible for coronary artery bypass grafting (CABG) CABG indications... - left main coronary artery dz - 2-vessel dz in patients who are diabetic - 3-vessel dz in patients who are not diabetic - left main equivalent: significant stenosis of proximal LAD & proximal left circumflex artery - significant proximal LAD dz with 1 or 2 vessels affected with left ventricular ejection fraction <50% &/or risk of infarction during noninvasive testing (stress test)

60 yo man has had weight loss & anorexia for past several months. He also describes vague epigastric discomfort that is not relieved by antacids. Barium study shows 2 ulcerations 2-cm with heaped-up edges on opposite walls of antrum, described by radiologists as "kissing ulcers." Endoscopy reveals lesions described, & multiple biopsy specimens return diagnosis of high-grade lymphoma of stomach (visceral lymphoma). Before specific modality of therapy chosen, it is important to first ascertain what factors?

*Depth of invasion of tumor into gastric wall* Gastric lymphoma - highly chemosensitive & radiosensitive - chemotherapy preferred; must first ascertain whether tumor has replaced entire thickness of gastric wall --> if so, there is risk for gastric perforation when antineoplastic treatment applied --> local surgical excision instead

59 yo African American man comes to office for routine physical exam. Completely asymptomatic. On physical exam a discrete, hard, 1.5-cm nodule is felt in his prostate during rectal exam. Previous rectal exam, performed a year ago, was unremarkable. His PSA level 3 months ago was normal for his age. He denies any fam history of prostate cancer. What is the best next step in management?

*Determination of patient's Gleason score* Work-up of prostatic nodule... - digital rectal exam - PSA levels - biopsy when necessary Biopsy necessary to aid in diagnosis when... - mass cannot be distinguished b/t cyst - mass cannot be distinguished b/t benign condition & cancerous one - staging Main purpose of biopsying mass - obtain histologic diagnosis & Gleason score = most commonly used classification system for histologic findings in prostate biopsy *Prostatic nodule needs to be biopsied & staged regardless of PSA level*

42 yo man presents to ED after vomiting "bright red blood." He was watching TV when he suddenly felt nauseated & had to rush to bathroom, where even occurred. Estimates appx cupful of blood. Past med history is unremarkable. Denies symptoms of heartburn or dyspepsia, nor does he consume alcohol. Had never used IV drugs. On physical exam, his temp is 97 F (36.1 C), with BP of 110/65 mmHg & pulse of 92/min. Exam of his oral cavity confirms blood. Chest & cardiovascular exams are normal. There is mild tenderness to palpation of his epigastrium. He does not have ascites or hepatosplenomegaly. Skin exam demonstrates no palmar erythema or spider angiomata. No clubbing, cyanosis, or edema peripherally. Nasogastric lavage returns bright red blood. He is started on IV hydration & is typed & crossed while waiting for endoscopy. On endoscopy, blood confirmed in gastric lumen. No evidence of ulcers, gastric wall erosion, or esophageal or gastric varices. What is the most likely etiology for patient's presentation?

*Dieulafoy lesion* = dilated submucosal vessel that failed to branch into capillaries --> penetrates overlying epithelium & bleeds - usually located along lesser curvature of stomach near gastroesophageal junction - identified, it can be banded or sclerosed = intermittently bleeding vessel that retracts under mucosa during non-bleeding periods Acute upper GI bleed... - nasogastric lavage, volume resuscitation, & endoscopy

69 yo man in cardiothoracic intensive care had coronary artery bypass graft 6 days ago; he passed large volume of black stool 1 hour ago. His surgery was uncomplicated & he was extubated immediately after surgery. He developed fever & SOB 4 days later & required intubation. Current meds include penicillin, gentamicin, furosemide, aspirin, & subcutaneous heparin. His temp is 38.9 C (102 F), BP is 180/94 mmHg, & pulse is 102/min. Loud rhonchi are heard bilaterally. Cardiac exam shows normal S1 & S2; there is a 2/6 systolic murmur at left sternal border. The abdomen is soft with mild epigastric tenderness & there are no masses. Rectal exam shows hemoccult-positive stool. Lab studies show leukcocyte count of 14,400/mm^3, hemoglobin of 9.8 g/dL, & hematocrit of 29%. What is the most likely source of this patient's bleeding?

*Diffuse gastritis* = large-volume, black, tarry stool - patient on aspirin & heparin --> predisposes to bleeding from stress gastritis = common in patient who have complicated hospital course with prolonged intubation, coagulapathy, burns, cranial trauma, etc - prophylactic IV H2-receptor antagonists or PPIs should be started on all patients with this to prevent dev't of stress ulcers

69 yo woman presents with nausea, dizziness, SOB, somnolence, fatigue. She began feeling symptoms 4 days ago. She denies any emesis or fevers. Past medical history notable for HT, CHF, coronary artery disease, atrial fibrillations, & emphysema. Meds include atorvastatin, digoxin, lisinopril, carvedilol, & aspirin. She used to smoke one pack of cigarettes per day, but quit 10 yeas ago. Week before her presentation, she was diagnosed with non-ST elevation MI & received coronary angiogram, but no action was taken. On physical exam, her BP is 98/46 mmHg, pulse is 48/min, & RR is 18/min. She appears uncomfortable. Vital exam reveals that she confuses green for yellow. Lung exam reveals prolonged expiratory phase, with mild crackles at bases. Peripheral edema shows 1+ pitting edema. Chest radiograph obtained that shows cardiac silhouette, flattened diaphragms, & mixed opacities. Lab data & EKG obtained & shown below: WBCs = 6300/mm^3 Hematocrit = 45% Platelets = 225,000/mm^3 Sodium = 137 mEq/L Potassium = 4.3 mEq/L Chloride = 103 mEq/L Bicarbonate = 21 mEq/L Glucose = 122 mg/dL Urea nitrogen = 30 mg/dL Creatinine = 2.2 mg/dL Atropine given, & her new vital signs are BP 115/65 mmHg, pulse 61/min, & respirations 18/min. What would be the next step in management of this patient?

*Digoxin levels* Digoxin toxicity - ECG = scopped ST segments - renal function worsened secondary to contrast nephropathy following previous catherization & digoxin clearance diminished = worsening AV node blockade = increased automaticity of ventricles, including junctional myocardium - administering atropine = initial step in treating symptomatic bradycardia with signs of hypoperfusion

16 yo boy comes to office complaining of recurrent headaches & easy tiring. These problems started 1 year ago & have become more severe with time. Bc he spent lots of time intensively studying in advanced high-school program he had attributed headaches to long hours of reading, but his parents have become concerned that something more serious is in question. Boy has had many med problems in past & takes no med. He is not engaged in any strenuous sports activity bc all his free time is devoted to academic endeavors. On physical exam, patient's upper body is well developed but his legs & his arm are disproportionately thin. Body temp, respiratory rate, & pulse are within normal limits. Femoral pulse noted to be delayed. On auscultation, short systolic murmur appreciated in upper mid back. Most likely to be present on chest radiograph?

*Erosion of posterior ribs on chest x-ray* - older patients = posterior rib notching from enlargement of intercostal artery = collateral blood flow - surgical correction should be performed as soon as patient is stable Coarctation of aorta = vast majority = below point of origin of left subclavian artery = more common in boys - increased incidence in Turner syndrome = associated with bicuspid aortic valve - may be missed in newborn while ductus arteriosus open - upper- or lower-extremity pulse delay = classic sign - short systolic murmur may be heard along left sternal border at 3rd-4th intercostal space or in upper mid back - complications = HT, HF, encephalopathy, intracranial hemorrhage; higher risk of endocarditis

47 yo woman comes to physician bc of frequent urge to go to bathroom for past 5 months. She has lost control of her urine. Episodes of incontinence have not been associated with any particular movement, strenuous activity, coughing, or sneezing. She denies burning on urination, blood in urine, or fever. She has ho HT, migraine headaches, & narrow-angle glaucoma. Current meds include captopril. She has smoked one pack of cigarettes daily for 23 years. Pelvic exam shows no pelvic or vaginal masses. Urinalysis is within normal limits. Urine culture negative. Patient states that she saw advertisement for tolterodine, & she requests prescription for this med. What is the most appropriate next step in management?

*Explain that tolterodine is not an appropriate medication for her* Urge incontinence = leakage of urine via involuntary bladder contractions = when detrusor muscle contracts too frequently = constantly have sensation that they need to urinate First-line treatment - behavioral therapy with frequent voiding (every 1-2 hours) while awake + wearing adult diapers at night in case of accidental incontinence - should be instructed to engage in pelvic muscle exercises (Kegel exercises) to be performed 3-4 times/week & continued for at least 15-20 weeks

Chronic form of perianal abscess that is spontaneously or surgically drained but the abscess cavity does not heal completely leading to partial tract epithelization

*Fistula-in-ano* - cavity become inflammatory track with primary opening (internal opening) in anal crypt at dentate line & secondary opening (external opening) in perianal skin - external opening usually visible as red elevation of granulation tissue (Sentinel pile) with purulent or serosanguineous drainage on compression Most patients have ho... - anorectal abscess with intermittent drainage - fecal soiling - occasional perineal discomfort

36 yo gravida 4, para 3, Ab 1 complains of painless, irregular, & intermittent vaginal bleeding for last 4-5 months. She uses 6-8 pads per day b/t her menstrual periods. Her previous history reveals regular menstrual cycles since age 14. Last year she underwent tubal ligation that was confirmed by hysterosalpingogram & an appendectomy at age 22. Vital signs include temp 37.2 (99 F), BP 115/75 mmHg, pulse 86/min, & respirations 14/min. Chest & abdominal exam is unremarkable. Pelvic exam shows no vulvar, vaginal, or cervical lesions. There is dark blood in vagina. Bimanual exam reveals symmetric, nonenlarged, nontender uterus with normal adnexa. Lab results: Hb = 9.6 g/dL Hct = 30% WBC = 9700/mm^3 Neutrophils = 60% Lymphocytes= 24% Platelets = 220,000/mm^3 beta-hCG = 3 mIU/mL (negative, <5 mIU/mL) PT = 12 s PTT = 35 s FSH = 28 mIU/mL (normal, 5-30 mIU/mL) LH = 25 mIU/mL (normal, 5-30 mIU/mL) Endometrial biopsy shows weakly proliferative endometrium with no evidence of hyperplasia or atypia. Based on patient's history & lab findings, what would be best initial treatment?

*High-dose estrogen & high-dose progesterone combination orally* - hemodynamically stable (normal vital signs, no alteration of consciousness, hematocrit 25-35%) + known ho DUB + iron deficiency anemia + moderate amount of prolonged bleeding --> adminster oral contraceptive containing combo of high doses of estrogen & synthetic progesterone 4x/day for 7 days --> arrests bleeding in most patients = used only in patients with established menstrual history - pregnancy must be excluded before initiating therapy

22 yo man brought to ED after being pinned by steel beam, which has fallen on his legs & lower torso. He is alert & oriented. His BP is 105/75 mmHg & pulse 95/min. Exam shows bilaterally crushed lower extremities. Lab studies show: Sodium 143 mEq/L (135-145 mEq/L) Potassium 5.2 mEq/L (3.5-5.2 mEq/L) Bicarbonate 20 mEq/L (20-29 mEq/L) Chloride 98 mEq/L (96-106 mEq/L) Urea nitrogen 37 mg/dL (7-20 mg/dL) Creatinine 1.1 mg/dL (7-20 mg/dL) Creatinine phosphokinase 15,300 U/L (52-200 U/L) Aspartate aminotransferase 112 IU/L (<40 IU/L) Alanine aminotransferase 99 IU/L (<40 IU/L) Hematocrit 38% (41-50%) Arterial blood gas on 40% oxygen shows PO2 80 mmHg, PCO2 37 mmHg, & pH 7.33. What is the most appropriate next step in management?

*IV crystalloid & bicarbonate* Crush injuries --> rhabdomyolysis - CK > 5x upper limit of normal = rhabdomyolysis - marker for myoglobin = directly nephrotoxic - *early intervention with copious alkalinized IV crystalloid can prevent renal damage*

68 yo woman comes to ED because of nausea, vomiting, & abdominal pain for 24 hours. She denies fever, chills, or rigors. She was recently diagnosed with multiple myeloma & she has a ho rheumatoid arthritis, HT, & hypercholesterolemia. She has had no chemotherapy yet. Her BP is 90/60 mmHg, pulse is 110/min, & respirations 16/min. Exam shows dry oral mucosa & decreased skin turgor. Lungs are clear to auscultation. Cardiac exam shows normal S1 & S2; no murmurs heard. There is no peripheral edema. Lab studies show: Hemoglobin = 16.8 g/dL Leukocyte count = 8,000/mm^3 Platelet count = 170,000/mm^3 Na+ = 134 mEq/L Cl- = 101 mEq/L K+ = 4.5 mEq/L HCO3- = 25 mEq/L BUN = 60 mg/dL Creatinine = 1.4 mg/dL Glucose = 80 mg/dL Calcium = 13.2 mg/dL Albumin = 4.2 g/dL What is the most appropriate next step in management of this patient's hypercalcemia?

*IV normal saline* Hypercalcemia treatment - varies according to clinical presentation & serum calcium levels - symptomatic (> 12 mg/dL) or severe (>15 mg/dL) = treated initially with infusion of normal saline to maintain urine output at 100-150 mL/h - hypovolemia is exacerbating hypercalcemia (due to hypercalcemia-induced salt-wasting & vomiting) - simultaneous calcitonin & bisphosphonates may be used also

35 yo man comes to physician bc of 2-week ho daily headaches that begin in morning & last for whole day. He says that the pain feels like a "squeezing tightness" around his head & is particularly intense in the back of his neck. He has no fever, nausea, vomiting, seizures, or visual changes. He does not drink alcohol or smoke cigarettes. He states that he eats a well balanced diet & that he drinks 4 cups of coffee daily. He works as an investment consultant in a brokerage firm. Physical exam shows no abnormalities. What is the most appropriate next step in management?

*Ibuprofen trial* Tension headache - triggered or worsened by stressful situations, anxiety, fatigue - most cases respond to NSAIDs = most common type of headache in general population

24 yo man + 10 day ho fever up to 38.2 C (100.8 F), muscle aches, loss of appetite, & sore throat. He denies nausea, vomiting, or diarrhea. He does not smoke cigarettes or drink alcohol. He is not sexually active. His temp today is 38.4 C (101.1 F), BP 124/78 mmHg, & pulse 90/min. Exam shows tonsillar erythema with exudate & bilateral anterior & posterior cervical adenopathy. There is fine, diffuse maculopapular rash. A streptococcal antigen test on throat swab is negative. What is the most sensitive & specific diagnostic study for this patient's condition?

*IgM to EB VCA* EBV = human herpesvirus 4 = found everywhere - US = most commonly in ages 10-35 - tender lymphadenopathy, especially anterior & posterior cervical, & splenomegaly - lymph node enlargement may be severe & may = airway obstruction - exudative pharyngitis/tonsillitis also commonly seen - *small number of patients have maculopapular rash*, especially if administered ampicillin/amoxicillin --> incidence goes up to almost 100% - *most sensitive & specific test for acute infectious mononucleosis = IgM Ab to VCA*

57 yo woman with ho rheumatic fever as child comes to physician bc of 6 mo ho slowly progressive dyspnea on exertion & orthopnea. Her BP is 110/60 mmHg, temp is 37 C (98.6 F), pulse is 93/min & irregular, & respirations are 18/min. Physical exam shows localized mid-diastolic murmur near apex. Loud opening snap heard after S2. Rhythm appears irregular. What is most likely to be found on physical exam?

*Increased S1 intensity* Mitral stenosis - decreased left ventricular filling = elevated left-sided atrial pressures = pulmonary congestion = left-sided HF = SOB & dyspnea on exertion - hemoptysis sometimes via rupture of small pulmonary blood vessels - pulmonary HT via right ventricle working against increased pressures secondary to chronic pulmonary congestion - atrial fibrillation common with mitral stenosis - early in course of dz = increased intensity of S1 = stenosis prevents valve from closing spontaneously after diastole

58 yo woman comes to doc bc of vulvar itching & burning for 2 months. She has slight pain in vaginal introitus after intercourse. She has had no vaginal bleeding. She has allergic rhinitis treated with loratadine, & RA treated with ibuprofen & methotrexate. Menopause occurred 7 years ago. She had 2 episodes of STDs 20 years ago. She is sexually active with 3 male partners & uses condoms inconsistently. Pelvic exam shows 1-cm plaque on right vulvar region that is white, flat, & glistening; there is thin skin & evidence of erythema with excoriations on right labia majora. What is most likely diagnosis & most appropriate initial pharmacotherapy?

*Lichen sclerosis, clobetasol cream* = vulvar dystrophy = most common symptom = vulvar itching - most commonly presents after menopause - important to confirm with vulvar biopsy - treatment = high-potency topical corticosteroids such as clobetasol or halobetasol

35 yo woman comes to doc bc of itchy patch of skin near hear right knee that developed after being bitten by mosquitoes in this area 6 months ago. Mosquito bites resolves but area continued to be pruritic. She reports scratching area periodically. Exam shows well defined, 6-cm diameter patch of skin that is dry, scaling, hyperpigmented, & thickened. There is ring of discrete brown papules at periphery of lesion. What is the most likely diagnosis?

*Lichen simplex chronicus* / Neurodermatitis circumscripta - induced by chronic scratching or rubbing - underlying causes of itch = atopic dermatitis, papular urticaria (bug bites), narcotic use/abuse, systemic dzes - chronic scratching --> defect in skin's permeability barrier - topical steroids or anesthetics (menthol, capsaicin), oral antihistamines, & physical barriers to scratching = helpful treatment

14 yo girl brought to dermatologist by her mother bc of acne. Girl reports worsening of lesions despite usage of OTC topical acne treatment. Exam shows open & closed comedones, especially on forehead. In addition, there are some comedones & many papules & large pustules on chin, in nasolabial folds, & on cheeks. There are few lesions on upper back, but none are seen on chest or deltoid regions. What is the most appropriate pharmacotherapy?

*Oral doxycycline plus topical retinoid* Acne vulgaris - mildest form: comedones on central face - marked trunk involvement most often in boys - closed comedones on forehead more often in girls = prolonged use of greasy hair preps Acne management: comedonal acne: - topical retinoid (tretinoin, adapalene) +/- benzoyl peroxide or azelaic acid mild papulopustular acne: - topical benzoyl peroxide + topical antibiotic or oral antibiotic with topical retinoid severe papulopustular acne: - oral antibiotic + topical retinoid nodulocystic acne & acne resistant to above therapy - isotretinoin

39 yo woman with long ho respiratory infections consults physician bc of severe pain & inability to look down & out with her left eye while going down stairs. Temp is 39.5 C (103.1 F). Physical exam demonstrates erythema & edema of eyelids & conjunctivae. Pupil is fixed & dilated; ocular muscle exam reveals inability to adduct & to abduct & depress eye. Lateral rectus exam is normal. What is the most likely diagnosis?

*Orbital cellulitis* = dangerous infection of orbital tissues = complication of paranasal sinusitis, eyelid trauma, dental/oral infections = potentially permanent visual loss secondary to optic neuritis, meningitis secondary to spread of infection to brain, cavernous sinus thrombosis secondary to extension of clots in orbital veins - inability to move her eyes = inflammatory process around ocular muscles = confirmed by inability to look down & out (CN IV) & to adduct eye (CN III) - pupillary dilation confirms lesion of CN III

43 yo woman presents to ER with painful red eye. She has also noticed some blurry vision. Pain & redness began approximately 2 days ago, & has progressed since. She denies any other symptoms, including fever. Her past med history is unremarkable, & she does not take any meds. She does not use IV drugs, nor does she smoke or drink alcohol. On physical exam, she is afebrile & normotensive. Her heart rate is 90 beats/min. She is saturating 95% on room air. Exam of her left eye reveals injection, mild proptosis, & pain with movement. No corneal abrasion is appreviated, & her anterior chamber is light & quiet. Her lens is intact & clear, & her funduscopic exam is normal. Rest of head & neck exam is normal. Her chest, abdominal, & peripheral exams are unremarkable. Computed tomography of orbits reveal soft-tissue density behind orbit, with fat stranding within & just outside of conus, consistent with retro-orbital inflammation. What is the most likely etiology for patient's eye condition?

*Orbital inflammatory pseudotumor* = idiopathic orbital inflammatory syndrome = poorly understood = nongranulomatous inflammation of retrobulbar fat, lacrimal glands, posterior sclera = lymphocytic predominant - severe --> treated with corticosteroids - unilateral eye pain & red eye --> differential = conjunctivitis, uveitis, scleritis, etc - diagnosis revealed by computed tomography findings of retrobulbar fat-stranding & inflammation

Recognize CT of pancreas transection Case "56 yo previously healthy woman admitted to hospital bc of 1-week history of severe mid-abdominal pain that radiates to back. One weeks ago, she was in motor vehicle accident & her abdomen was struck by steering wheel. Her temp is 37 C (98.6 F), BP is 130/75 mmHg, pulse is 96/min, & respirations are 20/min. Lungs are clear to auscultation bilaterally. Cardiac exam shows normal S1 & S2; no murmurs heard. Abdomen diffusely tender, without masses, rebound tenderness, or guarding. CT scan of abdomen shown. Location of patient's injury?

*Pancreas* Acute pancreatitis = abdominal pain radiating to back & abdominal tenderness - motor vehicle accident --> damage

44 yo man presents to clinic concerned about swollen left lower leg for 2 days. In initial evaluation of patient, what piece of info obtained by history or physical exam is most helpful in ruling in deep venous thrombosis (DVT)?

*Patient was in bed for 4 days last week because of pneumonia* - *history of immobilization (3 days in past 4 weeks) = strongest historical predictor of DVT = positive likelihood ratio of 2.4* - calf pain = little predictive value - positive likelihood ratio of patient with calf pain having DVT = 1.1

29 yo woman, gravida 2, para 2, comes to physician bc of urinary incontinence for 5 months. She explains that she loses small amounts of urine when she picks up her children & when she sneezes. She delivered an infant boy 16 months ago via normal vaginal delivery, at which time she suffered a second-degree vaginal laceration. Her med history is unremarkable. She takes no meds. What is the most appropriate next step in management?

*Pelvic examination* Stress incontinence = most common form of true urinary incontinence - seen in in middle-aged women - risk factors = multiple pregnancies, vaginal deliveries, vaginal trauma - increased intra-abdominal pressure from coughing, sneezing, exertion --> increased pressure within bladder First step = pelvic exam to evaluate anatomy

34 yo gravida 2, para 1 woman at 37 weeks' gestation comes to labor & delivery ward bc of large gush of clear fluid 30 minutes ago. Her pregnancy history is significant for being Rh-negative with father confirmed to be Rh-positive. She received standard dose of RhoGAM at 28 weeks' gestation. Her prenatal care during previous pregnancy was adequate & she had received all prophylactic doses at that time. Exam shows she has spontaneously ruptured her membranes, & cervical exam shows her to be 2-cm dilated. She is admitted & administered Pitocin for labor augmentation. After 16-hour labor course she delivers a 3,400- neonate. Because of prolonged & difficult labor, there is concern for fetomaternal hemorrhage. What is the most appropriate next step in management?

*Perform a rosette test on maternal blood* - 28 weeks' gestation --> 300-mcg prophylactic dose of anti-D immune globulin (RhoGAM) - standard dose of 300 mcg indicated unless there is concern for fetomaternal hemorrhage --> further testing indicated

65 yo man admitted to hospital for worsening headache, light-headedness, blurry vision, & fatigue over last 3 months. He also reports that he is getting very weak & has generalized itching, which usually occurs in hot weather. On exam, he is not in apparent distress. Vital signs are: BP 137/80 mHg, pulse rate of 98/minm & temp of 37 C (98.6 F). He has facial plethora. Abdominal exam reveals spleen edge 4 cm below left costal margin. Lab exam shows: hematocrit 62%, hemoglobin 18 gm/dL, leukocyte count of 18,000/mm^3 & a platelet count of 550,000/mm^3. Serum erythropoietin level is low. Serum leukocyte alkaline phosphatase is increased. What is the most likely diagnosis in this patient?

*Polycythemia vera* = generalized pruritus, especially after hot bath = unusual thrombosis = erythromelalgia = splenomegaly = persistent leukocytosis = persistent thrombocytosis & microcytosis via iron deficiency - erythropoietin level low - serum leukocyte alkaline phosphates can be increased - slightly more common in men = 60-75 yo mostly

24 yo woman who recently gave birth has had ongoing rectal pain for past several weeks. She notes extreme pain when defectating, & there is bright red blood in her stools & on toiler paper. She also feels pain with coughing, & it is relieved slightly by standing. Her past medical history is unremarkable & she takes no meds. She denies ho hemorrhoids & denies fevers or chills. What location is most typical for the lesions with which she is presenting?

*Posterior midline, distal to dentate line* Anal fissure = exquisit pain + minimal bright red bleeding, seen on toilet paper with defection, as well as with coughing & sitting - typical patient = young female - anal pruritus - 90% = along posterior midline, distal to dentate line - most common cause = constipation with hard stools - very tightly closed rectal sphincter cuts off blood supply to anal mucosa Management of acute (<6 weeks) & uncomplicated fissure = WASH regimen - warm water (siz bath after bowel movement) - analgesics - stool softeners - high-fiber diet Chronic cases - lateral sphincterotomy - Botulinum injections

67 yo man presents to clinic complaining of worsening urinary symptoms. He has noticed he is waking up more often at night to urinate, & when he tries to urinate he has to "push harder" to start his urinary stream. Previous medical & surgical history unremarkable Physical exam reveals uncircumcised phallus & normal testes. On rectal exam his prostate is smooth, symmetric, & weighs approximately 50 g. No nodules felt. He is given prescription for tamsulosin & sent home. During follow-up visit 4 weeks later, the patient reports mild improvement of his symptoms but is not happy with his therapy. He still complains of urinary frequency & dribbling. He asks that if other meds are prescribed, that they be generics, because his insurance will not pay for brand names. Urinalysis performed & reveals the following: pH = 4.2 RBC = 0-1//hpf WBC = 4/hpf Bacteria = scant Culture = 25,000 CFU/mL of E coli Best next step in management?

*Prescribe finasteride* = beneficial in men with prostates > 40 g BPH - patient did not have much improvement bc prostate is very large - 50 g, compared with the normal 20-25 g --> next step = add drug to reduce size of prostate = 5alpha-reductase inhibitor (finasteride) --> converts testosterone to dihydrotestosterone in prostate - dihydrotestosterone = hormone-dependent enlargement of prostate

65 yo woman brought to ED with chest pain & SOB. Patient has long ho CAD, HT, hyperlipidemia, DM complicated by diabetic retinopathy & nephropathy, anemia of chronic dz, & lower GI bleeding 6 months ago from diverticulosis. Patient currently taking atenolol, lisinopril, simvastatin, glyburide, erythropoietin. Soon after arriving in ED she loses consciousness & her pulse can't be palpated; she is quickly intubated without complications & CPR initiated. After 12 minutes of advanced cardiopulmonary resuscitation, patient regains sinus rhythm. Her vital signs are temp 36.5 C (97.7 F), BP 100/70 mmHg, & pulse 65/min. Auscultation of lungs reveals few bibasilar crackles. Heart sounds are distant, with no murmurs, rubs, or gallops. Rectal exam reveals decreased rectal tone with brown stool in rectum, negative for occult blood. Her initial lab workup reveals: WBC = 7300/mm^3 Hemoglobin = 11 g/dL Hematocrit = 31% Platelets = 230,000/mm^3 Sodium = 134 mmol/L Potassium = 4.9 mmol/L Calcium = 8.5 mg/dL Creatinine = 2.1 mg/dL BUN = 35 mg/dL Glucose = 180 mg/dL Hemoglobin A1C = 7.2% CK-MB = 4.1 ng/mL (normal, 0-3 ng/mL) Troponin = 0.6 (normal, <0.4 ng/mL) Administration of thrombolytic agent considered. What represents relative contraindication for thrombolytic therapy in this patient?

*Prolonged CPR* - greater than 10 minutes - likelihood of trauma to anterior chest wall high (fractures usually occur) --> increases risk for bleeding Absolute contraindications for thrombolytic therapy - previous intracranial hemorrhage - known structural cerebral vascular lesion - known malignant intracranial neoplasm - ischemic stroke within 3 months - hemorrhagic stroke anytime - suspected aortic dissection - active bleeding or bleeding diathesis - significant closed-head or facial trauma within 3 months - ho diabetic retinopathy Relative contraindications... - poorly controlled HT (BP > 180/110 mmHg) - ischemic stroke more than 3 months previously - dementia or other intracranial pathology - traumatic or prolonged cardiopulmonary resuscitation (>10 min) - major surgery within less than 3 weeks - internal bleeding within 2-4 weeks - non-compressible vascular puncture - prior allergic rxn to streptokinase - pregnancy - active peptic ulcer - current use of anticoagulants, INR greater than 2

68 yo woman with HT comes to physician with complaints of fatigue for past 6 weeks. Even though she has recently lost about 7 lbs, she does not want to eat. She is also worried bc every time she is watching TV or somebody is talking to her, she finds herself "wandering" and unable to understand, due to her inability to stay focused. She thinks this is due to her problem when she goes to bed: she has to wait 2-3 hours before falling asleep, & yet she wakes up early in the morning. She thinks all these events are bc of her "advanced age," and she "just feels like staying home." She tells the physician, "Nothing can be done, Doc." The last visit to her PCP was 3 months ago. At that time her BP was 150/90 mmHg. What is the most likely cause of this patient's new symptoms?

*Propranolol* - causes depression - dizziness, bronchospasm, nausea, vomiting, diarrhea, constipation Depression: changes in appetite, insomnia, lack of concentration, worthlessness for longer than 2 weeks

59 yo man comes to doc bc of 2-month ho low back pain that starts while walking. Ibuprofen does not relieve his symptoms. He has ho hyperlipidemia, type 2 DM, & HT. Current meds include simvastatin, metformin, & lisinopril. He works as computer engineer. He has smoked one pack of cigarettes daily for 33 years. MRI scan of spine shows osteophytes & an intraspinal canal area of 50 mm^2. What is most likely to be seen in this patient?

*Pseudoclaudication* - mimics claudication in vascular occlusion of leg = brought on by activity & relieved by rest - via nerve compression MRI scan --> spinal stenosis = common age-related condition = narrowing of spinal canal, etc = via repeated stresses on spine & intervertebral disks over time = osteophyte formation = intervertebral disk narrowing = ligamentous thickening = facet joint hypertrophy = associated leg pain exacerbated by walking & relieved by rest

Previously healthy 45 yo woman in motor vehicle accident. She suffers multiple internal & external injuries from which she is still actively bleeding when reached by an ambulence. Paramedics unable to get line in. Her BP is 50/20 mmHg. What would be the most likely result of a complete blood count performed in ER 15 minutes later?

*Red cell count 4.5 million per micro liter; white cell count 6000 per micro liter* = only values within normal limits - unless IV fluids administered, leading to dilutional effect, CBC during acute blood loss remains unchanged

48 yo man has had sudden onset of visual loss in left eye upon awakening. He has not routinely seen physician for yearly exams. At this time, ER obtains immediate ophthalmology consult. Ophthalmologist finds dilation of retinal veins, microaneurysms, retinal hemorrhage, edema, & hard exudates in patient's left eye. Small retinal hemorrhage & dilated veins seen in right eye. What is the most likely diagnosis of the underlying cause?

*Type 2 diabetes* Diabetic retinopathy = proliferative or nonproliferative Nonproliferative = dilation of veins, microaneurysms, retinal hemorrhages, retinal edema, hard exudates Proliferative = neovascularization via optic disc or major vessels - tractional retinal detachment may occur with proliferation into vitreous - proliferative retinopathy must be recognized early & treated with laser photocoagulation to prevent blindeness - vitrectomy may be needed --> removes vitreous hemorrhage = treats retinal photocoagulation, macular detachment, macular edema, etc

Recognize orbital floor fracture, which could result in *anterior maxillary tooth numbness*

Infraorbital branch of V2 (second division of trigeminal nerve) - traverses infraorbital groove & canal in orbital floor - innervates mucosa of maxillary sinus; premolar, canine, incisor maxillary teeth; skin & conjunctiva of inferior eyelid; skin of cheek, lateral nose, anteroinferior nasal septum; skin & oral mucosa of superior lip

Described as intense burning pain that occurs after injury.

Reflex sympathetic dystrophy / causalgia - pain management with local anesthetics or *surgical sympathectomy* with sympathetic block

Reye syndrome is an acute enephalopathy associated with high levels of

ammonia - lethargy, vomiting, irritability = characteristic for encephalopathy - delirium, seizures, coma may also occur

Most significant cause of morbidity from ovarian teratomas

torsion = 3.2 to 16% of cases

Used as adjuvant therapy in polycythemia vera pts who are older than age 60 years or those who have previously had thrombotic event or have cardiovascular risk factors

Hydroxyurea

Clubbing occurs in 80% of these patients

Interstitial Pulmonary Fibrosis (IPF)

You have been following a 68-yo woman with liver cancer & want to evaluate if she can qualify for hospice or palliative care. Many patients don't get palliative care referrals or hospice care referrals for numerous reasons. They are referred late because of health policy issues of care & other provider-related issues. You don't want to make that mistake with your patient. What is the best question you could ask to ensure her timely use of this type of care?

*"Would you be surprised if this patient died within the next 6 months?"* - prognosis of death within next 6 months = criterion for hospice benefits

36 yo woman, gravida 3, para 2, at 33 weeks' gestation comes to physician for prenatal visit. She has some fatigue but no other complaints. Her current pregnancy has been complicated by Group B Streptococcursurine infection at 16 weeks. Her past obstetric history is significant for primary, classic cesarean delivery 5 years ago for non-reassuring fetal tracing. Two years ago, she had repeat cesarean delivery. Past surgical history significant for appendectomy 10 years ago. What is the major contraindication to vaginal birth after cesarean (VBAC) in this patient?

*Classic uterine scar* = vertical incision into uterus that extends from lower uterine segment up into active myometrial portion toward fundus of uterus = 10% risk of uterine rupture - should have elective repeat cesarean delivery when fetus mature

4 yo girl brought to doc by mother bc of progressive blood, greenish, malodorous vaginal discharge over 3 days. Girl has no other symptoms. Mother reports no concerns regarding abuse of child. Pelvic exam is attempted but impossible bc of child's absolute refusal to be examined. Several efforts at persuasion are made but are unsuccessful. Besides refusal to be examined, child seems happy & well adjusted. What is the most appropriate next step in management?

*Examination under anesthesia* - discharge --> requires full evaluation - differential = infection, tumor, trauma, vaginal foreign body - *in 4 yo girl, vaginal body = common cause of greenish, bloody, foul-smelling vaginal discharge*: most common foreign body = toilet paper or stool - refuses voluntarily examination --> under anesthesia --> vaginoscopy

7 yo child present to your office with ear pain. Physical exam reveals bulging tympanic membrane & cloudiness behind the eardrum. Tympanometry can be helpful in making diagnosis of otitis media by demonstrating presence of

*Middle ear effusion*

SIADH is characterized by

- hyponatremia - clinical euvolemia - *increased intravascular volume* - decreased serum osmolarity - *elevated urine osmolarity* - excessive urine sodium excretion

Recognize ECG of digoxin. Case: 65 yo man brought to ED bc of dizziness, lightheadedness, general weakness for 2 hours. He has had no chest pain or SOB. He has ho HT, CAD, CHF, angina, & hyperlipidemia. Current meds include nitroglycerin, aspirin, digoxin, furosemide, & atorvastatin. He appears confused. His temp is 37 C (98.6 F), BP 100/65 mmHg, pulse 39/min, & respirations 20/min. His skin is pale & dry with slightly decreased turgor. Lungs are clear to auscultation. Cardiac exam shows irregular rate & distant heart sounds; no murmurs or rubs are heard. There is 1+ pedal edema. ECG shown...

Digoxin - 3rd-degree AV block / complete heart block - P waves completely dissociated from QRS complexes - dizziness, presyncope, syncope (Stokes-Adams attacks) - confusion, bradycardia (<40/min), hypotension - CAD = 40% of AV block

Next step after diagnosing complete atelectasis. Case: "56 yo man admitted to hospital bc of severe SOB, fever, cough. He receives IV ceftriaxone & azithromycin. His respiratory function worsens & he is intubated & placed on controlled mechanical ventilation. 2 days later his oxygen saturation decreases to 70% on 100% oxygen by mechanical ventilation. Decreased breath sounds on left side heard on auscultation & there is dullness to percussion over left lung fields. Radiograph of chest is shown. What is the most appropriate next step in management?

Suction through ET tube, followed by *Bronchoscopy* if ET tube suction failed to resolve hypoxia - endotracheal tube suction & bronchoscopy = removal of mucus plug Hypoxia + dullness to percussion + complete opacification of left lung on radiograph = airway obstruction --> atelectasis - probably mucus plug in mechanically ventilated patient

30 yo man comes to see his internist bc of unilateral right-eye pain, photophobia, & decreased vision in that eye. The doc has been following this patient for a number of years for Crohn's dz. On exam, the eye is red. Slit-lamp exam shows inflammatory cells in aqueous humor. Doc refers man to ophthalmologist. Further exam shows anterior chamber hypopyon & fibrin. In addition, there are small keratic ppts on corneal epithelium. What is the most likely diagnosis?

*Anterior nongranulomatous uveitis* - uveal tract = iris, ciliary body, choroid - anterior uveitis: inflammatory cells & flare seen within aqueous on slit-lamp exam - more severe cases may result in hypopyon = white cells layered together & fibrin within anterior chamber - occurs with systemic inflammatory dzes such as ankylosing spondylitis, psoriasis, IBD, reactive arthritis, Reiter dz, Behcet syndrome, Lyme dz, & Kawasaki dz in children - ophthalmoscopic exam = no iris nodules - keratic ppts = much smaller compared to granulomatous form

In a trauma situation with an Rh-negative mother, what must be done prior to the administration of RhoGAM in order to completely neutralize the fetal blood cells & prevent creation of maternal antibodies against Rh-positive fetal blood?

*Determine fetal blood cells in maternal circulation* - amount of feto-maternal hemorrhage must be determined prior to admin of RhoGAM

Treatment of Acute Respiratory Distress Syndrome (ARDS)

*Low tidal volume mechanical ventilation* - ventilation at 6 mL/kg of ideal body weight (IBW) reduces mortality Other options - permissive hypercapnia - high-PEEP - haven't yet been proven to decrease mortality

28 yo woman found to have TSH level between 5 & 10 mIU/L. She is asymptomatic & has normal physical exam. She is asked to return in 3 months for repeat testing. Her TSH level is in same range, & free thyroxine testing is normal. What statement is true about her condition?

*The benefits of treatment include improved pregnancy outcomes* After diagnosis of subclinical hypothyroidism... - follow-up scheduled every 6-12 months - patient trying to become pregnant, & L-thyroxine instituted? --> needs follow-up every 6 weeks until TSH level stabilized in normal range

33 yo woman with no significant past med history brought to ED with acute onset of severe SOB. Reports right-sided calf pain developed after long plan trip home from Australia, & that several hours after onset of calf pain she became acutely SOB. History difficult to obtain because of patient's extreme SOB, but her companion report no recent surgeries or ho bleeding. Temp is 37.8 C (100 F), systolic BP 70 mmHg, pulse 140/min, & respirations 43/min. Physical exam reveals woman who is in severe respiratory distress & using accessory respiratory muscles. Heart is rapid & regular, lungs are clear, & abdomen is benign. There is jugular venous distention. Right calf is swollen & tender. Ventilation-perfusion scan is high probability. Arterial blood gases show pH 7.48, pCO2 20 mmHg, & PaCO 48 mmHg on 6 L oxygen. What is the most appropriate management?

*Thrombolysis* / Thrombolytic agent - dissolves blood clot - contraindications = recent surgery or recent bleeding, uncontrolled BP, patient's age - if contraindicated = surgical embolectomy Pt has pulmonary embous + hemodynamically unstable

26 yo woman comes to doc bc of 1 yr ho amenorrhea. She has had occasional discharge from both breasts. She takes no meds. She has a 5 yr old child that she breast-fed until age 9 months. There is diffuse enlargement of thyroid gland. Breast exam shows expression of milk from both breasts. MRI of brain shows pituitary enlargement. Lab studies show: Serum prolactin = 160 ng/mL (normal, 4-30 ng/mL) TSH = 36 (normal, 0.4-5 mU/L) Thyroxine = 0.6 (normal, 0.8-1.8 ng/dL) Urine beta-hCG negative What is the most appropriate next step in management?

*Thyroxine replacement* - will restore normoprolactinoma = regression of pituitary enlargement Primary hypothyroidism - functional cause of hyperprolactinemic state = 25% of patients with primary hypothyroidism - thyrotrope-cell hypertrophy & hyperplasia

24 yo woman comes to physician for initial prenatal visit. Her last menstrual period was 7 weeks ago & a home urine pregnancy test was positive. She has had no bleeding or abdominal pain. She does not complain of increased fatigue lately & some mild nausea & vomiting. Exam is significant for a diastolic murmur. The uterus is 8 weeks' sized & nontender. What findings is the next best step in management of this patient's murmur?

*Echocardiograph* - diastolic murmur in pregnant woman must be thoroughly evaluated - mitral stenosis = most common rheumatic valvular lesion in pregnancy = rumbling diastolic murmur

48 yo man with end-stage small cell carcinoma of left lung has dyspnea that has been progressively worsening. He has been using his albuterol inhaler but is not receiving much symptom relief. What medication would be most appropriate for symptom relief?

*Morphine sulfate 5 mg every 3-4 hours*

Results from vasoconstriction of mesenteric vessels & hypoperfusion of small bowel. Typical patient is elderly person who has pre-existing arterial atherosclerosis, who begins to have diffuse abdominal pain after episode of hypoperfusion &/or vasoconstriction.

*Nonocclusive mesenteric ischemia (NOMI)* - angiography = string of sausages sign = alternating areas of narrowing & dilation of branches of superior mesenteric artery & absent submucosal circulation - CT scan = small-bowel thickening & foci of intramural gas

Hepatitis C patients who develop advanced liver dz should be ...

*evaluated for liver transplantation with liver biopsy* & treated with pegylated-interferon & ribavirin - variceal hemorrhage, ascites, encephalopathy = manifestations = decompensated cirrhosis

Form of acute-onset severe eczema of palms & soles. Characterized by marked erythema, vesiculation, and weeping.

Pompholyx

21 yo woman, gravida 2, para 1 at 28 weeks' gestation, comes to doc bc of spotting after intercourse & a foul-smelling vaginal discharge. Her prenatal course has been uncomplicated, & she has no med problems. Speculum exam shows inflammation of cervix with mucopurulent cervical discharge. Gonorrhea & Chlamydia test performed, which comes back positive for Chlamydia. What is the most appropriate pharmacotherapy?

*Azithromycin* - prolonged tissue half-life = can treat Chlamydia in single dose = greater compliance Chlamydia cervicitis - most common sexually transmitted bacterial organism in US - associated with PPROM & preterm labor - test of cure (TOC) should be performed 4-6 weeks after treatment --> ensures organism has been completely eradicated from patient & partners

8 yo boy brought to physician for routine health maintenance exam. Mother states that he has had difficulty reading & concentrating in his second-grade class. Physical exam shows 7 pigmented cutaneous lesions ranging from light to dark brown on body, as well as two small, soft masses above orbit. Skin lesions have distinct borders that are greater than 5 mm in diameter. There are also numerous freckles in axillary & groin areas. His past medical history is significant for seizure in two episodes, 4 & 6 months ago. His mother has lesions similar to the ones that he has throughout his body. What is the most likely complication of the underlying condition?

*Bony dysplasia* Neurofibromatosis (NF): NF-1 = 2 or more of... - 6 or more cafe-au-lair macules - 5 mm in greater diameter in prepubertal ind.s - 15 mm in greatest diametes in postpubertal ind.s - 2 or more neurofibromas or one plexiform neurofibroma - freckling in axillary or inguinal regions - optic glioma - 2 ore more Lisch nodules (iris hamartomas) - distinct osseous lesion (ex. sphenoid dysplasia or thinning of long-bone cortex) - first-degree relative with NF-1 - seizures more often (all 3 of phacomatoses = NF, tuberous sclerosis, Sturge-Weber) - skeletal manifestations = long-bone dysplasia, scoliosis - fracture may occur at site of dysplasia = pseudoarthritis

82 yo woman comes to physician bc of right-sided throbbing headache which has occurred intermittently for 2 weeks. She has also had intermittent jaw pain when chewing & fatigue. She has 25-year ho HT treated with hydrochlorothiazide. She is no distress. Her temp is 37.1 C (98.8 F), BP 125-83 mmHg, pulse 92/min, & respirations 20/min. Exam is remarkable for a weak, tender, but palpable right-sided temporal artery pulse, as well as tenderness to palpation on right side of face. What is the most appropriate next step in management?

*Erythrocyte sedimentation rate test* Temporal arteritis / Giant cell arteritis - affects large cranial arteries - more common in individuals with polymyalgia rheumatica Initial workup = ESR - ESR (>100 mm/hr) = temporal arteritis - lab studies may also = C-reactive protein or anemia of chronic dz

65 yo man brought to ED because of 2 day ho fever, headache, confusion. He has ho prostate cancer, type 2 DM, & HT. Current meds include lisinopril & metformin. He appears confused. Temp is 39.7 C (103.5 F), BP is 120/84 mmHg, & pulse 102/min. Exam shows neck stiffness. Lumbar puncture performed. Gram stain of CSF shows lancet-shaped, gram-positive diplococci. Most appropriate pharmacotherapy?

*Ceftriaxone & Vancomycin* Pneumococcal meningitis in children & adults (1-49 yo) empirically treated with cetriaxone (or cefotaxime) & vanc

Most important initial diagnostic study for defining type (systolic or diastolic) and severity of LV impairment

*Transthoracic two-dimensional echocardiogram with Doppler flow studies* - allows measurement of: EF, ventricular mass, chamber dimensions, & wall motion - allows measurement of: flow across mitral valve --> categorizes patients into: normal (E>A), delayed relaxation (E<A), & restrictive (E>>A) filling patterns --> abnormal E:A ratio associated with diastolic HF

Recognize *pleural plaque*, which is seen in

*asebsosis*

Felty syndrome

RA + neutropenia + splenomegaly

Symptoms of acute brainstem infarction are best evaluated with

angiography - of cerebral vessels --> evaluates sources of bleeding, thrombus, stenosis

gritty, chalk-like substance + subcutaneous nodules + older person

chronic gouty arthritis - any joints - tophi

Pts with repeated calcium oxalate stones should be treated with

thiazide diuretics

Increases afterload in hypertrophic cardiomyopathy

hand grip --> more blood volume in heart --> moves obstruction farther apart; decreases murmur

New-onset hyperthyroidism requires immediate treatment with

nonselective beta-blocker - to decrease risk for sudden cardiac arrhythmia & death

Sickle cell dz commonly causes cholelithiasis, specifically...

black pigment stones SC Dz - splenic autoinfarction - H-shaped vertebrae

Long-standing normal pressure hydrocephalus (NPH) results in irreversible cortical atrophy, so as soon as NPH is suspected clinically, diagnosis is confirmed by

brain imaging (CT or MRI) & then lumbar puncture (LP) - imaging should be performed without contrast --> would reveal dilated ventricular spaces, with normal cortical mantle, without widening of sulci or narrowing of gyri - discrepancy b/t ventricular dilation & absence of cortical atrophy = most important clue to diangosis of NPH

Centrally located pulmonary masses or nodules that are highly suspicious for malignancy should be investigated with

bronchoscopy - peripherally located lesions can be investigated with thoracoscopic or needle biopsies

Pts who have multiple brain metastases are generally treated with

whole-body radiation therapy - improves neuro deficits caused by brain mets & edema - prevents deterioration of neuro function

Presents with rash that starts on ankles & wrists & rapidly changes from maculopapular to petechial & spreads throughout body.

Rocky Mountain Spotted Fever

Shock: high cardiac output + low peripheral resistance

Septic shock

Latency of rabies

long = weeks to years - before pts sometimes become symptomatic

CSF findings characteristic of bacterial meningitis

- 200-5,000 cells/mL - high protein - low glucose levels - high pressure - cytology revealing predocminance of polymorphonuclear leukocytes - positive Gram stain & culture

45 yo male with metastatic lung cancer, is admitted to micu for sepsis. Plts 3, hct 23, inr-3, fibrinogen-70 diagnosis?

DIC - treat underlying cause

Workup for OA

ESR RF optional - synovial fluid X-rays mandatory - knees, hips, spine, elbows, ankles

Uncommon testicular neoplasma that typically present in older men with signs of feminization caused by overproduction of sex hormones by tumor. Usually cause excess androgens that then may be converted to *estrogens*. Typically benign. Characterized histologically by presence of intracytoplasmic inclusions.

Leydig cell tumors - Reinke crystals

Causes characteristic small red spots with bluish-white centers that appear on mucous membrane of mouth 1-2 days before rash appears & may be seen for further 1-2 days afterward

Measles - presents with fever, cough, coryza, conjunctivitis (3 Cs) followed by rash that begins on head & spread to trunk & limbs

Related to combo chemotherapy & radiation therapy. Many chromosomal abnormalities. Absence of lymphadenopathy & hepatosplenomegaly. Multiple chromosomal translocations & deletions present in bone marrow confirms diagnosis.

Myelodysplastic syndrome - adverse consequences of multiagent chemotherapy & radiation can occur many years after completion of therapy

Diagnostic modality of choice to evaluate pt suspected of having uretrhal injury

Retrograde urethrogram - inject water-soluble contrast into urethral meatus - lack of urethral extravasation with contrast entering bladder = normal study - partial disruption demonstrated by urethral extravasation accompanied by contrast entering bladder - complete disuprtion = urethral extravasation with no contrast entering bladder

Most common shoulder injury

anterior dislocation = external rotation of forearm = "squaring" of shoulder - can be associated with axillary nerve injury --> numbness in deltoid distribution

Typically management of meniscal injuries requires ruling out associated pathology (ligamentous injuries). After, appropriate next step is:

arthroscopic evaluation and intervention - typically cartilage debridement or repair

Pharmacotherapy for social anxiety disorder

beta-blockers (propranolol, etc) - limit autonomic responses - reduce symptoms such as tremor & palpitations

Chronic alcoholics who have rapid correction of chronic hyponatremia particularly susceptible to

central pontine myelinolysis (CPM) - rate should not be >10 mEq/24 h - MRI scan = bright patches within central basis of pons

Cervical spine trauma is best evaluated initially with

cervical spine radiographs &/or cervical spine CT imaging - reserve MRI for soft tissue or cord injury after CT

NSAID effect on kidney

constriction of afferent arteriole

Treatment of chronic adrenal insufficiency is aimed at replenshing

corticosteroid and mineralocorticoid deficiencies - supplementation with *both prednisone and fludrocortisone* required Adrenal insuffiency - hypotension, fatigue, abdominal pain, fainting episodes, dehydration, nausea - primary/addison = hyperpigmentation

First-line therapy for pt who has stage I HT without comorbidities

exercise, dietary modification, & thiazide diuretic

When max pharmacologic therapy for treatment of stable angina has been reached, next step is

percutaneous coronary angiography - extent of coronary artery dz will dictate whether angioplasty with stenting or coronary bypass grafting is indicated

hyaline casts seen in

prerenal azotemia, etc - urine sodium < 140 = prerenal

Preeclampsia without severe features (mild preeclampsia) is defined as

presence of HT (BP>140/90 mmHg) & proteinuria when pregnancy >20 wks in previously normotensive woman

Oral therapy for early localized Lyme dz

*doxycycline*, amoxicillin, cefuroxime axetil

Symptoms of water intoxication

polyuria vomiting diarrhea confusion lethargy

69 yo farmer of Irish origin has non-healing, indolent, 0.5-cm ulcer on lower lip, arising from vermilion border. Ulcer has been present & growing for past 8 mos. Pt does not drink, but smokes 1 pack of cigz per day. Physical exam shows no other ulcers or enlarged lymph nodes. His BP is 143/90 mmHg, pulse 78/min, & respirations 16/min. Most likely diagnosis & best way to confirm?

*Squamous cell carcinoma; full thickness biopsy at edge of lesion*

Drug eruptions are quite common and present with patches or plaques that result in postinflammatory hyperpigmentation. What drugs are common culprits?

*Sulfonamides* & anticonvulsants - ex. Trimethoprim-sulfamethoxazole - treatment = supportive

Pterygium is a benign growth of vascularized conjunctiva that extends onto cornea. What is indicated if pterygium interferes with vision by creating astigmitism or opacity in visual axis?

*Surgery* / surgical resection of tissue - management = topical lubricants, including dops, ointment, gels

A 32-year-old woman is evaluated because of slowly progressive dyspnea. For the last 6 months she has experienced progressive exertional dyspnea, exertional chest pressure, and dry cough. She is now short of breath when climbing one flight of stairs. She has no fever or weight loss. She reports one episode of a painful raised erythematous lesion on the anterior right shin accompanied by fever and ankle pain 6 months ago that resolved spontaneously after 3 weeks. She does not smoke. On physical examination, she is afebrile, blood pressure is 120/70 mm Hg, pulse rate is 90/min, and respiration rate is 20/min. Body mass index is 23. Skin appears normal. Results of cardiopulmonary examination are normal. Pulmonary function tests show Forced expiratory volume in 1 second (FEV1) of 75% of predicted, forced vital capacity (FVC) of 88%, total lung capacity of 78% of predicted, and residual volume of 70% of predicted. The FEV/FVC ratio is 68%. Chest radiograph is shown (flip for pic). Which of the following is the most likely diagnosis?

*sarcoidosis* Pulmonary sarcoidosis - acute dz + erythema nodosum, fever, arthralgia, hilar lymphadenopathy (Logfren syndrome) - 90% = pulmonary inv't

Injury to this muscle tendon is characterized by shoulder pain that is worse at night, limitation of abduction from 60-120 degrees, & positive "drop test"

*supraspinatus*

An ischemic stroke is...

*the most common stroke, caused by a clot* - 87% of strokes are caused by a clot - "clot" can be treated with fibrinolytic tPA if timing is right

2nd degree type II (Mobitz II) heart blocks consists of

- more P than Q waves - Narrow or wide QRS's - Every time there is a QRS wave, it is "married" to the P-wave & the PR intervals are consistent when they exist

Patient has features suggestive of multiple myeloma. What are the 3 criteria for diagnosis of multiple myeloma?

1. presence of monoclonal proteins in serum/urine 2. presence of tissue damage (renal insufficiency, anemia, bone lytic lesions) 3. presence of clonal marrow plasma cells (plasmacytomas) get bone-marrow biopsy! - definitive diagnosis = abundance of plasma cells (.30%)

Lab values indicating respiratory acidosis

pH < 7.38 PCO2 > 40 mmHg (5.3 kPa)

Indication for steroids in patients with SLE

pts who exhibit severe manifestations of dz - renal inv't - *thrombocytopenia* - hemolytic anemia - CNS involvement - SLE pericarditis

Botulism causes myasthenia-like illness, but it can be differentiated based on the finding of

pupillary dilation (absent in myasthenia) and incremental increase in muscle fiber contraction on EMG testing (opposite to myasthenia)

Most appropriate management for pt w/ nonalcoholic fatty liver dz (NAFLD)

therapeutic diet & lifestyle modification NAFLD - can range from asymptomatic hepatic steatosis to cirrhosis - usually results from insulin resistance & metabolic syndrome (obesity, diabetes mellitus, dyslipidemia, HT) - inflammation & fibrosis associated w/ NAFLD = nonalcoholic steatohepatitis (NASH)

disorder characterized by normal anion gap metabolic acidosis & hypokalemia.

type 1 (distal) renal tubular acidosis (RTA) - causes = autoimmune disorders: Sjogren syndrome, SLE, RA; drugs (lithium, amphotericin B); hypercalciuria, hyperglobinemia - kidney's ability to excrete hydrogen ions in response to acidemia impaired = inappropriately alkali pH of urine in presence of systemic acidosis - pH above 6 in setting of acidemia + nephrocalcinosis

2 yo girl brought to physician because of fever & pulling at her ear for 2 days. Patient had episode of acute otitis media 2 months ago & one 5 months ago. She has no allergies to meds. Her temp is 38.9 C (102 F). Lungs are clear to auscultation. She is coughing & there is some upper airway congestion. Pneumatic otoscopy shows erythema of right tympanic membrane with no mobility. Left tympanic membrane is normal-appearing. What is the most appropriate course of pharmacotherapy?

*A 10-day course of oral amoxicillin* - for children younger than age 6 years &/or with severe infection Acute otitis media - pneumatic otoscopy = inflammation (marked redness of tympanic membrane) & middle-ear fluid (lack of tympanic membrane mobility) - regardless of # of times child has had otitis media, first-line drug of choice = high-dose amoxicillin (80-100 mg/kg/d in 2 doses) --> child needs to be reevaluated in 48-72 hours to make sure organism is sensitive to prescribed antibiotic

48 yo man with ho hypertension + diabetes mellitus brought to ER by paramedics. 6 hours ago he started getting headache that he described as "the worst headache of my life." The headache started abruptly. A few minutes later, he passed out & had tonic-clonic seizures that were witnessed by his friends. The friends called paramedics, and the man was brought to the ER. He was postictal on arrival at the ER. His mentation improved over the next hour but he continues to complain of a splitting headache. He also complains of nausea. Physical exam in the ER is significant for BP 180/100 mmHg & some neck rigidity. There is no papilledema on fundus exam. Neuro exam shows no neurologic deficits. CT scan of the head shows blood in the subarachnoid space. Patient admitted to intensive care unit. Stat CBC, blood chemistry profile, & coagulation profile ordered. What additional tests should be ordered at this time?

*Cerebral angiography* Diagnosis of subarahnoid hemorrhage - no angiographic abnormalities seen in 15% of patients --> should have repeat cerebral angiography in 10-14 days *Once diagnosis of SA is made by CT or CSF analysis, etiology of bleeding should be determined with help of cerebral angiography* - MRA or CT angiography can be used as well

41 yo man with long ho schizophrenia has been on inpatient until for almost 2 weeks. This is his third admission in past 6 months, & each time he seems to be less responsive to treatment. In past he has been on typical antipsychotics & then risperidone, with limited success. His fam is supportive & makes sure he takes his med. Given his most recent poor response, what is the most appropriate next step in treatment?

*Clozapine* = atypical agent = more effective than conventional antipsychotics in treatment of resistant schizophrenia = antagonist effect on D1 & D4 receptors, as well as alpha-adrenergic, histaminergic, serotonergic, cholinergic systems = 30% effective in treatment of patients with resistant schiz in first 6 weeks Side effects - agranulocytosis - requires regular blood count

39 yo white man with no significant past medical history complains of fever & bilateral knee & shoulder pain for past several days. He reports that he was on camping expedition in Connecticut 2 weeks ago, where he had unprotected sexual encounter with woman he met on trip. He does recall tick bite & says that he removed tick immediately. His temp is 38.8 C (101.8 F), BP is 120/60 mmHg, & respirations are 22/min. Exam reveals warm, erythematous knees; pain on flexion & extension of his knee & shoulder joints; & hemorrhagic pustules on his right foot & both hands. What is the most likely explanation for this patient's knee pain?

*Disseminated gonococcal infection* = 1-2% of infected individuals = polyarthritis, tenosynovitis, rash (maculopapular, then hemorrhagic) - urethritis common = most common cause of septic arthritis in sexually active adults - treat with ceftriaxone or cefotaxime - rule of parsimony = simplest explanation that can explain greatest # of observations preferred over ore complex explanations

20 yo Caucasian man presents to clinic bc of newly discovered "bump" on right testicle. He denies pain or tenderness of testicle, & states that he has no other complaints. Exam reveals firm, palpable mass on right testicle. Ultrasound confirms presence of hterogenous hypoechoic testicuar mass. Following orchiectomy, histologic analysis demonstrates sheets of small, poorly differentiated cells with scant cytoplasm & crowded nuclei. Numerous mitotic paras & zones of necrosis also noted. Staging MRI scan demonstrates enlarged retroperitoneal lymph nodes, & lab studies show increased serum alpha-fetoprotein. What is the most likely diagnosis?

*Embryonal carcinoma* = least differentiation of germ-cell tumor types = small cells with indistinct borders & scant cytoplasm = high mitotic rate & necrosis = AFP classically elevated Testicular cancer - high cure rate with early diagnosiss - aggressive with early metastases: first to retroperitoneal lymph nodes & then to lungs, bone, & brain

24 yo HIV-positive man admitted to hospital for cough & weight loss. Originally given provisional diagnosis of PCP pneumonia, due to low CD4 count & lack of antimicrobial prophylaxis & is given IV trimethoprim/sulfamethoxazole & prednisone. His condition worsens, however. Further questioning = works at homeless shelter downtown. Patient transferred to negative-pressure room, & sputum samples collected for AFB smear analysis & culture. Patient is found to have active pulmonary TB, & is placed on 4-drug regimen. After appropriate inpatient treatment, he is discharged, with close follow-up planned via outpatient HIV clinic. Patient returns to clinic 2 weeks later for checkup & to start HAART. At this time, he is complaining of right-eye pain that is worse with movement of eye. Visual testing reveals visual acuity of 25/50 OS & 200/20 OD, with intact peripheral vision. Most likely cause of patient's symptoms?

*Ethambutol* - frequently used in TB - major adverse rxns = optic neuritis = central scotoma & pain worse with movement of affected eye

26 yo primigravid woman at 35 weeks' gestation comes to labor & delivery ward because of painful uterine contractions & gush of fluid. Sterile speculum exam reveals pool of clear fluid in vagina that is nitrazine positive. When fluid is examined under microscope, a "ferning" pattern is seen. Cervical exam shows patient to be 4 cm dilated, 100% effaced, and a 0 station. Fetal fingers can be felt along side the fetal head. External uterine monitoring shows contractions every 2 minutes. External fetal monitoring shows fetal heart rate to be in 130s and tracing reactive. What is the most appropriate next step in management?

*Expectant management* Compound presentation = extremity prolapses alongside fetal presenting part (fetal vertex along with fetal arm) = 1/1000 deliveries - when pelvic inlet is not completely occluded by fetal head - premature fetuses mostly - prolapses arm should be left along - often, arm will rise out the way as certex descends further

All anaerobic infections in the central nervous system should be treated with: Case... "39 yo alcoholic man brought to ED by his wife immediately after he had an episode of loss of consciousness & violent shaking that lasted 3 minutes. He had a sinus infection 1 month ago. He has had a severe headache that is not relieved by over-the-counter analgesics for 3 weeks. His temp is 38.6 C (101.4 F), BP is 102/64 mmHg, & pulse is 116/min. He is disoriented to time, person, & place. Lungs are clear to auscultation bilaterally. Cardiac exam shows normal S1 & S2; no murmurs are heard. Muscle strength is 3/5 in the left upper & lower extremities & 5/5 on right side. CT scan of head with contrast is shown. Brain biopsy specimen & culture grows Bacteroides fragilis only. What is the most appropriate next step in management?

*IV metronidazole* Brain abscesses - most commonly have Streptococcus 60-70% of cases - Bacteroides = 20-40% of brain abscesses = anaerobic gram-negative bacillus - corticosteroids added if substantial mass effect can be demonstrated on scan & mental status significantly depressed

59 yo man who lives in southeastern US taken to ED by wife in middle of summer bc of sudden onset of severe right flank pain accompanied by nausea & vomiting. He tells physician that he has been jogging outside recently & has been on low-carb, high-protein diet to lose weight. By the time he is seen by the doc, the pain has now moved downward toward the right testis. He tells the doc that this is the first time this has every happened, he has been in good health, & he takes no meds. What is the single most important therapy in reducing the chance of recurrence of this problem?

*Increasing fluid intake both day & night* Urinary calculi = polycrystalline aggregates = crysalloid & small organic matrix - presenting symptom = renal colic - pain occurs suddenly = localized to flank - episodic pain that radiates over abdomen - stones constantly moving - spiral CT = first-line tool in evaluating flank pain - radiolucent stone = visible on noncontrast CT Geography = contributing factor - high humidity & temp = higher during summer Encouraged to eat - low-sodium, low-protein diet

6 mo old male brought to physician by mother for well-child visit. Born at term without any complications & has been well. He has had not major medical illnesses, takes no meds, & is up to date on his immunizations. Bruit heard on auscultation of right upper quadrant of abdomen. Ultrasound of liver shows mass consistent with infantile hepatic hemangioma. What is the most consistent with this findings?

*It may be associated with congestive heart failure* Infantile hemangioma = most common benign tumor of childhood - may occur cutaneously or be present within any organ - begin involuting after 18 months - large or multiple = may have high-output cardiac failure = via increased blood flow to lesions - platelet sequestration & destruction = coagulopathy

22 yo man comes to clinic with complaint that his "eyelids are sticking together" since this morning. Patient also reports that he has had clear, watery discharge & burning sensation in his eyes. He denies photophobia. Patient has had URI for last 3 days. He is otherwise healthy college student. Exam reveals moderate clear discharge & moderate conjunctival injection in both eyes. His visual acuity is 20/20 bilaterally. Extraocular muscle function & fundoscopic exam are normal. Preauricular adenopathy noted as well. What would be most appropriate management in this case?

*No specific treatment is necessary* Viral conjunctivitis - most common cause of red-eye - clear discharge + conjunctival injection + preauricular adenopathy - no specific treatment necessary --> condition usually resolves in 5-7 days

35 yo woman comes to physician bc of persistent pain & swelling at base of her right thumb for 2 weeks. She has had minimal relief with ibuprofen. Two weeks ago she underwent an open reduction & internal fixation with placement of K-wire for a comminuted fracture at base of first metacarpal joint. Her leukocyte count is 12,300/mm^3. Radiograph of right hand shows intact alignment without hardware loosening or failure. What is the most appropriate next step in management?

*Nuclear triphasic bone scan* - shows increased uptake at all 3 aphses Osteomyelitits after operation

58 yo woman brought to ED bc of severe abdominal cramping for past 6 days. She says that her pain is epigastric & periumbilical, & the pain increases after eating & is relieved when stomach is empty. She has ho HT & is currently taking HCTZ. Physical exam shows diffusely tender abdomen that is worse with deep palpation. Bowel sound present. There is palpable purpuric rash on LEs bilaterally & necrotic skin changes in distal UEs. There is swelling & tenderness of metacarpophalangeal & proximal interphalangeal joints of both hands. Peripheral neurophathy is also present. Lab studies show erythrocyte sedimentation rate of 120 mm/hr & serum creatinine level of 2.4 mg/dL. X-ray film of chest shows no abnormalities. Most likely diagnosis?

*Polyarteritis nodosa* = abdominal angina, arthritis, skin changes, ulcerations + constitutional symproms = medium to small artery vasculitis = renal disease via vascular nephrophathy --> HT & oliguric renal failure - abdominal pain via mesenteric arteritis causing infarct - diagnosis via biopsy of peripheral lesions - abdominal angiogram may show diffuse, saccular aneurysms - retinal vessel involvement --> must undergo routine screening ophthalmoscopy - check hepatitis B serologies = 50% of cases

28 yo man comes to doc bc of 6 mo ho persistent headaches that are vague & dull. He has had no fever, neck stiffness, change in vision, nausea, or vomiting. His med history is unremarkable. Current meds include ibuprofen as needed for headaches. He does not smoke or drink alcohol. His BP is 155/90 mmHg & pulse 70/min. One year ago his BP was 107/64 mmHg. Cardiac exam shows normal S1 & S2; no murmurs are heard. No abdominal bruits are heard. There is no peripheral edema. One week later, repeat BP is 150/70 mmHg & pulse 75/min. Lab studies show: Na+ = 147 mEq/L K+ = 3 mEq/L Cl- = 107 mEq/L HCO3- = 30 mEq/L BUN = 13 mg/dL Creatinine = 0.8 mg/dL What is the most appropriate next step in diagnosis?

*Renin & aldosterone* - 28 yo with no ho HT --> secondary cause must be pursued - hypokalemia suggestive of excess mineralocorticoid state - both aldosterone & renin low --> Cushing syndrome or licorice - elevated aldosterone + suppressed renin --> primary aldosteronism - high renin + high aldosterone --> hypoperfusion

52 yo woman comes to see physician bc she is concerned about her risks for breast cancer. Her 54 yo sister was diagnosed recently with metastatic breast cancer; additionally, her mother & 2 of 3 maternal aunts also had breast cancer--all bilateral breast cancer at around age 40. She denies any current complaints & states that she has been in good health. A complete review of systems is unremarkable. She currently smokes a pack of cigarettes per week (& has done so on & off since age 30), has never used drugs, & drinks a glass or two of wine per week at most. Breast exam reveals no nodules, lymphadenopathy, tenderness, or nipple discharge. What is the most likely to reduce this patient's risk for breast cancer?

*Tamoxifen therapy* = nonsteroidal agent = anti-estrogen - competes with estrogen at binding sites in target tissues - *reduces risk for breast cancer when used prophylactically* - *currently the only drug approved by FDA for reduction of breast cancer incidence in high-risk women*

34 yo man brought to psychiatrist by friend because he is very loud & talkative. He states he has not slept for past 2 days because he has been working to establish catering service, for which he has been buying many kitchen utensils, baking supplies, & recipe books. He has also been "sampling wines from around the world" so that he can become wine expert for his new business. Patient's vitals are normal. Lab values show: Hgb = 14.2 g/dL WBC = 8,700/mm^3 Platelets = 320,000/mm^3 Sodium = 138 mEq/L Potassium = 4.4 mEq/L Chloride = 102 mEq/L Bicarbonate = 26 mEq/L BUN = 40 mg/dL Creatinine = 2.5 mg/dL Glucose = 8- mg/dL Calcium = 9.6 mg/dL Most appropriate treatment for man's condition?

*Valproate* Bipolar disorder + renal failure (BUN & creatinine high) - lithium contraindicated

Recognize CT of kidneys affected by ADPKD, which puts patient at increased risk for

*cardiac valve disease* - most often MVP & aortic regurgitation ADPKD - appear in 3rd-4th decade of life - HT, hematuria, renal insufficiency (BUN & creatinine elevated) - ho UTIs & nephrolithiasis commonly present - flank pain, fever, leukocytosis Complications - cerebral aneurysms, hepatic cysts, cardiac valve dz, colonic diverticula, abdominal wall & inguinal hernia

Once aortic stenosis (be able to recognize via auscultation) is noted in asymptomatic patient during physical exam, next step is

*order transthoracic echocardiography* - determine anatomy function of aortic valve using echocardiography = chamber size & ventricular function

Recognize radiograph of *airway obstruction* Case: "56 yo man admitted to intensive care unit for IV antibiotics of fever, severe SOB, & cough. His SOB worsened & he was intubated & placed on mechanical ventilation. One day later, his temp is 37.4 C (99.3 F), BP is 124/80 mmHg, & pulse is 115/min. His O2 sat is 70% on 100% oxygen by mechanical ventilation. Radiograph of chest taken immediately following intubation & film taken during hypoxia shown."

- chest radiograph suggestive of airway obstruction - complete opacification (whiteout) of left lung with mediastinal shift to left = loss of volume in left lung - main bronchus obstruction from mucus plug - mucus plugs = common in mechanical ventilation via impaired mucociliary motility = can be removed by suction

Classic features of Down syndrome

- hypotonia - upslanting palpebral fissures - low set ears - epicanthal folds - excess nuchal skin - enlarged tongue - *Clinodactyly* of 5th fingers - single transverse palmar crease

Recognize x-ray film of chest with acute respiratory distress syndrome (ARDS). What are the 3 main features?

1. bilateral infiltrates 2. *ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) of 200 mmHg or less* 3. no clinical evidence for elevated left atrial pressure or heart failure ARDS/Pulmonary Noncardiogenic Edema

Gender identity is a person's sense of maleness or femaleness and is typically present by what age?

3 yo

Cervical incompetence characterized by painless dilation, typically in second or early third trimester. Prophylactic cerclage placed in early second trimester and removed when?

36-38 weeks' gestation - when fetal ungs are considered mature

thrombocytopenia + MAHA + neuro signs + renal insufficiency + fever

TTP

Mammography screening guidelines

ACR or ACS guidelines - women age 40 & above should be screened for breast cancer with mammography ever 1-2 yrs USPSTF - screening mammography should begin at 50 yo - high risk = 40 yo

MI is circadian and is more common at white time of day?

AM - higher sympathetic tone

Truncated androgen receptor missing ligand-binding site. Remains active, however, as constitutive transcription factor in tumor cells. Resistant to androgen-receptor blocking agents (bicalutamide & enzalutamide) as well as androgen deprivation agents (abiraterone)

ARv7

*X-linked dz* that results from mutations that prevent transport of very long-chain fatty acids (VLCFA) into peroxisomes, thereby preventing beta-oxidation & breakdown of VLCFA.

Adrenoleukodystrophy - accumulaiton of abnormal VLCFA in affected organs (neurons & adrenal cortex) - neuro deficits = begins with weakness & spasticity --> proceeds to dementia, blindness, & quadriparesis - primary adrenal insufficiency = hyponatremia, postural hypotension, hyperkalemia, lack of repsonse to cosyntropin stimulation test

Reference ranges for Hgb, Hct, RDW

Adult male: Hgb = 14-18 Hct = 49-54 Adult female: Hgb = 12-15 Hct = 35-49 RDW = 11-14

68 yo man presents for routine screening. Has hsx of diabetes, HT, chronic kidney dz. CBC - Hgb = 9 - Hct = 28 - MCV = 75 - RDW = 14 Ferritin = 500 Iron = 22 TIBC = 200 Diagnosis?

Anemia of Chronic Disease typically... - low Hgb - normal/high ferritin - low/normal iron - low tibc

Occur in older pts after trauma. Clinical presentation includes senility & confusion that appear over short period of time with hx of recent trauma.

Chronic *subdural hematoma* - treatment = surgical decompression (evacuation of hematoma via craniotomy)

Best imaging modality for primary brain tumors is

MRI scan

Seborrheic dermatitis that is treatment resistant should raise suspicion for

HIV - treatments = topical steroids, antifungals (ketoconazole, etc)

Definitive diagnosis of Lech-Nyhan obtained by measurement of

HPRT enzyme activity in blood - most important part of management = treatment of hyperuricemia, since nephrolithiasis leads to renal failure = usualy cause of death

Gram-negative rod that can cause pneumonia in pts who have chronic lung dz or diabetes & those who are alcoholic or debilitated

Klebsiella pneumoniae - thick and bloody sputum (currant jelly) - bulging interlobar fissures on chest radiograph

Screening recommendations of fasting lipid profile in individuals who have average risk for dyslipidemia

NCEP III recommends: once every 5 years starting at age 20 years USPSTF recommends: starting at age 35 years in men & 45 years in women

Ugly-appearing vascular, friable papules that form at sites of prior trauma.

Pyogenic granulomas - treatment = surgical excision

What is the first treatment priority for a patient who achieves ROSC?

Optimizing ventilation & oxygenation

Stress test considered positive when there are...

ST depressions > 1 mm which last longer than 0.08 seconds or when there is dev't of hypotension (10 mmHg drop in systolic BP) or appearance of S3 or S4 heart sounds - *pts with positive stress tests require coronary angiogram* as next step to assess need for possible revascularization --> doc will be able to determine whether stenting or coronary artery bypass grafting indicated

Most common causes of acute epidural abscess

S aureus

Which Tanner stage for girl? - ages 12-15 - enlargement of breast & areola, without separation of their contours

Stage III

Characterized by erythema, pruritus, hyperpigmentation, & scaling. Typically over medial ankle proximal to medial malleolus. Associated with venous insufficiency.

Stasis dermatitis

Serious complication of chronic UC. Diagnosed by fever, leukocytosis, & colonic distention on abdominal x-ray films.

Toxic megacolon conservative treatment - can be attempted for 24-48 hrs - IV fluids - IV steroids - abx - if condition doesn't resolve, pt may need total colectomy

RTA associated with lytic bone lesions, myeloma

Type 2

RTA associated with DM, hypoaldosteronism, ACEIs

Type 4

Most often involve splenic artery and have tendency to rupture during pregnancy. Rare finding. Occur bc of weakness in arterial wall Can be characterized by "signet ring sign" on plain film when calcified aneurysm appears radiopaque in RUQ.

Visceral artery aneurysms (VAA) - hepatic artery & SMA most commonly invovled - CT angiography or cath angiography can delineate features of aneurysm

Electrolytes in pyloric stenosis

Vomiting --> fluid loss with chloride & hydrogen ions from stomach - decreased delivery of chlrodie to renal tubules --> increased reabsorption of bicarb = metabolic alkalosis - K+ moves from extracellular to intracellular fluid with alkalosis = decreased potassium *Hypokalemia, hypochloremic metabolic alkalosis* - IV correction of fluid & electrolyte statue must be done prior to sx with dextrose-containing sodium chloride & added K chloride

Trauma literature teaches us that penetrating neck injuries are broken into 3 zones:

Zone I - extends from clavicles to cricoid cartilage - panendoscopy prior to surgical intervention appropriate Zone II - extends from cricoid to angle of mandible - injuries mandate operative intervention to rule out underlying vessel injury Zone III - extends from mandible to base of skull

Where does Crohn disease cause ulcers?

anywhere in GI tract, from *mouth* to anus - abdominal pain tends to be more severe in Crohn dz than in UC - transmural involvement with skip lesions - granulomas - fistula formation

For small-cell lung cancer, treatment is primarily

chemotherapy-based - aggressive tumor - early metastases (may not be apparent on imaging studies) - surgical resection rarely effective

First step in any pt with new-onset or worsening cough and positive smoking history is

chest x-ray

Confer worst prognosis in pts who have acute viral hepatitis

coagulopathy or encephalopathy - high risk for fulminant hepatic failure

Colonoscopy screening for ulcerative colitis pts 8-10 yrs after diagnosis

colonoscopy every 1-2 yrs - pts with UC w/ dz extending beyond rectum = at increased risk of developing colorectal cancer - biopsies taken from flat mucosa throughout colon & evaluated for dysplastic changes

Pts with acute cocaine or amphetamine intoxication/overdose with signs and symptoms of cardiac ischemia should be treated with

combo of IV nitroglycerin, aspring, & IV benzos such as diazepam or lorazepam

Bloody pleural effusions in smoker should always be sent for

cytology - to determine presence or absence of malignant cells - next step after cytology = CT chest imaging to determine location of tumor

>90% of kidney stones of this size will pass without medical assistance

diameter <5 mm - 50% of stones will pass if size between 5-7 mm - stones unlikely to pass if size > 7 mm

Management of patients who have predisposition to recurrent calcium oxalate stones

dietary modification = adequate hydration = low sodium = low protein = normal calcium medical treatment = *thiazide diuretics* --> lowers urinary calcium

Class of drug that usually results in a decrease in levels of prolactin & a decrease in size of an adenoma

dopamine *agonist* - cabergoline or bromocriptine - reduces size of adenoma - reduces prolactin levels - resistance cases treated with surgery Prolactinoma - elevated serum pralactin + low GnRH, low FSH, low LH confirms diagnosis

Torticollis is involuntary contraction of neck muscles, leading to abnormal posture. Most cases are idiopathic. Treatment of torticollis and other acute dystonias include

dopamine agonists, anticholinergic/antihistaminic agents, muscle relaxants, benzos

Immediate management for suspicion of infective endocarditis

draw blood cultures & start empiric abx - TTE &/or TEE = diagnostic - surgery warranted for valvular abscess/destruction

Initial treatment for ventricular fibrillation

early defibrillation essential

Smallpox vaccine contraindications

eczema *coronary artery disease* pregnancy immunocompromised status allergy to neomycin, streptomycin, polymyxin, tetracycline

Numerous studies have demonstrated that use of OCPs significantly decreases woman's likelihood of what cancer?

endometrial - by 50% - greatest effects in those using the pill for at least 3 years - provides almost continuous exposure of endometrium to progestins

Indicated for any gastric ulcer bc of its strong association with underlying malignancy

endoscopic *biopsy* - often taken from margins of ulcer

Acute onset of constitutional symptoms with macular rash sparing palms & soles is concerning for

epidemic typhus - endemic typhus similar but less severe & less acute in onset

Seagull deformity associated with

erosive OA

RBC casts

glomerulonephritis - proteinuria, pitting edema, HT

Porcelain gallbladder (intramural calcification of gallbladder) usually incidental radiologic finding & is associated with high risk for progression to gallbladder cancer. Next step is

laparoscopic cholecystectomy - no need for biopsy

Leukemoid reaction characterized by what lab values?

leukocytosis exceeding 50,000/uL high leukocyte alkaline phosphatase

Labs of Addison dz

low serum sodium high potassium low bicarb (met acidosis) high serum urea nitrogen Skin findings - black freckles on shoulders, head, neck - bluish-black discoloraiton of areolas & mucous membranes (both oral & anogenital) - diffuse tanning (non-sun-exposed skin)

p-ANCA Ag

myeloperoxidase

CSF analysis in bacterial meningitis

neutrophil-predominant pleocytosis (WBC > 1,000/mm^3) high protein low glucose

The number 7 - uric acid

pH > 7 --> 90% uric acid = monosodium urate (MSU) - MSU soluble in plasma up to 7 mg/dL - target/goal of serum uric acid = 6 mg/dL

After kid has fracture of femur, what is an important next step?

perform a *skeletal survery* - to look for other possible fractures & evaluate for potential child abuse

Most sensitive test for detecting pheochromocytoma is

plasma free fractionated metanephrines

testicular pain + systemic problems + abdominal pain + renal angiogram

polyarteritis nodosa - beading of renal vessels - hepatitis B + - foot or wrist drop = mononeuritis - closely associated with temporal arteritis

Corresponding coronary artery: tall, broad R in V1, V2, ST depression; & tall, upright T waves in V1, V2, V3

posterior descending artery - posterior wall

Treatment of Body dysmorphic disorder

psychotherapy and/or SSRIs

Patients at risk for CKD can be screened for CKD with

serum creatinine measurement estimated GFR urinalysis

First step in management of any older patient who has microcytic anemia

serum ferritin - bleeding = most common cause of decreased serum ferritin --> iron def anemia --> occult bleeding via GI cancers should be major concern in elderly --> perform hemoccult test - normal to slightly elevated serum ferritin = anemia of chronic dz --> sequestration of iron in bone marrow --> inadequate production of RBCs

Evaluation of these levels = stepwise approach to organic erectile dysfunction (ED)

testosterone, prolactin, glucose (if risk of diabetes)

Loop electrosurgical excision procedure (LEEP) indicated for

therapeutic removal and histologic exam of cervical lesions including high-grade squamous intraepithelial lesions (HGSIL) & cervical intraepithelial neoplasia (CIN) grade 2 or 3 - outpt procedure - can be performed under local anesthesia Immediate complication - minor bleeding - infection Later complications - cervical stenosis - cervical incompetence

Most common locations for rapid blood loss due to trauma

thorax, abdomen, pelvis, & thighs

ECG abnormalities for inferior wall dz are always seen in leads II, III, and AVF. One of the most common complications of inferior wall MI is third-degree AV block. If pt with recent ho MI develops symptomatic complete heart block & doesn't improve after admin of atropine, then the best next step is

transcutaneous pacemaker

Most common cause of immediate death following motor vehicle accident

traumatic aortic rupture* - deceleration = twisting of aorta around ligamentum arteriosum = tear & rupture - symptoms = chest pain, back pain, hypotension - best next step = *spiral CT scan of chest, enhanced with IV contrast (CT angiogram)*

Treatment of choice for pt with bipolar disorder + renal failure

valproate - when lithium & valproate contraindicated, carbamazepine = drug of choice - lamotrigine approved only for bipolar depression

What is the immediate danger of excessive ventilation during post-cardiac arrest period for patients who achieve return of spontaneous circulation (ROSC)?

*Decreased cerebral blood flow*

57 yo man comes to his healthy care provider for preoperative evaluation. He has been a long-term pt in this office & has been treated for HT & gastritis. He has been scheduled for an elective cholecystectomy in 2 days bc of ongoing gallbladder symptoms. He currently takes omeprazole (Prilosec) for his gastritis & thiazide for his HT daily. He smokes 2 packs of cigz/day. His home BP log shows that his systolic pressures range from 150 to 190 mmHg, & his diastolic pressures range from 80 to 105 mmHg, indicating that his BP may be not adequately controlled for the surgical procedure. What med is most appropriate in the perioperative period for added BP control?

(Metoprolol) Lopressor - beta-blockers given to non-cardiac surgical pts who are at risk for cardiac events are associated with more favorable outcome in terms of postoperative cardiovascular morbidity & mortality

57 yo man comes to clinic bc of "depression." Chart states that he has been tearful & has experienced 15-pound weight loss in months following death of his wife. What is most appropriate initial question to open interview?

*"What brings you here today?"*

Appropriate ventilation strategy for adult in respiratory arrest with pulse rate of 80/min?

*1 breath every 5-6 seconds*

The team is hanging fluids for a patient post cardiac arrest to increase the blood pressure. What is the recommended initial fluid bolus?

*1 to 2 liters of isotonic or crystalloid fluid*

What is the recommended energy dose for biphasic synchronized cardioversion of atrial fibrillation?

*120 to 200 J*

Hemophilia shoud be suspected in a young male pt with bleeding diathesis & prolonged PTT. First step in diagnosis is to perform...

*1:1 mixing studies* = normalization of PTT in affected pts (due to replacement of missing clotting factors) - failure of PTT to normalize after mixing studies --> rules out clotting factor deficiency

A 32-year-old woman is evaluated during a routine office visit. She has been receiving her Pap smears every 3 years, and the results have all been normal. Her last Pap smear was 3 years ago. On physical examination, her vital signs and pelvic examination findings are normal. A human papillomavirus (HPV) DNA test is obtained. One week later, her cervical cytology results are reported as normal, and her HPV DNA test result is negative. When should the Pap smear be repeated?

*5 years* - screening for cervical cancer in women older than age of 30 yrs

A 68-year-old man is evaluated in the hospital. The patient was hospitalized 3 days ago for acute kidney injury secondary to a bladder outlet obstruction due to benign prostatic hyperplasia. Medical history is otherwise unremarkable, and he took no medications prior to admission. On admission, a bladder catheter was placed and resulted in immediate drainage of 800 mL of urine. Urine volume increased to 130 mL/h over the initial 48 hours of hospitalization. On physical examination today (hospital day 3), temperature is normal, blood pressure is 135/60 mm Hg, pulse rate is 68/min, and respiration rate is 14/min. Cardiopulmonary examination is normal. There is 1 + bilateral lower extremity edema. Laboratory studies (hospital day 3): Serum creatinine = 3.4 mg/dL (301 umol/L); value was 6.2 mg/dL (548 umol/L) on admission Serum sodium = 151 mEq/L (151 mmol/L) Urine osmolality = 326 mOsm/kg H2O (normal, 300-900 mOsm/kg H2O) Urinalysis = Specific gravity 1.012; pH 5; no blood; trace protein; no glucose Kidney ultrasound reveal bilateral hydronephrosis What is the most appropriate next step in treatment?

*5% Dextrose in water* - correction of water deficit with 5% dextrose in water Hypernatremia - relative deficit of water to sodium - experiencing post-obstructive diuresis & electrolyte imbalance that may occur when chronic urine obstruction causes retention of solute & acute tubular injury - correction rate of 6-10 mEq/L (6-10 mmol/L) per day reasonable

Ideal tidal volume for patients with acute respiratory failure due to COPD

*5-7 mL/kg*

Minimum systolic BP one should attempt to achieve with fluid, inotropic, or vasopressor admin in hypotensive post-cardiac arrest patient who achieves ROSC?

*90 mmHg*

Doc is called to see 69 yo woman who underwent cardiac catheterization via right femoral artery earlier in morning. She is now complaining of cool right foot. Upon exam she has pulsatile mass over her right groin with loss of her distal pulses, & auscultation reveals bruit over point at which right femoral artery was entered. What is the most likely diagnosis?

*Femoral pseudoaneurysm* - vascular complication of cardiac cath - pulsatile mass + femoral bruit + compromised distal pulses - can be confirmed by ultrasound of groin

Re-infarction in hospitalized pt evaluated best by

*creatinine kinase (CK)* - CK total levels & specific MB fraction elevated as early as 3 hrs after onset of chest pain & have duration of no more than 2 days, peaking w/in 18-24 hrs --> CK levels easier to track - sudden increase in CK levels represents new infarction rather than delayed effect from previous myocardial event

When should circumcision be performed in an infant with hypospadias (urethral opening ectopically located on ventrum of penis proximal to tip of glans penis)

*delayed* bc prepuce will be needed for plastic reconstruction - can be done after 6 mos of age when infant can better tolerate anesthesia

4 yo boy brought to doc by his 'rents bc of 3 wk ho progressive diarrhea, abdominal pain, & painful straining while passing stool. He has had 8-10 bowel movements daily over past week & blood in his stool. Fam recently returned from fishing trip on Amazon Rive in South America. He appears ill. His temp is 102 F, BP is 90/60 mmHg, pulse is 130/min, & respirations are 20/min. Exam shows diffuse abdominal pain; there is no rebound or guarding. Microscopic exam of stool shows protozoa with ingested erythrocytes. Most appropriate next step in management?

*Abdominal ultrasound* Entamoeba histolytica - typically 1-3 wk incubation period present, after which diarrhea can present --> sometimes progresses to colitis in children younger than age 5 years - disseminated amebiasis --> liver abscess --> abdominal ultrasound must be done to evaluate for hepatic abscess

61 yo man found to have malignant polyp in cecum. He undergoes right hemicolectomy, & the specimen reveals 2-cm adenocarcinoma extending into but not through muscularis propria. Eleven lymph nodes are negative, & there is no evidence of distant metastatic spread. He recovers uneventfully & is discharged home on postoperative day 6. Four weeks later he develops sudden onset of abdominal distention with vomiting & inability to pass flatus. Rectal exam reveals no masses & brown stool that is negative for occult blood. Nasogastric tube paced & he is put on NPO order & started on IV fluids. Diagnosis will best be made by what?

*Abdomen and pelvic CT scan* Small bowel obstruction - most likely etiology = adhesions that have cause obstruction - CT scan = best way to diagnose problem

73 yo Caucasian man presents to clinic complaining of headaches that wake him from sleep, nausea, and vomiting. He describes headaches as involving his whole head; they are not localized to any particular region of the head. He states that he also experiences headaches in the morning after waking from sleep & when he takes naps in the middle of the day. As an aside, he also notes that he has been losing weight for the last 3 months. On exam, the pt is a thin man who has atrophy of the subcutaneous tissues over his temples & a nagging cough. On a T1-weighted postcontrast MRI, a ring-enhancing lesion is seen at the grey-white junction in the parietal lobe on the right side. What tumors does the patient most likely have?

*Adenocarcinoma of the lung* Malignancy in brain: - classic brain tumor symptoms = headache that worsens with recumbency, wakes pt from sleep, present in morning - headache = holocephalic - often experience nausea - tumors metastatic to brain far more common than primary brain tumors - most common site for metastases to brain = junction of grey matter & white matter in cortex at watershed area between middle & posterior cerebral perfusion zones - lung cancer = most common cause of met dz to brain

42 yo woman evaluated bc of 2 wk ho jaundice, low-grade fever, & fatigue. Med hx notable for significant alcohol use, estimated at appx 10 cans of beer daily for past 20 yrs. She has no hx of injection drug use, blood transfusions, or known exposure to anyone with hepatitis. Med hx otherwise unremarkable. Only med is acetaminophen, 500 mg/dL, for past 3 days to treat fatigue. On physical exam, temp is 100.2 F, BP is 110/70 mmHg, & pulse rate is 100/min. Jaundice, spider angiomata, & mild muscle wasting noted. Abdominal exam shows mild splenomegaly, slightly enlarged & tender liver, & no ascites. Lab studies: Hgb 12.8 g/dL Leukocyte count 3400/uL Platelet count 99,000/uL INR 1.2 Aspartate aminotransferase 124 U/L Alanine aminotransferase 57 U/L Bilirubin, total 6.2 mg/dL Bilirubin, direct 3.8 mg/dL Albumin 3.4 g/dL Most likely diagnosis?

*Alcohol hepatitis* - excessive alcohol consumption + low-grade fever + jaundice + tender enlarged liver + chronic liver dz exam + AST:ALT > 2

26 yo woman comes to doc bc of 3 mo hx of irregular intermenstrual bleeding. She has also had fatigue, decreased bowel movements, & weight gain. She has had stiffness & cramping of her LEs for 6 wks. Her BP is 110/75 mmHg & pulse 56/min. Exam shows pale & dry skin. Pelvic exam shows normal external genitalia, a normal-appearing cervix, & a small uterus. There are no adnexal masses. Most likely cause of this pt's irregular vaginal bleeding?

*Anovulation* Hypothyroidism - fatigue/asthenia, somnolence, weight gain, constipation, stiffness & cramping of muscles, menstrual disorders - bradycardia typical - causes anovulation - without ovoluation --> no corpus luteum to produce progesterone --> endometrium continuously stimulated by unopposed estrogen = proliferative & unstable endometrium that eventually sheds = irregular bleeding

Management of stable pt w/ bacteremic pneumococcal pneumoniae

*discharged on oral amoxicillin to complete 7 days of therapy*

35 yo woman complains of increasing weakness, loss of energy, & SOB. She has had these problems for the last 2 months & is finding it increasingly difficult to keep up with her children. She explains that she is just "tired of it all." She endorses difficulty sleeping, decreased appetite, & loss of interest in her hobbies. Her past med history is otherwise unremarkable. She takes oral contraceptive pills & ibuprofen for tension headaches. Vital signs include temp 37 C (98.6 F), BP 120/72 mmHg, pulse 89/min, & respirations 12/min. Physical exam reveals inability to distinguish when examiner flexes her toes bilaterally. Chest is clear to auscultation & heart sounds are normal. Abdominal exam is benign. Conjunctivae are pale. Lab studies reveal: Hgb = 9 g/dL Hct = 27% WBC = 7,000/mm^3 Platelets = 200,000/mm^3 TSH = 10 uU/mL Most likely diagnosis?

*Autoimmune gastritis* - typ eA - elevated levels of anti-parietal cell Abs & anti-intrinsic factor Abs = decreased absorption of vit B12 - achlorhydria - will require intramuscular vit B12 to treat anemia & levothyroxine to treat hypothryoidism - clear depressive symptoms --> need to rule out organic etiology - TSH level high = hypothyroidism - anemia + decreased position sense = vit B12 def = subacute combined degeneration

What class of drug treats Parkinson disease

*dopamine precursor* Levodopa - precursor of dopamine - most effective drug for symptomatic treatment of PD

Diagnostic criteria of acute eosinophilic pneumonia require presence of what features:

- acute febrile illness of short duration (<1 wk) - hypoxemic res failure - diffuse pulmonary opacities on chest radiograph - BAL fluid showing >25% eosinophils - lung biopsy specimen showing eosinophilic infiltrates - absence of known causes of eosinophilic pneumonia, such as drugs, infections, asthma, or atopic dz *Treatment = corticosteroids*

39 yo woman with ho elevated mood lasting one week, abnormally high self-esteem along with irritability in past comes to her doc complaining of depressed mood, lack of energy, feelings of hopelessness & guilt, with diminished ability to concentrate & decreased appetite for past 5 wks. She has never had similar symptoms in past. Given hx, most likely diagnosis?

*Bipolar II disorder* - one or more major depressive episodes & one or more hypomanic episodes

Man is unrestrained front-seat passenger in car when it crashes; he sustains closed comminuted fractures of both femoral shafts. Shortly after admission, he develops BP of 80/50 mmHg pulse of 110/min, & becomes pale, cold, & clammy. The rest of the physical exam & x-rays of chest & pelvis are unremarkable. Focuses assessment with sonography for trauma (FAST) exam performed in ED is likewise negative. What most likely explains pts low BP?

*Blood loss at fracture sites* After extensive trauma to certain areas of body... - enough blood may accumulate to send pt into hypovolemic shock - one of areas = femur (other areas = thorax, abdomen, pelvis) - pts should be treated with massive resuscitation & transfusion to overcome their hypovolemia until reduction & fixation can be performed

35 yo man brought to emergency clinic by his mom bc of episode of slurred speech associated with uncomfortable sensation that his tongue is thick and curling up. Episodes started suddenly 30 minutes ago. Pt noted to be holding onto his tongue with his thumb & forefinger. His mom reports that pt has had schizophrenia for 10 yrs & consistently takes meds prescribed by his psychiatrist. Several days ago however pt ran out of one of his meds, but has continued to take the others. Admin of what should be included in the initial step in management of this pt?

*Benztropine* - prophylactic anticholinergic agent (benztropine, diphenhydramine, trihexyphenidyl) Acute dystonic rxn - one of the extrapyramidal side effects (EPS) associated with antipsychotic meds - related to antagonism of dopamine receptors in nigrostriatal pathway - pt likely ran out of anticholinergic = dystonic rxn occurred --> appropriate initial management of this pt = immediate IM admin of anticholinergic agent such as 2 mg of benztropine of 50 mg of diphenhydramine

25 yo man evaluated bc of 2 wk ho purulent drainage from small opening in previously healed right lower extremity wound. 6 mos ago, pt had open comminuted fracture of proximal tibia that was treated with internal fixation with metal plate. He recovered well after surgery, with complete healing of his surgical incisions. He has otherwise felt well. On physical exam, tem pis 98.9 F, BP 120/75 mmHg, & RR is 12/min. There is well-healed surgical incision overlying right tibia except for 2 mm opening at distal margin, with minimal surrounding erythema & slight purulent drainage. Remainder of exam normal. Swab samples from wound grow Enterococcus species that is susceptible to all abx tested. What is the most appropriate next step in management?

*Bone biopsy culture* - deep bone biopsy culture before antimicrobial therapy begun - dev't of draining sinus tract from wound above bone that underwent surgical instrumentation is highly suspicious for underlying contiguous osteomyelitis - pt's current condition presumably related to his initial open trauma & associated surgery 6 mos ago - microbiologic isolates from culture obtained from wound or draining sinus tract generally don't reliable correlate w/ pathogen in infected bone, w/ occasional exception of S aureus - identification of causative pathogens best attempted by bone biopsy performed surgically or percutaneously with radiographic guidance --> treatment usually = 6 wks of parenteral antimicrobial therapy

A 30-year-old man is evaluated for chronic cough that has lasted nearly 1 year. He recalls that the cough began after a "bad cold." He was treated with a course of a macrolide antibiotic without significant improvement. The cough is nonproductive, is most noticeable at night and on cold days, and sometimes occurs after exercise. He has no postnasal drip, nasal congestion, or heartburn. He does not smoke. He has no history of occupational or other exposures. Medical history is otherwise unremarkable except for gastroesophageal reflux for which he takes a daily proton pump inhibitor. On physical examination, vital signs are normal. The oropharynx is normal, without postnasal drip. Findings on pulmonary examination are normal. Spirometry shows forced expiratory volume in 1 second (FEV1) of90% of predicted and an FEV1/forced vital capacity ratio of80%. Chest radiograph is normal. Which of the following is the most appropriate diagnostic test to perform next?

*Bronchial challenge test* Cough-variant asthma - chronic cough - episodic cough triggered by cold air & hyperventilation

Typically affects elderly pts. No known triggers. Often experience severely pruritic urticarial lesions on trunk & proximal extremities. Mucosal lesions *rare*. Early eruption may look like urticaria. Eventually, tense bullae form, but bullae are easily ruptured & pts may present with erosions alone.

*Bullous pemphigoid* Histology - subepidermal blistering - eosinophilic inflammatory infiltrate - direct immunofluorescence = IgG & C3 ate BM - autoAbs clasically react against bullous pemphigoid Ag1 & bullous pemphigoid Ag 2 (type XVII collagen) = components of hemidesmosone - treatment = systemic steroids

42 yo man comes to doc complaining of 2 mo hx of depressed mood, difficulty sleeping, & decreased appetite. He says his work performance is also suffering. When discussing med therapy, pt tells his doc that he is extremely concerned about his sexual performance. He notes that recently has been having some sexual difficulties with his wife which he attributes to "getting older." What antidepressant would be the best choice for initial treatment of this pt?

*Bupropion* - antidepressant with few or no adverse sexual side effects

62 yo man presents to doc for annual checkup. He has felt well, & has no complaints. He denies fever, weight loss, fatigue, night sweats, diarrhea, or constipation.He has noticed no bleeding or bruising. His past med history is notable for HT, for which he takes HCTZ. He also takes supplemental vitamin C. He denies alcohol or tobacco use. His typical diet includes steak appx three times per week. His weight has not changed from his last visit. His BP is 133/83 mmHg & heart rate is 77 beats/min. Head & neck exam demonstrates no lymphadenopathy or carotid bruits. Chest exam reveals no clubbin, cyanosis, or edema. Rectal exam reveals minimally enlarged, smooth prostate. Stool is brown & is guaiac-positive. Last colonoscopy was 2 yrs ago & was unremarkable. Next step in management of this pt?

*Check the hematocrit* - positive fecal occult blood test without symptomatology --> first step = establish how much blood is being lost, if any, & whether this is a hemodynamically significant blood loss

22 yo woman with 4 yr ho type 1 DM comes to doc bc of high morning blood glucose levels for 2 wks. Her morning, pre-breakfast blood glucose levels are in the range of 150 to 180 mg/dL. Current meds include regular insulin & NPH insulin twice daily. Her temp is 98.8 F, BP is 124/80 mmHg, & pulse is 80/min. Exam shows no abnormalities. Her hemoglobin A1c is 7.1%. Most appropriate next step in management?

*Check blood glucose level at 3 AM* Elevated moring blood glucose in diabetic on insulin via 2 diff't effects: 1. dawn phen, 2. somogyi phen - most important enxt step = measure 3 AM blood glucose level dawn - relative insulin def via diminishing action of insulin in early morning - related to nocturnal release of 2 anti-insulin hormones: GH & cortisol - treatment = increased evening dose of insulin - measuring 3AM blood glucose = euglycemia somogyi - rebound morning hyperglycemia following nocturnal (3AM) hypoglycemia - treatment = decrease evening dose of insuling to prevent nocturnal hypoglycemia - measuring 3AM blood glucose = 3 AM hypoglycemia

After verifying unresponsiveness & abnormal breathing, you activate the emergency response team. What is your next action?

*Check for pulse*

26 yo man with Crohn dz brought to ED by his gf after 2 days of significant abdominal pain. Pain is colicky in nature, worse in his LLQ & left flank, & radiates medially to his scrotum & inner thigh. It started suddenly & has not remitted over 48 hrs. Is is not associated with nausea or vomiting, but the pt has had single episode of hematuria. On physical exam he has low-grade fever of 100.6 F & normal vital signs. He is in obvious distress. Abdominal exam is surprisingly benign for someone who is obviously in great pain. He has normal bowel sounds, very mild left-sided tenderness to palpation, & no distention. He has had Crohn's dz for several yrs; he is extremely anxious about his condition & wants to avoid surgery at all costs. Next step in management?

*CT scan without contrast* - flank pain radiating to inner thigh & scrotum + hematuria = nephrolithiasis --> diagnostic modality of choice after plain x-ray = helical CT scan without IV contrast - Crohn's dz --> higher incidence of nephrolithiasis secondary to uric acid & calcium oxalate stones via enteric fat malabsorption in terminal ileum - increased intraluminal fat binds with free calcium = leaves excess oxalate to be circulated & eventually excreted in urine, as opposed to binding calcium in gut & being excreted in feces

HIV pt + CD4 count <50 + tenesmus, urgency, *bloody diarrhea*, left lower quadrant pain

*CMV colitis* - treatment = ganciclovir & initiation of HAART if not already on it

32 yo man struck by taxi that is going appx 30 miles/hour. He is brought to ED, where he is noted to be awake, talking, & in no resp distress, but tachycardic to 110/min with BP 136/68 mmHg. On physical exam extreme tenderness of right calf is noted, with significant right-leg edema & thready right dorsalis pedis & posterior tibial pulse as compared with left lower extremity. X-ray confirms tibial-fibular fracture. Next step in workup of this pt?

*CT angiography of lower extremity* Closed fracture + weakened but present pulses - key decision = whether there is definite or possible vascular injury "Hard" signs of vascular injury to extremity are managed with immediate surgical exploration in OR. These signs are: - active hemorrhage - expanding hematoma - pulse deficit - bruit or thrill - distal ischemia "Soft" signs of vascular injury don't necessitate exploration, but require imaging of affected vessels. Soft signs include: - hx of hemorrhage at scene - stable, nonexpanding hematoma - proximity to major vessels - anatomically related nerve deficit - ankle-brachial index <0.9 - unequal pulses

56 yo woman with ho COPD hospitalized for treatment of newly diagnosed metastatic laryngeal cancer. Bc of large tumor burden & poor lung function, surgery is deferred, & she is currently being treated with chemo & radiation therapy for palliation. While in hospital she develops fever. Her temp is 39 C (101.2 F), BP 100/60 mmHg, pulse 113/min, & respirations 18/min. She is in no apparent distress. Her heart is tachycardic & regular without murmurs, lungs are clear bilaterally, abdomen is benign, & extremities are without edema or cords. She has no foreign instrumentation in place. Her skin is without obvious lesions. Lab studies show: Hemoglobin = 8 mg/DL Leukocyte count = 800/mm^3 Platelets = 17,000/mm^3 Hematocrit = 26% Neutrophils = 46% Lymphocytes = 32% Bands = 12% After pan culturing, what is the most appropriate next step in management?

*Cefepime* = fourth-gen cephalosporin = first-line --> broad coverage & action against Pseudomonas Neutropenic fever - likely secondary to chemo meds - absolute neutrophil count <1500/uL - calculated by multiplying total WBC count by (percentage of neutrophils + percentage of bands) - temp > 38 C (100.4 F) that persists for longer than 1 hour = significant in neutropenic host

Best initial test to make diagnosis of Guillain-Barre syndrome

*Cerebrospinal fluid studies* = essential for diganosis - reveal protein level at usually twice normal values but with normal amounts of WBCs, normal glucose level, & absence of pleocytosis (elevated lymphocytes) Treatment = plasmapheresis or gammaglobulin infusion

6 mo old boy brought to ED by his mother, who states that when she picked him up from the babysitter he was "not acting right." The babysitter stated that he was sleeping more & was fussy. The child appears stuporous. His temp is 99.9 F, pulse is 140/min, & respirations are 36/min. 4-cm ecchymosis is noted on right cheek. Fundoscopic exam shows retinal hemorrhages. Remainder of physical exam is unremarkable. CT scan of head, skeletal survery, chemistry panel, & CBC is ordered. Next best step in management?

*Coagulation studies* - even when shaken-infant syndrome is suspected, bleeding disorders have to be ruled out before hospitalizing the pt & reporting to Child Protection Services

27 yo Mexican American woman, gravida 4, para 1, ab 3, comes to doc for contraceptive counseling. She has been taking oral contraceptive pills but her husband "didn't want her to be on hormones." She is sexually active with her husband, & they use condoms inconsistently. Her last menstrual period was 3 weeks ago. Her last Pap smear 4 mos ago showed low-grade squamous intraepithelial lesion (LGSIL). At the time no HPV testing was done. She takes no meds. Pelvic exam shows normal-appearing vulva & vagina; the cervix is erythematous. Uterus is small & there is no adnexal masses. Urine hCG test is negative. What is the most appropriate next step in management?

*Colposcopy with endocervical curettage* Abnormal Pap with low-grade squamous intraepithelial lesion (LGSIL) - *in cases of abnormal Pap with LGSIL or high-grade squamous intraepithelial lesion (HGSIL), evaluation with colposcopic exam should be done* - all non-pregnant pts undergiong colposcopy for abnormal Pap should also have endocervical curettage (ECC) to screen for endocervical lesions if no lesion identified - during colposcopy, acetic acid applied to cervix --> tissue that is highly vascularized, inflamed, or has undergone dysplasia turns white --> these lesions may be biopsies for histologic evaluation

29 yo woman, gravida 2, para 2, comes to doc for contraceptive counseling. She & her partner have been using condoms for past 2 yrs but they occasionally forget. She does not wish to become pregnant any time soon but may want children in the future. She is concerned about unscheduled bleeding given her active life. She was diagnosed with chlamydia 1 wk ago & she & her partner have received treatment. She has never had surgery She takes no meds & has no drug allergies. Physical exam, including breast & pelvic exams, is completely normal. What contraceptive methods is best option for this pt?

*Combined oral contraceptive pills & condoms*

Infection of biliary tree can result in intrahepatic abscess. Liver abscesses caused by superinfection from biliary tree are termed "pyogenic" and managed with

*drainage*, either *percutaneous* or surgical

For past 25 minutes, an EMS crew has attempted resuscitation of patient who originally presented in ventricular fibrillation. After first shock, ECG screen displayed asystole, which has persisted despite 2 doses of epinephrine, a fluid bolus, & a high-quality CPR. What is your next treatment?

*Consider terminating resuscitative efforts after consulting medical control*

A 58-year-old man is evaluated because ofa 3-month history ofloud snoring and "gasping" during sleep. He also frequently falls asleep in a chair while reading in the evening. His medical history is otherwise unremarkable. On physical examination, temperature is 37.4°C (99.3°F), blood pressure is 130/82 mm Hg, pulse rate is 80/min, and respiration rate is 14/min. Body mass index is 34. Neck circumference is 45.7 cm (18.0 in), and a low-lying soft palate is noted. Polysomnography shows severe obstructive sleep apnea, with an apnea-hypopnea index of 42/h. Which of the following is the most appropriate next step in treatment?

*Continuous positive airway pressure (CPAP)* OSA - upper airway narrowing or collapse --> cessation (apnea) or reduction (hypopnea) in airflow despite ongoing efforts to breathe

What is the most reliable method of confirming & monitoring correct placement of an endotracheal tube?

*Continuous waceform capnography*

55 yo man has progressive, unstable angina that doesn't respond to pharmacologic therapy. He has ho T2DM & hypercholesterolemia for past 20 yrs. His BMI is 27. 2 of his bros sustained MI at age 50 yo. Cardiac cath shows 70% occlusion of 2 coronary arteries, including anterior descending. His left ventricular ejection fraction is 55%. Next best step in management?

*Coronary artery bypass using internal mammary artery* - vein grafts start to become occluded after 5 yrs, but internal mammary artery grafts are often patent at 10 yrs Unstable angina, progressive - multiple vessels involved --> CABG better than angioplasty - criteria for CABG over angioplasty = 3 or more stenotic vessels or dz of left main coronary artery - diabetic pt --> CAB done if there are more than 2 vessels involved or if left main coronary artery dzed

Baby becomes severely ill after delivery. Shock-hypotension, poor perfusion, metabolic acidosis, distant heart sounds, loud apical murmur (mitral insufficiency), cardiomegaly with pulmonary edema on chest x-ray & low voltage with ST-T wave abnormalities on ECG. Most likely cause?

*Coxsackie* myocarditis

A 6S-year-old man is evaluated because of chronic angina. He has a 10-year history of symptomatic coronary artery disease. The diagnosis was confirmed with an exercise stress test. Results of the test showed no high-risk features. His estimated left ventricular ejection fraction by echocardiography at that time was S6 %. He occasionally has chest pain after walking four blocks. The pain is relieved by taking one sublingual nitroglycerin or by resting. His exercise capacity has not diminished, and the frequency, character, and duration of the pain have not changed. He denies shortness of breath, orthopnea, or paroxysmal nocturnal dyspnea. Current medications include simvastatin, aspirin, metoprolol, and sublingual nitroglycerin. On examination, blood pressure is 122/82 mm Hg, pulse rate is 68/min, respiratory rate is 16/min, and body mass index is 27. There is no jugular venous distention, and there are no murmurs, gallops, rubs, or pulmonary crackles or peripheral edema. Which of the following is the most appropriate management?

*Current medical management* - managing chronic stable angina

Patient has hematuria, proteinuria, RBC casts. BP also high. All these features point towards a diagnosis of a

*glomerular disorder* - RBC casts = virtually diagnostic of glomerular disorder

Best initial step in suspected cases of empyee after thoracentesis is

*high-resolution CT scan of chest with IV contrast* Empyema pleural fluid - mucopurulent with studies showing low pH (<7.2) & glucose <60 mg/dL

Severe postoperative hypocalcemia later than 1 wk after parathyroidectomy is known as

*hungry bone syndrome* - prior to sx: PTH levels were elevated = rapid bone formation & resorption with net efflux of calcium and consequent hypercalcemia - adenoma removed --> PTH decreased precipitously --> skeleton underwent rapid demineralization --> increased ratio of osteoblastic to osteoclastic activity = dramatic increase in bony uptake of calcium, Mg2+, and phosphate --> severe/symptomatic hypocalcmia, hypomag, hypophosph

48 yo woman treated with atenolol & warfarin for last 4 mos for atrial fibrillatio is in clinic today bc of claudication for last 6 wks. Her past med hx is positive for benign positional vertigo diagnosed 9 yrs ago & treated with meclizine as needed. Physical exam reveals normal heart & lung exam with bilateral 1+ ankle edema & diminished pulses. An ankle-brachial index (ABI) of 0.8 is calculated, & the decision is made to suspend atenolol. Bc the pt has no structural heart abnormalities, she is immediately started on amiodarone. Next step in management of this pt?

*Decreases the warfarin dose* Chronic AF - was being treated with atenolol & warfarin Amiodarone = class III antiarrhythmic used in treatment of AF without structural defect - inhibits warfarin metabolism & increases warfarin levles - should decrease warfarin to avoid elevation of INR

A 55-year-old man is evaluated in the emergency department because of a 3-day history of swelling, pain, and erythema of the right leg. He is otherwise active and healthy and reports no recent immobilization, surgery, or cancer. On physical examination, temperature is 38.2°C (100.8°F). Other vital signs are normal. Examination of the left leg shows warmth and circumscribed erythema and tenderness limited to the posterior tibial area. The circumference of the left leg is 1 cm greater than that of the right leg when measured 10 cm below the tibial tuberosity. There is no pitting edema. Which of the following is the most appropriate next step in diagnosis?

*D-dimer assay* - most efficient, least invasive, & least expensive with fewest side effects - high negative predictive value, especially if suspicion for DVT is low - Wells score = clinical prediction tool = clinician assessment of likelihood of DBT - low clinical suspicion + negative finding on D-dimer assay = DVT can be reliably excluded without need for more invasive or complex imaging Wells criteria: 1 pt each - active cancer - paralysis or recent plaster cast - recent immobilization or major surgery - tenderness along deep veins - swelling of entire leg - difference in calf circumference of more than 3 cm compared with other leg - pitting edema - collateral superficial veins - clinical suspicion of alternative diagnosis = -2 points --> patient's wells score = -2 = low likelihood of DVT

64 yo woman comes to ED bc of intermittent chest discomfort. She reports substernal pressure that occasionally radiates to her left arm & lasts appx 10 minutes. She began noticing it when she walked distances greater than 1/2 mile. She has hx of HT, dyslipidemia, & gout. She is currently taking baby aspirin daily. She has smoked one half pack of cigz daily for past 45 yrs. Physical exam shows delayed carotid upstroke & systolic ejection murmur heard best at second intercostal space at right sternal border. Soft S2 without splitting & S4 also present. If pts instructed to perform hand-grip maneuver, what effects is most likely ot be seen?

*Decrease intensity of murmur* - hand-grip maneuver performed --> physical compression of forearm muscles on arterioles = afterload increases --> heart cannot pumpu out enough blood --> reduction in stroke volume + increase in end-systolic volume --> increase in left ventricular volume - increased afterload = increased pressure downstream --> reduced pressure gradient across stenotic aortic valve & turbulent flow across valve = reduced intensity of murmur Aortic stenosis - angina, syncope, heart failure - delayed carotid upstroke & soft S2 - A2 delayed & tends to occur simultaneously with P2 = only pulmonic component of S2 present

40 yo man brought in for eval by Coast Guard just after small plane he was piloting crashed into ocean. Man has survived crash with cuts and a broken arm, but he claims he has no idea how the crash happened or how he escaped the plane. He is unable to explain how he got his life jacket on. His physical exam is significant only for minor lacerations and a fractured right humerus, & he has no alteration in consciousness. CT scan is normal. Most likely diagnosis?

*Dissociative amnesia* - extremely stressful event has been followed by localized loss of memory or amnesia of circumstances surrounding event

You are receiving radio report from EMS team en route with patient who may be having an acute stroke. Hospital CT scanner not working at this time. What should you do in this situation?

*Diver patient to hospital 15 minutes away with CT capabilities*

45 yo woman evaluated in clinic bc of 1 wk ho fever. 1 wk ago, she was diagnosed with pyelonephritis & prescribed 10-day course of trimethoprim-sulfamethoxazole based on culture results. Urinary tract symptoms resolved over 3 days, but she continued to feel feverish. She took her temp at that time, & it was 101.3 F. Fever has persisted. She reports feeling well otherwise & has returned to normal activities. Medical history unremarkable. Only med is trimethoprim-sulfamethoxazole. On physical exam, temp is 101.1 F. Vital signs are otherwise normal. No rash, & other findings on physical exam are normal. Findings of CBC are normal. Repeat urinalysis shows 3 leukocytes/hpf, & findings are otherwise normal. Most likely cause of pt's fever?

*Drug fever* - antibiotics can cause or prolong fever = confusion for clinician - common cause = sulfonamide & beta-lactam antibiotics & nitrofurantoin - findings normal despite documented fever - diagnosis made by discontinuing drug --> should abate within 72 hrs

34 yo G1P0 woman brought to ED bc of spontaneous rupture of membranes. In delivery room, thin meconium seen within ruptured membranes. Upon delivery, newborn begins to cry & is placed under radiant warmer. Next best step in management?

*Dry the infant* Neonatal resuscitation - after delivery, first step = place infant on radiant warmer --> dry & stimulate

27 yo woman evaluated for 7 mo ho abdominal discomfort after eating. Initially, her discomfort was intermittent, but during last 4 mos it has been present with every meal. Discomfort described as sense of fullness over midepigastric region associated with bloating, & lasts for appx 1 hr before resolving. Eating smaller meals decreases intensity & duration of discomfort. Calcium carbonate antacids & simethicone don't relieve her symptoms. She does not have heartburn, regurgitation, vomiting, belching, dysphagia, odynophagia, diarrhea, or constipation. Pt doesn't smoke cigarettes or drink alcoholic beverages. She has gained appx 9 kg (20 lb) over past yr. Med hx otherwise unremarkable, & she takes no meds. On physical exam, vital signs normal. BMI 32. Remainder of exam, including abdominal exam, is normal. CBC normal. Urine pregnancy test negative. Most likely diagnosis?

*Dyspepsia* Rome III criteria for dyspepsia - bothersome postprandial fullness - early satiety - epigastric pain - epigastric burning - symptoms should be consistent for at least 3 months with initial onset at least 6 months before diagnosis - pt doesn't have alarm features such as unintentional weight loss, anemia, vomiting, or dysphagia

For new-onset supraventricular tachycardia, initiate vagal maneuvers (carotid massage, Valsava) to try to terminate tachycardia via...

*increase in AV conduction delay* - if vagal maneuvers fail, use adnosine - recognize WPW syndrome to avoid vagal maenuvers here since they can cause degeneration to ventricular fibrillation

Evaluation of inherited thrombophilia in pt on warfarin therapy

*initiated 2 weeks after patient completes warfarin therapy* Screening for factor V Leiden & prothrombin gene mutation (PTG2021A) - can be done at any time - antithrombin, protein C, protein S, & dysfibrinogenemia testing may be altered during acute thrombotic events & their treatment

Treatment of keloids

*intralesional steroid injection* - often following pretreatment with liquid nitrogen cryotherapy keloids - typically associated with crablike projections from original wound site - tend to recur following excision - tend to be painful

Some anti-tubercular drugs with anti-vitamin B6 effects can induce sideroblastic anemia which is usually microcytic. These include

*isoniazid*, pyrazinamide, cycloserine - anemia can be corrected by cessation of offending drug or by high-dose B6 administration

Lucy Liu, never smoker, has 6 cm mass in her left lung, mediastinal adenopathy, & multiple bone lesions on PET/CT. Biopsy confirms adenocarcinoma of lung. Next best step?

*EGFR mutation testing* - young Asian, nonsmoking (or never smoking) women = most likely to have activating EGFR mutation that makes their non-small cell lung cancer susceptible to erlotinib

What action is included in the BLS Survey?

*Early defibrillation*

9 yo boy brought to ER by his mom bc he stated, "My heart seems really fast & is pounding." This has been occurring for past 3 hrs. He has never complained of this before. In fact, he has been healthy, having had only the typical acute childhood illness, & has not even seen a doc for the past 2 yrs. Upon auscultation, his heart rate is about 200/min. He is easily converted to sinus rhythm after his face is submerged in iced saline for a few seconds. At this time, further exam discloses grade III holosystolic murmur over most of anterior left chest, along with gallop rhythm heard over lower left sternal border. Electrocardiogram is then performed at his normal heart rate & shows short P-R interval with slow upstroke of QRS. MOST likely diagnosis?

*Ebstein anomaly* - due to downward displacement of abnormal tricuspid valve into right ventricle = divides ventricle into 2 parts - increased volume in right atrium --> cyanosis - fatigue & palpitations may not present until later in childhood - physical exam = quiet precordium, holosystolic murmur from tricuspid regurgitation over most of anterior let chest, & gallop rhythm Acute onset of SVT - HR typically b/t 180 & 300 bpm - children tend to tolerate short runs of SVT well & only complain when heart beating fast - chest pain or even HR may be manifest w/ extremely rapid rates for prolonged periods - OTC cold meds containing sympathomimetic amines may ppt attack in otherwise normal child - SVT also associated w/ uncorrected congenital heart defect, particularly Ebstein anomaly - another common cause = Wolff-Parkinson-White (WPW) syndrome = short P-R interval & slow-upstroke of QRS - in older children, conversion may be achieved by submerging face in iced saline for several seconds - in infants, ice bag over face used - if SVT is recurring, older children may be taught use of vagotonic maneuvers - if these methods fail, preferred treatment in stable kids = rapid IV push of adenosine - if HF present --> initial management = synchronized DC cardioversion

2 yo Korean boy brought to doc after 6 days of spiking fever. His parents noticed swelling of his hands and feet on third day of fever ,& a red rash on his torso that developed yesterday. Parents deny cough, nause or vomiting, changes in his urine, or tugging at the ears. He has, however, diarrhea for past day with increasing irritability and has complained of RUQ pain. There are no known sick contacts. His has not had his 18 mo immunizations, as he had a cold at the time. On exam, the boy has polymorphic maculopapular rash on his torso. He has bilateral conjunctival injection, & there is the presence of unilateral enlarged, slightly tender cervical lymph node. His vital signs are temp 104 F, HR 140/min, RR 20/min, & BP 90/65 mmHg. He is admitted to hospital for further evaluation & treatment. Abdominal ultrasound ordered, which shows hydrops of gallbladder. What is part of initial evaluation of this pt?

*Echocardiography* - routinely done in all pts with Kawasaki dz to detect dilatation of aneurysm of coronary vessels - electrocardiogram also performed at this time - if coronary artery aneurysm develops, it is typically during transition from acute to subacute stage = 10-14 days from start of symptoms --> 2nd echo obtained --> no abnormalities? --> final echo done at 6-8 wks to determine if low-dose aspiring may be discontinued Kawasaki dz / mucocutaneous lymph node syndrome - vasculitis of medium sized vessels of unknown etiology - most common cause of acquired heart dz in children in US & Japan - can cause coronary aneurysms in 20-25% of pts not treated & in 3-5% of pts who are treated with IV immunoglobulin & aspirin *high dose through acute phase, then low dose through convalescence at 6-8 wks) Diagnostic criteria = fever >5 days that is unresponsive to anyipyretics + at least 4 of the following... - bilateral nonexudative bulbar conjunctival injections or anterior uveitis - intraoral erythema &/or dry, cracked lips - polylymorphic exanthem any kind, anywhere, except vesicular (would make it wrong diagnosis) - erythema &/or edema of distal extremities - lymphadenopathy: almost always single, large (>1.5 cm diameter) & somewhat tender cervical node - periungal deaquamation may occur at start of subacute phase (same timing of possibility of aneurysm) - other clinical findings = aseptic meningitis, irritablity, sterile urethritis, hepatitis, hydrops of gallbladder, diarrhea, vomiting, electrolyte abnomralities, arthralgias, arthritis - significant leukocytosis & increase in acute phase reactants - platelets steadily increase

50 yo man comes to doc bc of progressive thickening & swelling of skin on his legs & arms for 2 weeks. He has had no fevers, weight loss, chest pain, heartburn, or weakness. His med history is unremarkable. His BP is 126/82 mmHg. Exam shows patches of thickened erythematous skin over anterior surfaces of upper & lower extremities with orange-peel appearance. There are no lesions on fingers. There are no telangiectasias or calcinosis on skin. Diagnosis?

*Eosinophilic fasciitis* - puckered, orange peel-like (peau d'orange) appearance of skin - typically on legs & thighs - fibrotic disorder involving arms & legs - middle-aged men - develops rapidly --> eventual flexion contractures of arms & legs caused by fibrosis of muscle fascia - treatment = prednisone or cytotoxic agents

30 yo man comes to doc bc of fatigue, cough, headache, backache, joint pain, & chest pain for 6 days. One day ago, he had sudden onset of fever & chills, a worsening headache, & a rash that begun under his arms & spread to his trunk. He returned form missionary trip to South America 2 wks ago. He has had no exposure to farm animals. His temp is 101.8 F. Exam shows erythematous maculopapular rash over trunk & extremities that spares face, palms, & soles. There is diffuse muscle tenderness to palpation. What is the most likely diagnosis?

*Epidemic typhus* - via Richettsia prowazekii - insect vector = louse - transmission = any condition that predisposes to heavy lice infestation - louse transmitted via contact or clothing - central & northeastern Africa; Souther America - incubation period of 2 wks --> prodromal symptoms --> high fever --> delirium & stupor; macular rash that appears first in axilla & then spread over trunk & extremities, sparing face, palms, & soles - treatment = doxycycline or chloramphenicol

Patient in cardiac arrest. High-quality chest compression are being given. Patient is intubated, & an IV has been started. Rhythm is asystole. First drug-dose to administer?

*Epinephrine 1 mg IV/IO*

A 19-year-old man is admitted to the hospital because of a sickle cell pain crisis. Over the next 48 hours, he develops worsening dyspnea, chest pain, and fever. On physical examination, temperature is 38.0°C (100.4°F), blood pressure is 123165 mm Hg, pulse rate is 1181min, and respiration rate is 221min and labored. Oxygen saturation is 86% with the patient breathing oxygen, 6 Umin by nasal cannula. There is no jugular venous distention. Cardiopulmonary examination discloses decreased bilateral breath sounds at the lung bases, but no crackles or S3• There is no peripheral edema. Results oflaboratory studies show a hemoglobin level of 4. 9 gldL (49 glL), a reticulocyte count of 4.4% of erythrocytes, and a leukocyte count of 6900lµL (6. 9 x 109 IL) with a normal differential. Chest radiograph shows multilobar infiltrates that were not present on the admission chest radiograph. Broad-spectrum antibiotics are begun, and incentive spirometry is initiated. Which of the following is the most appropriate additional treatment?

*Erythrocyte transfusion* - if hypoxia persists despite supplemental O2 Acute chest syndrome - identification of new infiltrate on chest radiograph that involves at least one lung segment & at least one or more of: chest pain; temp less than 38.5 C (101.3 F), tachypnea, wheezing, cough or labored breathing Management - empiric broad-spectrum antibiotics - supplemental O2 - pain meds to diminish chest splinting - bronchodilators if reactive airway dz present - avoidance of overhydration

You arrive on scene with code team. High-quality CPR in progress. An AED has previously advised "no shock indicated." Rhythm check now finds asystole. After resuming high-quality compressions, what action do you take next?

*Establish IV or IO access*

35 yo woman, gravid 4, para 3, at 38 wks' gestation comes to labor & delivery ward after gush of clear fluid from vagina. After gush, she has had increasing contractions. Sterile speculum exam shows pool of clear fluid in vagina that is nitrazine-positive. Cervical exam shows that pt is 5 cm dilated, with fetal face presenting in mentum anterior position. External uterine monitoring shows that pt is contracting every 2 minutes, & external fetal monitoring shows that fetal heart rate is in the 140s & the tracing is reactive. Most appropriate next step in management?

*Expectant management* Face presentation - typically, fetus in labor is in occiput presentation - 1/500 = face presentation - causes = anencephalic fetus, pelvic contraction, high parity - fetus in mentum anteriorposition can be delivered vaginally --> expectant management = standard of care (if said mentum posterior = C section!)

41 yo gas station attendant shot once with 0.38 caliber revolver. Entry wound is in left midclavicular line, 2 inches below nipple. There is no exit wound. He is hemodynamically stable. Chext x-ray shows small pneumothorax on left & demonstrates bullet to be lodged in left paraspinal muscles. In addition to appropriate treatment for pneumothorax, what will this pt most likely need?

*Exploratory laparotomy* - any gunshot wound below nipples & above pubic symphysis = considered to involve abdomen - penetrating abdominal wounds = absolute indication for exploratory laparotomy

Term newborn delivered vaginally following breech presentation. Pediatric orthopedic surgeon called to newborn nursery bc on physical exam, Barlow test positive for bilateral subluxation of hips. There is decreased abduction of both hips. Besides breech presentation, what infants are most at risk for this condition?

*Female infants* Developmental dysplasia of hips - generally includes subluxation (partial dislocation) of femoral head, acetabular dysplasia, complete dislocation of femoral head from acetabulum - left hip more commonly involved than right - bilateral inv't more common than inv't of right hip alone - 3-4% = breech

Initial management of SVT is to do vagal maneuvers / carotid massage; however, since carotid massage is contraindicated bc of soft blowing murmurs found on neck auscultation (bilateral carotid stenosis), what would be the next step in this case?

*Forcefully exhaling against closed mouth & nose* (Valsalva maneuver) - this is also a vagal maneuver

Patient with STEMI has ongoing chest discomfort. Heparin 4000 units IV bolus & heparin infusion of 1000 units per hour are being administered. Patient did not take aspirin because he has history of gastritis, which was treated 5 years ago. Next action?

*Give aspirin 160 to 325 mg to chew* STEMI - start adjunctive therapies as indicated - don't delay reperfusion

A 25-year-old woman is evaluated during a follow-up examination. The patient was first seen 3 months ago because of fatigue, a malar rash, and arthralgia. After laboratory confirmation of systemic lupus erythematosus, she was treated with hydroxychloroquine and a 1month course of low-dose prednisone. She reports some improvement, although fatigue and joint pain continue. On physical examination, temperature is 36.4 °C ( 97 .6 °F), blood pressure is 148/95 mm Hg, pulse rate is 84/min, and respiration rate is 18/min. The facial rash has resolved, the joint examination is normal, and there is trace bipedal edema. The remainder of the examination is unremarkable. Laboratory studies are significant for a serum creatinine level of 1.0 mg/dL (88.4 µmol/L) and a urinalysis showing 2+ protein; 3+ blood; 5-10 leukocytes/high-power field (hpO, 15-20 erythrocytes/hpf, and 1 erythrocyte cast/hpf. Serum complement levels (C3 and C4) are decreased. Which of the following is the most appropriate next step in this patient's treatment?

*High-dose prednisone* - HT, ankle edema, hematuria, proteinuria, erythrocyte casts on urinalysis = highly suggestive of lupus nephritis despite absence of kidney insufficiency - to prevent irreversible kidney damage, early treatment with high-dose glucocorticoids indicated for patients whose condition raises strong suspicion for lupus nephritis

62 yo man suddenly experienced difficulty speaking & left-sided weakness. He meets initial criteria for fibrinolytic therapy, & a CT scan of brain is ordered. What best describes guidelines for antiplatelets & fibrinolytic therapy?

*Hold aspirin for at least 24 hours if rTPA is administered*

71 yo man w/ T2DM, hypercholesterolemia, & varicose veins comes to doc bc of non-healing ulcer at heel of his right foot for 4 wks. He has had no pain over ulcer or his right foot. Current meds include metformin, glyburide, & lovastatin. Exam shows 3.5-cm ulcer w/ some dirt & debris in base; there is little granulation tissue. Skin around ulcer is normal-appearing. There is absent sensation to pinprick over right LE & foot. Peripheral pulses are weak. Hgb A1c level is 9.8%. Most likely underlying cause of pt's poor ulcer healing?

*Hypoxia* Diabetic ulcer - most important factor in poor healing = hypoxia secondary to microvascular dz - w/out adequate restoration of tissue oxygenation --> healing of ulcers = problematic - restoration of tissue oxygenation can be achieved w/ vascular surgery or w/ use of hyperbaric oxygen

55 yo man with ho prostate cancer comes to ED bc of progressive weakness in his right arm & leg that started yesterday. He also had difficulty walking. He denies headaches, seizures, or change in vision. He takes no meds. His temp is 98.2 F & BP 140/70 mmHg. Muscle strength is 0/5 in right upper & lower extremities. There is decreased sensation to position & vibration of right upper & lower extremities.; in left extremities there is decreased sensation to pinprick & temp. Babinski sign present on right side. Most appropriate next step in management?

*IV dexamethasone* - anti-inflammatory - should decrease pressure on spinal column --> prevent any permanent or long-term damage before other interventions can occur - most significant within first 8 hrs of injury Acute spinal cord injury - most likely via epidural spinal cord compression from met prostate cancer - this is atypical presentation affecting cervical spinal cord - most likely type of spinal cord injury = Brown Sequard syndrome - first intervention = high dose of IV steroids after initial neuro exam

Patient in cardiac arrest. Ventricular fibrillation has been refractory to initial shock. If no pathway for med administration is in place, what method is preferred?

*IV or IO*

Drug of choice for pts presenting with hypertensive emergency and coexisting signs of ischemic heart disease

*IV* nitroglycerin - blood pressure should be lowered by 25% of initial presentation over first 2 hours to prevent ischemic infarction of brain, heart, & kineys

Intracranial bleed is a strong contraindication for initiating or continuing anticoagulation therapy. A pt who has a DVT or pulmonary embolism who experiences complication from anticoagulation therapy requires what?

*IVC filter* - to prevent further embolism

29 yo man comes to doc bc of severe fatigue & low-grade fever for 3 weeks, & progressive nausea & jaundice for past 4 days. His med history is unremarkable & he takes no meds. he admits to occasionally injecting cocaine. He is sexually active & he uses condoms inconsistently. Hist mother died of breast cancer at age 63 & his father has HT. His temp is 38.2 C (100.8 F). Exam shown (jaundiced eyes). What is the best serologic marker of this patient's condition?

*IgM Anti-HBc* = acute HBV infection = early in clinical phase - + HBsAg = acute dz - multiple risk factors for HBV = IV drug use, occasional "unsafe" sex

A 52-year-old man is evaluated for a 3-month history of fatigue and pain of the hands and knees. The pain has progressively worsened and is accompanied by 1 hour of morning stiffness. He takes ibuprofen as needed, which provides minimal pain relief. On physical examination, vital signs are normal. Synovitis of the proximal interphalangeal joints, elbows, left knee, and ankles is noted. Radiographs of the hands and knees are normal. Aspiration of the left knee reveals a synovial fluid leukocyte count of12,000/µL (12 x 109/L). Which of the following is the most likely diagnosis?

*rheumatoid arthritis*

A 3S-year-old man is seen in the clinic for follow-up evaluation for recurrent symptomatic calcium oxalate kidney stones. His episodes of nephrolithiasis are associated with significant pain and are disabling. His last attack was 1 month ago. He first developed kidney stones S years ago and typically has one to two episodes each year. He has been adherent to recommendations to increase his fluid intake and maintain a low-sodium diet. On physical examination, vital signs are normal. The remainder of the examination is unremarkable. Laboratory studies: Urinalysis = pH S.O; 1 + blood; no protein; 0-3 erythrocytes/high-power field; no bacteria; no glucose 24 hour urine collection: Calcium = Normal Uric acid = Normal Citric acid = Normal Oxalate = High Radiograph of the kidneys, ureters, and bladder reveals a 3-mm calculus in the right upper pole. In addition to avoiding foods high in oxalate and adhering to a lowprotein diet, which of the following is the most appropriate next step in this patient's management?

*Increase dietary calcium intake* - high-calcium diet = calcium binds oxalate in gut & prevents its absorption & ultimate filtration at level of kidneys - & initiation of low-protein diet Recurrent calcium oxalate stones due to secondary hyperoxaluria - via increased GI absorption of oxalate - can be caused by increased intake of oxalate-rich foods such as rhubarb, peanuts, spinach, beets, chocolate - oxalate binds urine calcium as it is eliminated by kidneys = calcium oxalate stone formation

29 yo woman evaluated for 2 day ho fever, cough, nasal congestion, myalgia, & fatigue. Primary adrenal insufficiency diagnosed 3 mos ago. Meds are replacement doses of hydrocortisone & fludrocortisone. She has been able to take her meds as scheduled & fluids as needed. On physical exam, temp is 100.8 F, BP is 102/68 mmHg w/out orthostatic changes, pulse rate is 88/min w/out orthostatic changes, & RR 21/min. Erythema noted in posterior pharynx, & bilateral small cervical lymph nodes present. Remainder of physical exam is unremarkable. Most appropriate next step in management?

*Increase hydrocortisone dose* Primary adrenal insufficiency / Addison dz - + URI - she has continued to take adequate amounts of fluids & her meds as scheduled - *her hydrocortisone dose during her intercurrent illness should be increased appx threefold over her baseline replacement dose, & increase should be continued for 3 days* = necessary to minimize possibility of adrenal crisis

69 yo woman comes to doc bc of 1 wk ho lower abdominal pain & bloody diarrhea. She has not traveled recently. She has ho stable exertional angina, HT, & MI 3 yo. She retired from her job as a librarian 4 yo. Her temp is 38.6 C (101.4 F), BP 120/84 mmHg, pulse 96/min. Exam reveals moderate tenderness to palpation of LLQ. Rectal exam shows blood stool & no masses. Most likely diagnosis?

*Ischemic colitis* - weight loss from fear of pain = characteristic - via occlusion, vasospasm, &/or hypoperfusion of mesenteric vasculature --> ischemic colitis - abdominal pain + left side of abdomen + tenderness + bloody diarrhea - diagnosis suspected clinically & confirmed via CT = segmental pattern - colonoscopy may show pale mucosa with petechial bleeding or bluish hemorrhagic nodules

Young woman comes to doc for help. During interview, she reveals that she was raped when she was a teenager. She is currently dating a man with whom she would like to have sexual intercourse. When they tried, however, she said "I feel like I'm being torn, & he is just hitting a wall" and they could not have intercourse. Most likely treatment of this condition?

*Kegel exercises* Vaginismus - involuntary muscle contraction of outer third of vagina - interferes with intercourse - prevalent in women with ho sexual trauma, emotional abuse, rigid religious upbringing, or psychosexual conflicts - treated with kegel exercises & dilators

What is the best predictor of long term mortality in a patient who just had a STEMI?

*Left ventricular function* "Time is muscle"

64 yo man undergoing chemotherapy & has occasional nausea & vomiting, which are treted with IV prochlorperazine. After several days of therapy, pt complains that he feels very restless & agitated & he cannot stop moving his legs. He has never experienced these symptoms before & is concerned that they were caused by his recent therapy. What medications would best treat his symptoms?

*Lorazepam* - benzo - useful in reducing symptoms of akathisia Akathisia - feeling of restlessness - sometimes occurs as rxn to use of antipsychotic meds such as prochlorperazine & haloperidol

Drug of choice for DVT prevention

*Low molecular-weight fractionated heparin* - more reliable & practical than unfractionated hepatin

Idiopathic destructive arthritis of shoulder. Typically elderly women with bilateral pain, swelling, and loss of joint function. Large effusion with severe destruction on radiograph.

*Milwaukee shoulder* = Basic Calcium Phosphate dz

19 yo Caucasian woman comes to office bc she missed several of her birth control pills in past 2 mos and a home urine pregnancy test was positive. She cannot remember when she had her last period. She is feeling well & has no complaints. He past med hx is non-contributatory. She lives with her mom & 2 younger siblings. She does not smoke, drink alcohol, or use illicit drugs. Her temp is 98.6 F, BP 104/78 mmHg, pulse 72/min, & respirations 16/min. Physical exam reveals tender breasts, gravid uterus, blue-tinged cervix, & is otherwise unremarkable. Sonogram shows intrauterine pregnancy of 12 wks. Prenatal labs drawn, & Pap smear & urine & cervical cultures are obtained. Urinalysis shows moderate bacteriuria with positive leukocyte esterase & positive nitrites. She is administered prenatal vitamins & folate. Best next step in management?

*Nitrofurantoin* - pregnancy category B drug - concentrates in kidney = works well locally = useful in small concentrations UTI common in pregnancy - most common cause = E coli - abx safe to use in preganncy = nitrofurantoin & cephalexin

11 mo old infant brought to clinic by her parents bc she has abdominal pass. Physical exam shows small bulge at umbilicus, appx 1 cm in diameter, which pops out when girl cries. Contents of bulge can be easily reduced. It is not painful, & girl is otherwise asymptomatic. She is reaching all dev'tal milestones. Most appropriate next step in management?

*No therapy unless mass persists beyond age 2 yrs* Small umbilical hernias - can close spontaneously in children up to age 2 yrs - doc should allow time for spontaneous resolution - risk factors for congenital umbilical hernias = African-Americans, male, infant prematurity

What is the recommendation on the use of cricoid pressure to prevent aspiration during cardiac arrest?

*Not recommended for routine use*

33 yo man comes to doc bc of severe left eye pain for 2 wks. He has had stabbing headache behind his left eye. He denies photophobia, nausea, or seizures. In past, these episodes of headaches have lasted up to 6 wks. he appears agitated. His temp is 99.2 F, BP is 145/90 mmHg, pulse is 98/min, & respirations are 17/min. Exam shows tearing of left eye. Left pupil measures 2 mm, right pupil is 4 mm, & left eyelid is slightly drooped. Visual acuity is normal. Most appropriate next step in management?

*Oxygen* - by non-rebreather mask - always administered first in acute setting - no side effects Cluster headache - unilateral - located behind one of orbits - may be accompanied by autonomic symptoms = conjunctival injection, lacrimation, rhinorrhea, nasal congestion, ptosis - common in young men - oxygen & sumatriptan = most effective acute treatments

What is a sign of effective CPR?

*PETCO2 > 10 mmHg*

Helpful in establishing diagnosis of multiple myeloma.

*urine fixation* - immunofixation confirms presence of M protein & determines its type - M protein produced & secreted by malignant plasma cells & is detected by serum protein electrophoresis &/or urine protein electrophoresis combined with immunofixation of serum & urine

25 yo G1P0 woman who is at 24 weeks' gestation comes to ED dep't bc of worsening dyspnea & orthopnea over past 10 yrs. Treatment with IV furosemide was administered, but there is no improvement in her symptoms. She has ho rheumatic heart disease & mitral stenosis. She is currently receiving digoxin. Echo from 1 year ago showed mitral valve area of 1 cm^2. Her BP is 100/75 mmHg & her pulse is 135/min. Physical exams show jugular venous distention at 15 cm of H2O & bilateral crackles on auscultation of the chest. What is the next best step in management?

*Percutaneous balloon valvuloplasty* Life-threatening edema in setting of critical mitral stenosis - saving life of mother = prime concern - most effective therapy for mitral stneosis in *pregnancy* - pregnancy women can be readily be treated with balloon valvuloplasty

A 19-year-old man is evaluated after the recent sudden death of his father at 45 years of age. He reports no chest pain, shortness of breath, palpitations, dizziness, or syncope. He does not smoke or use drugs and is not hypertensive. He takes no medication. The patient has no siblings. On physical examination, he is afebrile, blood pressure is 120/ 60 mm Hg, pulse rate is 60/min, and respiration rate is 14/min. A grade 2/6 midsystolic murmur that increases during the strain phase of the Valsalva maneuver is heard. The lungs are clear to auscultation. Electrocardiogram shows sinus rhythm and increased QRS voltage in the precordial leads. Echocardiogram shows asymmetric basal and midseptal hypertrophy, a thickened septum, and increased left ventricular outflow tract gradient. Which of the following is the most appropriate management?

*Placement of an implantable cardioverter-defibrillator* Hypertrophic Cardiomyopathy (HCM) - management in this asymptomatic patient = prevention of sudden cardiac death

57 yo man comes to doc bc of progressive SOB & cough over past 3 months. He used to walk one half mile per day but is unable to do so now bc of fatigue & SOB. He now has SOB at rest. He has history of HT & type 2 DM controlled with diet. His home blood glucose log shows range of values from 108-201 mg/dL. Current meds include lisinopril & HCTZ. He has no allergies. He has smoked 2 packs of cigz daily for 40 years, & he drinks one glass of whisky every night. He weighs 102 kg (225 lb) & is 178 cm (70 in) tall. His BP is 152/88 mmHg & pulse is 82/min. Lungs are hyperresonant to percussion, & bilateral basilar wheezes heard on auscultation. Grade 2/6 systolic ejeciton murmur heard along upper right sternal border that radiates to carotids bilaterally. There is S4 gallop. There is no pedal edema. Pulmonary function testing shows FEV1 is 60% of predicted, & FEV1-to-FVC ratio is decreased. What is the most appropriate preventive measure for this patient?

*Pneumococcal polysaccharide vaccine* - indicated for all adults over age 65 yo - indicated in younger patients who have CV dz, COPD, DM, alcoholism, & chronic liver dz COPD - cough, dyspnea, hyperresonant chest, wheeze - decreased FEV1/FVC <0.7 = hallmark - recommended that COPD patient receive vaccinations against influenza & pneumococcus

32 yo man admitted to hospital for 3 wk ho increasing dyspnea on exertion, dry cough, pleuritic chest pain, & fever. Pt has had multiple sexual partners of both genders. On physical exam, temp is 101.5 F, BP 110/66 mmHg, pulse rate 112/min, & RR 24/min. Oxygen sat is 89% on ambient air. Oropharynx shows scattered white plaques. Lung auscultation shows diffuse crackles bilaterally. Remainder of exam is normal. Result of rapid HIV test is positive. Sputum Gram stain shows few neutrophils, pseudohyphae, & mixed bacteria. Chest radiograph shows bilateral diffuse reticular infiltrates. What is the most likely diagnosis?

*Pneumocystis jirovecii pneumonia* - subacute presentation with dry cough & dyspnea & chest radiograph findings of diffuse interstitial dz = typical presentation of PCP in pts with AIDS - most common opportunistic infection in pts no taking Pneumocystis prophylaxis - bronchoscopy with lavage can be done with special stains to confirm diagnosis

58 yo man has been having annual PSA determinations since age 50. His value last year was 2.8 ng/mL. This year's result is 8 ng/mL. Doc performs digital rectal exam, which shows area of induration within the right lobe of the prostate. He voids give times/day & two times/night. He has good force of urinary stream & denies urinary dribbling. If this pt's confirmatory diagnostic test shows positive for localized disease, which would be the most appropriate treatment?

*Radical prostatectomy* - if localized carcinoma identified (no invasion of capsule), best treatment = radical prostatectomy

25 yo AAF comes to ED complaining of severe sore throat, fever, & shaking chills. Symptoms began 2 days ago & have progressed to point that she is weak, confused, & barely able to get out of bed. She reports diffuse myalgias & arthralgias for 1 wk, accompanied by mild nonproductive cough, headache, & mild abdominal pain. Before this she has been generally healthy, although she states that she takes med for her thyroid condition. In addition to this, she takes oral contraceptive pill daily & OTC pain med as needed. Vital signs are temp 103 F, BP 80/40 mmHg, pulse 120/min (regular), & respirations 30/min. Exam reveals an ill-appearing young woman without any localizing findings. CBC shows: Hct 29% Hgb 9 g/dL Leukocyte count 200/mm^3 Platelet count 30,000/mm^3 Most likely cause of pt's current condition?

*Propylthiouracil* Agranulocytosis - potentially irreversible condition - propylthiouracil & methimazole = common causes of reversible agranulocytosis = 0.5% of pts --> high risk of sepsis - best next step = I121 ablation or subtotal thyroidectomy

58 yo woman comes to clinic bc of painless lump in her neck & excessive sweating for 4 mos. She has felt warm & flushed, even when others have felt comfortable. She has had frequent stools, insomnia, & heart palpitations. She takes no meds. Her temp is 100.4 F, BP 138/88 mmHg, pulse 121/min, & respirations 20/min. Exam shows thin woman who has resting tremor. There is palpable, nontender, 0.5-cm nodule in left lobe of thyroid gland. Lab studies show: TSH 0.1 uU/mL T4 13.2 ug/dL Radioactive iodine (RAI) scan most likely to show what?

*Reduced RAI uptake in non-nodular tissue* Thyrotoxicosis --> hyperthyroidism: Toxic adenoma - focal area of hyperplasia independent of TSH-mediated regulation - appears as focal area of increased uptake in radioactive iodine uptake (RAIU) scan - excessive production of thyroid hormone inhibits TSH --> normal portion of gland halts colloid production --> reduced RAI uptake

Present in 92-97% of patients at time of amebic liver abscess diagnosis.

*Serum antibodies*

60 yo man w/ ho diabetes & HT presents to ED complaining of 2 days of lower abdominal pain. Pain is mostly on left side & has not migrated during previous 48 hrs. He has no appetite & has had 2 episodes of nonbloody diarrhea during this period. His physical exam is notable for fever of 102.9 F, BP of 88/44 mmHg, & pulse of 123/min. His abdominal exam is significant for LLQ tenderness to light palpation & for voluntary guarding. His lab studies are significant for WBC count of 19,000/mm^3 w/ 88% neutrophils. CT scan of abdomen & pelvis is obtained & reveals significant sigmoid diverticulitis w/ large LLQ phlegmon & at least 5 small abscesses w/in large inflammatory mass. After fluid resuscitation & IV abx, what would be the most appropriate next step in management?

*Surgically remove sigmoid colon* - source of sepsis has to be removed --> surgical resection of sigmoid colon - septic shock indicated by hypotension & tachycardia

15 yo boy brought to doc bc of recurrent acne. He reports washing his face 2x daily with mild saop but admits to eating large amounts of chocolate & spicy food. Exam shows mild to moderate acne, mostly consisting of open comedones, some closed comedones, & few pustules on forehead & cheeks. Remainder of exam is unremarkable. Most appropriate recommendation?

*Topical application of tretinoin or adapalene* Acne vulgaris: Comedolytic agents: Retinoids - tretinoin, adapalene, new yeast-derived agend azalaic acid - for mild to moderate forms of non-inflammatory acne (open comedones) = improvement within several weeks after starting treatment

What is an appropriate & important intervention to perform for patient who achieves ROSC during out-of-hospital resuscitation?

*Transport patient to facility capable of performing PCI*

Commonly occurs when there is rapidly expanding lesion in supratentorial parenchyma, such as intracranial hemorrhage.

*Transtentorial (uncal) herniation* Intracranial HT: Cushin triad - HT + bradycardia + depressed respirations - may be late finding

55 yo man screened for TB w/ tuberculin skin test during preemployment physical exam. 48 hrs later, he has 16 mm of induration at site of injection. He has never had reactive TB skin test & has no known exposure to TB. History shows no risk factors for TB. He has no other medical problems & takes no meds. Findings on physical exam & review of systems are normal. Results of blood tests, including HIV & aminotransferase levels, are normal, as are results of chest radiography. What is the most appropriate management for this pt?

*Treatment with isoniazid for 9 months* Pt meets clinical criteria for latent TB - should receive treatment w/ isoniazid for 9 mos to prevent reactivation TB - has greater than 15 mm induration on TB skin testing - he is at high risk for dev't of reactivation TB - bc pt has no signs or symptoms of active TB or HIV infection & has normal results on chest radiography, he has latent infection - in pts who are at high risk for active TB, treatment w/ isoniazid may reduce risk of active dz by up to 90%

62 yo man with ho HT, hyperlipidemia, claudication, chronic renal failure, & type EDM comes to ED bc of substernal chest pressure for past 1 hour. He states that pain comes in waves & is associated with SOB & diaphoresis. He says he has had anginal-type chest pain in past, but this pain is different in nature & more severe. ECG shows T-wave flattening & inversions in lateral & inferior leads. Lab studies reveal elevated myoglobin but normal creatinine kinase & borderline-elevated troponin T level. Treatment with sublingual nitroglycerine, aspirin, metoprolol, enoxaparin, morphine, & glycoprotein IIb/IIIa inhibitor begun, but the patient continues to have chest pressure. His BP is 100/55 mmHg. What is the next best step in patient care?

*Urgent transfer to coronary catheterization lab for angiography* - inability to control chest pain = indication for early angiography (cardiac cath) - ongoing pain = continued ischemia

Nodulocystic acne + prominent scarring --> treatment?

*oral retinoid meds* - to quickly treat acne & halt formation of new scars - most commonly used = isotretinoin

Recommended dosage of folic acid that should be taken everyday for the average pregnant woman

0.5 mg/day - 4 mg/day if they have had previous NTD-affected pregnancy

1 unit pRBCs =

1 pt Hgb or 3-4 HCT rise

Zollinger-Ellison syndrome should be suspected when patients have recurrent epigastric pain & diarrhea refractory to treatment with PPI. The tests should be performed in the following order...

1. *serum gastrin level* - can be performed when patient is off PPI for at least 1 week 2. secretin stimulation test 3. somatostatin receptor scintigraphy

Definition of CKD

1. Duration of > 3 months 2. Presence of either/both: - eGFR < 60 mL/min/m2 - kidney dz as defined by structural abnormalities or functional abnormalities other than low eGFR

Classic triad for HUS

1. microangiopathic hemolytic anemia - anemia - elevated reticulocyte count - lactate dehydrogenase level - low haptoglobin level - schistocytes on peripheral blood smear 2. thrombocytopenia 3. AKI - in setting of dysentery caused by enteric pathogen

Lithium levels presenting with mild toxicity

1.5 - 2.5 mEq/L

Risk of wound infection of contaminated wound

10-15%

In any otherwise normal individual, further investigation of primary amenorrhea should not be undertaken until what age?

15 years

Stool Osmotic Gap using Stool Electrolytes =

290 - 2 x [stool sodium + stool potassium] - gap greater than 100 mOsm/kg (100 mmol/kg) = osmotic cause of diarrhea - lactose malabsorption = most common cause of stool osmotic gap

Risk of wound infection of dirty wound

30-35%

Diabetes screening in healthy population begins at what age in healthy population?

45 years

Surgical bleeding does not usually occur unless platelet count <

50,000 - spontaneous bleeding = <10,000 - general surgery > 50,000 - neurosurgery > 75,000

Age of child? - on full oral feedings of formula form bottle - 2-3+ deep tendon reflexes that symmetric with no Babinski present - palmar, rooting, parachute, & asymmetric tonic neck reflexes absence - Moro present - pulls-to-site with no head lag - sits without support - can roll supine to prone but not reverse - can grasp rattle & reach for her bottle - smiles at her mom's face - has single syllable babble

6 mo old - no longer has palmar grasp (gone by 3 mo old) - no longer has rooting reflex (lessens after first mo) - moro reflex lasts until 6 mo - asymmetric tonic neck disappears at 6-7 mo - parachute does not begin until 7-8 mo = lasts for life

Recommended duration of treatment for S aureus-associated valve infective endocarditis

6 wks - IV vancomycin or daptomycin

normal apnea-hypopnea index (AHI)

<5 - CPAP if symptomatic

Recognize *second-degree atrioventricular block (Mobitz II block)*

= regular PR-QRS intervals until dropped beats - site of block most often below AV nodal (infranodal) - atrial rate usually 60-100 beats/min - ventricular rate slower than atrial rate - common etiology = acute coronary syndrome that involves branches off left coronary artery Therapy - transvenous pacer

Pts with secondary HT due to renal disease treated first with

ACEI (or ARB)

Stage I HT defined as

BP greater than 140/90 mmHg & less than 159/99 mmHg - *first line therapy = exercise, dietary modification, & thiazide diuretic*

Causes short, episodic vertigo provoked by particular head movements.

BPPV - caused by otoliths in semicircular canal producing sensation of movement despite not moving - can be confirmed by nystagmus elicited during Dix-Hallpike maneuver

ATN

BUN to creatinine 10:1

First-line treatment for status epilepticus bc they can rapidly control seizures

Benzodiazepines - increase chloride conductance in CNS GABA(A) receptors --> decrease neuronal excitability - other drugs to treat status epilepticus = phenytoin (or fosphenytoin), barbiturates, propofol

Drug that may help bladder contractility in MS patients. Mildly bladder-sensitive cholinergic agent.

Bethanechol

Shock: high CVP + low cardiac output

Cardiogenic shock

High fever with chills + RUQ pain + jaundice

Charcot's triad - cholangitis - elevated alk phosphatase - + mental status change = Reynolds' pentad - should be referred for ERCP = diagnostic & therapeutic

What should be done to minimize interruptions in chest compressions during CPR?

Continue CPR while defibrillator is charging

In pregnant pts with psychotic depression with increased risk for suicide, most expeditious treatment to protect mother and fetus is

ECT

Hct equation

Hcg x 3

Lab abnormalities of Vitamin D-resistant rickets

Hereditary *hypophosphatemic* rickets - X-linked disorder Labs - *hypophoasphatemia* - normal serum calcium - increased PTH, vitamin D, alkaline phosphatase

Helps decrease inflammation and spinal cord compression. Administered before MRI scan and surgical evaluation are started.

High-dose dexamethasone

Free air under diaphragm, seen on upright film, along with sudden onset of abdominal pain, should raise suspicion for perforated viscus. Treatment?

Immediate laparotomy

Systemic Sclerosis Classification: less lung, kidney, heart dz, serious GI dz, *pulmonary hypertension*

Limited dz - gradual dev't of CREST features

Most sensitive test for subarachnoid hemorrhage beyond 12 hours after onset of symptoms

Lumbar puncture with CSF spectrophotometry - can detect xanthochromia = release of pigment by lysed RBCs

Increases risk of falsely low B-type natriuretic peptide (BNP)

Obesity

Early diagnosis of avascular necrosis be made with

MRI scan - plain x-ray films can be diagnostic in advanced stages

Presence of urine metabolites of both epi & NE implies that adrenal gland is location of pheochromocytoma; this can be confirmed with

MRI scan of adrenals

Most common cause of pneumonia in children age >5 is

Mycoplasma pneumoniae - radiograph shows bornchial thickening & infiltration in lower lobes - treatment = macrolide (azithromycin) or tetracycline (don't use in pts age <8)

Breast cancer invading through skin is classified as inflammatory. Best treatment strategy?

Neoadjuvant chemotherapy followed by modified radical mastectomy

Mothers who acquire this bacteria may experience flu-like illnesses, with headache, malaise, fever, nausea, vomiting, & generalized body aches. Early neonatal can cause amnionitis with characteristic brown, murky amniotic fluid.

Neonatal listeriosis - ampicillin necessary for treatment = may be combined with aminoglycoside

ECG finding pathognomonic of hypothermia

Osborn wave - upward deflection following R wave - lead II - J wave of Osborn

Condition of overexertion of quadriceps when tibial tubercle is still developing, resulting in knee pain in children age 10-15 yo

Osgood-Schlatter dz - management = conservative = rest & ice after activities - physical activity should not be discontinued

Most appropriate management of prostate cancer follow-up

PSA measurement every 6-12 months - as many as 75% of recurrences discovered by 5th year of follow-up - recurrent dz after definitive therapy of early-stage prostate cancer is incurable, but significant palliation can be achieved with hormone deprivation therapy & chemotherapy

Occurs when foreskin of uncircumcised penis remains retracted for prolonged period of time causing swelling & pain & may lead to ischemia if uncorrected

Paraphimosis - correction via manually reducing foreskin to its original location

Autoimmune attack against desmosomes. Oral mucosa involved.

Pemphigus vulgaris - Nikolsky sign - treat with immunosuppressives

Treatment for tertiary syphilis

Penicillin G benzathine 3 doses of 2.4 million units IM at 1-wk intervals for: gummas, aortitis Penicillin G IV for 10-14 days for: neurosyphilis

What action increases chance of successful conversion of ventricular fibrillation?

Providing quality compressions immediately before defibrillation attempt

clinical triad of hypotension, JVD with clear lung exam, & chest pain is highly specific for

right ventricular infarction - management = *volume loading with aggressive fluid administration* to increase preload & cardiac output

Atypical antipsychotic indicated for management of psychotic disorders. Also indicated for us in combo wiht antidepressants to treat psychotic depression. One common side effect of this drug is metabolic syndrome which includes significant *weight gain*

Quetipaine

Rheumatoid factor most closely associated with what dzes?

Rheumatoid Arthritis Sjogren's Syndrome Cryoglobulinemia - hepatitis B, C

Suspect what pathogen in pt with fever, headache, &/or signs of meningeal irritation with recent hx of CNS shunt manipulation

S epidermidis - most common cause of shunt infections

3 countries with lowest infant mortality

Singapore, Sweden, Hong Kong

Upper GI bleeds are approached similarly to lower GI bleeds, with stabilization of unstable pt utilizing transfusion of blood products as necessary. In hemodynamically stable pts, workup starts with gastric lavage using nasogastric (NG) tube, followed by

direct visualization with upper endoscopy

57 yo woman being seen for management of her AD polycystic dz. She is doing well without uremic symptomatology. ROS: Denies: nausea, vomiting, metallic taste, weight loss Admits: swelling of LEs, fatigue PE: Gen: BP 150/90, HR 80, well developed Ext: 1+ pitting edema to shins Labs: 3 months ago: serum creatinine 2, eGFR 30 mL/min/m2 Today: Serum creatinine 3, eGFR 15 mL/min/m2 What stage of CKD does she have? How does staging help us?

Stage IV/V CKD (severe failure) - at high risk of progression to failure - needs intensive nephrologic counseling & management Management - target < 140/90 BP; <130/80 with nephrotic range proteinuria - RAAS blockade indicated for proteinuria - diuretics for volume overload - CCBs useful

Used to reduce total body potassium or for chronic management after acute hyperkalemia is resolved

kayexalate and loop diuretics

Magnesium sulfate is excreted by

kidneys - dosing needs to be adjusted in pts who have renal insufficiency

Recognize radiograph of tuberculosis

Tuberculosis risk factors: - HIV infection - homelessness - alcoholism - group living reactivational/secondary TB signs... - productive cough - fever - cavitary lesion in upper lobe diagnosis should be confirmed with... - sputum microscopy - bronchoalveolar lavage

Accounts for paradoxically split S2. Diagnostic for ventricular preexcitation by accessory AV connection, with short P-R interval, prolonged QRS duration, & slurred onset of QRS interval.

Wolff-Parkinson-White syndrome - in symptomatic patient with recurrent palpitations or syncope, radiofrequency ablation of accessory pathway likely to provide most definitive improvement

Acute epididymitis should be treated with

abx & scrotal support + bed rest, scrotal elevation, analgesics, ice packs

Differential diagnosos for lower abdominal pain in young, sexually active woman

acute appendicitis, pelvis inflammatory disease, ruptured ectopic pregnancy, ovarian torsion, corpus luteum cyst formation - presence of normal vital signs, normal labs, benign physical exam = distended *corpus luteal cyst* most likely cause of unilateral lower abdominal pain

Acute complication most commonly presenting 3-5 days after MI

acute papillary muscle rupture - mortality rate = high - emergent surgical intervention = treatment of choice - presenting symptoms = pansystolic murmur radiating to axilla, sudden drop in BP, & acute HF

Acid-based disturbance most often seen with pulmonary embolism, acute asthma, and chest trauma

acute respiratory alkalosis with hypoxemia (high pH, low pCO2, low pO2)

First-line treatment for neurocysticercosis

albendazole for infection & corticosteroids for inflammation

Treatment of BPH that compresses urethral sphincter involves bladder drainage with urinary cath as well as

alpha-blocker

Pts who have recent exposure to hep A should...

always receive hepatitis A vaccine if not previously immunized - most hepatitis A transmission occur through household contacts

An acute exacerbation of chronic bronchitis (ACEB) in pt who has COPD that results from Streptococcus pneumoniae & Moraxella catarrhalis should be treated with

amoxicillin/clavulanate

When is the varicella vaccine recommended?

any visit on or after the first birthday (12-15 mos old) for susceptible children (those who have not had virus) second dose = 4-6 years

Most of the mortality and morbidity with Marfan syndrom are related to cardiovascular manifestations, like

aortic root dilatation - accompanied by aortic insufficiency - typically doesn't start until adolescence & young adulthood - repeat echo measurement of aortic root diameter over time needed in order to prevent aortic root aneurysm

Any symptomatic adult with aortic stenosis requires...

aortic valve replacement - high risk of mortality when symptoms develop - balloon valvuloplasty reserved for those who are poor surgical candidates

resting hypoxemia defined as

arterial PO2 of 55 mmHg or less or arterial oxygen saturation of 88% or less - oxygen administered at least 15 h/day

Appropriate treatment for secondary syphilis

benzathine G 2.4 million units IM in single dose - characteristic rash develops 1-3 mos after infection

PCP-induced agitation & psychosis treated with

benzodiazepines (diazepam, *midazolam*, lorazepam) or haloperidol - benzos preferred bc antipsychotic meds (chlorpromazine, haloperidol) can amplify hyperthermia, dystonic reactions, anticholinergic effects, & can ever lower seizure threshold) - cranberry juice or ascorbic acid --> acidifies urine --> speeds up elimination of drug

Mastitis in breastfeeding woman should be treated with

beta-lactamase-resistant drug, like *dicloxacillin*

What is defined as extremely low birthweight (ELBW)?

birth weight less than 1,000 g (2 lb, 3 oz) - most born at less than or equal to 27 wks' gestational age - at particular risk for *intraventricular hemorrhage (IVH)* via vulnerability of germinal matrix & bc protective cerebral autoregulartion present in older babies has not yet developed

Pagent disease presents with pathologic fractures, high output heart failure, and diminished hearing. Classic lab abnormality is elevated ALP with normal calcium. Treatment involves

bisphosphonates

All positive screens of phenylketonuria need to be followed with what lab?

blood phenylalanine level

Most common tumors that metastasize to bone

breast, prostate, lung

Mechanism of hypercalcemia in patient with primary hyperparathyroidism

calcium mobilized from bone with increased GI absorption & increased kidney absorption - most common cause of hypercalcemia diagnosed in outpatient setting - Often diagnosed incidentally by routine blood testing before dev't of symptoms

Treatment of early-stage, aggressive, diffuse large B-cell non-Hodgkin lymphoma

chemotherapy (usually cyclophosphamide, doxorubicin, vincristine, prednisone with rituximab [R-CHOP]) & immunotherapy with rituximab - radiation therapy often shorter course of chemoimmunotherapy in pts with localized or bulky dz

New hemothorax in setting of hypotension indicates urgent need for

chest tube placement

Pt who has Crohn's dz can develop symptoms of small bowel obstruction, which is a common and important complication as a result of

chronic transmural inflammation, which both partially destroys normal bowel and *constricts it with thick bands of fibrosis*

Once malignancy is ruled out, what is the treatment for hemorrhoids?

conservative treatment with sitz baths, stool softeners, stool bulking agents - surgery reserved for patients who don't respond to medical treatment or who have advanced-stage dz

Familial melanoma syndrome most likely associated with germline mutation in

cyclin-dependent kinase inhibitor 2A (CDKN2A) gene - also known as p16INK4/p14ARF - proteins coded for are tumor suppressor genes = serve as checkpoints in cell cycle - loss of function of the proteins (loss of heterozygosity) --> unchecked cellular profileration

In a child who has failure to thrive, digital clubbing, chronic diarrhea &/or cough, rales on physical exam, & diffuse bronchiectasis on chest radiography, suspect...

cystic fibrosis

Tension pneumothorax requires immediate

decompression followed by chest tube placement - imaging never precedes immediate treatment of tension pneumothorax

Adenosine is drug of choice in managing SVT unresponsive to carotid massage & other vagal maneuvers. If adenosine fails to terminate SVT after 3 attempts, the next step should be to ...

decrease rate of AV nodal transmission with IV beta-blockers, *calcium-channel blockers*, or digoxin

All forms of allergic contact dermatitis (reactions to soap, detergents, latex, sunscreens, neomycin, jewelry) are mediated by

delayed-type (cell-mediated) hypersensitivity = type IV HS rxn - urushiol binds to cell surface proteins = recognized as foreign Ag by T-cell receptor on memory CD4+ T lymphocytes - linear, erythematous plaques with overlying vesiculation = hallmark of poison ivy - treatment = antihistamines & topical steroids

Next step after determining low serum B12...

determine etiology before treatment - hx suggestive of pernicious anemia (dyspepsia, older patient, autoimmune conditions)? --> determine *serum anti-intrinsic factor Abs & parietal cell Abs*

Most common extra-articular manifestation of RA

dry eyes & dry mouth

High alkaline phosphatase, high total bilirubin, anemia, & stool that is occult blood-positive should bring to mind

duodenal tumor that obstructs common bile duct - ampulla of Vater = most likely location

Ascending cholangitis presents as Charcots triad: RUQ abdominal pain, jaundice, fever; additional symptoms of shock & altered mental status constitute Reynold's pentad. Management is

emergency decompression of biliary tree via ERCP or surgical exploration - cholecystectomy indicated but can be deferred to later time once biliary tree has been decompressed

Any pt who has alarm symptoms & long-standing GERD requires

endoscopy with biopsies to guide further management decisions

Unilateral scrotal pain that is relieved by lifting testes and is accompanied by fever & ho multiple sexual partners points toward a diagnosis of

epididymitis - any male presenting with acute testicular pain should always get Doppler sonogram to rule out testicular torsion

Anaphylaxis treatment

epinephrine IM 1:1000 = immediate first step - IV fluids, steroids, antihistamines = adjuvant treatments

Most abdominal gunshot wounds require immediate

exploratory laparotomy

Sebaceous cell carcinoma occurs most frequently in upper lids of what individuals?

females over age 50

Needlestick transmission in unvaccinated pt...

hepatitis B > hepatitis C > HIV > other viruses & microorganisms

Treatment for mild RA

hydroxychloroquine or sulfasalazine or methotrexate

Indications for dialysis in chronic kidney disease

hyperkalemia acidosis fluid overload pericarditis mental status changes - *ineffective at lowering phosphate & increasing calcium* - hyperphoaphatemia, hypocalcemia, & resultant secondary hyperparathyroidism best treated with reduced phosphate diet, gut phosphate binders, calcitriol, & oral calcium

Begun immediately for any symptomatic heart block or bradycardia

immediate transcutaneous pacing

Infertility is defined as

inability to achieve pregnancy after 12 mos of unprotected & frequent intercourse in women age <35 (after 6 mos in women age >35) Standard work-up for fertility - semen analysis to screen for common causes of male factor infertility - bc of variability of semen quality, at least 2 samples should be collected for semen analysis 4-6 wks apart

azotemia

increased BUN - uremia = increased BUN + symptoms + decreased erythropoietin (anemia)

In pts who have severe HERD & who fail med therapy, surgical treatment of choice is

laparoscopic Nissen fundoplication - effective in improving symptoms in 85-90% of pts

Intraoperative dev't of coagulopathy during prolonged abdominal surgey for multiple trauma with multiple transfusions is treated empirically with platelet packs & fresh-frozen plasma. If there is hypothermia & acidosis in addition to coagulopathy, what's the next step?

laparotomy has to be terminated, with packing of bleeding surfaces & temporary closure with towel clips - operation can be resumed later when pt has been warmed & coagulopathy treated

Diagnostic and therapeutic for patients with suspected normal pressure hydrocephalus

large-volume lumbar puncture (30-50 mL removal of CSF)

With present evidence of proliferative diabetic retinopathy, what should be performed to avoid blindness?

laser photocoagulation

Always nonreassuring, indicating current or impending fetal acidemia. In Uteroplacental insufficiency.

late decelerations

Corresponding coronary artery: ST elevation in V2-V4

left anterior descending artery - anterior wall

Eclampsia is end result of preeclampsia spectrum disorders. Initial seizure activity during eclampsia usually short duration & often occurs in controlled setting. Treatment is therefore primary directed at prevention of recurrent convulsions rather than control of initial seizures. Drug of choice is

magnesium sulfate

3 areas of knee commonly affected by osteoarthritis

medial tibiofemoral - pain walking on flat - genu varus - quadriceps weakness - joint line tenderness - crepitus on passive flex-extension lateral tibiofemoral - difference = genu valgum deformity femoropatellar - pain walking up & down stairs - crepitus on passive flex-extension - pain via femoral condyles or subluxation - x-ray views = sunrise or merchant views

Most common valvular involvement of all children & adolescents with Marfan syndrome

mitral valve prolapse with some degree of mitral insufficiency

Hallmark of ATN

muddy brown granular & renal tubular epithelial casts in urine

Parasympathetic overdrive (increased secretions, bradycardia, hypotension) in acute setting should raise concern for

organophosphate poisoning - atropine with pralidoxime = treatment of choice - differentiate from anticholinergic toxicity (dry hot, confused pts)

Factors associated with poor prognosis in sarcoidosis

osseous involvement lupus pernio chronic hypercalcemia chronic pulmonary sarcoidosis black race

Appx 2/3 of all arthritic dzes

osteoarthritis - most common joint disorder in US

Cirrhosis patients with new ascites, fever, and leukocytosis need a

paracentesis - to evaluate for spontaneous bacterial peritonitis

Current treatment for hepatitis C

peg-interferon + ribavirin antiviral meds - especially those who have measurable HCV & liver biopsy specimen showing portal or bridging fibrosis w/ at least moderate inflammation & necrosis

Indicated for type 2 second-degree heart block & third-degree heart block

permanent pacemaker placement

Exercise treadmill ECG testing for stable angina is first-line; if baseline ECG is abnormal (ex. left axis deviation) or cannot exercise, pursue...

pharmacologic or echocardiographic stress testing

Duchenne muscular dystrophy is an X-linked genetic disorder characterized by progressive muscle weakness due to mutations of gene coding for

plasma membrane protein (dystrophin) of muscle fibers

shoulder & hip girdle pain in morning. older than 50. high ESR. treatment...

prednisone-low dose

If pt presents with pharyngitis, best initial step is to order

rapid strep test - >95% specific

Most appropriate test in child presenting with recurrent UTIs who has anatomical abnormality & vesicoureteral reflux (VUR)

renal ultrasound - urinary tract anomaly - look for hydronephrosis voiding cystourethrogram (VCUG) - diagnoses & evaluates severity of reflux

Best initial step to evaluate UTI, initial, recurrent, or febrile UTIs in children

renal ultrasound (RUS)

Treatment of choice for renovascular HT via fibromuscular dysplasia

renovascularization via angioplasty

What should be started as soon as maternal hypothyroidism is identified?

replacement therapy with thyroid hormone (thyroxine) - 50-100 ug/day - follow-up thyroid function tests checked in 4-6 wks - levothyroxine - hypothyroidism predisposes to: early pregnancy loss, preeclampsia, placental abruption, low birth weight, perinatal mortality, neuropsych impiarment

Treatment for carpal tunnel syndrome

rest & wrist splints - NSAIDs provide additional relief - steroid injections or surgical release if conservative management doesn't suffice

3% IV sodium chloride indications

seizures - short, fast

Zollinger-Ellison syndrome (gastrinoma) characterized by watery diarrhea & refractory ulcers or multiple ulcers occurring in distal duodenum or jejunum. First step in diagnosis is

serum gastrin level after abstaining from antisecretory therapy for 1 wk - levels >1,000 pg/dL = diagnostic of Zollinger-Ellison syndrome

Pericarditis radiates to

shoulders

most commonly diagnosed cancer in men & women

skin cancer

patellofemoral compt's - OA evaluted by

sky view

enthesitis present in

spondyloarthropathies - sites of attachment inflamed

Headache with nuchal rigidity in setting of significantly elevated BP points toward diagnosis of

subarachnoid hemorrhage - first step = reduce BP, with target range of 160-170 mmHg for systolic BP - IV nitroprusside = drug of choice in HT emergencies

Hepatic adenomas are *cold* on

sulfur colloid scans - shows no uptake in adenomas, but show uptake in FNH Hepatic adenomas - can occur in patients on OCPS or steroids - benign but can rupture - surgical resection for large lesions = treatment of choice

If a pt with hypertrophic cardiomyopathy remains symptomatic after beta-blocker and CCB, pt is eligible for what treatment?

surgical *myectomy* - conventional indication = resting left ventricular outflow tract gradient of more than 50 mmHg in patient refractory to medical therapy

Primary causes of air embolism

surgical procedures

If umbilical cords for multiple fetuses are fused, what can result?

twin-twin transfusion syndrome - one twin inadequately perfused = increased risk of fetal complications

Microhematuria following minor trauma may be indicative of a congenital anomaly of genitourinary system First step (cost effective, noninvasive) is an

ultrasound - if no anomaly found, repeat urinalysis should be performed over next 2 wks to demonstrate expected clearing of hematuria - gross hematuria, microscopic hematuria of greater than 50 RBCs per high power field, deceleration injury, or flank pain with or without bruising = suggestive of more serious urologic trauma --> study of choice = spiral CT

Recognize *ventricular fibrillation*

unusual figure

Lyme dz vector vs pathogen

vector = *Ixodes* species pathogen = Borrelia burgdorferi

Maximum interval for pausing chest compressions

*10 seconds* High-Quality CPR - compress chest hard & fast - allow complete chest recoil after each compression - minimize interruptions in compressions (10 seconds or less) - avoid excessive ventilation - switch compressor every 2 minutes or earlier if fatigued

57 yo woman has palpitations, chest discomfort, & tachycardia. Monitor shows regular wide-complex QRS at rate of 180/min. She becomes diaphoretic, & her BP is 80/60 mmHg. What action do you take next?

*Perform electrical cardioversion*

Recognize *pleural plaque*, which is seen in ...

*asbestosis*

Good alternative diuretic therapy for intubated patients with severe metabolic alkalosis

Acetazolamide

Classic CSF findings associated with Guillain-Barre syndrome

Albuminocytologic dissociation - *elevated protein levels in CSF* - normal WBC count

Commonly used in cement spacers to maintain normal anatomic alignment once prosthetic joint has been removed for duration of antibiotic therapy.

Antibiotic-impregnated polymethylmethacrylate - antibiotic agent achieves high concentrations in surrounding tissues as it elutes from polymethylmethacrylate - spacer removed at time of reimplantation

Can present acutely (usually trauma, most common) or progressively (usually tumors). Pts have ipsilateral spastic paralysis, ispilateral Babinski, ipsilateral loss of position and vibration sense, and contralateral loss of pain & temp below level of lesion.

Brown-Sequard syndrome

Pt has longstanding UC and has now developed pruritus in setting of elevated alkaline phosphatase. This is consistent with diagnosis of ____ diagnosed by ____.

PSC --> involves both intra- & extrahepatic ducts = diagnosed by *ERCP* --> shows multifocal stricturing & dilation of intrahepatic &/or extrahepatic bile duct = "beads on string' appearance - young men - associated with UC - triad = fatigue, pruritus, jaundice - liver transplant = only curative treatment

Arsenic exposure increases risk for

SCC

Most appropriate intervention for rapidly deteriorating patient who has sinus tachycardia in lead II ECG?

Synchronized cardioversion

RA + symptoms of lupus

TNF inhibitor (ex. infliximab) - side effect - stop drug!

Most common cancer found in smokers with asbestos exposure

adenocarcinoma and squamous cell carcinoma

Atypical antipsychotics most likely to cause NMS

risperidone

Cerebral palsy is a disorder characterized by non-progressive motor impairment and often accompanied by other conditions, including:

trouble with feeding, *constipation* cognitive disability mental retardation visual impairment skeletal malformations communication disorders seizures poor oral-motor function poor growth and development

Bloody urine visualized on attempted placement of Foley cath should raise concern for

urethral injury

Histoplasmosis is a fungus found in soil with bird or bat feces (caves) & causes interstitial pneumonia with symptoms of fevers, chills, headache, myalgia, anorexia, and cough. Diagnosis is made with

urine & serum polysaccharide antigen test - severe dz treated with amphotericin B or itraconazole

First-line treatment of hyperemesis gravidarum

pyridoxine-doxylamine followed by promethazine &/or ondansetron if N/V refractory

Empiric therapy for toxoplasmosis of brain

pyrimethamine & sulfadiazine - after 2 wks of therapy, if pt has not improved, biopsy of brain lesion indicated to evlauate for lymphoma

Treatment for postoperative ileus

usually resolves faster than obstructive ileus with *maintenance of nothing-by-mouth (NPO) status & insertion of nasogastric tube to decompress*

Supracondylar fractures are prone to

vascular & nerve injuries - specifically the brachial artery & median nerve

Allergic contact dermatitis to metal caused by HS to nickel caused by what type of rxn?

*Delayed hypersensitivity* (Type IV delayed HS rxn) - takes hours to reach max - occurs in absence of demonstratable Ab in serum - mediated by T lymphocytes

AKI

- Cr>0.3 mg/dL within 48 hours - >1.5 baseline within 7 days - urine volume <0.5 mL/kg/hr

Most appropriate treatment in patient with breast cancer + brain metastasis + increased intracranial pressure

glucocorticoids (dexamethasone) & radiation therapy

Prior to contrast procedures, patients at risk for contrast nephrotoxicity should receive hydration with

normal saline - before cath

Normal shedding of endometrium after delivery of placenta. May last up to 8 wks in some pts

Lochia - normal progression: bright-red bleeding (lochia rubra) --> pinkish-brown (lochia serosa) --> whitish-yellow (lochia alba)

Infants who have newborn screening in first 24 hours of life should have it repeated when?..

again within 2 weeks of life

Diagnosis of osteogenesis imperfect confirmed with

biochemical testing of collagen in cultured dermal fibroblasts & DNA analysis

Instructions to pt regarding smoking cessation once bupriopion has started include

gradual discontinuation of smoking during second week of treatment while dose of bupropion is titrated up to full therapeutic dose - recommended dosage of bupropion for smoking cessation = 300 mg/day given as 150 mg, twice daily - dosing should begin at 150 mg/day for first 3 days, then increased to 300 mg/day - initiate treatment while pt is still smoking & set target date for smoking cessation within first 2 wks of treatment --> continue therapy for 7-12 wks - if pt has not reduced smoking by 7th week, it is unlikely he/she will quit during attempt = therapy should be discontinued

Procedure of choice for both diagnosis and treatment of foreign-body aspiration in children

rigid bronchoscopy under general anesthesia

Most common type of malignancy of lips and oral cavity

squamous cell carcinoma

54 yo man presents to doc with epigastric pain that radiates to back. Pain has become progressively worse over past 12 wks. He also has noticed yellowing of eyes & skin. His stools have appeared white & his urine is tea colored. There has been weight loss, but no fevers or night sweats. He has persistent nausea & anorexia. He does not use alcohol, tobacco, or illicit drugs. He has not noticed hematemesis, melena, or hematochezia. On physical exam, he appears thinner than at his last visit & he has scleral icterus. His lung & heart exams are normal. There is pain on palpation of epigastrium, but no hepatosplenomegaly is noted. His neuro exam is nonfocal. Liver function tests show: AST = 56 U/L ALT = 45 U/L Alkaline phosphatase = 569 U/L Bilirubin, total = 8.2 mg/dL Bilirubin, conjugate = 7.5 mg/dL Best initial step in management of this pt?

*Abdominal CT scan* - can be used to stage for resectability & to detect liver mets Pancreatic head tumor compressing common bile duct - obstruction of biliary flow into duodenum

31 yo woman, gravida 3, para 3, comes to doc for placement of IUD. She is in monogamous relationship & has no ho STD or any other med probz. She takes no meds & has no drug allergies. Physical exam is normal, & gonorrhea & Chlamydia testing performed within last mo was negative. Copper T-380 IUD placed without complication. Most appropriate time to replace this pt's IUD?

*10 years* IUD - inhibition of sperm transport, inhibition of implantation of zygote, stimulation of endometrial inflammation - gradually releases copper - can be replaced after 10 years - contraindicated in those with Wilson dz or hx of copper allergy

Always the next best step in management for a pt with acute pulmonary edema as a result of heart failure

*100% oxygen* - important to ensure sufficient oxygenation bc this will have immediate benefit for pt who is acutely short of breath

What is the recommended duration of therapeutic hypothermia after reaching target temperature?

*12 to 24 hours*

You are caring for a patient who has been admitted to the hospital for rapid atrial fibrillation. The cardiologist has tried to treat the patient with calcium channel blockers. But the fast heart rate is now causing the BP to drop as well. The team is preparing to sedate & synchronize cardiovert. How many joules will the cardiologist request?

*120 to 200 joules* = 2015 recommended amount of joules for rapid atrial fibrillation - SVT = 50-100 joules recommended

Patient is in refractory ventricular fibrillation & has received multiple appropriate defibrillation shocks, epinephrine 1 mg IV twice, & an initial dose of amiodarone 300 mg IV. Patient is intubated. What best describes the recommended second dose of amiodarone for this patient?

*150 mg IV push* Adult Cardiac Arrest Algorithm Drug Therapy: - Epinephrine IV/IO dose = 1 mg every 3-5 minutes - Amiodarone IV/IO dose: first dose = 300 mg bolus. second dose = 150 mg

22 yo woman, gravida 2, para 0 at 8 weeks' gestation, comes to doc for prenatal visit. She has no complaints. Her first pregnancy resulted in 22-wk loss when she presented to her doc with bleeding from vagina, was found to be fully dilated, & delivered the fetus. Exam of pt today is unremarkable. She declines to have cerclage placed. Most appropriate time to begin regular cervical exams?

*16 weeks* Obstetric hx consistent with abnormal cervical competence - diagnosis may be made when pt has hx of painless cervical dilation in 2nd trimester = cause of 2nd-trimester pregnancy loss & preterm delivery - may be congenital &/or acquired Cervlage = procedure in which suture placed at level of internal os after bladder dissection (Shirodkar) or as high up on cervix as possible (McDonald) - prophylactic cerclage placed b/t 12 & 16 wks' gestation - placed --> should not engage in sexual intercourse, prolonged standing, or heavy lifting - this pt refused to have cerclage placed --> she needs to be followed closely to ensure that any signs of cervical incompetence are detected as soon as possible - regular exams of cervix, either digitally or with ultrasound, should begin at 16 weeks, bc cervical incompetence becomes concern during 2nd trimester

How often should you switch chest compressors to avoid fatigue?

*2 minutes* - alternate with compressor every 5 cycles or 2 minutes (or earlier if signs of fatigue set in), ideally during rhythm analysis

Patient presents to ED with dizziness & SOB with sinus bradycardia of 40/min. Initial atropine dose was ineffective, & your monitor/defibrillator is not equipped with transcutaneous pacemaker. Appropriate dose of dopamine in this patient?

*2 to 10 mcg/kg per minute*

Should be obtained in all pts presenting with nephritic syndrome

*24-h urine protein* - prompt initiation of prednisone therapy = first step in management Nephrotic syndrome - heavy proteinuria (>40 mg/m^2/h) - hypoalbuminemia (<2.5 g/dL) - edema - hyperlipidemia

Treatment for polycythemia vera

*aspirin & phlebotemy* - low dose aspirin = decreased risk of thrombosis - phlebotomy = highest overall survival rates = should be performed once or twice weekly until target Hct value of less than 45% achieved, followed by intermittent phlebotemy to maintain hematocrit value b/t 40-45% - 97% of pts with PV = activation of JAK2 (JAK2 V617F mutation) - serum EPO often suppressed

58 yo man who has ho HT comes in for evaluation of recurrent nephrolithiasis. According to patient, he first had kidney stone 10 years ago. At that time he had presented to ED with left-sided flank pain, hematuria, & vomiting. An IVP done at that time revealed a 10-mm stone in left ureter. He had undergone surgical lithotomy at that time. Since that time he has had multiple stones on both sides. On two occasions he ha extracorporeal shock wave lithotripsy (ESWL). Several times he has passed small stones. Appx 1 year ago, he had stone analysis done that revealed the stone composition to be calcium oxalate. Patient takes amlodipine & lisinopril at home. He also takes NSAIDs whenever he has bout of renal colic. He denies taking any herbal meds. His father also had ho recurrent nephrolithiasis. Physical exam unremarkable. Lab results show: CBC with differential RBC count = 4.4 million/mm^3 Hgb = 14.5 g/dL HCT = 45% HbA1c = 3% WBC = 9000/mm^3 Neutrophils = 54% Eosinophils = 1% Basophils = 0.2% Lymphocytes = 26% Monocytes = 5% Blood chemistry Sodium = 136 mEq/L Potassium = 4.5 mEq/L Chloride = 100 mEq/L Magnesium = 2 mEq/L Calcium = 9 mg/dL Bicarbonate = 26 mEq/L Uric acid = 7.6 mg/dL BUN = 16 mg/dL Creatinine = 1 mg/dL PTH = 450 pg/mL Urinalysis shows urine pH of 5.5. There are no crystals or casts seen. What additional tests should be ordered at this time?

*24-hour urine for calcium, citrate, oxalate, & creatinine* Recurrent nephrolithiasis - should undergo complete metabolic evaluation = determine risk factors for stone formation

16 yo girl brought to ED by ambulence after she was extracted from burning vehicle that was in an accident on local highway. She was only person in car, which burst into flames after it was rear-ended at high speed. She swerved off road & collided with side railing. When abulence arrived, she was unconscious in driver's seat. On arrival at ED, patient is in moderate resp distress. Her BP is 80/40 mmHg, pulse is 120/min, & respirations are 30/min. After securing patient's airway & administering oxygen & IV fluids, doc evaluates extent of sustained burn injury. There is diffuse erythema & edema of patient's face, and most of her scalp hair is scorched with some blistering of underlying skin. Both arms show diffuse erythema, edema, & areas of extensive blistering. Rest of body shows no significant burns. Estimated body surface area of burn?

*27* - first-degree burns of face - superficial second-degree burns of scalp & both arms Rule of 9s = 27% - head & upper limbs = 9% each - lower limbs = 18% each - trunk = 36% (18% for front & 18% for back) - rule of palm = burns that involve less than 10% body surface area - child's palm = 1% of child's body surface area

A 66-year-old woman is evaluated in the emergency department for a 1-day history of nausea, vomiting, weakness, and confusion. Today, she has difficulty walking and has fallen several times. Medical history is significant for a recent diagnosis of depression for which fluoxetine was started 3 weeks ago. She takes no other medications. On physical examination, the patient appears chronically ill. She is unable to stand without assistance because of generalized weakness. Temperature is normal, blood pressure is 130/78 mm Hg and pulse rate is 68/min without orthostatic changes; respiration rate is 18/min. Cardiopulmonary examination is normal. There is no peripheral edema. The neurologic examination is nonfocal. Lab studies: Serum creatinine = 0.9 mg/dL (79.6 umol/L) Serum sodium = 115 mEq/L (115 mmol/L) Glucose, random plasma = 105 mg/dL (5.8 mmol/L) Serum osmolality = 245 mOsm/kg H2O Urine osmolality = 408 mOsm/kg H2O Urine sodium = 90 mEq/L (90 mmol/L) What is the most appropriate treatment?

*3% Saline infusion* - rapidly increases sodium level - typical goal for treating symptomatic hyponatremia = to increase sodium level to appx 120 mEq/L (120 mmol/L) - increase in serum sodium level by appx 4-6 mEq/L (4-6 mmol/L) over first 24 hours is sufficient in symptomatic patients Hypo-osmolar hyponatremia - rapid increase in serum sodium level using 3% saline infusion indicated - presentation consistent with SIADH as cause of hyponatremia, likely from recently starting antidepressant med - low serum osmolality with urine sodium level exceeding 40 mEq/L (40 mmol/L) & urine osmolality that is inappropriately concentrated relative to her serum osmolality (above 100 mOsm/kg H2O & usually greater than 300 mOsm/kg H2O) without evidence of hypovolemia

What is the recommended target temperature range for achieving therapeutic hypothermia after cardiac arrest?

*32 C to 34 C*

Ms. Pearl brought into ED by EMS. She had pulled her car over to the side of the road, & she slumped over & went into cardiac arrest. EMS was called & bystanders initiated effective chest compressions. The paramedics arrived & defibrillated Mrs. Pearl back into a sinus rhythm. The team is now discussing the initiation of the hyperthemia temp management protocol. Recommendations for temp management?

*32-36 degrees Celsius for 24 hours* - temp management should be started within 6 hours of resuscitation, & maintained for 24 hours

Max radiation dose a pregnant woman may receive without any demonstrated harm to the fetus

*5 rad*

Vagal maneuvers have not been effective for this patient in supraventricular tachycardia (SVT). The patient's BP is stable. What is the dosing of adenosine for SVT?

*6 mg then 12 mg IV push fast, & flush* - may initially cause 10 seconds of asystole

What is the proper ventilation rate for patient in cardiac arrest who has advanced airway in place?

*8 to 10 breaths per minute*

Urine sodium concentration is prerenal azotemia

*<20 mEq/L* Prerenal azotemia - hypovolemia or hypoperfusion of kidneys - BUN:creatinine ratio > 20 - FENa < 1% - urine osmolarity > 500 mEq/L

52 yo man comes to clinic for routine healthcare checkup. Aside from being overweight, he has had no major medical problems. Recently he has noticed a mass in his left groin that he thinks gets worse when he strains or bears down. He states that the mass has been painful for the past couple of days and is only rarely noticeable. On physical exam his temp is 100.5 F, BP 110/60 mmHg, pulse 94/min, & respirations 14/min. When the pt performs Valsalva maneuver, a small mass can be felt pressing against the lateral aspect of the examiner's finger when the finger is invaginated in the external inguinal ring. Physical exam is otherwise unremarkable. What defects most likely account for this pt's current condition?

*A defect in the posterior wall of the inguinal canal* Direct inguinal canal - protrude directly through defect in floor of inguinal cnala - felt along lateral aspect of examiner's finger when finger placed in external inguinal ring

Your 68 yo patient who has emphysema is in telemetry unit. She is complaining of dizziness & fatigue. The patient's heart rate is 40 bpm, the BP is 96/54 mmHg, & respiratory rate is 18 breaths/minute. O2 sat remains unchanged at 94%. Appropriate first medication?

*A focused assessment, 12-lead ECG, & consider Atropine 0.5 mg* - atropine 0.5 mg given for unstable bradycardia - every 3 to 5 minutes with max of 3 mg

34 yo gravida 2, para 1 woman at 26 weeks' gestation comes to ED bc of painless vaginal bleeding that started 1 hour ago. She was having sexual intercourse with her husband when she saw small amount of bright red vaginal bleeding on sheets. Past med history unremarkable. Her temp is 37 C (98.6 F), BP is 110/67 mmHg, pulse is 87/min, & respirations are 12/min. Fetal heart tones are in the 150s. Pelvic exam shows that her perineum is grossly bloody. What is the most appropriate next step in management?

*Abdominal ultrasonography* Placenta previa = classically associated with painless vaginal bleeding possibly ppted by sexual intercourse - caused by low-lying placenta, which, partially, or completely covers cervical os

36 yo gravida 6, para 5 African-American woman at 34 weeks' gestation who has dichorionic diamniotic twin pregnancy comes to ED bc of vaginal bleeding that started while she was shopping in mall 1 hr ago. She doesn't have any pain, contractions, or leakage of clear fluid. She has had regular prenatal care, smokes six cigz a day, and uses cocaine occasionally. Aside from tobacco & cocaine use, her pregnancy has been uncomplicated. Her temp is 99 F, BP is 91/60 mmHg, pulse is 110/min, & respirations are 12/min. Physical exam shows that her pants & underwear are soaked with blood. Two large-bore IV caths are placed & bolus of 500 mL of Ringer's lactate is administered followed by infusion at rate of 200 mL/hr. Two fetal heart tones are auscultated & estimated to be in 140s. Most appropriate next step in management?

*Abdominal ultrasound* Placenta previa - multiple C sections & multiple gestations = risk factors - most pts present with painless vaginal bleeding - diagnosis based on ultrasound: transabdominal approach used first, with transvaginal approach used if diagnosis still in question

92 yo man with 45 yr hx of COPD intubated in ICU bc of bout of viral pneumonia that fails to improve after 72 hrs of abx. Although inspired fraction of oxygen is 100%, the pt's pO2 remains at 57 mmHg. PEEP added to allow inspired raction of oxygen. 12 hrs after intro of PEEP, pt suddenly becomes hypotensive. At same time, oxygen sat drops from 92% to 61%. On physical exam, his BP is 80/50 mmHg & pulse is 124/min. He has distended neck veins & distant heart sounds. What would also most likely be seen on pt's physical exam?

*Abence of breath sounds on affected side* Sudden hemodynamic collapse in pt who has developed tension pneumothorax while being given PEEP on respirator - sudden hypotension + decreased oxygenation --> tension pneumothorax = compressing venous return to right side of heart = JVD - tracheal deviation to opposite side on chest x-ray along with collapse lung = confirmed but rarely indicated

43 yo woman presents to ER complaining of productive cough of 3 days' duration with spiking fevers. She has 10 yr ho RA & takes NSAIDs to control her dz. Her vital signs in ED include: temp 101.5 F, BP 123/75 mmHg, pulse 98/min, RR 22/min. Her pulse oximetry reads 94% on room air. Physical exam reveals rhonchi in the right middle & lower lobes & normal heart sounds with regular rate & rhythm. Abdominal exam is nontender & nondistended. Spleen is palpable 2 cm below costal margin. She has rheumatoid nodules present on extensor surfaces of her fingers & lower legs bilaterally. Chest radiograph shows right lower lobe consolidation with effusion. What additional findings is most likely seen in this pt?

*Absolute neutrophil count <1,500/mm^3* - secondary to immune complex-mediated destruction in peripheral blood Felty syndrome = rare / 1% - complication seen in pts with RA - triad = high-titer RA, neutropenia (absolute neutrophil count <1,500/mm^3), splenomegaly - drugs of choice = gold or methotrexate, w / G-CSF reserved for severe neutropenia or unresponsive dz where splenectomy contraindicated or not possible

A 45-year-old woman is evaluated for a pigmented area on her toe. She reports that the dark area has been there for several months. There is no history of trauma, and the lesion is not painful. On physical examination, the vital signs are normal. The skin lesion is shown (Plate 23). Which of the following is the most likely diagnosis?

*Acral lentiginous melanoma* - can present in various forms, including longitudinal dark pigmented streak on fingernail or toenail, dark pigmentation of proximal nail fold, & dark pigmented patches on palms or soles - most common type among Asian & dark-skinned ppl - only 5% of melanomas

22 yo woman, gravida 3, para 1 (1 prior abortion) at 40 weeks' gestation confirmed by ultrasound at 18 weeks' gestation comes to ED with intense abdominal pain for past 8 hrs. Her pregnancy has been uneventful so far. In ED she has contractions every 3 minutes, lasting 50 seconds each. Physical exam shows she is 70% effaced, 6-cm dilated, & at zero station. She is transferred to labor & delivery, where an epidural is administered to help ease pain. Four hours later physical exam shows cervix to be 70% effaced & 6-cm dilated, & fetus at zero station. Fetal heart tracings are reactive. Most likely diagnosis?

*Active phase arrest of labor* - epidural anesthesia = possible cause of arrest of labor - amount of anesthesia should be reduced - if no change in cervical status occurs, pitocin augmentation should occur Active phase of labor - active phase starts after pt reaches >3 cm cervical dilation with rapid dilation Arrest - defined as no change in cervical dilation for >4 hours with adequate contractions & >6 hours with inadequate contractions

32 yo woman evaluated for 10 day ho malaise, RUQ abdominal discomfort, & progressive jaundice. She has no recent travel hx, does not drink alcoholic beverages or use illicit drugs, & takes no prescription or OTC meds. She has no other med probz. On physical exam, pt is awake & alert. Temp is 99.5 F, BP 106/68 mmHg, pulse rate 90/min, & RR 18/min. Scleral icterus noted, & liver enlarged & tender. Remainder of exam normal. Lab studies: INR 0.9 (normal range, 0.8-1.2) Albumin 3.8 g/dL Alkaline phosphatase 220 U/L Alanine aminotransferase 920 U/L Asparate aminotransferase 850 U/L Bilirubin, total 14.4 mg/dL Bilirubin, direct 10.6 mg/dL Abdominal ultrasonography shows hepatic enlargement. There is no bile duct dilatation, & portal vein & spleen are normal. Most likely diagnosis?

*Acute viral hepatitis* Diagnosing acute viral hepatitis in pt with new-onset jaundice - degree of elevation of serum aminotransferases levels suggests acute viral hepatitis

A 64-year-old man is evaluated in the emergency department for a 7-day history of fever and cough. His wife reports that he has had progressively decreasing oral intake and lethargy for the past 2 days. On physical examination, the patient is confused but responsive. Temperature is 40.2°C (104.3°F), blood pressure is 70/48 mm Hg, pulse rate is 120/min, and respiration rate is 18/min. Oxygen saturation is 86% (ambient air). Pulmonary examination reveals decreased breath sounds at both bases. The remainder of the examination is normal. Bladder catheterization produces 350 mL of dark urine. Lab studies: Serum creatinine = 5 mg/dL (442 umol/L) Urine sodium = 70 mEq/L (70 mmol/L) Fractional excretion of sodium = 1.3% Urinalysis = Specific gravity 1.023; 1+ protein; many casts Chest radiograph shows bilateral lower lobe pulmonary infiltrates. Supplementary oxygen and antibiotics started. What is most likely cause of patient's acute kidney failure?

*Acute Tubular Necrosis* - ppted by pneumonia with associated hypotension & hypoxemia - aside fro prerenal acute kidney failure, ATN = most common cause of acute kidney failure in hospital setting - urine findings: muddy brown casts, tubular epithelial cell casts, high urine sodium concentration (>20 mEq/L) in patient with oliguria & fractional excretion of sodium (FENa) greater than 1%= characteristic of ATN

23 yo woman comes to ED bc of abdominal pain. Pain began 8 hrs ago. 2 hrs later, she began feeling nauseated & vomited twice. Over past 4 hrs, abdominal pain has become more severe. Her last menstural period wast 10 days ago. She is seuxally active & uses condoms intermittently. Physical exam shows right lower quadrant tenderness with rebound. Deep palpation in left lower quadrant causes pain in right lower quadrant. Pelvic exam shows no abnormalities. Most likely diagnosis?

*Acute appendicitis* - second most common cause in US, behind hernia, of severe acute abdominal pain that requires abdominal operation - classically shifts to right lower quadrant - Rovsing sign = when palpation of left lower quadrant causes pain in right lower quadrant

20 mo old boy brought to doc by his mom bc of 2-day ho non-productive cough. His mother reports that he has also had rhinorrhea. His temp is 98 F, pulse is 90/min, & respirations are 24/min. Physical exam shows normal S1 & S2 w/out any murmurs, gallops, or rubs. Wheezing, rales, & inspiratory stridor heard on auscultation of chest. Most likely diagnosis?

*Acute laryngotracheobronchitis* (viral croup) - affects kids younger than 3 - has symptoms of barking cough & inspiratory stridor - usually preceded by 12-72 hrs of low-grade fever & coryza - hoarseness & characteristic croupy or barking cough develop as illness progresses - symptoms worse at night --> peak b/t 24 & 48 hrs --> resolve within 1 wk

59 yo woman evaluated in ED for acute onset of severe diffuse abdominal pain that began 1 hr ago. She has ho coronary artery disease & underwent three-vessel coronary artery bypass graft surgery 2 yrs ago. Current meds are lisinopril, atenolol, simvastatin, & aspirin. On physical exam, temp is 36.8 C (98.2 F), BP 78/56 mmHg, pulse rate 142/min, & RR 29/min. Abdominal exam discloses diffuse mild abdominal tenderness to palpation with no guarding or rebound & no masses. Lab studies reveal leukocyte count of 14,000/uL, serum bicarbon level of 14 mEq/L, & elevated serum lactate level. Computed tomographic scan of abdomen shows thickening of small bowel wall & intestinal pneumatosis Most likely diagnosis?

*Acute mesenteric ischemia* - based on suggestive CT scan findings, presence of metabolic acidosis with elevated serum lactate, & presence of pain out of proportion to exam findings (less tenderness than expected based on symptoms) - CT = bowel wall thickening or intestinal pneumatosis (air within wall of bowel) - most common cause = embolism to SMA originating from left atrium or ventricular mural thrombus - traditional angiography = diagnostic gold standard = can be used for admin of therapeutic vasodilators & stenting

19 yo woman evaluated for 1 wk ho left ear canal pruritus, redness, & pain. She swims 1 mile each day & has recently started wearing plastic earplugs to keep water out of her ears while swimming. Her hearing is normal. On physical exam, she is afebrile, BP is 98/66 mmHg, pulse rate is 62/min, & respiration rate is 16/min. She appears healthy & is in no distress. There is pain with tugging on pinna & compression or movement of tragus. Left ear canal is shown. With irrigation, left tympanic membrane appears normal. No preauricular or cervical lymphadenopathy. Most likely diagnosis?

*Acute otitis externa* - swimming = risk for otitis externa via moist conditions created by daily water immersion - symptoms = otalgia, itching or fullness w/ or w/out hearing loss, pain intensified by jaw motion - signs = internal tenderness when tragus or pinna pushed or pulled; diffuse ear canal edema; purulent debris; erythema, w/ or w/out otorrhea - pneumatic otoscopy = good tympanic mobility - ototopical agent containing neomycin, polymyxin B, & hydrocortisone frequently used = effective when given 7-10 days

47 yo man consults doc bc of pain when he urinates. He has been urinating more often than usual & has now developed burning on urination. He denies any experiences of similar episodes in past. His temp is 101.3 F. BP & pulse are within normal limits. His abdomen is non-distended & is soft to palpation with no tenderness or palpable masses. Bowel sounds are normoactive. On genital exam, there is no urethral discharge & testes are non-tender. Physician unable to conduct thorough digital rectal exam due to pain. Most likely diagnosis?

*Acute prostatitis* - low back pain, fever, perineal pain, irritative urinary symptoms - warm, exquisitely tender, swollen prostate - treatment of choice = fluoroquinolones for 4-6 wks

82 yo woman admitted to hospital after suffering precipitous decline in level of consciousness. She has past med hx of Alzheimer's dz & osteoporosis. Home meds include donepezil, vitamin D, calcium, & alendronate. Over next 24 hrs blood & urine cultures reveal presence of gram-negative rods. IV abx started. On day 3 she becomes tachypneic & complains of diffuse chest pain. Her BP is 88/40 mmHg, pulse 120/min, respirations 36/min, & temp 100.3 F. Pulse oximetry reads 80%. Auscultation of chest reveals diffuse crackles. Heart sounds are normal. Chest radiograph shows diffuse bilateral aveolar infiltrates & normal cardiac silhouette. Patient is transferred to ICU, where she is intubated. Arterial blood gas shows pO2 of 60 on 100% oxygen. Hemodynamic parameters obtained in ICU reveal central venous pressure 15 cm H2O (normal 12, pulmonary capillary wedge pressure 8 mmHg, & ejection fraction 59%. Most likely diagnosis?

*Acute respiratory distress syndrome* - sepsis = most common cause - urosepsis that progressed to ARDS - clinically mimics large pneumonia - diagnosis based on bilateral pulmonary infiltrates, hypoxemia defined by ratio of arterial oxygen tension to fraction of inspired oxygen of <200, & normal pulmonary capillary wedge pressure - treatment = supportive ventilatory care - very hard to oxygenate these pts due to atelectasis

32 yo woman brought to ED by her friends for evaluation of altered mental status. They report that for the last few days she has been acting strangely, speaking with normal words but in a random fashion that makes no sense. Today she was found naked on her couch, unable to explain where she was or what she was doing. Before this current episode, her friends report that she has been in good health, both physical and mental, except for a minor cold she had last week, with fever and headaches. Vital signs are BP 129/82 mmHg, pulse 112/min, respirations 20/min, & temp 38.3 (101 F). Exam reveals disoriented woman in moderate distress. Although her pupils & extraocular movements are normal, she shies away from your penlight. Additionally, she moans in pain as he neck is flexed. CT scan reveals mild cerebral edema of left temporal lobe. Lumbar puncture shows: Opening pressure 90 mm (normal 70-180 mm) WBCs 382 cells/mm^3 (80% lymphocytes) RBCs 470 cells/mm^3 Protein 78 mg/dL Glucose 70 mg/dL Gram stain reveals no organisms. Cultures sent, & pt treated empirically pending results. Ceftriaxone & vancomycin therapy initiated. In addition to these measures, pt would likely benefit from treatment with what?

*Acyclovir* HSV encephalitis - PCR-based assays used to examine CSF for evidence of HSV - viral Abs can also be tested but will not be positive until after acute infection

24 yo man evaluated bc of 3 day ho painful penile lesions accompanied by dysuria, generalized myalgia, malaise, & fever. Pt is sexually active. On physical exam, temp is 100 F & the remaining vital signs are normal. Exam of genital area shows painful vesicular lesions on erythematous base. Most appropriate treatment?

*Acyclovir* Primary genital herpes simplex virus infection - several lesions + systemic symptoms (malaise, fever) = primary infectoin - pending results of diagnostic testing, pt should begin antiviral therapy to reduce severity & duration of symptoms - acyclovir, valacyclovir, & famcyclovir = appropriate agents for treatment of HSV infection - in primary infection, treatment ideally started within 72 hrs of onset & continued for 7-10 days

A 55-year-old woman is evaluated because of a recent increase in symptoms of asthma characterized by daily cough and dyspnea. She reports waking up two to three nights per week with her typical asthma symptoms. She has no postnasal drip, nasal discharge, fever, or heartburn. Her medications are medium-dose inhaled corticosteroids and albuterol as needed. She demonstrates proper use of her metered-dose inhalers. On physical examination, she appears comfortable and is in no respiratory distress. Pulse rate is 76/min, and respiration rate is 18/min. Pulmonary examination shows bilateral wheezing. The remainder of the findings on examination are normal. Which of the following is the most appropriate treatment?

*Add a long-acting beta2-agonist inhaler* Treat adequately controlled asthma - pt was doing well until recent exacerbation of asthma --> now classified as moderate persistent, based on National Asthma Education & Prevention Program guidelines (daily symptoms of asthma & nocturnal awakenings more than once per week)

A 33-year-old woman is evaluated during a follow-up examination. Rheumatoid arthritis was diagnosed 3 months ago, and methotrexate was begun at that time. The patient also takes ibuprofen and acetaminophen. Despite this treatment, she still has 2 to 3 hours of morning stiffness daily and wakes frequently during the night with pain and stiffness. On physical examination, vital signs are normal. The neck and shoulders are stiff but have full range of motion. The wrists and metacarpophalangeal and metatarsophalangeal joints are tender bilaterally, and there is synovitis of the wrists. The left knee has a small effusion. Laboratory studies show a hemoglobin level ofl2.2 g/dL (122 g/L), platelet count of 460,000/µL (460 x 109/L), and erythrocyte sedimentation rate of 45 mm/h. Radiographs of the hands show periarticular osteopenia and erosion of the right ulnar styloid. Which of the following is the most appropriate next step in this patient's treatment?

*Add etanercept* - added to baseline methotrexate therapy - early, aggressive RA --> addition of etanercept indicated - when adequate dz control not achieved with one or more oral DMARDs, biologic therapy indicated

A 24-year-old woman is evaluated because of worsening symptoms of asthma. She uses an as-needed albuterol inhaler two to three times per week and has been waking at night at least once a week with asthma symptoms that require use oft he inhaler. She is still able to perform most of her daily activities, including regular exercise, if she uses albuterol for prevention. She is allergic to house dust mites, ragweed, grass, trees, and cats. On physical examination, vital signs are normal. Pulmonary examination is normal with no wheezing. Spirometry shows forced expiratory volume in 1 second (FEV1) of 85% of predicted and an FEV 1/forced vital capacity ratio of 80% of predicted. Which of the following is the most appropriate treatment?

*Add low-dose inhaled glucocorticoid Mild persistent asthma - symptoms more than 2 days per week but not daily - wakes up once a week but not nightly - preferred therapy = low-dose inhaled glucocorticoid + as-needed short-acting beta2-agonist

A 64-year-old man is evaluated in the emergency department because of chest pain. He describes the chest pain as nonradiating pressure in the midchest that began at rest 1 hour ago and is not associated with any symptoms. Medical history is remarkable for hypertension, type 2 diabetes mellitus, hyperlipidemia, and a 20-pack-year history of smoking. Medications are hydrochlorothiazide, metformin, and simvastatin. On physical examination, he is afebrile, blood pressure is 140/80 mm Hg, pulse rate is 78/min, and respiration rate is 16/min. There is no jugular venous distention, the lungs are clear, and the findings on heart examination are normal. Electrocardiogram shows a normal sinus rhythm and T-wave inversions in leads V2 through V6 without Q waves. Initial cardiac biomarkers are within normal limits. He is given aspirin, clopidogrel, low-molecular-weight heparin, and a nitrate, with resolution of his chest pain. Which of the following is the most appropriate next step in management?

*Add metoprolol* Unstable angina: acute-onset chest pain, normal cardiac biomarkers, T-wave inversions - first-line therapies for acute coronary syndromes = dual antiplatelet therapy with aspirin & thienopyridine (clopidogrel, prasugrel, ticagrelor), beta-blocker, nitrates, anticoagulation (heparin) - morphine may also be given in patients with active chest pain - treatments attempt to minimize ischemia by addressing both supply & demand of oxygen within myocardial cells

A 75-year-old man is evaluated for a nodular lesion on the anterior portion of his left ear. He reports that the lesion has been slowly enlarging over the past year and spontaneously bleeds. It is not painful and does not itch. On physical examination, his vital signs are normal. The skin lesion is shown (Plate 22). No other skin lesions or lymphadenopathy noted. Which of the following is the most likely diagnosis?

*Basal cell carcinoma* - pink, pearly or translucent, dome-shaped papule - as lesion grows, central area often ulcerates = rolled edge - most readily recognized clue = changing skin lesion = ulceration or erosion that spontaneously bleeds

25 yo law school student comes to doc for follow-up visit 2 weeks after discharge from psychiatric inpatient unit where she was diagnosed & treated for first episode of schizophrenia. She is compliant with her med (olanzapine) & seems to be tolerating it well. She no longer seems to be having psychotic symptoms, but she also is not socializing with friends or relatives & is not interested in returning to school. She broke up with her bf appx a week before this ppt. Her parents are concerned that she may have hard time dealing with her illness. What is the most appropriate next step in management?

*Address patient's feelings & suicide risk* - in first-episode schizophrenic patients who have been successful before illness, suicide risk increases after discharge & during stabilization of psychotic symptoms --> depressed & hopeless about future = period of post-psychotic depression

54 yo man presents to doc bc he fells that his "eye has been sticking too far out." He has noticed this symptom for the past few mos. He also experiences headaches, recently more frequently. He occasionally experiences blurry vision. His past med hx is unremarkable, & he does not take any meds. He doesn't smoke or drink alcohol. On physical exam, he is afebrile & normotensive. Head & neck exam reveals right-eye proptosis with decreased movement on lateral gaze of right eye. No erythema or swelling noted over eye, nor is there regional lymphadenopathy. His lungs are clear. CV exam normal, & his abdomen is benign. CT demonstrated mass arising from right lacrimal gland, compressig lateral rectus muscle & eroding lateral orbital wall. Most likely diagnosis?

*Adenoid cystic carcinoma* - proptosis + headaches + blurry vision + CT: mass arising from lacrimal gland - aggressive = carcinoma - most frequent carcinoma of lacrimal gland = adenoid cystic carcinoma = rare tumor that also occurs in salivary glands - rarely metastasizes to lymph nodes & instead to distant sites, including lung & liver

35 yo woman has palpitations, light-headedness, & a stable tachycardia. Monitor shows regular narrow-complex QRS at a rate of 180/min. Vagal maneuvers have not been effective in terminating the rhythm. An IV has been established. What drugs should be administered?

*Adenosine 6 mg* - increases AV block - terminates appx 90% of reentry arrhythmias within 2 minutes Therapy for narrow QRS with regular rhythm - attempt vagal maneuvers - give adenosine If SVT does not respond to vagal maneuvers... - give adenosine 6 mg as rapid IV push in large (antecubital) vein over 1 second - follow with 20 mL saline flush & elevate arm immediately - If SVT does not convert within 1-2 minutes, give second dose of adenosine 12 mg rapid IV push following same procedure

14 yo boy brought to doc by his parents bc of difficulty staying awake in school. He states that he always feels tired & needs to take a nap every day before dinner. His parents reports that he is in bed by 9 pm on school nights, & he gets up at 630 am. On non-school nights he is in bed at 10pm & awakens at 9am. His weight is 170 lb, & his height is 5 ft 3 in; BMI is 30.1. Physical exam shows tonsillar enlargement & nasal intonation. Most likely result in immediate symptomatic improvement in this pt?

*Adenotonsillectomy* - most common therapy for OSA inchildren with adenotonsillar hypertrophy OSA - via anatomic factors that increase resistance to airflow --> upper airway collapse during sleep with resultant hypoventilation & apnea - *adenotonsillar hypertrophy = most common predisposing factor in children - other causes = abnormal neural control (Down syndrome, CNS injury, brain-stem dysfunction, certain drugs, obesity)

A 57-year-old man is evaluated after a recent diagnosis of stage III colon cancer. Three weeks ago, he underwent a hemicolectomy with removal of all evidence of tumor. His postoperative recovery has been uneventful. He has no symptoms. On physical examination, his vital signs are normal. Abdominal examination reveals a well-healing surgical scar and is otherwise unremarkable. Which of the following is the most appropriate next step in this patient's treatment?

*Adjuvant chemotherapy* - to eradicate possible micrometastatic dz after removal of primary tumor - first-line agents = 5-fluorouracil & leucovorin for 6 months; oral capecitabine for 24 wks; or 5-fluorouracil, leucovorin, & oxaliplatin for 24 weeks Stage III colon cancer - tumor involving regional lymph nodes

49 yo man with ho HT & hyperlipidemia comes to doc bc of 2 day ho severe headache & blurry vision. He also has blood in urine. Current meds include atenolol, HCTZ, & lovastatin. His temp is 37 C (98.6 F), BP is 196/140 mmHg, pulse is 83/min, & respirations are 10/min. Physical exam shows no abnormalities. What is the most appropriate next step in management?

*Administer IV nitroprusside & admit patient to hospital* - IV nitroprusside drip = decreases BP within seconds to minutes & can be titrated easily = both arteriolar & venous dilatory effects Hypertensive emergency = systolic > 180 = diastolic > 120 = with end-organ damage = hematuria, headache, blurred vision --> signs of end-organ damage Current recommendations = reduce BP by no more than 25% of original value over period of 1-2 hours, followed by target reduction to 160/100 mmHg within 2-6 hours

29 yo man comes to ED because of nausea & vomiting blood for 2 hours. Her has had 2 episodes of upper GI bleeding during last year. He has history of bleeding from duodenal ulcer. Current mes include pantoprazole. He does not drink alcohol. His BP is 130/75 mmHg. Endoscopy shows one ulcer in the distal duodenum & one in the jejunum. What is the most likely cause of his symptoms?

*Autonomous production of gastrin* High acid secretion by stomach --> gastinoma probz = gastrin-secreting neuroendocrine tumor triggering high level of acid release - tumors likely either in pancreas or proximal small bowel - serum gastrin level > 1,000 pg/mL = gastrinoma - surgical resection of tumor = cure of peptic ulcer dz

39 yo primi gravid woman at 40 wks' gestation comes to labor & delivery ward with contractions. Her prenatal course has been unremarkable. She has hypothyroidism, for which she takes levothyroxine. She has no known drug allergies. Her prenatal lab studies show: Blood type: A-negative Hep B surface antigen: Negative Rubella: Immune Rapid plasma reagin: Nonreactive HIV: negative Glucose loading test: 100 mg/dL Pt delivers 6 lb 14 oz female fetus with Apgar scores of 9 & 9. Fetal blood type found to be A-positive. Pt plans to breasfeed her infant. Most appropriate next step in management?

*Administer RhoGAM* - to prevent mom from being sensitized to Rh(D) antigen - within 72 hrs of delivery - pt's blood = A-negative = she does not have Rh(D) antigen - infant = A-positive = infant does have Rh(D) antigen - fetal cells entering maternal bloodstream can lead to maternal immune reaction against Rh(D) antigen present on fetal cells

39 yo woman, gravida 3, para 2, at 40 wks' gestation comes to labor & delivery ward after gush of fluid with regular, painful contractions every 2 minutes. She is found to have rupture of membranes & to have cervix that is 5 cm dilated, fetus in vertex presentation, & reassuring fetal heart race tracing. She is admitted to labor & delivery ward. Two hours later she states that she feels hot & sweaty. Temp is 101 F. She has mild uterine tenderness. Her cervix is now 8 cm dilated & fetal heart tracing is reassuring. Most appropriate management of this pt?

*Administer abx to mom now & allow vaginal delivery* Chorioamnionitis - infection that can develop any time b4 & during delivery - most common findings = fever & uterine tenderness - elevated fetal heart rate often seen - essential abx be started immediately = better maternal & neonatal outcomes than if therapy delayed - most frequently = ampicillin or penicillin with gentamicin - vaginal delivery acceptable - not an indication for C section

Monitored patient in ICU developed sudden onset of narrow-complex tachycardia at rate of 220/min. Patient's BP is 128/58 mmHg, PETCO2 is 38 mmHg, & pulse oximetry reading is 98%. There is vascular access in left arm, & the patient has not been given any vasoactive drugs. 12-lead ECG confirms supraventricular tachycardia with no evidence of ischemic or infarction. The heart rate has not responded to vagal maneuvers. Next action?

*Administer adenosine 6 mg IV push*

36 yo man brought to ED by friend bc he has had multiple seizures over last hour. Friend says he has had 3 episodes in which he abruptly lost consciousness & all of muscles of arm & legs as well as chest & back became stiff. Soon afterward he appeared to be in deep sleep & then gradually woke up. He was diagnosed with nonspecific seizure disorder for which he has been taking phenytoin for past 3 yrs. Bc of recent loss of job, he has been unable to pay for his phenytoin. Pt stops seizing long enough for IV to be established and set of vital signs to be obtained, though he does not return to his baseline mental status. His temp is 98.6 F, BP 120/80 mmHg, pulse 110/min, & respirations 16/min. During physical exam pt begins to have another episode in which he loses consciousness & his body stiffness & begins to jerk & twitch. Most appropriate next step in management?

*Administer lorazepam* - typically first choice = rapid onset = prolonged duration of seizure prophylaxis (4-6 hrs) - can be given IV or IM - diazepam or midazolam = 2 additional benzos that can be used in IV; diazepam = rectal form - increase chloride conductance in CNS GABA(A)A receptors --> decrease neuronal excitability Status epilepticus - single unremitting seizure for duration of 10-30 minutes or multipel seizures without return to baseline between siezures - initial action = attempt abortive therapy: first-lne agents = benzos (lorazepam)

An AED advises shock for pulseless patient lying in snow. Next action?

*Administer shock immediately and continue as directed by AED*

55 yo woman seen for recurrent calcium oxalate nephrolithiasis. She has had several episodes in the past 6 months & had a nephrostomy tube placed to relieve obstruction & infection. She comes to clinic a week after the nephrostomy tube is removed. On physical exam, she is afebrile & normotensive, & no focal findings are identified. What is the next step in her management?

*Administer thiazide diuretics* - cause resorption of filtered calcium - therapy aimed at decreasing calciuria

17 yo boy brought to ED immediately after parents witnessed seizure. He has also been acting "strange," according to parents. He has had bizarre behavior and has been talking about strange smells. His past med hx is unremarkable, & he takes no meds. He does not use illicit drugs or alcohol. His temp is 100.7 F, BP 120/80 mmHg, pulse 95/min, & respirations 17/min. He is confused but follows commands. Neuro exam shows no focal abnormalities. Remainder of exam shows no abnormalities. CT scan of brain shows hemorrhage in frontotemporal lobes. Most appropriate next step in management?

*Administration of IV acyclovir* Herpes simplex virus encephalitis - via HSV-1 - predilection for temporal lobes - permanent neuro deficits found in up to 2/3 of pts treated early with acyclovir = should still be instituted without delay

72 yo woman admitted to hospital with acute MI. She is quickly brought to cardiac angiography suite, where she is found to have severe 3-vessel disease. She is taken to operating room for emergent coronary artery bypass graft. She recovers well & is extubated on first postoperative day. Her chest tubes are removed on postop day 2 & she is started on clear liquid diet. On postop day 3 she develops abdominal pain & acute abdominal distention. She is put on NPO & a nasogastric tube is inserted, with only minimal bilious output. Fluids & electrolytes are kept within normal parameters, & an abdominal x-ray film is obtained. It shows only minimally dilated loops of small bowel but diffusely dilated large bowel, all the way down to simgoid, with transverse colon measured at 10 cm. No free air under diaphragm is seen, however. A quick proctosigmoidoscopic exam rules out obstructing carcinoma & easily visualizes distended part of colon. What is next step in management?

*Administration of IV neostigmine* Colonic pseudo-obstruction / Ogilvie syndrome - nonmechanical obstruction of large bowel - caused by sympathetic/parasympathetic imbalance - common in postoperative period - exacerbated by narcotic use & electrolyte imbalances - large-bowel version of postoperative ileus Findings: - constipation &/or obstipation - abdominal distention - diffusely dilated large bowel on abdominal x-ray

What is the recommended initial intervention for managing hypotension in the immediate period after return of spontaneous circulation (ROSC)?

*Administration of IV or IO fluid bolus*

What is recommended depth of chest compressions for adult victim?

*at least 2 inches* - more often too shallow than too deep - optimal to target compression depth from 2 to 2.4 inches (5-6 cm)

18 yo woman comes to doc along with her mom, who states that she doesn't know what to do with her daughter. Every since the daughter started modeling, she has become concerned about her weight. Daughter states that she has a fear of gaining weight, for which she binges & purges. She had not had her menstrual period for 5 mos. She denies use of laxatives or diuretics. On exam, she is thin & has fine hair all over her body. She has scars on her knuckles & poor dentition. Her BP is 90/70 mmHg, pulse is 54/min & regular, & BMI is 16.5. Most appropriate next step in management?

*Admit pt to hospital to reestablish weight & correct metabolic abnormalities* Anorexia nervosa - grossly unerweight yet continues to have intesne fear of gaining weight - BMI < 17 - *immediate hospitalization indicated when life-threatening or potentially lethal abnormalities such as bradycardia or other rhythm disturbance, hypotension, electrolyte abnormalities, altered mental status*

A 72-year-old woman is evaluated for follow-up because of exacerbation of COPD. She has severe COPD without resting hypoxemia. The patient presented 1 week ago with fever, productive cough, and mild dyspnea over her baseline. Use of an albuterol inhaler was increased to six times daily, and a P-lactam/P-lactamase inhibitor and glucocorticoid taper were started. On follow-up today, she is fatigued and dyspneic relative to baseline. The medical history is otherwise unremarkable. Medications are tiotropium, fluticasone-salmeterol, and albuterol. On physical examination, temperature is 37.8°C (100.0°F), blood pressure is 130/85 mm Hg, pulse rate is 95/min and regular, and respiration rate is 28/min. She is dyspneic at rest. Pulmonary examination shows bilateral expiratory wheezing. Oxygen saturation is 86 % on ambient air and 92% on 2 L oxygen via nasal cannula. Chest radiograph shows no infiltrate and no cardiomegaly. Which of the following is the most appropriate next step in management?

*Admit to the hospital* Manage acute exacerbation of COPD - pt has not responded to appropriate outpatient treatment & now has mild oxygen requirement - should be admitted to hospital for more aggressive treatment with inhaled bronchodilators, continuous oxygen therapy, pulmonary toilet, antibiotics, glucocorticoids, monitoring for potential complications

Parents bring 2 mo old baby to pediatrician bc of colic pain. Baby cries a lot in pain & often bends himself forward at level of trunk. Parents state that baby burps within about 5 minutes after feed. Pediatrician notes presence of three characteristically shaped, hypopigmented lesions on bab'y skin that are more apparent with UV light. Exam os all other systems reveals nothing significant. What is the most appropriate treatment after confirming most likely diagnosis?

*Adrenocorticotropic hormone* (ACTH) = mainstay of med treatment of infantile spasms - overproduction of CRH --> excess excitability - suppresses CRH by negative feedback Tuberculous sclerosis - one of the neurocutaneous syndrome - hallmark cutaneous lesion = hypopigmented ash-leaf macule = becomes more visible with Woods (UV) lamp - in infancy, common presentation = infantile spasms - characteristic electroencephalographic pattern = hypsarrhythmia = high-voltage, asynchronous, chaotic slow-wave activity Tubers (collections of various types of neural tissue) in brain = major pathology - usually present in convolutions of brain & inside ventricular system, where they calcify - depending on location, my produce obstruction - neuro impairment proportional to # of tubers present

38 yo woman is usher at local movie theater & has BMI of 34 kg/m^2; she has been on orlistat for past 6 months. She comes to office complaining of difficulty driving in low lights or foggy conditions. She reports multiple small accidents while working during movie function. Review of system reveals dryness of eyes & multiple ecchymoses. Past medical history positive for impaired glucose tolerance & hyperlipidemia. She states that she smokes marijuana at least once a week. Vital signs unremarkable. Labs reveal: Hb = 10.5 g/dL Hct = 34% Platelets = 220,000/mm^3 WBC = 5,000/mm^3 Neutrophils = 58% Eosinophils = 1% Lymphocytes = 30% PT = 16 sec PTT = 37 sec Visual exam significant only for difficulty visualizing letters or structures when lights are dimmed. Exam of eye reveals conjunctival dryness & appearance of small, white patches on sclera. Corneal & retinal exam is without abnormalities. What is most likely cause of patient's symptoms?

*Adverse drug effect* Symptoms of vitamin A deficiency - earliest sign = night blindness - later = xerosis & anemia

A 65-year-old man is evaluated during a follow-up examination. The patient has a first-time diagnosis ofleft popliteal venous thrombosis made 10 days ago in the emergency department. He reports no recent travel, surgery, trauma, or period ofimmobilization. There is no family history of venous thromboembolism. He has a 30 pack-year history of smoking and quit 5 years ago. On physical examination, vital signs and general examination findings are normal. Which of the following is the most appropriate evaluation?

*Age- & sex-specific cancer screening* Idiopathic venous thromboembolism - ensure screening up to date - cancer increases risk of VTE by 4- to 20-fold - express tissue factor on surface --> induce tissue factor expression by endothelial cells & monocytes = prothormbotic state - highest risk with pancreatic & brain tumors

27 yo man brought to ED bc he sustained penetrating injuries of chest & abdomen when he was repeatedly stabbed with long ice-pick. At time of admission he has right pneumothorax, for which chest tube is placed before he undergoes general anesthetic for exploratory laparotomy. Operation reveals no intra-abdominal injuries & is terminated sooner than he had been anticipated. Pt remains intubated, waiting for anesthetic to wear off. Bc he is not moving enough air, he is placed on respirator. He then suddenly goes into cardiac arrest & dies. Through his entire time he has been hemodynamically stable & never has any signs of hypotension or arrhythmias. Most likely cause of his cardiac arrest?

*Air embolism* - truly sudden death without warning = highly suspicious for diagnosis of air embolism - deep, penetrating injuries that may have involved major vein & adjacent bronchus - when placed on respirator --> air forced through tracheobronchial tree into vein, & thus heart - fatal air embolus occurs when well over 120 mL of air introduced into venous circulation within matter of seconds - other causes = poor technique during placement or removal of central venous catheters - immediate therapy should include placement of pt in Trendelenburg position with left lateral decubitus positioning to trap air bubble in heart apex

54 yo woman comes to doc bc of SOB. She has had progressive dyspnea over past 8 mos & she has had difficulty climbing stairs at her home. SHe uses one pillow to sleep at night. She appears cachetric with plethoric facies. She begins to cough up bloody sputum in exam room. Physical exam shows loud mid-diastolic rumble heard best at apex on expiration when she lies in left lateral position. An ECG shows no abnormalities. An echo shows mitral valve area of 1.1 cm^2 (normal 4-6 cm^2). Next best step in pt care?

*Balloon valvotomy* Moderate symptomatic mitral stenosis - mitral valve area < 1.5 cm^2 = need for valvotomy - asymptomatic --> watchful monitoring - symptomatic --> diuretics

5 mo-old boy brought to ED by his parents bc he has been having crying spells for past several hours. He was apparently doing fine in morning, when he suddenly started crying. He appeared to be in severe pain. This lasted for 10-15 minutes, & then he became very tired & drowsy. At first the parents thought it was colic, but after several episodes of similar attacks the infant started vomiting & passed stool twice. He is breastfed, & the mother has started adding solids over previous 3-4 wks. He has otherwise been well. Infant appears very well nourished, pale, diaphoretic, & in moderate distress. His tem pis 98 F, pulse 100/min, & respirations 22/min. Physical exam of abdomen shows mild tenderness to palpation without distention. Right lower quadrant feels empty on palpation. Abdominal x-ray shows absence of air in right lower quadrant. Most appropriate next step in management?

*Air enema* or contrast enema - both diagnostic & therapeutic - treatment of choice for symptoms of less than 48 hours' duration Intussusception - when portion of GI tract slips or telescopes into portion just distal to it - mostly ileocolic - episodes of distress & crying interspersed with quiet periods of normal behavior & playing - acute onset of cramping & colicky abdominal pain = hallmark - pts may have vomiting - as obstruction progresses, pt may develop fever & lethargy - currant-jelly stool = classically late - passing stool may temporarily relieve pain - sometimes, a sausage-like mass may be palpable in right upper adbomen

62 yo Caucasian man presents for evaluation of chronic right-sided otitis media & difficulty swallowing. He has been treated with multiple courses of abx in affeor to relieve his ear infection, but it has never resolved. His difficulty swallowing has come on slowly, subsequent to dev't of otitis. He has hx of chronic alcohol abuse, obesity, HT, & poorly controlled DM. He works as farmed & has been exposed to aflatoxin & arsenic in the past. Exam of lymph nodes reveals posterior cervical mass on palpation, & the oral mucosa reveals an ulcerated mass in right posteiror oropharynx, biopsy specimen of which demonstrates squamous cell carcinoma. Most likely contributed to dev't of this pt's dz?

*Alcoholism* SCC of oropharynx (head & neck) - associated with alcoholism, chronic tobacco use, infection with HPV (16, 18, 30) - most commonly affects men age >50 (may just be that men more likely to abuse alcohol & tobacco) - most commonly palate & tongue - red or white plaques (erythroplakia & leukoplakia) - tumors in nasopharynx & oropharynx often don't become clinically evident until severe (stage III or IV)

54 yo woman requests advice regarding maintaining bone health. She has no ho fracture. She underwent menopause at age 52 yrs & has persistent hot flashes. Her risk factors hos osteoporosis include a slim body habitus, a mother hwo had a hip fracture at age 67 years, & a 25-pack-year ho cigarette smoking, although she is currently a nonsmoker. Physical exam findings, including vital signs, are normal. BMI is 20. Results of lab studies are normal. Dual-energy x-ray absorptiometry scan shows T-score of -2.1 in lumbar spine, -2.3 in femoral neck, & -1.9 in total hip. Her Fracture Risk Assessment Tool score indicates 22% risk of major osteoporotic fracture & a 2.4% risk of hip fracture over next 10 yrs. Optimal calcium & vitamin D supplementation & weight-bearing exercise are recommended. What pharmacologic agents is most appropriate to start in this patient?

*Alendronate* = bisphosphonate - she is younger than recommended age for osteoporosis screening (age 65 years in average-risk women), but her risk factors (fam hx, low BMI, smoking hx) = indication for bone mineral density testing - she has low bone mass determined by dual energy x-ray absorptiometry scan

70 yo man with ho chronic arthritis comes to doc with 2 days of acute cramping right-sided abdominal pain. Physical exam is abnormal for right knee redness & swelling. Urinalysis reveals hematuria. CT scan shows multiple kidney stones in right renal pelvis. He passes kidney stone & analysis indicated it is uric acid stone. His serum uric acid level is 12 mg/dL & his serum creatinine level is 1.9 mg/dL. His knee effusion is tapped & shows urate crystals. Most appropriate long-term treatment for this patient?

*Allopurinol* = xanthine oxidase inhibitor that lowers serum & urine uric acid levels Uric acid stones + gouty arthritis + elevated uric acid levels - urate stones best detected on CT or ultrasound, since they are radiolucent to normal X-rays - initial management = hydration, low purine diet, potassium citrate for alkalinization of urine - *for those who continue to form uric acid stones, long-term management = allopurinol*

Longstanding hepatitis C & cirrhosis predispose to HCC. HCC should be suspected in pt who has cirrhosis & who presents with sudden clinical deterioration. This marker is usually elevated & the serum level correlates to tumor size.

*Alpha-fetoprotein (AFP)*

55 yo woman evaluated for persistent acid reflux symptoms. Omeprazole daily for 1 month followed by pantoprazole daily for several weeks did not provide significant improvement. Pt does not have dysphagia, odynophagia, or unintentional weight loss. Upper endoscopy performed 4 mos ago was normal & didn't show evidence of H pylori infection. CBC done at time of upper endoscopy was normal. Physical exam findings, including vital signs & general exam, are normal. Studies that should be done next to confirm pt's most likely diagnosis?

*Ambulatory esophageal pH-impedance monitoring* - esophageal pH monitoring identifies reflux of acid - impedance monitoring detects reflux of other gastric contents in small percentage of pts who have symptoms related to non-acid reflux GERD diagnosis - gold-standard for diagnosis = 24-hr esophageal pH-impedance monitoring --> establishes whether increased esophageal exposure to acid is present - most helpful in pts who have GERD-like symptoms that fail to respond to adequate trial of PPI to correlate presence of acid in esophagus at time pt is having symptoms

42 yo woman + progressive fatigue & itchiness + over past few mos, she has lacked any energy to pursue her usual activities & is fatigued easily, though her mood is unchanged. Her skin has become progressively more pruritic, requiring her to use OTC steroid & antihistamine ointments, which provide some relief. Further, friends & fam have commented on slight yellowish tint to her skin, present for at least last month. She has never had similar symptoms in past, though she has suffered from hypothyroidism & Raynaud syndrome for last 5 yrs. Vital signs are within normal limits. Exam of pt's skin, however, shows multiple excoriations & obvious jaundice. Abdominal exam reveals marked hepatosplenomegaly. Based on these findings, set of liver function studies are ordered, which shows: ALT 42 U/L Alkaline phosphatase 1200 U/L AST 42 U/L Bilirubin, total 4 mg/dL Based on woman's likely diagnosis, what serologic studies is most likely to be elevated?

*Anti-mitochondrial Abs* Middle-aged, itchy woman = classic initial presentation of Primary Biliary Cirrhosis - jaundice, pruritus, hepatomegaly - associated conditions = thyroid dysfunctio, Raynaud syndrome, CREST syndrome - alk phosph = elevated strikingly

A 55-year-old man is evaluated during a routine examination. He has a 2-year history of nonischemic cardiomyopathy, with echocardiogram showing left ventricular ejection fraction of 3S%. He is feeling well and reports no shortness of breath; he walks 2 miles daily without symptoms. Medical history is remarkable for hypertension. Medications are lisinopril, carvedilol, and chlorthalidone. On physical examination, blood pressure is l50 I 90 mm Hg and pulse rate is SO/min. No jugular venous distention is present. Lungs are clear to auscultation. Cardiac examination shows a regular rhythm with no murmurs or gallops. No edema is present. Laboratory studies show serum creatinine level ofl.S mg/dL (133.0 µmol!L), sodium level of138 meq/L (138 mmol!L), and potassium level of 4.0 meq/L (4.0 mmol!L). Electrocardiogram shows a normal sinus rhythm and left ventricular hypertrophy. Which of the following calcium channel blockers should be added to this patient's medical regimen?

*Amlodipine* Resistant HT + systolic HF - BP no at target value with 3-drug therapy with diff't classes of drugs, including diuretic - should begin taking newer-generation dihydropyridine CCB, such as amlodipine, to improve control of BP

34 yo man comes to doc for increasing pedal edema for 2 mos. He has no hx of medical illness, but is a former IV drug abuser, quitting one year ago. He denies arthralgia, rash, or hematuria. His temp is 98.6 F & his BP is 130/90 mmHg. On exam, pt has normal lungs, cardiac S4 with a laterally displaced PMI, large palpable liver, & 4+ edema to mid-calf. Multiple old skin ulcers are noted on both lower extremities. Lab analysis shows: K+ 3.7 mEq/L Creatinine 1.6 mg/dL Urea nitrogen 20 mg/dL Albumin 2.1 mg/dL Urinalysis shows 4+ protein, no heme, & no cells or casts. Spot urine albumin to creatinine ratio is 8.5. Renal ultrasound reveals large kidney, each measuring appx 13 cm. Echocardiogram shows dissue cardiac hypertrophy. HIV test is negative. Most likely diagnosis?

*Amyloidosis* Nephrotic syndrome = >4 g proteinuria, edema, hypoalbuminemia - may be due to primary renal dz (FSGS, minimal change dz) or secondary causes (HIV nephropathy, diabetic nephropathy, amyloidosis) - organomegaly = suggest amyloidosis with nephropathy = may occur in drug users who "skin pop" their drugs & have recurrent soft-tissue infections

A 68-year-old man is evaluated in the emergency department for nontraumatic low-back pain and left leg numbness ofl day's duration. He has no weakness or bowel or bladder incontinence. He has a past medical history of prostate cancer treated with external-beam radiation 8 years ago. On physical examination, his vital signs are normal. There is tenderness around the L4 vertebra. Deep tendon reflexes are normal. There is no weakness or saddle anesthesia. Prostate-specific antigen (PSA) level is 50 ng/mL. His last PSA measurement 6 months ago was 1 ng/mL. Magnetic resonance imaging of the spine reveals an osteoblastic metastasis at L4 with nerve root impingement. In addition to intravenous glucocorticoids and external-beam radiation to the lumbar spine, which of the following is the most appropriate next step in management?

*Androgen deprivation* - provided with GnRH agonist or, less commonly, surgical orchiectomy - GnRH agonists = chemical castration --> disrupt pituitary-testes axis --> decrease testosterone levels - recurrence of prostate cancer 8 yrs after treatment for localized prostate cancer... - *mainstay of treatment for local treatment failure = ADT*

19 yo woman comes to doc bc she has not had menstrual period. She experienced normal breast dev't through puberty but has yet to have period. She has not other concerns. She has no med problems. Physical exam shows patient to be tall with long arms & big hands. Breasts are normal-appearing except that nipples are immature & areolae are pale. Pelvic exam shows scant pubic hair with blind-ended vaginal pouch. What is the most likely diagnosis?

*Androgen insensitivity syndrome* / Testicular Feminization Syndrome - genotypically male (46,XY) - phenotypically female - no internal female structures - testes rather than ovaries present - minimal axillary or pubic hair - experience abundant breast dev't at puberty bc testosterone unable to suppress formation of breast tissue - tend to be very tall with big hands & fett & long arms - testes should be removed after pubertal dev't completed bc many patients develop gonadal malignancies after puberty

22 yo primigravid woman comes to labor & delivery ward at term with regular, painful contractions. Her prenatal course was unremarkable. She has past med hx significant for mitral valve prolapse with regurgitation demonstrated on echo. She takes no meds & has no allergies to meds. Exam shows that her cervix is 4 cm dilated & fetus is vertex presentation. Fetal heart rate reassuring. Most appropriate management of this pt?

*Antibiotic prophylaxis not necessary* - 2007 AHA guidelines for endocarditis no longer recommend routine endocarditis prophylais in pts who have acquired valvular dz - endocarditis prophylaxis should be given for: prosthetic heart valves, prior hx of endocarditis, unrepaired cyanotic congenital heart dz, cardiac valvuloplasty in transplanted heart

Most appropriate management of patient's transition from parenteral LMWH to warfarin therapy requires

*at least 5 days of overlap with LMWH and warfarin therapy and an internalized normalized ratio of 2 or more for 24 hours* - randomized clinical trials show that 5-7 days of treatment with unfractionated heparin is as effective as 10-14 days of treatment when transitioning to warfarin therapy

Most appropriate medical regimen for pt with Graves

*atenolol & methimazole*

A 53-year-old woman is evaluated for anemia. She has taken lowdose methotrexate for 5 months for treatment ofrheumatoid arthritis. Her only source of obvious bleeding is menstrual blood loss. She continues to have menses every 28 days, with flow lasting 5 days and requiring three to four pad changes daily. Laboratory studies: Before Methotrexate Therapy: - Hgb = 10.8 - Leukocyte count = 6200/uL - Platelet count = 372,000/uL - Reticulocyte count = 0.7% of RBCs - MCV = 92 fL - Iron = 49 ug/dL - Iron-binding capacity, total = 394 ug/dL - Ferritin = 36 ng/mL Current Values - Hgb = 9.7 g/dL - Leukocyte count = 6750/uL - Platelet count = 382,000/uL - Reticulocyte count = 0.8% of RBCs - MCV = 93 fL - Iron = 15 ug/dL - Iron-binding capacity, total = 317 ug/dL - Ferritin = 29 ng/mL Most likely cause of patient's anemia?

*Anemia of inflammation plus iron deficiency* - pt has RA = cause of anemia inflammation - inflammatory cytokines block iron utilization & decrease transferring saturation & calculated serum TIBC levels - ferritin = acute phase reactant --> serum ferritin levels tend to increase in patients with anemia of inflammation - iron def associated with increased transferrin saturation & calculated serum TIBC levels & decreased serum ferritin levels - serum ferritin levels < 10-15 ng/mL = iron deficient - in pts with RA, serum ferritin levels expected to rise by as much as threefold as result of effects of inflammatory cytokines --> pt's serum ferritin levels of 29-36 ng/mL support diagnosis of iron deficiency in setting of inflammatory illness - serum ferritin levels less than 100-120 ng/mL reflect iron deficiency in pts with inflammatory conditions

72 yo woman evaluated during follow-up exam. Pt has 2 yr ho chronic iron def anemia associated wiht several episodes of melena. Source of bleeding has remained undiagnosed despite multiple upper endoscopy & colonoscopy exams. During her last episode of melena, technetium 99m pertechnetate RBC scan identified potential source of bleeding in SI. She has no other med problems & takes no meds. Physical exam findings, including vital signs, are normal. What is the most likely cause of this pt's bleeding?

*Angiectasia* Obscure GI bleeding in elderly pt - probz small bowel angiectasia - recurrent bleeding without defined source following standard upper endoscopy & colonscopy - mainly with sources in SI b/t ligament of Treitz & ileocecal valve = mid-GI bleeding - most common cause of SI bleeding in elderly = 80% of cases - usually causes chronic blood loss - can also cause acute hemodynamically significant bleeding

65 yo man comes to see his PCP bc of pain in his legs, primarily in calves, on walking. Pain usually relieved by rest. Pt's med hx significant for HT & hyperlipidemia; he takes HCTZ & atorvastatin. He is retired college professor. He does not drink alcohol, & he quite smoking 6 mos ago. His temp is 97.7 F, BP 130/74 mmHg, pulse 82/min, respirations 18/min, & oxygen sat 98% on room air. Physical exam reveals no apparent distress. Lungs clear to auscultation. Heart sounds normal, with no murmurs. Abdomen soft, nontender, & nondistended. Exam of extremities reveals decreased femoral pulses & absent pedal pulses. Best next test in management?

*Ankle-brachial index* - simple & inexpensive - determined by measuring systolic BP (Doppler probe) in ankle & arm - highest value obtained from ankle divided by highest value from arm (ratio = ABI /ankle-brachial ratio) - normal = 1 - 1.3 - >1.3 = calcified vessel = diabetes or vasculitis - <0.9 = 95% sens & 1-% spec for detecting angiogram-positive per art dz - 0.4 - 0.9 = degree of arterial obstruction often associated with claudication - <0.4 = advanced ischemia Peripheral vascular disease / Arterial occlusive dz - claudication = most common symptom of PAD

22 yo primigravid woman at term comes to labor & delivery ward bc of painful contractions every 2 minutes. She has no gush of fluid & no bleeding from vagina. Her prenatal course was unremarkable. She takes no meds & has no allergies to meds. Physical exam shows that her cervix is 6 cm dilated & 100% effaced; the fetus is at 0 station. The fetal heart rate has baseline in 150s & the tracing is reactive. Patient desires epidural for pain relief. What should be given orally shortly before epidural placed?

*Antacid* Aspiration pneumonitis - major cause of anesthesia-related death in obsetrics - delayed gastric emptying in pregnancy - increased levels of progesterone & displacement of pylorus by pregnant uterus - caused by gastric juices entering lungs = chemical pneumonitis Treatment - positive-pressure ventilation with 100% oxygen through endotracheal tube - given epidural? --> given antacid to increase stomach pH

What is the recommended first choice for establishing intravenous access during attempted resuscitation of a patient in cardiac arrest?

*Antecubital vein*

27 yo semiprofressional football player brought to ED after he was tackled from behind during game; he is in severe left knee pain. On physical exam, left knee looks swollen & the leg can be pulled anteriorly with knee flexed at 90 degrees. Similar finding can be elicited with knee flexed at 20 degrees by grasping thigh with one hand & pulling leg with other. What is the most appropriate management for this patient's condition?

*Anterior cruciate ligament reconstruction* - athletes require surgical consultation - sedentary patients = knee-brace immobilization - anterior drawer/Lachman test = ACL injury - next step in management of knee injuries = MRI - treatment = conservative or surgical

29 yo man comes to clinic complaining of pain & swelling in his right arm. He has noticed these symptoms over the past 2 mos, and they have become more pronounced. He notices that the symptoms worsen when he raises his arm. His past med hx is unremarkable & he takes no meds. He doesn't smoke, & drinks alcohol socially. He took up heavy weight-lifting appx 1 yr ago, & he uses several supplements for weight gain & muscle-building. On physical exam, he is afebrile & normotensive. He is well-developed. Head & neck exam is unremarkable. Some pitting edema is noted on right arm. His radial pulse is 2. He is instructed to raise his arm above his head. After 1 minute, the swelling increases markedly in the right arm. Lung, CV, & abdominal exams are unremarkable. What is the most likely source of the pt's symptoms?

*Anterior scalene muscle* Thoracic outlet syndrome (TOS) - subdivided into neuro, arterial, or venous - neuro symptoms result from impingement on brachial plexus --> paresthesia & muscular atrophy - multiple etiologies = *hypertrophy of scalene muscles*, cervical ribs, elongated C7 transverse processes, & traumatic hyperectension injury

Perfusion territory of this artery includes anterior horn cells and part of pain & temp pathways. Thrombosis of this artery causes flaccid paralysis, loss of bowel & bladder function & loss of pain & temp sensation.

*Anterior spinal artery* - supplies 2/3 of spinal cord

Treatment for extrinsic allergic alveolitis (EAA)

*avoidance of antigen*

68 yo woman admitted to hospital bc of fever & back pain that has worsened over the last several weeks. Medical history significant for kidney failure secondary to HT. She has been treated with hemodialysis for lat 4 months. On physical exam, temp is 100.8 F, BP is 138/82 mmHg, pulse rate is 92/min, & RR is 12/min. There is tunneled dialysis catheter in left upper chest without evidence of inflammation. There is tenderness to palpation over lumbar spine. Remainder of physical exam is normal, with no focal neuro findings. Lab studies include leukocyte count of 13,000/uL w/ 72% neutrophils. MRI shows destructive changes to T12 & L1 vertebral bodies, with no parapsinal collections or spinal cord impingement. Blood culture findings are positive for methicillin-resistant Staph aureus. In addition to removal of dialysis cath, what is the most appropriate next step in management?

*Antibiotic therapy alone* - 4-6 wks of abx - hematogenous vertebral osteomyelitis can often be successfully treated w/ abx alone, with relapse rates of less than 10% at 6-12 months of follow-up

67 yo man comes to doc bc of 9 mo ho burning epigastric pain. Current meds include omeprazole. He has had no nausea, vomiting, odynophagia, or dysphagia. Upper endoscopy shows abnormal-appearing gastric mucosa. Biopsy specimen of stomach shows neoplastic lymphocytes forming lymphoid follicles & sheets as well as gram-negative rods; there is no tissue invasion. Immunohistochemical exam of tissue shows positivity of CD19, CD20, & CD22, & negativity for CD5, CD10, & CD23. Most appropriate next step in management?

*Antibiotics* MALT extranodal marginal zone B-cell lymphoma - less than 10% of non-Hodgkin lymphomas - typically occur in setting of chronic inflammation arising from autoimmune condition or infection - evidence of H pylori --> regimen = amoxicillin, clarithromycin, omeprazole, or quadruple therapy = omeprazole, bismuth subsalicylate, metronidazole, tetracycline

66 yo man presents to doc for unrelenting diarrhea, fatigue, & weight loss. Symptoms have been insidiously progressing for past 2 mos. He has also noticed that his stools are "floating" more than they used to. He voids appx 7 times/day. He also complains of increasing arthralgias. He denies recent travel or recent camping trips. His pas med hx is notable for HT, for which he takes HCTZ. On physical exam, he appears frail & in no acute distress. His BP is 110/75 mmHg & his pulse is 88/min. Head & neck exam demonstrates mild glossitis & lymphadenopathy. His pulse is regular; however, he has systolic murmur. His lungs are clear to auscultation. He has increased bowel sounds overall, without hepatosplenomegaly or tenderness. Peripheral exam demonstrates no cyanosis, clubbing, or edema. Neuro exam demonstrates profound ataxia & difficluty with rapid alternating movements. Steatorrhea is confirmed on 24-h stool collection. Biopsy of his small bowel demonstrates PAS-stained macrophages in lamina propria. Stains for fungi & acid-fast bacteria are negative. He is also found to be HIV-negative. Most appropriate intervention for this pt?

*Antibiotics* Whipple disease

A 35-year-old woman is evaluated in the emergency department for the acute onset of right leg swelling and pain and associated dyspnea. Symptoms were present upon arising this morning. She reports no recent travel, periods of immobilization, trauma, or surgery. Medical history is significant for two pregnancies ending in miscarriages. She does not smoke or drink alcoholic beverages. Her mother was diagnosed with systemic lupus erythematosus at age 32 years. On physical examination, temperature is normal, blood pressure is 138/78 mm Hg, pulse rate is 96/min, and respiration rate is 24/min. Oxygen saturation is 86% (ambient air). Cardiopulmonary examination reveals a right sternal lift and increased intensity of P 2. The right calf is swollen and tender to palpation. Lower extremity Doppler ultrasound reveals a right popliteal and common femoral deep venous thrombosis. Prior to initiating anticoagulation therapy, the activated partial thromboplastin time is obtained and is prolonged. Which of the following is the most likely diagnosis?

*Antiphospholipid syndrome* - acquired autoimmune disorder - associated with venous or arterial thromboembolism, pregnancy loss, thrombocytopenia, kidney impairment, vasculitis, cardiac valvular abnormalities - can cause thrombosis by: inducing tissue factor expression, disrupting protien C antithrombin function, or activating platelets & complement cascade - associated with high risk of thromboembolism

7 yo girl complains of increased urinary frequency, dysuria, itching on urination. Her urinalysis is consistent with urinary tract infection. Last year, she was diagnosed with vesicoureteral reflux, grade 2. This is her 20th infection in the past year, despite adequate antibiotic coverage. Next appropriate step?

*Antireflux surgery* Vasicoureteral reflux (VUR) = common anatomical cause of recurrent UTIs in children - retrograde flow of urine into ureter &/or kidney before voiding - occurs bc of incompetent vesicoureteral valve - many children outgrow mild degrees of reflux if maintained on prophylactic abx Indications for surgery - any breakthrough infection while pt on prophylactic abx - new renal scars detected on renal scan - failure of VUR to resolve - certain stages, especially bilateral & younger age

Indicated for pt with chronic HCV infection & advanced fibrosis

*Antiviral therapy* - based on pegylated interferon & ribavirin - intro of protease inhibitors (boceprevir, simeprevir, telepravir) & direct-acting antiviral agents (sofosbuvir) - goal = sustained virologic response = undetectable HCV beyond 6 mos after end of treatment

30 yo man comes to doc for routine health maintenance exam. He has no history of any major medical illnesses & takes no meds. He only drinks alcohol socially. His BP is 160/70 mmHg & his pulse is 75/min. Physical exam shows brachial pulses that are markedly more prominent than the femoral, popliteal, & dorsalis pedis pulses. A CT scan of the chest with contrast shows coarctation of aorta just above ligamentum arteriosum. What is the most likely to be associated with this patient's condition?

*Aortic stenosis* - patients often asymptomatic - if symptomatic = headaches, nosebleeds, signs & symptoms consistent with decreased lower-extremity perfusion Aortic coarctation associated with several cardiac lesions - VSDs, bicuspid aortic valve, left ventricular hypoplasia - bicuspid aortic valves associated with higher rate of aortic stenosis & insufficiency

74 yo man brought to ED bc of stable angina & diaphoresis. His BP is 145/93 mmHg & pulse 98/min. Physical exam shows JVD & basilar crackles. No abnormal heart sounds are heard but peripheral pulses are faint. X-ray of chest shows mild interstitial pulmonary edema. ECG shows inferior ST-segment elevations. Closest hospital with angioplasty capability is 2 hours away. What drugs is most appropriate for this patient?

*Aspirin, heparin, & alteplase* Acute coronary syndrome: ST-elevation MI - calls for urgent revascularization - delay of greater than 90 minutes --> thrombolytic therapy indicated - thrombolytic therapy / alteplase within 30 minutes if can't get to primary PCI

A 43-year-old woman is evaluated because of a 3-month history of substernal exertional chest pain and worsening dyspnea on exertion. Medical history is significant for Hodgkin lymphoma diagnosed 15 years ago that was treated with radiation therapy that involved the thorax. On physical examination, temperature is normal, blood pressure is 148/41 mm Hg, pulse rate is 80/min, and respiration rate is 14/min. Carotid upstrokes are rapid and accentuated, with a rapid decline. She has no jugular venous distention. The S2 is diminished in intensity, and there is no S3 gallop present. A grade 2/6 high-pitched blowing diastolic decrescendo murmur is heard to the left of the sternum at the third intercostal space. The apical point of maximal impulse is displaced inferiorly and laterally. There is no hepatojugular reflux. Which of the following is the most likely cause of the patient's symptoms?

*Aortic valve regurgitation* Radiation-induced aortic valve regurgitation - diastolic murmur = key - carotid arteries have rapd, accentuated upstroke with rapid decline (Corrigan pulse) - point of maximal impulse displaced = left ventricular volume overload - pulse pressure widened (systolic pressure - diastolic pressure; normal < 40 mmHg)

A 19-year-old man is admitted to the hospital because of a 3-week history of nosebleeds, malaise, and fever. He recently had a viral syndrome, which resolved about 6 weeks ago. Medical history is otherwise unremarkable. He takes no medications and has no known allergies. On physical examination, temperature is 38.6°C (10l.6°F), blood pressure is 102/54 mm Hg, pulse rate is 114/min, and respiration rate is 12/min. Examination of the skin discloses petechiae and bruising of the lower extremities. There is no lymphadenopathy or splenomegaly. Laboratory studies: Hgb = 7.8 g/dL Leukocyte count = 1000/uL with 20% neutrophils & 80% lymphocytes Platelet count = 28,000/uL Reticulocyte count = 0.2% of erythrocytes Most likely diagnosis?

*Aplastic anemia* - bone marrow fails to produce cells = hypocellular bone marrow & pancytopenia - nosebleeds / thrombocytopenia - malaise & fatigue / anemia - fever / neutropenia - had viral syndrome 6 wks ago --> EBV & CMV can cause aplastic anemia - very low reticulocyte count

A 17-year-old girl is evaluated in the emergency department for progressive fatigue, shortness of breath, and lethargy over the past week. The patient had mild flu-like symptoms several weeks ago with fever and joint pains, but these symptoms have improved. Medical history is significant for sickle cell disease (Hb SS). She has had several pain crises but no acute chest syndrome or stroke. Her only medication is folic acid daily. On physical examination, temperature is 35.7°C (96.4°F), blood pressure is 96155 mm Hg, pulse rate is 1141min, and respiration rate is 221min. Other than tachycardia, the cardiopulmonary examination is normal. There is no lymphadenopathy or splenomegaly and no rash. Results oflaboratory studies show a hemoglobin level of 5.2 gldL (52 glL) (compared with 8.2 gldL (82 glL] 3 months ago) and a reticulocyte count of 0.1 % of erythrocytes. A chest radiograph is normal. Which of the following is the most likely diagnosis?

*Aplastic crisis* - worsening of chronic anemia - recent viral syndrome --> presented with fever & arthralgia = consistent with parvovirus B19 infection - inability to maintain RBC production needed to replace hemolyzed cells = reflected in very low reticulocyte count - confirmation via IgM Abs against parvovirus B19 or PCR studies detecting parvovirus B19 DNA

27 yo office manager w/ ho GAD has had multiple recent visits to doc for several-mo ho fatigue. Evaluation thus far has revealed normal physical exam & screening labs that are within normal limits. Inquiries about specific symptoms of depression on last visit yielded diagnosis of persistent depressive disorder, & treatment options were discussed w/ patient. On visit she expressed frustration that a medical etiology of her fatigue has not been identified & she demands to see clinic notes from her last several visits. What would be the most appropriate response the doc could make?

*Arrange to review her clinic records with her as soon as possible* - pt's med records are technically their property = they may review them at any time

78 yo man comes to doc for routine health maintenance exam. He has ho hyperlipidemia treated w/ pravastatin. He is retired from his job as a miner. Exam shows numerous small keratotic papules on palms & soles; there are more lesions over the thenar & hypothenae eminences. There is a hyperkeratotic plaque on abdomen. Remainder of exam shows no abnormalities. Biopsy specimen shows invasive SCC arising from SCC in situ. Chronic exposure to what is most likely responsible for this pt's condition?

*Arsenic* = plamoplantar "arsenical" keratoses & SCC/SCC in situ in non-sun-exposed areas of body Palmoplantar keratoses and SCC in region of body not chronically exposed to UV light - chronic UV exposure over many yrs = most common risk factor for SCC - arsenic & aromatic hydrocarbons = well known env'tal carcinogens that increase risk for cutaneous SCC Env'tal arsenic exposure - farming: herbicides & animal feed - mining: direct exposure while mining & contaminated groundwater in mining towns - - semiconductor manufacturing - some metallurgic & glass-making occupations

An 83-year-old man is evaluated for poorly controlled pain from osteoarthritis of the left knee. Osteoarthritis was diagnosed 15 years ago, and his pain had been controlled until recently with regular doses of acetaminophen. Over the past 8 weeks, acetaminophen has no longer provided relief. There is no history of trauma, and he does not have fever or chills. Medical history is significant for hypertension, chronic kidney disease, and a healed peptic ulcer. Medications are amlodipine and metoprolol. On physical examination, vital signs are normal. Body mass index is 26. The left knee has a moderate-sized, ballottable effusion without overlying erythema or warmth. There is crepitus with knee flexion and extension. The remainder of the examination is unremarkable.

*Arthrocentesis and intra-articular glucocorticoid injection* - successful injections provide pain relief for average of 3 months - intra-articular injection may be particularly useful in patients who obtain no relief from acetaminophen & may have contraindications to use of NSAIDs

If you have Monoarticular Arthritis/Arthralgia, always consider what for diagnosis?

*Aspiration* - cell count, crystals, gram stain, culture Differential: infection, crystal-induced dz, osteoarthritis/trauma, seronegative spondyloarthropathy, early onset inflammatory arthritis - RA or SLE

You are caring for 66-yo man with ho large intracereberal hemorrhage 2 months ago. He is being evaluated for another acute stroke. CT scan negative for hemorrhage. Patient is receiving oxygen via nasal cannula at 2 L/min, & an IV has been established. His BP is 180/100 mmHg. What drug do you anticipate giving to this patient?

*Aspirin* Does CT scan show hemorrhage? No--> Probable acute ischemic stroke; consider fibrinolytic therapy. Patient not a candidate for fibrinolytic thearpy? --> Administer aspirin --> Begin stroke or hemorrhage pathway. Admit to stroke unit or ICU

A SS-year-old woman is evaluated in the emergency department for chest pain, diaphoresis, and shortness of breath of 4 hours' duration. Three years ago she was diagnosed with a non-ST-elevation myocardial infarction and was treated medically. Additional medical history includes type 2 diabetes and hypertension. Her current medica tions are aspirin, lisinopril, atorvastatin, and glargine insulin. On physical examination, she is afebrile, blood pressure is 125/60 mm Hg, pulse rate is 48/min, respiratory rate is 18/min, and oxygen saturation is 98% on ambient air. Cardiac examination shows no jugular venous distention, and the lungs are clear. An S4 is present. Electrocardiogram shows ST-segment elevation and T-wave inversions in leads II, III, and a VF. The initial troponin T measurement is elevated. The nearest hospital capable of percutaneous coronary intervention is more than 2 hours away. The patient has no contraindication to thrombolytic therapy. Which of the following is the most appropriate initial management for this patient?

*Aspirin, heparin, clopidogrel, intravenous nitroglycerin, & thrombolytic therapy* STEMI + inferior leads + elevated troponin T level - treatment = reperfusion therapy = thrombolytic therapy or primary percutaneous coronary intervention (PCI) - time to achieve balloon inflation = major determinant of benefits of PCI vs thrombolytic therapy --> if PCI must be delayed, thrombolytic therapy should be considered

34 yo man comes to doc bc of 2-year ho increasing pain & stiffness in his back. His symptoms improve with activity. Recently, he has awakened at night because of the pain. He has had 5-lb weight loss over last 5 months. He works in construction. What is the most appropriate next step in diagnosis?

*Assess spinal mobility using Schober test* - part of physical exam - used to assess spinal mobility during forward flexion of lumbar spine - pt most likely has ankylosing spondylitis - first step in diagnosis = identification of inflammatory back pain = characterized by onset after 40 yo, insidious onset, improvement with exercise, no improvement with rest, pain at night

50 yo man comes to ED bc of 2 wk ho dull abdominal pain. He has had no fever, nausea, vomiting, diarrhea, or constipation. Lab studies are WNL. CT scan of abdomen shows 1.5-cm right adrenal nodule that is hypodense & has smooth, rounded contour; no other abnormalities seen. Most appropriate next step in management of adrenal nodule?

*Assure pt that adrenal nodule does not appear to be malignant* Adrenal nodule / Incidentaloma - adrenal masses = one of most common of incidental findings = 5% of pts undergoing CT scan of abdomen = 8.7% reported on autopsy series - most are benign - <4 cm & radiologically consistent with benign adenoma = should have radiographic reevaluation at 3-6 mos & then annually for 1-2 yrs Radiologic features that point toward benign etiology - size <4 cm - hypodense nodules = higher fat content - smooth, rounded contours

24 yo graduate student comes to doc 3 months prior to traveling to Brazil for 1 year. His med history is unremarkable, & he takes no meds. He has no allergies to meds. He drinks 2-4 beers on the weekends. He is sexually active & uses condoms consistently. Exam shows no abnormalities. What is the most appropriate malarial prophylaxis?

*Atovaquone-proguanil* CDC - atovaquone-proguanil recommended for malaria prophylaxis in ALL malaria-endemic areas of world, except chlorquine-sensitive endemic areas - chloroquine used as first-line agent in chloroquine-sensitive areas (Caribbean, Mexico, Costa Rica, El Salvador, Paraguar, Argentina) - alternatives to atovaquone-proguanil & doxycycline & mefloquine

A 34-year-old woman is evaluated in the emergency department after the acute onset of palpitations approximately 1 hour ago. She reports no shortness of breath, chest pain, presyncope, or syncope. The medical history is unremarkable, and there is no family history of sudden cardiac death. She takes no medications. On physical examination, she is afebrile, blood pressure is 118/64 mm Hg, and pulse rate is 165/min. Other than a regular, rapid pulse, the cardiopulmonary examination is normal. Baseline electrocardiogram shows a narrow complex tachycardia at 165/min. Adenosine is given as a rapid intravenous push, and the patient converts to normal sinus rhythm. Which of the following is the most likely diagnosis?

*Atrioventricular nodal reentrant tachycardia* (AVNRT) - most common paroxysmal SVT - involves slow pathway & fast pathway within AV node - slow pathway conducts slowly but repolarizes quickly - fast pathway conducts quickly but repolarizes slowly - typical AVNRT = slow-fast = often has R-P interval so short that P wave is buried within QRS complex

Patient presents to ED with new onset of dizziness & fatigue. On exam, patient's heart rate is 35/min, BP is 70/50 mmHg, respiratory rate is 22 breaths/min, & O2 sat is 95%. Appropriate first med?

*Atropine 0.5 mg*

67 yo HT man presents to ED via ambulence complaining of abdominal pain. Six hours earlier he was sitting down to eat when he suddenly felt severe, epigastric pain. There was associated nausea. He has past med history of duodenal ulcers treated with clarithromycin, amoxicillin, & omeprazole. Vital signs are temp 37.6 C, pulse 126/min, BP 146/94 mmHg. On physical exam patient is sweating excessively. No chest tenderness, & breath sounds are clear bilaterally. Muffled heart sounds which are regular in rate & rhythm, with no murmurs or rubs. ECG reveals ST-segment elevation in leads II, III, & aVF. 24 hours post-percutaneous coronary intervention, patient's BP noted to have quite vigorous irregular outward pulsations. After performing hepatojugular reflux, persistent increase of jugulovenous pulse seen. Best initial treatment?

*Atropine* Post-MI setting: Atropine followed by placement of temporary pacemaker, such as transcutaneous pacemaker = initial step in following cases: - symptomatic bradycardia via sinus node dysfunction - mobitz type I heart block that doesn't repond to atropine - complete heart block or mobitz type II heart block

Diffuse axonal injury in severe trauma = CT: diffuse blurring of gray-white matter interface with multiple small, punctate hemorrhages. Therapy?

*Attempt to decrease intracranial pressure without surgery* - maintain ICP by head elevation, hyperventilation, avoidance of fluid overload Next line of management: - ICP monitoring - mannitol/furosemide - deep sedation

4 yo boy brought to doc by his mom bc child has been ignoring her for 3 mos. Boy pays no attention when she asks him question, especially when she stands on left side. He has had four episodes of ear infection during past year. His last ear infection was 4 mos ago. He plays well with other kids & speaks in full sentences. His temp is 98.8 F. Pt appears comfortable at rest. When doc asks boy to bring toy to her, he immediately complies. Pneumatic otoscopy exam shows bilaterally dull & retracted tympanic membranes with fluid level on left. Most appropriate next step in management?

*Audiometry* Chronic otitis media with effusion (OME) - subjective loss of hearing + bilateral dull, retracted tympanic membranes - longer than 3 os? = need audiometry test to objectively assess loss of hearing - if there is hearing loss = myringotomy indicated

Baby has just been born to young, single mother who did not have prenatal care. In delivery room, infant is noted to be cyanotic & mildly tachypneic & is given oxygen. All attempts to remove oxygen result in continued cyanosis. Baby is transferred to neonatal ICU & placed in hood with 100% oxygen. Pulse oximetry reading shows saturation of 68%. Hypoxemia confirmed with arterial blood gas showing PaO2 of 37 mmHg while on 100% oxygen. PaCO2 is 36 mmHg with pH of 7.43. Upon auscultation, there is normal precordial impulse, single, loud second heart sound, & soft systolic ejection murmur at mid left sternal border. Next step in management?

*Begin continuous IV infusion with prostaglandin E1* - done whenever ductal-dep lesion possible - maintains patency of ductus arteriosus Most common cyanotic lesion presenting in immediate newborn period = transposition of great arteries (TGA) - simple dextro-TGA = d-TGA = intact ventricular septum - venous return & AV connections normal - aorta arises from physiologic right ventricle & pulmonary artery from phys. left ventricle - survival dep upon mixing of arterial & venous blood through foramen ovale & ductus arteriosus - mixing improved if there is VSD - 2nd heart sound usually loud & single & murmurs may be absent or there may be soft systolic ejection murmur at mid left sternal border - chest radiography classically shows: mild cardiomegaly with narrow mediastinum (egg on string) & increased pulmonary blood flow - fixed shunt = arterial oxygenation would not arise appreciably upon 100% oxygen

42 yo woman arrives at ER by ambulance accompanied by her husband. She is unconscious. Quick history from husband indicates that for past few days she has been very tired and has not gone to work. Today she complained of continued headache, & gradually become confused & did not understand what he was saying to her. He also noticed some unusual "purple blotches" on her arms & legs. Bc of concern about her airway breathing, she is intubated & placed on ventilator. Most obvious initial finding on exam is scattered purpura & petechiae & she appears very pale. She has following findings: Hct = 22% Reticulocytes = Marked increase Peripheral smear = Many nucleated RBCs, schistocytes, & helmetcells Platelets = 3,000/uL LDH = 800 units/L Bilirubin = 6.2/0.6 mg/dL PT, PTT, fibrinogen = Normal BUN = 20 mg/dL Creatinine = 1.4 mg/dL Urine = Hemoglobin present Most important step in initial management of patient?

*Begin large-volume plasmapheresis* TTP - microangiopathic hemolytic anemia (MAHA), thrombocytopenia, elevated serum LDH - etiology = deficiency of von Willebrand factor-cleaving protease --> platelet agglutination & endothelial adherence - more common in patients b/t 20 & 50 - slight female predominance - most commonly ppted by pregnancy, use of estrogens, infections, drugs (quinine & ticlopidine) - may also occur as complication of bone-marrow transplantation - presentation = anemia, bleeding, neuro complications - reticulocytosis - initial treatment = emergent large-volume plasmapheresis

Have been shown in multiple studies to improve survival after MI

*Beta blockers* - decrease both oxygen demand & incidence of ventricular arrhythmia - in post-MIT pts with normal EF, beta-blockers are more beneficial than ACEIs - If this pt had low EF, this would not be a fair question bc with low EF both drugs (beta blockers & ACEIs) have been proven to have significant mortality benefit

68 yo woman has nodule on her right eyelid for more than 5 yrs that has partially resolved spontaneously. She is still able to palpate residual "bump" in her eyelid. She has no med probz & has been in good health. Exam of right upper eyelid reveals firm, painless, indurated, nodular lesion with minimal conjunctival injection. Small mount of pus can be expressed. Upper eyelid has yellowish appearance & there is loss of lashes around that area. Visual acuity & pupillary exams are normal, as is the rest of physical exam. Most appropriate management?

*Biopsy of nodule* Sebaceous cell carcinoma - often mistaken for recurrent chalazion - firm, painless, indurate nodular lesion with loss of lashes & yellowish eyelid --> biopsy of lesion --> to exclude any possible malignancies before treatment for likely chalazion (nontender chronic granulomatous inflammation of meibomian gland)

66 yo woman evaluated for 1 mo ho abdominal discomfort. She describes deeply painful sensation in midepigastric region & also notes early satiety. Bc of decreased appetite, she reports 1.4 kg (3-lb) weight loss. Pt has taken OTC proton pump inhibitor for past week that has helped relieve her symptoms. Med hx otherwise unremarkable, & she takes no other meds. On physical exam, vital signs are normal. Abdomen soft with normal bowel sounds & no masses. Deep palpation in midepigastrium produces moderate tenderness. Upper endoscopy reveals 9-mm ulcer in gastric antrum proximal to pylorus. Most appropriate management for this pt's ulcer?

*Biopsy of the ulcer* Newly diagnosed gastric ulcer - event small, benign-appearing gastric ulcers may harbor malignancy

Natural inhibitor of kidney stone formation

*citrate* General advice for stone prevention - fluid intake > 2 L/day - moderate calcium intake 1-2 g/day - protein intake of 1.2 g/kg/day (reduce animal protein) - salt restriction 2 g/day - oxalate restriction (southern diet: spinach, rhubarb, beets, nuts, strawberries, chocolate, grits, beans, collards, etc) - DASH diet

40 yo woman has 8 mo ho diffuse joint pain & swelling that involves both hands & knees. She states that she cannot get any work done in the morning bc of pain, but it usually subsides as the day progresses. She tires easily & constantly feels "feverish." Her temp is 100 F, BP 110/70 mmHg, pulse 60/min, & respirations 18/min. Physical exam shows tender, swollen, & "boggy" hands & knees. Lab studies show hematocrit 34% & hemoglobin 10 g/dL. Radiograph of pt's knee most likely to show what?

*Bone erosions* RA - chronic inflammatory - extra-articular manifestations - middle-aged women - join pain - rheumatoid nodules - normochromic, normocytic anemia - increased ESR - PIP, MCP, wrist joints - radiographic findings = soft-tissue swelling, joint effusions, juxta-articular osteopenia, loss of articular cartilage, joint space narrowing, bone erosions

31 yo woman, gravida 1, para 0, at 36-weeks' gestation with twins comes to doc for prenatal visit. Pt has had no contractions, bleeding from vagina, or loss of fluid, & the babies are moving well. Based on today's ultrasound, fetus A is vertex & 2450 grams. Fetus B is in breech presentaiton with estimated fetal weight of 2300 grams. Pt wants to know if she should have vaginal or cesarean delivery. Proper counseling for this pt?

*Both vaginal delivery & cesarean delivery are acceptable* - pts with vertex-vertex twins are generally allowed to have vaginal delivery - pts with non-vertex are generally advised to have cesarean delivery - pts with presenting twin vertex and non-presenting twin non-vertex may decide which mode of delivery they would prefer - once presenting (vertex) twin has delivered, there are 2 options for delivery of second (non-vertex) twin --> 1) external cephalic version = head of second twin is guided into pelvis so that it may become a vertex presention; 2) breech extraction of twin = may be performed so long as there is an adequate pelvis, fetal weight >2000 g, experienced doc, flexed head, and available general anesthesia

7 yo child brought in for evaluation bc he has developed diplopia for last 2 wks. He states that 3 mos ago he felt that his neck was getting stiffer, but for the last 2 wks his neck is bent to one side. Exam shows right-sided facial weakness, which includes forehead. MRI scan shows marked enlargement of pons, displacing but not occluding fourth ventricle. Most likely diagnosis?

*Brainstem glioma* - long hx of minor complains - slow growing tumor - can produce local neck pain, dystonic posturing, as well as facial & auditory dysfunction - typically, signs of increased intracranial pressure are uncommon

47 yo chronic alcoholic woman goes on 3 wk drinking binge & ends up with protracted vomiting, aspiration, & right lower lobe pneumonia. Her fam hx is positive for MS. She is hospitalized in evening, & initial lab studies show PT of 22 sec, serum sodium of 123 mEq/L, & WBC count of 17,000/mm^3. During ensuing 12 hrs, she is placed on abx, receives IV drip of 5% saline, & is administered several ampules of vit K. By next morning, her PT is 18 sec, her serum sodium is 141 mEq/L< & her WBC count has decreased to 12,000/mm^3. On morning rounds, however, she is found to be unresponsive. Further exam reveals that she is actually conscious & oriented but is unable to move her extremities or to speak. She can respond to commands only by moving her eyes up & down & by blinking. Although complete neuro exam was not done at admission, at that time she was awake & alert & had no obvious neuro complaints or deficits. If done at this time, MRI scan of head will most likely show what findings?

*Bright patches within central basis of pons* Locked-in syndrome - complete paralysis of voluntary muscle in all parts of body except for eye movements - via strokes in base on pons, traumatic brain injury, or demyelinating dzes - this pt = via central pontine myelinolysis that followed rapid correction of chronic hyponatremia - chronically alcoholic pts susceptible to iatrogenic condition --> thus, correcting hyponatremia at rate of 10 mEq/24 hrs desired

Pts who have nephrotic syndrome have increased incidence of renal vein thrombosis, due to hypercoagulable state form loss of urinary anticoagulant proteins. Therefore, diagnosis can be established with

*CT angiography of renal arteries and veins* - treatment = warfarin

26 yo woman evaluated in ED for 8 day ho sore throat, fever, neck pain. She has severe pain on left side of her neck w/ swallowing. She has had fevers for last wk, with rigors starting today. Over last 3-4 days, she has had increasing cough. She is otherwise healthy & takes no meds. On physical exam, temp is 102.3 F, BP 108/68 mmHg, pulse rate 116/min, & RR 20/min. BMI 19. She appears ill. Neck is tender to palpation along left side, without lymphadenopathy. Pharynx is erythematous, with tonsillar enlargement & no exudates. Chest is clear to auscultation. Remainder of exam is normal. Chest radiography is shown. Leukocyte count 18,400/uL w/ 17% band forms. Serum creatinine level 0.8 mg/dL. What test is most likely to establish diagnosis?

*CT of neck with contrast* Lemierre syndrome - fever + leukocytosis + sore throat + unilateral neck tenderness + multiple densities on chest radiograph = suggestive of septic emboli = septic thrombosis of internal jugular vein - suspect in anyone w/ pharyngitis, persistent fever, neck pain, septic pulmonary emboli - CT of affected vessel w/ contrast - treatment = IV antibiotics that cover streptococci, anaerobes, & beta-lactamase-producing organisms - penicillin + beta-lactamase inhibitor & carbapenem = reasonable choices (amp-sulbactam, piper-tazobactam, ticarcillin-clavulanate)

29 yo woman brought to ED after being in motor vehicle accident. Emergency medical personnel report she was a front seat passenger & was wearing her seat belt. Car had been traveling on highway at appx 55 mph when another care swerved in front of it, resulting in head-to-side collision. IN ED< pt appears ill & complains of severe epigastric pain. Her BP is 138/62 mmHg, pulse is 105/min, & respirations are 20/min. Physicla exam shows abdominal distention & tenderness to palpation in all 4 quadrants. Ecchymosis is seen across her abdomen in oblique pattern. Most appropriate next step in management of this pt?

*CT of the abdomen & pelvis* Blunt abdominal trauma - determine presence of internal organ injury or internal bleeding in stable pt

68 yo man admitted to hospital for delirium associated with UTI. Upon adequate treatment of infection, pt's mental status improves significantly, though he remains partly disoriented. He also shows impairment in short-term memory, difficulties in naming simple objects, & impaired concentration. His fam members confirm 8-mo ho gradual progressive decline in cognitive abilities, which they attribute to old age. However, man is no longer able to manage his finances & has gotten lost while driving to grocery store on two occasions. Prior to his discharge from the hospital, the nursing staff reports that he continues to drip urine, although his infection has resolved. Nurses also noticed that he cannot walk straight & requires assistance when walking. No other obvious signs or symptoms noted. What will best confirm the diagnosis of this pt's condition?

*CT scan followed by lumbar puncture* - lumbar puncture both diagnostic & therapeutic for NPH Normal pressure hydrocephalus (NPH) - potentially reversible cause of dementia - classic triad = gait disturbance, urinary incontinence, dementia - enlargement of ventricles observed on CT - normal opening CSF pressure observed on lumbar puncture

59 yo man comes to clinic complaining of urinary urgency & frequency for past 6 wks. He also states that he hasnoticed passage of small bubbles of air with his urine, & that the urine has become foul-smelling with traces of mucus. He denies any prior urinary symptoms or dz. He has had nocturia once per night, & occasionally he has felt that his urine stream was becoming weaker. His bowel habits are unchanged and he denies blood per rectum, diarrhea, & constipation. His medical hx is significant for T2D. His sx hx is negative. He drinks alcohol socially & doesn't smoke. On physical exam, he is afebrile with normal vital signs & is not in any distress. His abdomen is soft & nondistended; bowel sounds are normal. There is mild tenderness to deep palpation in LLQ. Genital exam is normal without any urethral discharge. On rectal exam, his sphincter tone is good & his prostate is small without nodules or tenderness. Stool is guaiac-negative. His leukocyte count is 12,500/mL with noral differential. Urinalysis sent after cath shows many leukocytes & many bacteria & is positive for nitrites. Urine culture returns with multiple organisms. Most appropriate next step in management?

*CT scan of abdomen & pelvis with contrast* Colovesical /Enterovesical / Vesicoenteric fistula - b/t colon & bladder - via diverticulitis - may be via adenocarcinoma of sigmoid colon & very rarely from cancer of bladder - symptom = pneumaturia (air in urine) = 50% of pts with this symptom - UTI considered abnormal in men = treat aggressively - management begins with NPO & IV abx, & ultimately surgical exploration with colonic resection

53 yo man brought to ED after motor vehicle accident, with multiple abdominal blunt traumas. In sx, pt is found to have seat-belt injury to small bowel, & he requires resection & re-anastomosis of affected area. After all intra-abdominal injuries are successfully repaired, abdomen is closed. Pt then has uneventful postoperative course unti ltenth postoperative day, when he experiences temperature spikes. He has been tolerating oral intake since fifth postoperative date, & at this time, his physical exam is unremarkable except for fresh midline wound & some mild tenderness in periumbilical area. Rectal exam is unremarkable. CBC shows: Hgb 13 g/dL Hct 43% WBC 18,400/mm^3 Segmented neutrophils 85% Lymphocytes 10% Basophils 0.5% Monocytes 1% Eosinophils 3% Etiology of fever will most likely be demonstrated by what imaging?

*CT scan of abdomen* - fever that starts 10-15 days after contaminated abdominal surgical procedure = most likely caused by anastomotic disruption or deep abscess, either pelvic or subphrenic = further supported by elevated WBC count - pelvic abscess can be ruled out by rectal exam performed as part of his postoperative physical exam - *subphrenic abscess can best be demonstrated by CT scan of abdomen*

63 yo man presents w/ mid-abdominal colicky pain, that is associated with nausea, anorexia, & vomiting for past 48 hrs. Pt has hx of DVT & had pulmonary embolus in distant past, but he is not currentl yon anticoagulants. His temp is 98.6 F, BP 95/60 mmHg, & pulse 102/min. On physical exam, a distended & tympanic abdomen is noted, with some guarding but no rigidity. Abdominal x-rays show multiple distended loops of small bowel & distention of right colon, up to middle of transverse colon. Stool is positive for occult blood. Most appropriate next diagnostic step?

*CT scan of abdomen* - or MRI - excellent diagnostic yield when looking for mesenteric venous thrombosis Mesenteric ischemia - via reduction in intestinal blood flow - most commonly arises from occlusion, vasospasm, &/or hypoperfusion of mesenteric vasculature

6 yo boy brought to ED immediately after having seizures that lasted 10 minutes. He has had fevers, vomiting, ear pain & most recently severe headache for last week. Current meds include amoxicillin for 3 days. He is in no distress. His temp is 103 F, BP is 128/80 mmHg, pulse 86/min, & respirations 18/min. Otoscopy shows erythematous left tympanic membrane with perforation, & purulent material in external ear canal. Fundoscopic exam shows elevation of left optic disc, with obscuring of blood vessels at disc margin. Most appropriate next step in management?

*CT scan of head* One of most serious complications of sinusitis & chronic otitis = *cerebral abscesses* - can be visualized by head CT or MRI (preferred study) - most common reasons for brain abscesses in children = sinusitis, chronic otitis media, meningitis, cellulitis of face or scalp, orbital cellulitis, dental infections, right-to-left cardiac shunts with embolizations (ex. tetralogy of Fallot), penetrating head trauma, immunodef & ventricular-peritoneal shunts

17 yo is brought to ED from high school football game on backboard with cervical collar in place. He was tackled while running & was thrown backward to ground. He was unconscious for a few minutes, & then woke up spontaneously. He doesn't recall event, but he complains of right shoulder pain. On exam, he is alert and oriented to person, place, & time, & remembers ambulance ride to hospital. He has no focal neuro deficits. His right clavicle is exquisitely tender with palpable defect laterally. He has no motor or sensory deficits in his right upper extremity & his radial pulse is palpable. Chest x-ray shows fracture of distal third of clavicle but no rib fracture or pneumothorax. What is the next step in management?

*CT scan of the head without IV contrast* - loss of consciousness secondary to trauma = absolute indication for CT scan of head - CT scan of head is highly sensitive for intracranial bleeding & is performed without IV contrast - clavicular fracture is most commonly managed conervatively with shoulder sling &/or para-8 shoulder brace for 6-8 wks

Screening for bleeding disorders in patient prior to surgery

*clinical history* - should focus on abnormal bleedingin pastor any systemic illnesses that might increase bleeding risk (such as liver dz)

Herpes zoster ophthalmicus: what is sufficient to start treatment?

*clinical presentation* - no lab studies necessary

66 yo man comes to urgent care clinic with progressive jaundice, which he first noticed 6 wks ago. He has no significant past med hx & takes no meds. He has smoked 1 pack of cigz a day for past 30 yrs & drinks glass of wine each evening. He has total bilirubin level of 22 mg/dL, with direct (conjugated) bilirubin level 16 mg/dL. Transaminase levels are minimally elevated, whereas alkaline phosphatase levels are appx 6 times upper limit of normal. Sonogram shows dilated intrahepatic ducts, dilated extrahepatic ducts, & very distended, thin-walled gallbladder without stones. Most appropriate next step in diagnosis?

*CT scan of upper abdomen* Obstructive jaundice - high alkaline phosphatase + dilated biliary ducts - malignancy suggested by dilated, thin-walled gallbladder wihtout stones - cancer of head of pancrease can be detected by CT scan

2 day old newborn girl who was born at 38 weeks' gestation brought to ED bc of progressively worsening lethargy & poor feeding. In ED, newborn is in severe respiratory distress & appears cyanotic. Physical exam shows grunting with nasal flaring and tachypnea. Normal S1 & S2 with regular rate & rhythm are heard upon auscultation of chest. Lung sounds are also normal. Newborn's breathing & color improve when she cries but deep inspirations are ineffective. Direct laryngoscopy is performed and shows no abnormalities. Most likely to confirm diagnosis?

*CT scan with contrast of head* Choanal atresia - obliteration or blockage of posterior nasal aperture - most newborn are obligate nose-breathers, spells of crying force mouth-breathing --> improves ventilation - cyanosis that worsens during feeding & improves when infant cries

67 yo man complains of recent onset of passage of "bubbles" with his urine. He states that this started appx 2 weeks ago & has not improved. There is also some burning on urination, & the pt thinks that he may have even seen some fecal material when he urinates. His med hx is significant for diverticulitis appx 1 yr ago. He denies any recent weight loss, blood in stool, or recent change in bowel habits. Physical exam is normal & stools are guaiac-negative. Diagnostic studies most likely to confirm diagnosis?

*CT scan* - would likely confirm diagnosis by revealing inflammatory diverticular mass Pneumaturia - passage of air with urination Fecaluria - passage of fecal material with urination Cause = fistual b/t bladder & GI tract (colovesical fistula) - most common site for fistula = sigmoid colon - most common cause = diverticulitis - sigmoid cancer = 2nd most likely cause- bladder cancer = distant third possible source

A 43-year-old man is evaluated in the hospital for perioral paresthesias and severe cramping of both hands. He underwent total thyroidectomy yesterday because of papillary thyroid cancer. The surgery was uncomplicated, and no involved lymph nodes were found. On physical examination, vital signs are normal. Cardiopulmonary and abdominal examinations are unremarkable. Results of muscle strength testing are normal. Although the patient reports cramps, no tetany is detected. Results oflaboratory studies show a serum calcium level of 4.1 mg/dL (1. O mmol/L), a serum magnesium level of 1. 7 mg/ dL ( O. 70 mmol/L), and a serum phosphorus level of 4.7 mg/dL (1.52 mmol/L); kidney function studies are normal. An electrocardiogram is normal. Which of the following is the most appropriate immediate treatment for this patient?

*Calcium* - most likely to diminish acute symptoms in patient who recently underwent thyroidectomy - patient requires emergency rapid increase in serum calcium concentration = best accomplished by oral calcium (carbonate or citrate) supplementation - IV calcium more rapidly increases serum calcium level & may be indicated in patients with very low (<7.5 mg/dL [1.9 mmol/L]) - patient most likely will require more prolonged calcium therapy, depending on degree of hypoparathyroidism after surgery

19 yo college student has new-onset bloody diarrhea & abdominal pain that started appx 4 hrs before this office visit. He has no significant past medical history & takes no meds. He recently returned from camping trip where he was drinking water from fresh mountain streams. In addition to drinking the water, he often would bbq shrimp & hamburgers & eat potato salad that was prepared 2 days before trip. Last night, after arriving home, he ate his roommate's cold, leftover fried rice from a Chinese takeout restaurant. His temp is 39 C (102.2 F), BP is 110/70 mmHg, pulse is 93/min, & respirations are 16/min. His abdomen is soft & nontender with hyperactive bowel sounds. Stool is positive for occult blood. What organisms is most likely responsible for this pt's diarrhea?

*Campylobacter jejuni* = most common cause of bloody diarrheas - bloody diarrhea via: Salmonella, Shigella, E coli, & Campylobacter jejuni

56 yo man has been having blood bowel movements on & off for past several weeks. He reports that blood is rbight red, it coats outside of stools, & he can see it in toilet bowl even before he wipes himself. When he wipes, there is also blood on toilet paper. Further questioning reveals that he has been constipated for past 2 mos and that caliber of his stools has changed. They are now very thin compared to previously. Most likely diagnosis?

*Cancer of rectum* = combo of red blood coating stools & change in bowel habit & stool calbier + age group - physical exam followed by endoscopic evaluation = diagnostic

A 52-year-old woman was evaluated in the emergency department because of acute onset of dyspnea while shoveling snow this morning. The dyspnea resolved within 2 minutes of rest but recurred an hour later while she was watching television. Over the previous 10 days she has had several similar episodes of dyspnea with mild exertion, such as walking upstairs, and also at rest. She has no chest pain, palpitations, or orthopnea. She has a 15-year history of type 2 diabetes, hyperlipidemia, and hypertension treated with aspirin, metformin, chlorthalidone, ramipril, and rosuvastatin. On physical examination, temperature was 37°C (98.6°F), blood pressure was 110/70 mm Hg, pulse rate was SO/min, respiratory rate was 18/min, and oxygen saturation was 96% on ambient air. There was no jugular distention, normal cardiac sounds were present without extra sounds or murmurs, and the lungs were clear to auscultation. The initial electrocardiogram showed ST-segment changes. The first troponin I level was O ng/mL (0 µg/L). An hour after admission to the emergency department, she had an episode of acute dyspnea. A repeat electrocardiogram at this time is shown. Repeat troponin level is 0.8 ng/mL (0.8 µg/L). What of the following is the most appropriate next diagnostic test?

*Cardiac catheterization* - patient will benefit from early invasive approach that includes coronary angiography & subsequent revascularization (percutaneous coronary intervention or surgical revascularization) - managing non-ST elevation MI

The EMS arrives on the scene of a traumatic cardiac arrest, where you have started CPR. There is an organized rhythm on the monitor but still not pulse. What are the causes of PEA?

*Cardiac tamponade & tension pneumothorax* Other potentially causes of cardiac arrest - hypoxia - hypovolemia - hydrogen ions (acidosis) - hypoglycemia - hypothermia - hyper/hypokalemia - toxins/tablets - thrombosis - coronary & pulmonary - trauma

A 76-year-old man is evaluated because of an episode ofleft-handed weakness involving all five digits that occurred yesterday and gradually subsided over 3 hours. He has had two similar episodes in the last 2 weeks. Medical history is unremarkable. His only medication is a daily low-dose aspirin. On physical examination, blood pressure is 156178 mm Hg and pulse rate is 76/min and regular. Cardiac examination shows a right carotid bruit. Other findings on physical examination, including a neurologic evaluation, are normal. Electrocardiogram shows normal sinus rhythm with no evidence of ischemia. Carotid duplex ultrasound shows 80% to 99% stenosis of the right internal carotid artery, which is confirmed by computed tomographic angiography. Magnetic resonance imaging of the brain shows a 5-mm infarct in the right middle cerebral artery distribution. Which of the following will have the greatest effect in reducing the risk ofrecurrent stroke in this patient?

*Carotid endarterectomy* - highly effective in reducing risk of recurrent stroke in immediate poststroke period - NNT = 17 - - pt should be referred for immediate endarterectomy of right internal carotid artery - had acute ischemic stroke caused by high-grade carotid stenosis - risk of recurrent stroke = 26% over next 2 years

55 yo woman comes to office with complaints of burning & tingling sensations in left hand for several mos. She relates that she has been frequently awakened at night by aching pain in same hand. Past med hx is significant for HT for 3 yrs & hypercholesterolemia for 2 yrs. She is on thiazide & atorvastatin. Exam fails to detect any impairment in sensation, but pain is elicited by extreme dorsiflexion of wrist. Pt unable to correctly identify different types of cloth by rubbing it b/t left thumb & index finger. Most likely diagnosis?

*Carpal tunnel syndrome* - pain + tingling sensations + hypoesthesia in distribution of median nerve - exacerbations at nighttime - shocklike pain upon percussion on volar aspect of wrist = TInel sign

38 yo white man brought to doc by his mom. Mother states that pt has become increasingly paranoid & irritable over last 2 yrs. He suspects her of poisoning his food. Whie he had many friends when he was young, he now has few friends & rarely socializes. On physical exam, doc notest that man shows random, uncontrollable, jerky movements. Pt scores 24 on MMSE. Most likely to be seen in neuroimaging in this pt?

*Caudate nucleus atrophy* Huntington's dz - AD - atrophy of caudate nucleus - choreoathetoid movements + cognitive deficits + behavioral abnormalities

55 yo man brought to ED bc of altered mental status. According to patient's daughter, he has been complaining of headache for 2 days. Last night, he was febrile & had few episodes of vomiting. This morn he was difficult to arouse. He has past med ho HT, DM, chronic renal insufficiency, & coronary artery dz. Meds include aspirin, clopidegrel, metoprolol, glyburide, & lisinopril. His temp is 38.4 C (101.1 F), BP 190/106 mmHg, pulse 102/min, & respirations 16/min. Physical exam shows patient who is confused & difficult to arouse. Patient moves all 4 extremities but is not cooperative for complete neuro exam. Remainder of exam is unremarkable. Head CT is normal. Lumbar puncture shows: Opening pressure 195 mmHg H2O Appearance opaque Cell count 400/mm^3 Dominant cell type neutrophils, 10 RBCs/field Glucose 20 mg/dL Protein 518 mg/dL Most appropriate therapy?

*Ceftriaxone + vancomycin + ampicillin + dexamthesone* Bacterial meningitis - 3rd gen ceph/ceftriaxone = gram-positive & gram-negative - vanco = pen-resistant S pneumoniae - ampicillin = L moncytogenes suspected (age extremes = <1 month or >50 years & immunocompromised) - steroids = adjuvant to antimicrobial therapy in all cases of bacterial meningitis

38 yo man with ho genital herpes comes to doc bc of right knee pain & swelling. He reports that the symptoms started earlier in day & it is extremely painful to move or even touch his knee. He denies any trauma to affected knee. He also reports recent unprotected sex with prostitute. His temp is 39 C (102.2 F), BP 125/90 mmHg, pulse 108/min & regular, & respirations 15/min. Physical exam reveals swollen & tender right knee with palpable effusion. Patient is tachycardic but exam is otherwise normal. An arthrocentesis is performed & fluid is sent for analysis. What finding is most likely?

*Cell count with 75,000 WBC* Septic arthritis + fever + patient <40 yo + gonococcal dz - diagnosis of septic arthritis = WBC >50,000/mm^3 - gram stain negative in gonococcal septic arthritis in 50% of cases

26 yo woman arrives in ED with severe headache. Never had headaches before, & she ranks this one as 8/10 in terms of pain. She is fully conscious. She has noticed bilateral UE weakness. Denies neck stiffness. Past med history notable for lupus, for which she takes prednisone. She is also taking oral contraceptive for birth control. She denies alcohol or tobacco use, & she has not used any illicit substances. On physical exam she is afebrile & normotensive. She is saturating 97% on room air. Pulse is 93/min. Head & neck exam unremarkable. Chest clear to auscultation & she has no abnormal heart sounds. Abdominal exam reveals no focal tenderness. Extremities demonstrate no cyanosis, clubbing, or edema. She has 3/5 strength in both UEs, & her left facial muscles are mildly weak. Complete blood count shows: WBCs = 7800/mm^3 Hematocrit = 43% Platelets = 322,000/mm^3 Computed tomography of brain demonstrates bilateral infarcts along anterior & posterior frontal lobes & parietal lobes, extending into white matter. What is most likely to reveal diagnosis?

*Cerebral venogram* Dural sinus thrombosis - most likely of superior sagittal sinus - risk factors = lupus & contraceptive use - should be tested for antiphospholipid Abs after acute presentation resolves - sagittal sinus infarcts tend to cross arterial vascular territories & extend into white matter - treatment = anticoagulation & possible thrombolysis in acute phase

34 yo African-American woman comes to urgent care clinic complaining of dyspnea on exertion & nonproductive cough. She has previously been in good health, except fo rho mononucleosis while in college. She does not smoke nor drink. She has been monogamous with her husband since they were married 16 yrs ago. On physical exam, her temp is 100.9 F, BP 132/80 mmHg, pulse 74/min, & respirations 22/min. There are purple areas of swelling on her nose & cheeks. Pharynx is clear. There are scattered cervical lymph nodes & clubbing of peripheral fingernail beds. Bilateral inspiratory crackles are heard on lung exam. There is regular S1 & S2. Liver span is 13 cm in mid-clavicular line, & spleen tip is palpable. Chest x-ray film reveals bilateral hilar lymphadenopathy. Most appropriate next step in eval of this pt?

*Cervical lymph node biopsy* - AA female + bilateral hilar adenopathy --> sarcoidosis - lupus pernio - in eval of DD of hilar lymphadenopathy = tissue diagnosis to r/o other possibilities in differential diagnosis

Your rescue team arrives to find a 59 yo man lying on the kitchen floor. You determine that he is unresponsive & notice that he is taking agonal breaths. What is the next step in your assessment & management of this patient?

*Check the patient's pulse*

A 63-year-old man is evaluated for fatigue and a persistent cough of 7 weeks' duration. He has a 60-pack-year smoking history. On physical examination, his vital signs and physical examination are normal. A chest radiograph reveals a right hilar mass. A computed tomography (CT) scan of the thorax confirms the presence of a right perihilar mass and enlarged hilar and mediastinal lymph nodes. An endobronchial mass is identified by bronchoscopy; brushings and biopsy reveal small cell lung cancer. A CT scan of the chest and abdomen is negative. A bone scan and magnetic resonance imaging of the brain are negative. Which of the following is the most appropriate next step in the management of this patient?

*Chemotherapy with adjunctive radiation therapy* Limited-stage small cell lung cancer - Veterans Administration Lung Study Group staging system typically used --> classifies dz as limited or extensive = dz limited to one hemithorax + hilar & mediastinal lymphadenopathy that can be encompassed within one tolerable radiotherapy portal - chemo initiated within addition of radiation to chest concurrent with first or second cycle of chemo - radiation decreases rates of local recurrence & increases median survival

60 yo woman presents to office with diarrhea & weight loss of appx 20 lbs in last 3 months. She describes her stools as bulky & foul-smelling. ROS reveals very poor appetite in last few months with occasional nausea. She denies abdominal pain, blood in stools, & dark-colored stools. Her history is significant for HT, DM, hypercholesterolemia, CAD, & end-stage renal disease. Physical exam shows undernourished female. Pulse rate is 89/min, respirations are 14/min, & BP 110/72 mmHg. She is afebrile. Lungs clear to ausculation. CV exam within normal limits. Abdomen soft, nontender, nondistended. Extremities show no pitting edema. She is hospitalized for further evaluation. 24-hour-stool study reveals 40 g of fat. CT of abdomen reveals 2 cm mass at head of pancreas. Liver shows multiple areas of hypoattenuation. What is the most appropriate next step in management?

*Chemotherapy* = 5-FU + leucovorin + oxaliplatin + irinotecan - poor functional status? = gemcitabine Pancreatic cancer - + metastasis = mortality rate of 100% = surgery not recommended

Three minutes after witnessing cardiac arrest, one member of your team inserts an endotracheal tube while another performs continuous chest compressions. During subsequent ventilation, you notice the presence of a waveform on capnography screen & a PETCO2 level of 8 mmHg. Significance of this finding?

*Chest compressions may not be effective*

A 63-year-old woman is evaluated in the emergency department because of sudden onset of anterior chest pain and shortness of breath. The pain is sharp, is worse with inspiration, and does not radiate. She cannot walk more than a few steps without dyspnea. The medical history is significant for lung cancer that was diagnosed 2 weeks ago. She is undergoing radiation therapy. She has not been hospitalized recently. She has no cough, fever, chills, or hemoptysis. She has a 35-pack-year history of smoking and stopped smoking 3 months ago. On physical examination, she is afebrile, blood pressure is 110/70 mm Hg, pulse rate is 115/min, respiration rate is 22/min, and oxygen saturation is 84% on ambient air. Findings on cardiopulmonary examination are normal. The extremities are normal, without pain or edema. The electrocardiogram shows sinus tachycardia with ST-segment depression in leads V 3 to V 6, unchanged from 2 months ago. The initial troponin I level is 0.1 ng/mL (0.1 µg/L). Chest radiograph shows a right hilar mass that is unchanged from 2 weeks ago. Which of the following diagnostic tests should be performed next?

*Chest computed tomographic angiography* Pulmonary embolism

A 70-year-old man is evaluated for sharp left-sided pleuritic chest pain and shortness of breath that began suddenly 24 hours ago. The pain has been persistent over the last 24 hours and does not worsen or improve with exertion or position. The patient's history is significant for a SO-pack-year smoking history and severe chronic obstructive pulmonary disease, although he is currently a nonsmoker. Medications are ipratropium and albuterol. On physical examination, temperature is normal, blood pressure is 128/80 mm Hg, pulse rate is 88/min, and respiration rate is 18/min. Oxygen saturation on ambient air is 89%. The trachea is midline. Lung examination shows hyperresonance, decreased chest wall expansion, and decreased breath sounds on the left. Cardiac examination shows distant heart sounds but no extra heart sounds. Which of the following is the most appropriate diagnostic test to perform next?

*Chest radiograph* - he has COPD - findings consistent with spontaneous secondary pneumothorax = sudden, sharp, nonradiating pleuritic chest pain & SOB with hyperresonance, decreased breath sounds, decreased chest wall expansion on side of pneumothorax in patient with underlying lung dz - diagnostic test of choice if pneumothorax suspected = upright chest radiography --> findings = separation of parietal & visceral pleura by collection of gas & absence of vessels in space - increased risk for pneumothorax bc of COPD - primary spontaneous pneumothorax more often in men, smokers, those with fam history

60 yo man comes to ED with SOB & dull, left-sided chest pain. He has had low-grade fever for past 3 days. He was treated recently for pneumonia with antibiotics, but says that he never quite returned to baseline. He has no other medical issue & has no allergies. He denies alcohol abuse or drug use. His temp is 37.8 C (100 F), BP 120/80 mmHg, & pulse 70/min. Exam reveals decreased breath sounds on left & decreased tactile fremitus. Left decubitus chest x-ray is consistent with large left-sided pleural effusion > 15 mm with layering. Thoracentesis reveals turbid fluid with WBC count 70,000, RBC count 20,000, LDH 1,500 IU/L, serum LDH 600 IU/L (normal 50-150 IU/L), & pleural fluid pH 7.1. Repeat chest x-ray reveals pneumonia in left upper lobe. Gram stain of fluid fails to reveal organisms. Cultures of pleural fluid are sent to lab. What is most appropriate initial management?

*Chest tube insertion* Pneumonia: parapneumonic exudative effusion - elevated WBC, acidic pH = complicated parapneumonic effusions that tend to loculate & form adhesions if not drained immediately via chest tube --> 3 categories = uncomplicated, complicated, empyema Empyema - presence of organisms in gram stain or gross pus obtained from thoracocentesis Complicated pleural effusion - may be uniloculated or multiloculated Uniloculated effusions - drained via chest tube

21 yo woman comes to doc bc of "bumps" on her vulva that she has just recently noticed. These bumps don't cause her symptoms, but she wants to know what they are and wants them removed. She has no med probz, takes no meds, & has no allergies to meds. She smokes one half pack of cigz per day. She is sexually active with 3 partners. Pelvix exam shows 3 cauliflower-like lesions of right labia majora. Most appropriate next step in management?

*Cryotherapy* - freezing of skin Condyloma acuminata / genital warts - via HPV - infects epidermal cells = warty growths - treatment = local destruction via cryotherapy, laser therapy, trichloroacetic acid (chemical destruction of skin), or imiquimod

51 yo man comes to ED bc of 2 day ho fever, nausea, vomiting, & severe abdominal pain that radiates to right shoulder. His med hx is unremarkable & he takes no meds. His temp is 101 F, BP is 130/70 mmHg, & pulse is 90/min. Exam shows tenderness in RUQ, with abrupt cessation of inspiration on deep palpation of his right upper quadrant. Sclera are anicteric. Most appropriate next step in management?

*Cholecystectomy in 24-48 hrs* Symptomatic cholecystitis - fever, RUQ pain radiating to shoulder, nausea, vomiting - most common associated with longstanding gallstones & less frequently with severe illness (acalculous cholecystitis) - therapy = prompt surgical removal of inflamed gallbladder - if left in place --> increased risk for infection, abscess formation, sepsis - all pts should receive IV fluids, resuscitation, &, if ill appearing, coverage with broad-spectrum abx

A 67-year-old woman is admitted to the hospital after falling and fracturing her left hip. The patient resides in a nursing home. A review of her medical records reveals a serum creatinine level ofl.3 mg/dL (US µmol/L) 12 months ago and 1.4 mg/dL (124 µmol/L) 3 months ago. Her serum creatinine level today is 1.4 mg/dL (124 µmol/L). Which of the following will best estimate her glomerular filtration rate?

*Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation* = validated measurement derived from large population of patients with both normal & abnormal kidney function - performs better at higher (normal) values of GFR & in patients with mild chronic kidney dz - estimates GFR - Natinal Kidney Foundation Kidney Dz Outcomes Quality Initiative (NFK KDOQI) recommends use of mathematical equations to estimate GFR - equations should only be used when serum creatinine level has been stable for at least 24-48 hours

49 yo man being evaluated in ED for recent fall & blow to his head. CT scan normal, & his injuries involve only small laceration over right eye. Past med history significant for chronic gastritis & osteoarthritis for which he sometimes takes acetaminophen. Lab workup shows: RBC Count = 4.1 x 10^6/mm^3 Hematocrit = 39% Hemoglobin = 12 g/dL Leukocyte count = 7,500 MCV = 110 um^3 Platelet count = 140,000/mm^3 Peripheral smear = hypersegmented neutrophils Anti-IF Abs = Negative Alkaline phosphate = 50 U/L LDH = 150 U/L AST = 150 U/L ALT - 66 U/L Total bilirubin = 1 mg/dL Above findings consistent with what diagnoses?

*Chronic alcohol abuse* - chronic gastritis = common cause is alcohol abuse - elevated MCV = folate & thiamine def = megaloblastic anemia - high AST & ALT (AST>ALT) - history of fall

A 47-year -old man is evaluated for a 3-week history of paresthesia of the left leg and a 6-month history of a nonproductive cough. He also has allergic rhinitis and a history of asthma. Medications are fluticasone and inhaled albuterol as needed. On physical examination, temperature is 37.l °C (98.8°F), blood pressure is 150/100 mm Hg, pulse rate is 100/min, and respiration rate is 18/min. There is no rash, and ocular, nasal, and oral mucous membranes are normal. Examination of the lungs reveals scattered expiratory rhonchi. There is weakness of eversion of the left foot. Laboratory studies: Leukocyte count = 12,500/µL (12.5 x 109 IL) with 44 % neutrophils, 32% eosinophils, 15 lymphocytes, and 9% monocytes Creatinine = 1.8 mg/dL (159.1 µmol/L) Perinuclear anti-neutrophil cytoplasmic antibody = Positive Urinalysis = 1 + protein, 5-10 erythrocytes/high-power field (hpf), 0-5 leukocytes/hpf A chest radiograph reveals scattered bilateral nodular pulmonary infiltrates. Which of the following is the most likely diagnosis?

*Churg-Strauss syndrome* - systemic vasculitis - occurs in setting of antecedent asthma, allergic rhinitis, sinusitis - eosinophilia, migratory pulmonary infiltrates, purpuric skin rash, mononeuritis multiplex - fever, arthralgia, myalgia - 40% have p-ANCA positivity with specificity for antimyeloperoxidase Abs

Has been shown to improve symptoms of peripheral claudication & is FDA-approved for this purpose, particularly if antiplatelet agents & exercise rehabilitation are ineffective and revascularization cannot be offered or is declined by pt

*Cilostazol* - does not improve mortality - c/o in HF Other drugs shown to have improvement in peripheral vascular dz (PVD) - aspirin, dipyridamole, clopidogrel

Medical student interviewing 78 yo man who has brought from nursing home to ED. Student has been talking to man for almost 30 minutes and has obtained very little info. Every time he asks a question pt starts talking and goes into unnecessary details, eventually answering the question but only after he has told his entire story to the medical student. Student is becoming frustrated with the pt bc there are two other pts waiting to be interviewed. Pt's speech is an example of what?

*Circumstantiality* - speech that is delayed from reaching the point - over-inclusion of details - eventually it does get to original goal

22 yo woman in labor progresses to 7 cm dilation, & then has arrest of labor. She therefore undergoes primary cesarean section. Exam 2 days after section shows temp of 39.1 C (102.F F), BP of 110/70 mmHg, pulse of 90/min, & respirations of 14/min. Lungs clear to auscultation bilaterally. Her abdomen is moderately tender. Dressing is clean, dry, & intact. Incision approximated with no evidence of erythema. Pelvic exam demonstrates uterine tenderness. Appropriate therapy?

*Clindamycin-gentamicin* - anaerobic coverage, along with gram-positive & gram-negative coverage Endometritis (Postpartum) - via organisms ascending from vagina = polymicrobial infection of endometrium - fever & chills + lower abdominal pain + foul-smelling vaginal discharge + malaise - C-section = major risk factor

62 yo man comes to ED with large, swollen, tender ankle. He had been running to catch a bus when he fell on his inverted foot & twisted his ankle. Physical exam shows swelling & abnormal angulation of ankle. AP, lateral, & mortise x-rays show displaced fractures of both malleoli. What would be the preferred form of treatment?

*Closed reduction & splinting, then open reduction & internal fixation* Displaced fractures of both malleoli = unstable --> requires surgical repair - bimaleolar fracture = open reduction & internal fixation - pt's ankle should be splinted with joint at 90 degrees & should remain non-weightbearing - presence of significant swelling = strong indication that surgery must be delayed until swelling subsides, likely in a few days

Antisocial personality disorder includes a prior diagnosis of

*conduct disorder* ASPD - cannot be diagnosed until 18 yo

26 yo man arrives in ED bc of acutely painful & swollen left calf. He is IV drug user who admits to use of black-tar heroin on daily basis for past 2 wks. He has resorted to "skin-popping," bc he is no longer able to find veins to inject. He has been hospitalized several times over past few yrs for infective endocarditis. He is HIV-negative as of 3 mos ago. On physical exam, his temp is 101.8 F, BP 106/65 mmHg, & pulse 120/min. He appears undernourished & disheveled with diaphoresis & pallor. He has poor dentition, but no oral abscesses are noted. There is no cervical lymphadenopathy. Lungs are clear to auscultation & CV exam reveals no murmurs. Abdominal exam is benign, & no hepatosplenomegaly appreciated. Skin reveals no lesions on his palms or soles. Indurated, 3-cm fluctuant lesion noted on left calf. Acutely painful to touch, & there is surrounding crepitus. Lab data show WBC 18,000, Hct 38%, & platelets 568,000/mm^3. Most likely etiology agent?

*Clostridium spp* IV drug users + fever - indurated, inflamed lesion on calf = source of infection *Black-tar heroin* - Clostridium = predominant organism - prep results in inoculation of spores into final product - crepitus = ominous sign = gas-forming organisms & deep infection - pt will require emergent surgical debridement & fasciotomy in addition to IV abx (clindamycin, penicillin) - hyperbaric chamber may be used

17 yo girl brought to ED by paramedics. She had been at party that evening that was described as "wild" by her friends. In early morning hours she was found unconcious & barely breathing, so her friends called an ambulance. Friends told paramedics that patient was known to get high with her bf from time to time. On physical exam the pupils are dilated & there is hemorrhagic, frothy fluid in the mouth. Her pulse is 100/min, respirations are 6/min, & BP 70/35 mmHg. What is most likely causing this condition?

*Cocaine* - euphoria Complications - cerebrovascular accidents secondary to HT - rhabdomyolysis - pulmonary edema with alveolar hemorrhage = hemorrhagic, frothy fluid - pneumomediastinum - pneumothorax - cardiomyopathy

17 yo boy brought to doc by his mom bc "he has been sick for some time, & the docs don't seem to known what is wrong with him." For past few days, they have noticed yellowing of his sclera. On further questioning, hx of protracted diarrhea elicited. For appx 3 yrs mg/dL with 2.9 mg/dL conjugated, alkaline phosphatase level 625 U/L, & near-normal transaminase levels. Sonogram of RUQ shows strictures & dilation of intrahepatic & extrahepatic ducts, no gallstones, & no evidence of liver abscess. Stool cultures negative. Pt is at increased risk for what malignancies?

*Colon cancer* Jaundice + high alkaline phosphatase + dilated intra- & extrahepatic ducts = primary sclerosing cholangitis (PSC) - seen in conjunction with IBD = intermittent crampy, bloody diarrhea in 17 yo - associated with UC - surveillance colonscopy recommended in all pts who have IBD & PSC

24 yo Caucasian woman comes to doc bc of 6 mo ho crampy RLQ abdominal pain that is worse with eating. She has had 4 semi-formed bowel movements daily, & aching in her knees & ankles. She has had 7 kg (15-lb) weight loss over past 6 months. She denies fever, chills, or night sweats. Exam shows 2 oral ulcers on inner lower lip that are covered by gray exudate & surrounded by erythematous halo. Abdominal exam shows tenderness in RLQ; there are no masses or hepatosplenomegaly. Rectal exam shows brown stool that is guaiac-positive. Most appropriate diagnostic test for this pt's condition?

*Colonoscopy* Crohn's dz - young adults + subacute or chronic symptoms + RLQ pain + diarrhea + weight loss - extraintestinal manifestations = aphthous ulcers & arthralgias - terminal ileum = most common site of inv't --> colonscopy with entry into terminal ileum & biopsy - characterized by non-caseating granulomas

23 yo woman evaluated for abdominal pain of several years' duration. Pain is crampy in nature and occurs mostly in lower abdomen. Her pain symptoms don't change with eating but improve somewhat with defecation. Pain is frequently associated with diarrhea, especially when she is under stress, or with intermittent constipation, although when she is under stress, or with intermittent constipation, although on most days she has normal bowel movements. She has not noted blood mucus in her stools, but reports a 8-lb weight loss over past year. Med hx is otherwise unremarkable & she takes no meds. On physical exam, she appears thin but otherwise well. Temp is 98.4 F, BP 114/53 mmHg, pulse rate is 70/min, & respiration rate is 12/min. BMI is 18. Abdomen is diffusely tender. There are no abdominal masses or hepatosplenomegaly. Remainder of exam, including pelvic & rectal exams, is normal. Lab studies are significant for hgb level of 9.5 g/dL, leukocyte count of 4000/uL, & a platelet count of 148,000/uL. What is the most appropriate next step in management?

*Colonscopy* - 2 alarm symptoms = weight loss, anemia = not consistent with IBS --> young patient = concern for inflammatory bowel disease --> colonoscopy preferred = allows direct visualization of colonic mucosa & terminal ileum = diagnosis of UC or Crohn dz

77 yo woman comes to ED bc of 12 hr ho passing bright red blood from her rectum. She has become dizzy on standing. She has had no nausea, vomiting, diarrhea, constipation, or abdominal pain. She appears pale. Her temp is 36.6 C (97.9 F), BP is 112/60 mmHg supine & 90/56 mmHg sitting upright, & pulse is 110/min. Abdominal exam shows no abnormalities. Most likely cause of her bleeding?

*Communication between arteriole & venule in cecum* Vascular ectasia = communication b/t arteriole & venule in cecum - form of angiodysplasia - second most common cause of painless colonic bleeding in elderly (after diverticulosis) - may present with acute GI bleeding, chronic GI bleeding, or iron-deficiency anemia

Best diagnostic study of bladder cancer

*cystoscopy*

Absolute contraindications to use of oral contraceptives

pregnancy recent hx or increased risk of thormbotic events - DVT, PE, *SLE with APLA*, CVA, etc smoking in pts age >35 undiagnosed vaginal bleeding estrogen-dependent neoplasms

35 yo man comes to doc bc of 6 mo hx of pain in his right arm that began 1 mo after he fractured his humerus. He states that when pain first started, skin on his right arm was sweaty & warm. Recently he has had constant burning or aching sensation. He has had severe pain with light touch against skin of his right arm. He has had no fever, weight loss, weakness, change in vision, or episodes of incontinence. He works in construction. Exam shows that skin of distal arm is cool, shiny, & cyanotic. There is early flexion contracture of fingers & wrist of right hand. What conditions best explains this pt's symptoms?

*Complex regional pain syndrome* - most commonly occurs unilaterally in UE after trauma to that extremity - hypothesized to be result of aberrant nerve healing following injury Three phases 1. within weeks - months after injury = severe pain brought on by innocuous stimuli in addition to redness, swelling, hyperhidrosis, joint pain 2. similar pain + atrophy of skin & its appendages + coolness & pallor of affected extremity 3. atrophy of skin & underlying muscles & flexion contracture of affected extremity = claw-hand deformity in severe cases

56 yo woman evaluated for 8 mo ho abdominal pain & diarrhea. Pain localized to midepigastrium & is worse after eating. She has 6-8 bowel movements each day, which usually occur after a meal, & has lost 6.8 kg (15 lb) over past 6 months. Pt drinks 6-8 glasses of vodka daily. Med hx otherwise unremarkable, & she takes no meds. On physical exam, pt is afebrile & other vital signs normal. Pt thin with BMI of 21. Abdominal exam discloses midepigastric tenderness but no evidence of hepatosplenomegaly or masses; bowel sounds normal. Rectal exam reveals brown stool that is negative for occult blood. Remainder of exam normal. Lab studies significant for normal serum aspartate aminotransferase & alanine aminotransferase levels & a serum lipase level of 289 U/L. Tests most likely to establish diagnosis in this patient?

*Computed tomography of abdomen* Chronic pancreatitis diagnosis - CT scan of abdomen = most appropriate for pt who has chronic pancreatitis secondary to alcohol abuse via malabsorption - presence of pancreatic calcifications on imaging studies = confirmed = detects 90%

Woman comes to clinic with her 13 yo grandson, stating that he has had behavioral probz for past 4 yrs. She says that she has been trying to handle this issue on her own, but that he is getting out of control. Her grandson is living with her now bc his mom is in a drug rehab center. She describes that the boy answers back to & argues with her & with teachers & adult neighbors. He often blurts out answers to questions before questions are completed & is hyperactive & impulsive. He deliberately argues to annoy ppl. He has been removed from school bus for lying about another student & challenging the driver. Recently, she caught him stealing from her wallet; when confronted he showed no remorse. He is about to be expelled from school since he punched his classmate in the face. Most likely diagnosis?

*Conduct disorder* - basic rights of others violated - reserved for pts younger than 18 yo At least one of the following present in the past 6 mos - destruction of property - aggression to animals & ppl (pt hit his classmate) - deceitfulness or theft (lied & was caught stealing) - serious violations of rules

59 yo man comes to physician complaining of weight loss, jaundice, pruritus, and vague right upper quadrant abdominal pain that have been present & progressing for past 3 months. His hx is significant for UC, which he has had for at least 30 years. For past 10 years he has also been known to have sclerosing cholangitis. He is found to have hepatomegaly; lab studies show bilirubin level of 16 mg/dL with 13 mg/dL direct (conjugated), minimally elevated transaminase levels, & alkaline phosphatase level 10 times normal value. Sonogram initially inconclusive, so an abdominal CT scan is performed, which reveals ductal dilation in both hepatic lobes & small gallbladder. Right and left hepatic ducts could not be visualized. Pt's obstruction most likely located in what structures?

*Confluence of hepatic ducts* Obstructive jaundice: Sclerosing cholangitis - high risk for developing cholangiocarcinoma = 10-15% risk - sonogram = best initial study but often difficult to interpret Klatskin tumors - subtype of cholangiocarcinoma that occur at confluence of right and left hepatic bild ducts, with or without thickened wall = intrahepatic ductal dilation & contracted gallbladder bc of obstruction to outward biliary flow - ERCP can be performed to obtain ductal brushings for cytologic evaluation & definitive diagnosis

8 day old boy brought to ED by his parents bc of left-sided neck mass. Child was born at 39 wks' gestation by way of spontaneous vaginal delivery after uncomplicated pregnancy. Parents say they didn't notice mass before his discharge from hospital. They report that he has been tolerating his feedings without problems and has had no episodes of respiratory distress. He is afebrile. He does not appear to be in acute respiratory distress. His head appears to stay turned to left at rest. Palpation of neck shows firm, nontender, well circumscribed mass. CBC shows no abnormalities. MRI scan of brain shows dense, nonenhancing enlargement within body of left sternocleidomastoid muscle. Next best step in management?

*Congenital management for likely congenital torticollis* - AKA stenocleidomastoid tumor of infancy - masses = dense, fibrous tissues with absence of normal striated muscle - usually regress over 4-8 mos - more than 80% resolve completely with no treatment - most pts affected = first-born children

31 yo woman with HIV comes to doc bc of 3 mo ho watery diarrhea, low-grade fever, severe weakness. She has had 22 lb weight loss over past 3 mos. Her temp is 100 F. Abdominal exam shows no abnormalities. Lab studies on stool bacteria, ova, & parasites are repeatedly negative. Most likely cause of her diarrhea?

*Cryptosporidiosis* - typical small bowel-type diarrhea seen in pts who have HIV with watery diarrhea, weakness, & weight loss - biopsy specimen of SI = spores on tips of villi - especially in AIDS pts who have CD4+ counts less than 100/mm^3

A 66-year-old man is admitted to the hospital with a 2-month history of progressive dyspnea and worsening pedal edema. Medical history is significant for coronary artery bypass surgery 3 years ago. He has a 10-year history of hypertension. Medications are metoprolol, atorvastatin, and aspirin. On physical examination, temperature is normal, blood pressure is 118/64 mm Hg, pulse rate is 120/min, and respiration rate is 26/min. Jugular venous distention that increases with inspiration is noted. Cardiac examination shows no murmur, rub, or gallop. Pulsus paradoxus of 5 mm Hg is present. Lungs are clear to auscultation. Hepatojugular reflux is present. Pedal edema of 2 + is noted. Electrocardiogram shows sinus rhythm with increased voltage in the precordial leads. Echocardiogram shows a normal left ventricular ejection fraction, restrictive left ventricular filling, increased ventricular wall thickness, biatrial enlargement, a small pericardia! effusion, and abnormal diastolic to-and-fro ventricular septa! motion. Chest radiograph shows no infiltrates. Which of the following is the most likely cause of this patient's dyspnea?

*Constrictive pericarditis* - dyspnea + lower extremity edema - elevated right ventricular heart pressure on exam (JVD, hepatojugular reflux, pedal edema) - no evidence of left-sided heart failure - Kussmaul sign = jugular vein engorgement with inspiration = *recognized potential complication after coronary artery bypass surgery*

83 yo woman evaluated in ED bc of hematemesis associated with hypotension & tachycardia. Two 16-gauge IV catheters are placed, & IV fluid & erythrocyte resuscitation is initiated with bolus administration of 2 L of 0.9% saline & two units of packed RBCs. IV omeprazole is also begun, & she is transferred to the ICU. Pt has no ho GI bleeding or liver dz. She has osteoarthritis for which she takes daily aspirin. On physical exam in ICU 2 hrs later, BP is 87/58 mmHg, pulse rate is 112/min, & RR is 12/min. Abdomen is nontender, & there is no organomegaly. There are no stigmata of chronic liver dz. What is the most appropriate next step in management?

*Continue IV fluid & erythrocyte resuscitation* - pt has experienced large GI hemorrhage with resultant hemodynamic instability - ho aspirin suggests upper GI source of bleeding - despite appropriate IV access, 0.9% saline fluid boluses, & IV PPI infusions, she remains unstable & has hgb of 7 g/dL --> most important & urgent treatment = RBC transfusion & IV crystalloid admin to achieve hemodynamic stability - initial hgb level of less than 8 g/dL = concerned bc re-equilibration in 24-48 hrs after initial bleeding episode may reveal even lower hgb level

70 yo M with known CAD & chronic stable angina. Chest pain predictably after walking 3 blocks. Resolves at rest or NTG use. No change in his functional status in the past year. Vitals HR 59 BP 122/82 RR 16 Normal PE Low risk cardiac stress test 3 months ago Current meds: Aspirin, atorvastatin, metoprolol, SL NTG Next step?

*Continue current management* Reserve cardiac cath for... - lifestyle limiting symptoms despite optimal medical Tx - unable to tolerate antianginals due to side effects - high risk findings on stress testing

A 42-year-woman is evaluated in the emergency department for swelling of the right leg after an 8-hour plane ride. She does not have shortness of breath, chest pain, or previous episodes of venous thromboembolic disease. The patient does have an 8-year history of systemic lupus erythematosus treated with hydroxychloroquine. She also reports two miscarriages, 7 and 5 years ago. On physical examination, vital signs are normal. The right leg is obviously swollen. The remainder of the examination is normal. Doppler ultrasound shows a deep venous thrombosis of the right femoral vein. Laboratory testing reveals a prolonged activated partial thromboplastin time and positive beta2-glycoprotein 1 IgG antibody assay. The patient is started on heparin followed by warfarin. Twelve weeks later, the beta2-glycoprotein 1 lgG antibody assay is repeated and is again positive. Which of the following is the most appropriate anticoagulation management?

*Continue warfarin indefinitely* Antiphospholipid syndrome - clinical criteria = arterial or venous thrombosis & pregnancy loss or complications - other manifestations = livedo reticularis (lattice-like skin rash), thrombocytopenia, valvular heart dz, unexplained prolongation of activated partial thromboplastin time, microangiopathic kidney impairment - may occurs as independent syndrome or secondary to SLE - Abs = anticardiolipin, anti-beta2-glycoprotein 1, lupus anticoagulant

24 yo woman, gravida 1, para 0, who is at 34 wks gestation comes to ED after being in motor vehicle accident 30 mins ago. Her husband was dropping her off at work when their car was rear-ended. They were both wearing seat belts. The husband drove them to ED after reporting the accident. Pt is having mild contractions every 10 to 1 minutes & is very worried about her baby. Her temp is 99.3 F, BP 116/78 mmHg, pulse 86/min, & respirations 16/min. Her physical exam is normal except for mild lower back pain & bruises on her lower abdomen & right shoulder. Pelvic exam show closed posterior cervix. There is no vaginal bleeding or amniotic fluid pooling. Obstetric sonogram shows fetal heart tones are 164/min. Type & screen shows her blood type is O+. Most appropriate next step in management?

*Continuous electronic fetal monitoring* - even with normal ultrasound, pt is at risk for placental abruption Placental abruption - may manifest several hours after accident bc of trauma to lower abdomen = most important consideration of abdominal trauma in pregnancy - associations = car accidents, direct abdominal trauma, falls, cocaine abuse, victims of violence - best prevention for pregnant woman = wearing seat belt with both shoulder & lap restraints, even late in pregnancy

55 yo man evaluated during routine follow-up exam. Pt has compensated cirrhosis & is currently asymptomatic. Med hx significant for chronic hepatitis B virus infection & esophageal varices. His only current med is propranolol. On physical exam ultrasonography, temp is 99.7 F, BP 120/70 mmHg, pulse rate 68/min, RR 16/min. Spider angiomata present on neck & upper chest. Spleen tip palpable. Screening abdominal ultrasonography discloses nodular-appearing liver, splenomegaly, & changes consistent w/ portal HT. 1.6-cm lesion noted in right hepatic lobe; lesion was not present on ultrasound exam done 6 mos ago. What is the most appropriate diagnostic test to perform next?

*Contrast-enhanced computed tomography of abdomen* HCC diagnosis - pts w/ hepatitis B may develop HCC in absence of advanced liver dz - screening for HCC every 6-12 mos recommended for pts with cirrhosis of any cause & for pts with chronic hep B who are considered at high risk

Appropriate treatment for patient with atrial fibrillation with rapid ventricular response

*diltiazem IV* - a fib via rapid & uncoordinated electrical activation within atria - absence of P waves Patient symptomatic but hemodynamically stable --> initial goal = reduce HR to 60/min-110/min with rate control agent - IV options = diltiazem, verapamil, metoprolol, esmolol

A 62-year-old man with coronary artery disease is evaluated for angina. He was diagnosed 4 years ago, and since that time, his symptoms have been well controlled with metoprolol and isosorbide mononitrate. He had exertional angina 8 months ago. His dosages of metoprolol and isosorbide were increased and long-acting diltiazem was added, with improved control of his symptoms. He has had increasing symptoms over the last 2 months and now requires daily sublingual nitroglycerin for relief of angina during exercise. He has not had any episodes of angina at rest. His medical history is significant for hyperlipidemia treated with atorvastatin. On physical examination, the patient is afebrile, blood pressure is 110/60 mm Hg, pulse rate is SS/min, and respiration rate is 12/min. Results of cardiopulmonary examination are unremarkable, as are the remainder of the findings of the physical examination. Electrocardiogram shows no acute ischemic changes. Which of the following should be the next step in this patient's management?

*Coronary angiography* - evaluating chronic stable angina - continued symptoms despite optimal medical therapy - allows direct evaluation of coronary anatomy, with possible percutaneous coronary intervention or surgical revascularization if indicated

A 38-year-old man is evaluated in the emergency department. He has a 2-week history ofnonpleuritic, sharp, anterior chest pain. Each episode of pain lasts 3 to 10 hours. He describes the pain as being located mostly to the left of the sternum, although at times it radiates across the entire chest but not to his shoulders, arms, or back. The pain sometimes occurs at rest and is worsened with lateral movement of the trunk. It does not worsen with exertion. He has no other symptoms and no other medical problems. He does not use drugs and takes no medications. On physical examination, temperature is 37.0°C (98.6°F), blood pressure is 132/70 mm Hg, pulse rate is 90/min, and respiration rate is 14/min. There is reproducible point tenderness along the left sternum. The remainder of the examination, including the cardiovascular examination, is normal. Which of the following is the most likely diagnosis?

*Costochondritis* - musculoskeletal chest pain has insidious onset & may last for hours to weeks - more recognizable when it is sharp & localized to specific area of chest - can also be poorly localized - pain my be worsened by turning, deep breathing, or arm movement - may or may not be reproducible by chest palpation - treatment typically anti-inflammatory drugs

A 34-year-old man is evaluated in the emergency department for a 1-month history of worsening dyspnea and "cola-colored urine." For the past week, he has had decreased urine output and a cough productive of blood-tinged sputum. Until 1 month ago, he felt well. He has no significant medical history and takes no medications. On physical examination, temperature is normal, blood pressure is 15S/102 mm Hg, pulse rate is 104/min, and respiration rate is 22/min. Oxygen saturation is 88% (ambient air). Body mass index is 27. There is no jugular venous distention. Other than tachycardia, the cardiac examination is normal. Inspiratory crackles are heard over both lower lung lobes. There is no peripheral edema. Lab Studies: Hemoglobin = 10.4 g/dL (104 g/L) BUN = 22 mg/dL (7.7 mmol/L) Serum creatinine = 3.8 mg/dL (336 umol/L) Albumin = 3.4 g/dL (34 g/L) Urinalysis = 2+ blood; 2+ protein; 10 leukocytes/high-powerfield; 15-20 dysmorphic erythrocytes/high-power field with hyaline casts Urine protein-creatinine ratio = 5 mg/mg Chest radiograph shows bilateral lower lobe patchy infiltrates. A kidney biopsy is performed. What glomerular lesion is most likely to be seen?

*Crescentic glomerulonephritis* - patient has pulmonary-renal syndrome characterized by hemoptysis & rapidly progressive kidney failure associated with nephritic syndrome - most likely histologic correlate of rapidly progressive glomerulonephritis is crescentic glomerulonephritis - crescent formation via necrosis & rupture of basement membrane, allowing coagulation proteins, macrophages, epithelial cells, & fibroblasts to enter & replace Bowman space

21 yo man brought to ED after reportedly sustaining gunshot wound to his right lower back. He is alert & oriented but complaining of back pain. He is breathing without difficulty & has bilateral breath sounds with oxygen sat of 99% on room air. He is dynamically stable, with BP 126/68 mmHg & pulse 98/min. Two 18-gauge IV lines are inserted & lab studies are sent. On exam wound is seen in right lower back, just inferior to subcostal margin, 4 cm posterior to posterior axillary line. It is oozing bright-red blood. Abdomen is nondistende and pt denies tenderness to palpation. Foley cath is placed & yields clear urine. Chest x-ray film reveals no pneumothorax or bony abnormalities, & bullet not visualized. Next step in management?

*Cross table x-ray* = least invasive - would likely reveal bullet in posterior positio - pt remarkedly stable for someone who just got gunshot wound to abdomen --> doc wonders if they were shot - only one bullet hole noted, no exit wound - possible the bullet did not traverse superficial layers to enter retroperitoneum or even peritoneum

Most appropriate treatment for young man with epididymitis

*doxycycline, ceftriaxone* Epididymitis - unilateral pain & tenderness in epidydmis & testis (epididymitis-orchitis) - spermatic cord enlarged & tender on palpation - some pts find relief with elevation of testicle, whereas elevation usually exacerbates pain of testicular torsion 2010 CDC & Prevention recommendation - admin of ceftriaxone, 250 mg IM as single done for N gonorrhoeae - all pts with N gonorrhoeae should receive azithromycin or doxycycline bc of high rate of coinfection with C trachomatis

9 mo old girl brought to doc by her mom bc of itchy rash for 1 wk. Mother states that the infant has been rubbing & scratching, especially at night. Infant has been on soy formula bc of inability to tolerate cow's milk formula in first months of life. Temp is 98.4 F. Exam shows maculopapular rash on face with excoriations. There are bilateral red, crusty patches on elbows. Most appropriate next step in management?

*Cutaneous hydration with emollients* Atopic dermatitis / Eczema - associated with elevated IgE levels - hydration by lukewarm soaking baths, followed by application of emollient such as thick cream or ointment, allows for retention of moisture & provides symptomatic relief

45 yo woman seen in clinic bc of 1 year ho involuntary loss of urine after experiencing sudden need to urinate. She denies episodes of incontinence with coughing or sneezing. She has never been pregnant. Pelvic exam shows normal-appearing vulva, vagina, & cervix. There is no prolapse, & bimanual exam shows 8-week size uterus with no masses. Neuro exam shows normal pain, temp, & vibratory sensation & 5/5 motor strength in all extremities. Her reflexes are 2+ in upper & lower extremities. Fasting serum glucose level is 95 mg/dL & glycosylated hemoglobin level is 5.2%. Urinalysis within normal limits. Urine cultures show no growth of bacteria. What is the most appropriate next step in diagnosis?

*Cystometry* - looks at bladder capacity, detrusor stability, contractility, & voiding ability - in presence of detrusor instability or dyssynergia = destrusor contraction even with small volume of urine in bladder - detrusor instability or dyssnergia/urge incontinence

34 yo man evaluated after having 3 episodes of severe hypoglycemia in past mo. Pt has 19 yr ho T1DM. He states that he no longer experiences any warning symptoms before he becomes hypoglycemic. He has mild background diabetic retinopathy, mild peripheral neuropathy, & occasional orthostatic hypotension. Meds are insulin glargine, 24u at bedtime, & insulin lispro, 6-10 units before meals based on pre-meal testing & what he is eating. On physical exams, vital signs normal. BMI 30. Remainder of physical exam unremarkable. Lab studies significant for hgb A1c of 6.6% & no evidence of albuminuria. Most appropriate treatment?

*Decrease insulin doses* Treat hypoglycemic unawareness - pt's doses of both long-acting & rapid-acting insulin should be decreased by appx 20%

50 yo man comes to doc bc of progressive pain around his ears for 1 wk. 3 days ago his ears began to swell. He denies any changes to his diet or recent travel. His med hx is unremarkable. He takes a multivitamin daily. His temp is 98.2 F, BP is 110/80 mmHg, pulse is 75/min. Oxygen sat is 94% on room air. Exam shows bilateral tenderness and swelling over cartilaginous portions of his ears. Noncartilaginous areas show no abnormalities. Biopsy specimen of ear shows granulation tissue in cartilage. Pulmonary function testing most likely to show what?

*Decreased expiratory flow* Relapsing Polychondritis - autoimmune response twoards cartilage-containing structures - ear, nasal cartilage, trachea/larynx affected - pulmonary function testing shows low flow on inspiration

Team is continuing resuscitation efforts in the doc's office. After a shock of 200 J the patient remains in ventricular fibrillation. CPR is continued for two minutes, epinephrine 1 mg IV push given. Next treatment recommended?

*Defibrillation at 360 J* = max joules available recommended in V-Fib algorithm if initial shock did not work - amiodarone = next drug of choice, at dose of 300 mg IVP

3 yo boy brought to clinic with complaints of headache & vomiting. His BP is 130/80 mmHg. Child's past med hx is significant for sx for undescended testes 1 yr ago. He has also been followed by dev'tal ped for dev'tal delay. On On physical exam, he appears pale & is noted to have large abdominal mass. HEENT exam reveals hypopasia of both irises. Abdominal CT scanning reveals poorly vascularized tumor in upper pole of right kidney. Most likely cause of presentation?

*Deletion of gene on chromosome 11* Wilms tumor/nephroblastoma - malignant tumor of embryonal kidney cells - WAGR mutation = Wilms tumor + aniridia + genitourinary abnormalities & growth &/or dev'tal retardation - via deletion of chr 11 - peak incidence = 2-5 yo - may be unilateral or bilateral - most common presentation = asymptomatic mass in child - renovascular HT, hematuria, abdominal pain, constipation

42 yo man comes to doc bc of progressive left-sided weakness for 1 month. He has had blurry vision & difficulty walking. His med history is unremarkable, & he takes no meds. He has smoked one pack of cigarettes daily & drinks 8-10 beers daily. He used IV drugs for 8 years, but he quit 6 months ago. His temp is 37.1 C (98.8 F), BP is 128/82 mmHg, & pulse is 82/min. Neuro exam shows right-sided hemianopsia, & muscle strength is 3/5 on left upper & lower extremities with brisk reflexes on left side. There is no papilledema. ELISA for HIV is positive. CD4+ T lymphocytes count is 40/min^3. There is cervical lymphadenopathy. CT scan of head shows numerous patchy nonenhancing hypodensities in subcortical white matter. What is the most likely cause of this patient's symptoms?

*Demyelination (PML)* AIDS: Progressive Multifocal Leukoencephalopathy (PML) - dz of white matter - via JC virus - reactivates in immunosuppression - imaging limited to white matter = patchy, focal, nonenhancing

45 yo man comes to ED bc of pain in his left leg for 2 weeks. Pain began in lower back after he was swinging sledgehammer at concrete block during home renovation. Several days later, he experienced burning sensation "shooting"down side of his leg. He smokes one pack of cigarettes daily. He does not use illicit substances. His temp is 37 C (98.6 F). Pain is reproduced when left lower leg is passively extended with patient in seated position. MRI scan of lower back shows herniation of L3-L4 intervertebral disk. What physical exam findings is most likely to be seen in this patient?

*Depressed knee-jerk reflex* Herniation/prolapse of L3-L4 - increased risk in smokers - straight leg raise = reproduction of pain with passive extension of leg while patient supine or seated = supports diagnosis of sciatica - compression of L4 = weakness of quadriceps, numbness of medial shin, decreased or absent knee-jerk (patellar) reflex

34 yo G1P1 delivered healthy, term male infant 48 hrs ago through uncomplicated vaginal delivery. Vital signs this morning reveal temp of 98.6 F, BP 120/76 mmHg, pulse of 67/min, & respiratory rate of 12/min. She has no complaints, is toelrating oral intake, & passed her first bowel movement this morning. Upon discharge, pt should be told to expect what regarding postpartum lochia?

*Discharge should progress from bright red to pinkish-brown to yellowish-white* Lochia = due to normal shedding of endometrium after delivery of placenta - normal = after delivery --> progresses from bright red blood (lochia rubra) to pinkish-brown (lochia serosa) to yellowish-white (lochia alba) - may last for up to 6-8 wks in duration - duration = 4 wks total - not correlated to breast-feeding

HCRT "ground glass" appearance usually represents

*early* dz state of IPF

41 yo woman admitted to ICU bc of 1-day ho progressively worsening mental status & jaundice. Med hx significant for advanced autoimmune hepatitis. On physical exam, temp is 91.4 F, BP 105/55 mmHg, pulse rate 110/min, & respiration rate is 27/min. BMI 18. She is unresponsive & jaundiced. Lungs are clear, & findings on cardiac exam are normal. Abdominal exam shows distended abdomen with detectable fluid wave. Lab studies shows leukocyte count of 9800/uL, serum creatinine level of 1.6 mg/dL, & lactic acid level of 6 mg/dL. Chest radiograph is normal, & findings of urinalysis are unremarkable. Blood & urine culture results are pending. Treatment is initiated with IV fluids & empiric broad-spectrum antibiotics. What is the most appropriate next step in management?

*Diagnostic paracentesis* - to identify potential source of infection Septic shock - should be assumed first & excluded as cause - pt meets criteria for systemic inflammatory response syndrome (SIRS) (altered temp, tachycardia, hyperventilation, abnormal leukocyte count) - organ dysfunction + SIRS = severe sepsis - treatment = aggressive IV fluid therapy & treatment with empiric broad-spectrum abx --> next step = identifying source of potential infection - ascites associated w/ pt's chronic liver dz = potential source of infection that should be evaluated = important in guiding choice of appropriate empiric antibiotic coverage & focusing longer-term abx therapy once organism has been identified - pt's worsening liver failure & new-onset encephalopathy can be ppted by infection

72-year-old man is evaluated because of progressive dyspnea that began 3 weeks ago. Six years ago, he underwent replacement of the aortic valve with a prosthetic value for treatment of calcific aortic stenosis. Until 3 weeks ago, he had been doing well. He has no other medical problems, and his only medication is warfarin. On physical examination, he is afebrile, blood pressure is 134/ 68 mm Hg, pulse rate is 88/min, respiration rate is 20/min, and oxygen saturation is 96% on ambient air. Cardiac examination shows a laterally displaced apex beat, regular S1 and S2, a sharp aortic valve click, expiratory splitting of the S2, a 2/ 6 systolic murmur that is loudest at the right second intercostal space without radiation, and a 1/6 blowing diastolic murmur that is loudest at the third left intercostal space. The remainder of the physical examination is normal. Chest radiography shows cardiomegaly without interstitial edema or pulmonary vascular congestion. Electrocardiogram shows left bundle branch block. Which of the following physical examination findings most strongly suggests dysfunction of the prosthetic heart value?

*Diastolic murmur* - dev't of new diastolic murmur of aortic regurgitation = most closely associated with prosthetic valve dysfunction Aortic regurgitaiton - soft, blowing diastolic murmur - best heard at third left or second right intercostal space - can be heard best with patient leaning forward in end-expiration

A 58-year-old man is evaluated because of insidious onset of slowly progressive dyspnea over the last 3 years. At this point, he must stop to rest when walking 1 block. Previously, he walked 1 to 2 miles daily without difficulty. He has no cough, chest pain, or orthopnea. He has no other medical problems. On physical examination, vital signs are normal. Body mass index is 35.0xygen saturation is 93% breathing ambient air. Dry crackles are noted on auscultation. Cardiac examination shows a parasternal heave and persistent splitting of S2• Chest radiograph shows diffuse reticular infiltrates that are most prominent in the upper lung zones. Spirometry shows forced expiratory volume in 1 second (FEV1) that is 60% of predicted and an FEV1 /forced vital capacity ratio of 80%. Total lung capacity is 70% of expected. Diffusing capacity of carbon monox ide is 45% of expected. Which of the following is the most likely diagnosis?

*Diffuse parenchymal lung disease* - such as pulmonary fibrosis - DLCO reduced - crackles + diffuse reticular infiltrate = lung: cause of restrictive abnormality - reduced FEV1 but normal FEV1/FBC ratio = restrictive lung disease - low total lung capacity

Most week days, a 36 yo man stands on the same subway platform at 7am because across the tracks, a group of high school girls gathers at that time daily. If no one else is on the platform, the man opens his coat and exposes his genitals to the girls hoping to shock & frighten them. This behavior is most characteristic of what disorder?

*Exhibitionistic disorder* = paraphilic disorder = need for public exposure of genitals to evoke shock or fear in victims - offenders usually male

3 yo boy admitted to hospital bc of fever, cough, & SOB for 10 days. He has hx of liver abscess & perirectal abscess, both caused by S aureus. Temp is 101.8 F. Exam shows hepatosplenomegaly. There are crackles in left lung fields. X-ray film of lung shows 3-cm abscess in left lower lobe. Abscess is aspirated. Cultures of aspirate grew Serratia marscescens. Best initial test to support diagnosis?

*Dihydrorhodamine (DHR)-123 fluorescence* Chronic granulomatous dz - functional deficiency of neutrophils via defect of generation of microbicidal oxygen metabolites - X-linked - neutrophils unable to generate hydrogen peroxide needed to work in conjunction with myeloperoxidase = necessary for phagocyte-mediated killing of bacteria & fungi - usual presentation = male, whose maternal uncle is affects, who has recurrent skin, lymph node, & liver abscesses due S aureus Males suffer numerous infections with common catalase-producing pyogenic organisms, such as - S aureus - Burkholderia cepacia - Nocardia - Salmonella - Aspergillus - Candida albicans

55 yo man comes to ED bc of lower back pain for 2 weeks & episodes of incontinence for 1 day. He has had no fever, chills, SOB, or recent trauma. He has ho small cell lung carcinoma treated with chemotherapy 5 years ago. He takes no meds. His brother has ho ankylosing spondylitis. His temp is 36.8 C (98.2 F). Muscle strength is 4/5 bilaterally in lower extremities. Additionally findings most likely in this patient?

*Diminished anal sphincter tone* Cauda equina syndrome - ho malignancy (prostate, breast, lugn tumors most common forms of metastases) - present with acute onset of lower back pain & neuro deficiencies via compression of cauda equia nerve root - saddle anesthesia & diminished sphincter tone - bowel & bladder incontinence = late findings - most common initial complaint = low back pain --> becomes progressively more severe & radicular - median time b/t dev't of pain & cauda equina diagnosis = 7 weeks

35 yo man comes to ER with complaints of cough. His PO2 found to be 83 mmHg & he is hospitalized. On second day in hospital, pt develops generalized muscle aches & abdominal cramps with loose stools. He denies abdominal blating & blood or mucus in his stool. He complains of chills but does not have fever. He also has clear nasal discharge. Exam is unremarkable except for dilated pupils. What meds will be most useful for treating man's autonomic symptoms?

*Diphenhydramine* - helps relieve autonomic symptoms of withdrawal - anticholinergic effects Heroin withdrawal - generalized muscle aches, abdominal cramps with loose stools, chills, clear nasal discharge, dilated pupils

71 yo man comes to doc complaining of fatigue. Noticed symptoms for past 6 months. Noted dyspnea on exertion, but no chest pain. Denies chronic cough, diarrhea, cramping, hematochezia, melena, orthopnea, paroxysmal nocturnal dyspnea, edema, weight loss, or fevers. Occasionally drinks alcohol, but does not smoke. Appetite is intact. Past med history unremarkable, although he has not seen doc for many years. He does not take any meds. On exam, BP is 131/72 mmHg & pulse is 98/min. He is saturating 96% on room air. He has pale mucous membranes. There is no sceral icterus, JCD, or carodtid bruits. Lungs clear to auscultation. 2/6 early systolic urmur, heard best at lower left sternal border. Abdominal exam reveals no hepatosplenomegaly or ascites. Bounding pulses with no clubbin, cyanosis, or edema. Lab values are: WBCs = 5,600/mm^3 Hct = 29% Platelets = 225,000/mm^3 Mean RBC volune = 103 fl Iron = 50 mcg/dL Ferritin = 150 ng/mL Serum folate = 8 ng/mL Serum B12 = 35 pg/mL LDH = 113 U/L Peripheral blood smear = hypersegmented neutrophils, macrocytosis Antiparietal cell Abs & anti-intrinsic factor Abs negative. Decision to perform Schilling test made, & urine assay for radiolabeled B12 negative. Weeks later, Schilling test repeated in addition to intrinsic factor. Urine assay for oral B12 still negative. Most likely diagnosis in this patient?

*Diphyllobothrium latum infection* - high affinity for vit B12 - no urinary B12 excretion after admin of both intrinsic factor & oral B12 --> small-bowel malabsorption (Crohn or celiac dz) or competition via Diphyllobothrium latum infection likely

29 yo woman comes to doc bc of fever, back pain, & intractable vomiting. She is otherwise healthy with no significant past med history. Exam is significant for temp of 101 F, moderate costovertebral angle tenderness, leukocytosis, & white & red blood cells in urine. Pt diagnosed with pyelonephritis & admitted to hospital for therapy with IV antibiotics. Over next 2 days she improves rapidly, & by hospital day 3 she is tolerating oral intake, voiding without difficulty, & feeling no pain, & she has not had fever for 48 hrs. Most appropriate next step in management?

*Discharge home to complete 2-wk course of oral antibiotics; no follow-up needed* Uncomplicated course of pyelonephritis - can be treated on outpt basis - once pt's condition has improved & she is tolerating oral intake, she may be discharged home to complete 2 wk course of antibiotics

A 47-year-old woman is seen for a routine follow-up visit. She feels well and has no current complaints. Her medical history is significant for a complete vaginal hysterectomy 1 year ago that was performed because of pelvic pain because of several large leiomyomas. Before the surgery, she received cervical Papanicolaou (Pap) tests every 3 years since around age 25 years, and all results had been normal. She takes no medications and does not smoke. On physical examination, her vital signs are normal. Her general medical examination findings are unremarkable. Which of the following is the most appropriate recommendation for Pap testing in this patient?

*Discontinue Pap smears* - discontinue screening for cervical cancer in pts who have had hysterectomy for benign dz

79 yo woman evaluated for recent dev't of frequent episodes of confusion & forgetfulness. She has 6 yr ho T2DM. Meds are glyburide & metformin. On physical exam, temp is normal, BP is 142/77 mmHg, pulse rate is 87/min, & RR is 16/min. BMI is 20. All other exam findings are unremarkable, including those from mental status exam. Results of lab studies show serum creatinine level of 1 mg/dL & hgb A1c value of 6.2%. What is the most appropriate immediate next step in management?

*Discontinue glyburide* Manage hypoglycemia in pt taking sulfonylurea - should stop taking glyburide! - may take several days after discontinuation for glyburide to decrease to undetectable levels --> checking clinical symptoms & re-evaluating her plasma glucose level in 2 wks would also be appropriate

36 yo man recently diagnosed with acute promyelocytic leukemia. Started on all-trans-retinoic acid & daunorubicin. Two days after receiving his first dose, patient presents to ED with weakness & lethargy. He has new-onset epistaxis, bright red blood per rectum, & hematuria. Physical exam reveals conjunctival pallor & obvious bleeding from Kiesselbach's plexus. His underwear is stained with bright red blood, & rectal exam reveals bright red blood on examining finger. Pulse is 100/min, respiratory rate is 16/min, & BP is 90/70 mmHg. He is afebrile. Skin exam shows diffuse petechiae. Cardiovascular exam shows tachycardia. Lungs clear to auscultation. Extremities show no pitting edema. Lab workup shows: Hgb = 9.2 g/dL WBC = 28,000 (previously 29,000/mm^3) Platelets = 12,000/mm^3 Sodium = 136 mEq/L Potassium = 4.7 mEq/L Chloride = 101 mEq/L Bicarbonate = 27 mEq/L BUN = 40 mg/dL Creatinine = 1.8 mg/dL Glucose = 80 mg/dL Calcium = 9.2 mg/dL PT = 18 sec INR = 2 PTT = 60 sec Peripheral smear show red-cell fragmentation. Most likely diagnosis?

*Disseminated intravascular coagulation* - at time of diagnosis or shortly after starting treatment with cytotoxics in patients with APL; M3 subtype - low platelet counts - elevated PT & PTT - high D-dimer levels - low fibrinogen levels - evidence of microangiopathy = fragmented RBCs

A 66-year-old woman is evaluated in the hospital for abnormal bleeding. She was admitted yesterday with a urinary tract infection and bacteremia. The patient has no other medical problems and was on no medications before admission. On physical examination, temperature is 39.2°C (102.6°F), blood pressure is 85/60 mm Hg, pulse rate is llSlmin, and respiration rate is 18/min. Bleeding is noted on mucous membranes around intravenous access sites. Multiple ecchymoses are present on her arms and legs. Laboratory studies: Hgb = 8.5 g/dL Platelet count = 35,000/uL Prothrombin time = 15 s Activated partial thromboplastin time = 30 s D-dimer = Elevated Fibrinogen = Decreased Examination of a peripheral blood smear shows many fragmented erythrocytes and diminished platelets. Which of the following is the most likely cause of this patient's bleeding?

*Disseminated intravascular coagulation* - most commonly occurs in pts with infections (gram negative most common), cancer, obstetrical complications Diagnosis based on - prolonged coagulation time (prothrombin time & activated partial thromboplastin time), elevated D-dimer titer, decreased serum fibrinogen level & platelet count, presence of MAHA

Infant girl with breech presentation has APGARs of 9 & 9 at 1 & 5 minutes respectively. Fam asks doc to check her hips carefully bc an older sibling has significant disability from dev'tal dysplasia of hip (congenital dislocation) that was not properly diagnosed. On physical exam, doc cannot completely abduct infant's thighs when her hips & knees are flexed, but a click or snap cannot be elicited when doc tries to manually dislocate or reduce femoral heads. Infant's legs are of same length, & gluteal folds are symmetric. Most appropriate course of action?

*Do ultrasound exams* - inability to abduct thighs = suggestive of congenital hip dislocation or dev't dysplasia of hip - treatment = pavlik harness with splinting in abducted fashion for appx 6 mos - femoral heads no calcified in newborns = will not show up on x-ray films

70 yo woman with ho CHF, A fib, & dementia comes to doc for routine health maintenance exam. Current meds include digoxin, warfarin, fosinopril, aspirin, furosemide. Her BP is 124/82 mmHg, & her pulse is 76/min & irregular. Lungs clear to auscultation. 1+ pedal edema Her INR is 2.3. Her husband is taking herbal med & she inquires about herbal supplements. What herbal supplements is most likely to increase patient's risk for bleeding?

*Dong quai* - can prolong INR if receiving warfarin - used for variety of female healthy disorders - considered for tonic women who are tired, recovering from illness, or have low vitality - used for reduction in SM spasms

Patient initial atropine doses were ineffective, & the physician requests a vasoactive infusion. Her BP is now 84/50 mmHg. She is responding to your commands, & is OK with laying flat in her bed. What is an appropriate medicated infusion for this patient?

*Dopamine 2 to 10 mcg/kg per minute* - lowest dose dopamine may dilate coronary arteries & help heart pump - titration to higher dose may be necessary

5 mo old boy brought to office for mass in left groin area. Infant is on exam table, quietly sucking on pacifier. Mother states that she first noticed mass after baby fell from his bed 2 days ago. On exam, there is sacculated cavity that does not reach inguinal ring. Light easily passes through sac. What is the most appropriate next step in management of this pt's condition?

*Doppler ultrasound* - needs to be done to assess perfusion, event if acute scrotum clinically unlikely - urgent Hydrocele - trauma often brings area to attention

34 yo man with ho epilepsy comes to doc bc he is planning trip to Africa. He has plans to visit rural areas in addition to major cities. He has had no loss of consciousness or migraines. His last seizure was 2 yrs ago. Current meds include phenytoin. He has no allergies. He has been vaccinated against hepatitis B. In addition to mosquito-avoidance measures, what is recommended for malaria prophylaxis?

*Doxycycline* - 100 mg daily form start of travel until 4 wks after departure from malaria area Chloroquine-resistant malaria is common - mefloquine preferred but contraindicated with cardiac conduction abnormalities, neuropsych disorders, & seizure disorders --> doxycycline acceptabel alternative

18 yo college student brought to ED by concerned friends after he was unable to get out of bed. He reports 3-day ho progressive weakness & fatigue. His symptoms initially began in his feet, with some tingling & burning, & progressed up both of his legs until they were too weak to weak to support him. He also reports difficulty taking deep breaths & is unable to cough. His medical history is unremarkable. He has no HIV risk factors & does not take any meds or use illicit substances. His temp is 37 C (98.6 F), BP 130/88 mmHg, pulse 100/min, & respirations 36/min. Physical exam reveals young man in mild distress who is having difficulty completing sentences & clearing secretions. Cranial nerve exam shows patient has difficulty raising his head against gravity. UE strength is 3/5 bilaterally & deep tendon reflexes are normal. LE strength is 1/5 bilaterally & LE deep tendon reflexes absent bilaterally. Cardiac & lung exams are normal. What is the most appropriate next step in management?

*Elective intubation* GBS - can result in suddent GBS - difficulty breathing & tachypnea = may soon lose enough function to work his chest wall & diaphragm Increased likelihood of mechanical ventilation - time of onset of symptoms to admission of less than 7 days - inability to couhg - inability to stand - inability to lift elbows - inability to lift head - elevated liver-associated enzymes

24 yo pt comes to ED after being in accident. Her husband was dropping her off at work when they got rear ended. They were both wearing seatbelts. Husband drove them to the ED after reporting accident. Pt has no complaints but is very worried about her baby. She is 34 wks gestational age. Vital signs at ED are stable. Her obstetrician was contacted who stated that her pregnancy has been unremarkable & that she is Gravida 1 Para 0, blood type O+. Her physical exam is normal except for mild lower back pain & bruises on her lower abdomen & right shoulder where her seatbelts restrained her. Pelvic exam shows closed posterior cervix. There is no vaginal bleeding or pooling. Obstetric sonogram is normal & fetal heart tones are 164/min. Next best step in management?

*Electrical Fetal Monitoring* - even w/ normal ultrasound, pt is at risk for placental abruption --> may manifest several hours after accident due to trauma to lower abdomen - close monitoring of fetal heart tones necessary for several hours following trauma ~ 24 hrs - pts should be monitored while lying on their side to deflect large uterus from great vessels to enhance uteroplacental blood flow - uterine tenderness may be sign of abruption - in some cases, bleeding is concealed by placenta

Previously healthy 37 yo woman comes to doc bc of recurrent episodes of double vision & drooping of her eyelids for last month. Such episodes occur without apparent reason, last for hours, & resolve spontaneously. She also reports occasional hoarseness & difficulty in swallowing, which also comes & go. Vital signs & physical exam are normal. What tests will confirm diagnosis?

*Electrodiagnostic study with repetitive stimulation* Myasthenia gravis - autoimmune - fluctuating muscle weakness + diplopia &/or ptosis + speech/swallowing probz - responds to cholinergic agents such as pyridostigmine - *>10% decremental response on 3-Hz repetitive stimulation is helpful in making diagnosis*

First-step in diagnosis of Dermatomyositis

*Electromyogram (EMG)* - rules out other causes of muscular weakness - will reveals increased membrane irritability in form of classic triad = increased insertional activity & spontaneous fibrillations, abnormal myopathic low amplitude, short-duration polyphasic motor potentials, & complex repetitive discharges

22 yo gravida 2, para 1 woman comes to labor & delivery with painful uterine contractions & rupture of membranes that happened 4 hrs previously. Her past med hx is remarkable for prior Caesarean section, performed for breech presentation 2 yrs ago. She desires to undergo trial of labor for vaginal birth after Caesarean section. Physical exam shows cervix to be 4-cm dilated. Fetal heart tones are in 140s with heart rate accelerations and no decelerations. Internal uterine contraction monitor shows contractions every 3-4 minutes. Physicians is called 2 hrs later for increasing abdominal pain. Maternal blood pressure is 96/65 mmHg & pulse is 124/min. Fetal heart rate is in the 90s. Pelvic exam show shows no evidence of vaginal bleeding & cervix dilated to 8 cm. Internal uterine contraction monitoring shows decreased intensity of uterine contractions. Best next step in management?

*Emergent laparotomy* - to control bleeding - to deliver fetus - to repair rupture Underwent trial of labor after C section & rapidly deteriorated in short period of time - indicates intra-abdominal hemorrhage via uterine rupture - fetal bradycardia + decreased intensity of uterine contractions via uterine dehiscence = classic findings - fetal limbs may sometimes be palpated free-flowing in abdomen in severe cases

7.5-lb female newborn delivered at 40 weeks' gestation to 29 yo woman, gravida 3, para 2. Apgard scores are 3 & 4 at 1 & 5 minutes, respectively. During labor, fetal heart monitor showed late decelerations & loss of short- & long-term variability. Membranes were ruptured to expedite delivery, & amniotic fluid contained meconium. Infant delivered 45 minutes later. Infant appears cyanotic & limp. Exam shows poor tone; deep tendon reflexes are absent. Moro reflex is absent. 10 hours later, neonate has seizure. Most likely cause of this pt's condition?

*Encephalopathy from asphyxia* - late decelerations via fetal hypoxia --> predisposes fetus to perinatal asphyxia - all organs can be involved in perinatal asphyxia - poor tone & resp effort indicate the same - seizures would be expected several hours after moderate hypoxia

56 yo woman who is a smoker undergoes right hemicolectomy for colon cancer. Anastomosis performed with stapler, and no intraoperative complications are encountered. On night of surgery, doc is called to evaluate pt bc of her temp of 102 F. On exam, pt is comfortable except for normal incisional pain. Her oxygen sat is 93% of 2 L of nasal cannula oxygen. Her nasogastric tube is in place, BP is 123/86 mmHg, pulse is 102/min, & respirations are 16/min. Surgical dressing is clean, Foley cath is draining clear urine, & there is no lower extremity edema or tenderness. Venodyne boots have been implemented since time of surgery. Most appropriate next step in management?

*Encourage use of incetive spirometer* Most common source of fever in postoperative pt on first day = atelectasis - treatment requires that ventilation be improved via deep breathing, coughing, and incentive spirometry use to expand lung - severe cases = positive pressure can be used to provide alveolar recruitment & improve oxygenation

Transient erythroblastopenia of childhood is self-limited form of pure red-cell aplasia that is usually preceded by viral infection. Therefore, management includes

*follow-up of Hb levels until resolution* Presentation - gradually increasing pallor & fatigue - tachycardia & cardiac flow murmur

52 yo man comes to doc bc of skin lesions on his arms & legs for 6 mos. He has ho hypothyroidism, diabetes, severe hyperlipidemia, CAD, & chronic renal insufficiency. He had been on renal dialysis for past 2 years before undergoing kidney transplant 3 wks ago. Current meds include cyclosporine, prednisone, metformin, aspirin, & diltiazem. Exam of skin shows numerous dome-shaped papules on legs & arms. Some lesions have central keratotic scale & other lesions are excoriated & have central pustule. Most likely associated with appearance of these skin lesions?

*End-stage renal disease* Acquired perforating dermatosis (APD) / Kyrle disease - associated most commonly with chronic renal failure & DMA - often coexist - histologically, collagen fibers can be seen extruding through epidermis - dz may remit after renal tranplant - treatment of condition usually not satisfactory

75 yo man presents to ED for bright red blood in his stools. He has been bleeding for past day, & he has begun feeling faint. He has never had blood in his stools before. He denies history of hemorrhoids. His past med hx is notable for HT & CAD, for which he takes lisinopril & atorvastatin. On physical exam, he is afebrile, his BP is 90/55 mmHg, & his pulse is 110/min. Head, neck, cardiovascular, & lung exams are normal. There is no tenderness to palpation of abdomen. There is blood in rectal vault on digital rectal exam. Lab data demonstrate hematocrit of 32%. He is immediately given IV fluid & 2 units of packed RBCs. CT scan is unremarkable, & he undergoes mesenteric angiography, which demonstrates dilated slow-filling vein in ascending colonic wall. What is true about lesion responsible for pt's presentation?

*Endoscopic ablation is first line of treatment* - either cautherization or laser coagulation = first-line - if fails --> surgical resection of affected bowel Lower GI bleeding + hemodynamic instability - must be stabilized with IV fluids & blood replacement - workup = abdominal CT scan, endoscopy, angiography - differential = diverticulosis, angiodysplasia, colonic neoplasm, hemorrhoids - angiodysplasia secondary to diverticulosis = most common cause of lower GI bleeding

67 yo obese man diagnosed with type 2 DM at screening conducted at local shopping center, & is then referred to an internist. In comprehensive that ensues, several abnormalities are uncovered in addition to diabetes: pt has alkaline phosphatase level 4 times upper limit of normal, his total bilirubin is 2.7 mg/dL, he has hemoglobin of 9 mg/dL, & his stools are positive for occult blood. Sonogram of upper abdomen shows dilated intrahepatic & extrahepatic ducts. Most appropriate next diagnostic test?

*Endoscopic exam of duodenum* Early obstruction of biliary tract + blood in lumen of gut - bleeding enough to become anemic - *only single lesion that could account for both of these = cancer of ampulla of Vater* - endoscopic exam of duodenum should reveal cancer --> allow biopsy specimens to confirm diagnosis

36 yo worker presents with ho heartburn. Pain occurs more frequently after large meals & at night when he is lying in bed. He noticed severe pain with swallowing for last 2 days, which prompted him to visit his doc. He also reports bitter taste in back of throat & persistent nonproductive cough. Antacids & over-the-counter ranitidine did not relieve his symptoms. His physical exam is remarkable only for moderate obesity. Most appropriate next step in diagnosis?

*Endoscopy* - indicated if trial fails or if there are worrisome symptoms suggestive of other problems: anorexia, nausea/vomiting, dysphagia, odynophagia, blood in stool, weight loss, anemia, age >45 yo at set of symptoms GERD - symptoms of persistent nonproductive cough for nocturnal cough, hoarseness, feeling of fullness in throat, frequent sore throat, & loss of dental enamel

35 yo man with 19 yr ho type 1 diabetes comes to doc bc of progressive early satiety, abdominal bloating, nausea, & recurrent episodes of vomiting after large meal for 1 wk. he has had no fever, fatigue, or weight loss. His temp is 37.1 C (98.8 F), BP 115/75 mmHg, & pulse 80/min. Abdominal exam shows no abnormalities. There are 2 healed ulcers on ventral surface on his left foot. Most appropriate next step in management?

*Endoscopy* - may show presence of residual food in stomach after overnight fast --> supports diagnosis of gastroparesis Gatroparesis via autonomic neuropathy - via long-standing diabetes - mechanical obstruction & mucosal dz should be ruled out first with endoscopy, especially given short duration of symptoms

63 yo man brought to ED w/ altered mental status after he was found lying on his living room floor. Paramedics report that he had been lying there for an indeterminate period of time. He had generalized seizure activity in ambulance. In ED he is unresponsive, afebrile, & hemodynamically stable, saturating 99% on room air. He has clear bilateral breath sounds. He is unresponsive to verbal commands but responds to sternal rub by opening his eyes and moaning incoherently. He has no motor function. Next step in management?

*Endotracheal intubation* - pt has compromised mental status = unreliable to protect his own airway - man's Glasgow Coma Scale (GCS) = 5 --> endotracheal intubation warranted with GCS <8

Patient is in cardiac arrest. Ventricular fibrillation has been refractory to second shock. What drug should be administered first?

*Epinephrine 1 mg IV/IO* VF/Pulseless VT drug therapy: Epinephrine IV/IO dose: - 1 mg every 3-5 minutes Amiodarone IV/IO dose: - first dose = 300 mg bolus - second dose = 150 mg

Patient is in refractory ventricular fibrillation. High-quality CPR in progress. One dose of epinephrine was given after second shock. Antiarrhythmic drug was given immediately after third shock. You are team leader. What medication do you order next?

*Epinephrine 1 mg* Drug therapy for Adult Cardiac Arrest Algorithm: Epinephrine IV/IO dose: - 1 mg every 3-5 minutes Amiodarone IV/IO dose: - first dose = 300 mg bolus - second dose = 150 mg

Patient has sinus bradycardia with heart rate of 36/min. Atropine has been administered to total dose of 3 mg. Transcutaneous pacemaker has failed to capture. Patient is confused, & her BP is 88/56 mmHg. What therapy is now indicated?

*Epinephrine 2-10 mcg/min* Adult Bradycardia with Pulse Algorithm: Doses/Details: Atropine IV dose - First dose = 0.5 mg bolus - Repeat every 3-5 minutes - Max = 3 mg Dopamine IV infusion - usual infusion rate = 2-20 mcg/kg per minute - titrate to patient response - taper slowly Epinephrine IV infusion - 2-10 mcg per minute infusion - titrate to patient response

What intervention is most appropriate for treatment of patient in asystole?

*Epinephrine* Asystole Continue high-quality CPR --> as soon as IV/IO access available, given epinephrine - Epinephrine = 1 mg IV/IO - repeat every 3-5 minutes Administer drugs during CPR. Do not stop CPR to administer drugs - consider advanced airway & capnography

46 yo man comes to doc bc of itchy rash in his groin for 3 wks. He has had no relief after using OTC antifungal cream. He has had no fevers. He has hx of T2DM controlled with diet & HT treated with losartan. He has no known allergies to meds. He does not drink or smoke. Exam shows sharply demarcated, dry, brown, slightly scaly patches bilaterally in both genitocrural creases. There are similar but smaller patches in axillae & in 4th interdigital space on feet. Woods light exam shows coral-red fluorescence in all 3 locations. Most likely diagnosis?

*Erythrasma* = sharply delineated, red-brown, slightly scaling patches in intertriginous areas - especially in axillae, genitocrural creases, and interdigital web spaces - most common site = b/t 4th & 5th toes = macerated white plaque - asymptomatic usually, but groin lesions can burn or itch - causative microorganism = gram-positive rod Corynebacterium inutissimum - Woods light exam = diagnostic test of choice = pathognomic coral-red fluorescence via coproporphyrin III in stratum corneum - treatments = oral erythromycin & topical clindamycin & benzoyl peroxide

COPD is a known cause of this. Due to chronic hypoxia --> secretion of erythropoietin, which increases as response to long-term hypoxia.

*Erythrocytosis* - helps increase oxygen delivery to tissues

4 yo girl found drinking bottle of liquid drain cleaner & is immediately brought to ED. She appears to be very irritable & is unwilling to swallow any liquid med. Her mother reports that the child has been crying intensely & has had nausea but no vomiting. Exam of oral cavity reveals no evidence of burns or ulcerations. Most appropriate management?

*Esophagoscopy* (flexible) - important to perform chest radiograph first to rule out overt perforation & mediastinitis - no injury? --> no treatment necessary - for mild to moderate burns = IV hydration, analgesics, abx - most common & important complication = esophageal stricture Liquid drain cleaner = highly alkaline substance - tasteless - ingestion --> esophageal necrosis of liquefaction type - full-thickness injury common - severe --> esophageal perforation & mediastinitis - acid ingestion = coagulation necrosis & eschar formation - eschar tends to protect esophagus from full-thickness injury & corrosive perforation - presence of at least 2 or 3 symptoms (vomiting, dysphagia, abdominal pain, drooling, hematemesis, stridor, oral burns) = severe esophageal injury

29 yo woman, gravida 3, para 2, ab 1, comes to doc bc she has not had her period since she gave birth 11 mos ago. She is sexually active & uses no form of contraception. She stopped lactating 6 mos ago bc she wasn't producing enough milk. She has not had any nipple discharge or vaginal secretions. Pelvic exam shows normal-appearing vulva, vagina, & cervix. Uterus is symmetric & not enlarged. Urine hCG test is negative. Serum prolactin level is 8 ng/mL (normal 4-12) & serum TSH level 3.2 mIU/L (normal 0.4-5). She administered IM progesterone. After 6 days, she has not had any bleeding. Most appropriate next step in management?

*Estrogen & progestins* Secondary amenorrhea - absence of menses for 3 mos if menses was previously regular OR absence of menses for 6 mo if menses was previously irregular - pregnancy = most common cause; after pregnancy, most common causes = hormonal = inadequate progesterone or estrogen - progesterone challenge test used to diagnose secondary amenorrhea - withdrawal bleeding after progesterone challenge test = anovulation as cause for amenorrhea - negative progesterone challenge test (no withdrawal bleeding) followed by estrogen-progesterone challenge test --> withdrawal bleeding at this point = def of estrogen

During routine medical checkup, 58 yo woman found to have serum calcium level of 11.8 mg/dL. Repeated testing confirms values b/t 10.9 & 12.2 mg/dL. She is also found to have elevated concentrations of parathyroid hormone. She is asymptomatic, has no pertinent fam hx, & has no evidence of renal stones or bone dz. He is offered option of elective parathyroidectomy, but she declines & elects to have close medical followup. While doing so, it would be advisable for her to be placed on what therapies?

*Estrogen-progestin replacement* - beneficial in postmenopausal women who have primary hyperparathyroidism - reduces bone resorption, increases bone density, decreases serum calcium concentrations Parathyroid adenoma - surgical removal = only cure

A 60-year-old man is evaluated because of a 3-month history of intermittent chest pain. He has occasional substernal chest pressure when he exercises at the gym and occasionally after he eats a spicy meal. The pressure is not consistently relieved with rest and is occa sionally relieved with antacid. He has no associated symptoms of shortness of breath, dizziness, or diaphoresis. His medical history includes hypertension and hyperlipidemia. Medications are lisinopril and pravastatin. On physical examination, blood pressure is 128/80 mm hg, pulse rate is 84/min, and respiration rate is 16/min. Findings on cardiovascular examination are normal. The electrocardiogram is shown. Which of the following is the most appropriate diagnostic test to evaluate the patient's chest pain?

*Exercise electrocardiography* - diagnosing chronic angina with exercise stress test - exercise ECG testing standard stress test for diagnosis of CAD in patients with normal baseline ECG findings - exercise preferred to pharmacologic stressors bc it provides gauge of functional capacity & contextual understanding of symptoms as well as record of hemodynamic response to exercise

26 yo African-American F comes to ED complaining of severe SOB that began while she was jogging in park earlier today. Didn't improve despite repeated use of inhaler, which she has been instructed to carry with her always. Her past med hx is significant for asthma & seasonal allergies. Her meds include oral contraceptive pills & 3 resp meds, 2 of which are inhaled &, she says, are closely managed & changed by her allergist. Her resp rate is 44/min & she is exhibiting supraclavicular retractions. She has difficulty completing her sentences while speaking. On auscultation her lungs have exp & insp wheezes. Her nail beds & oral mucosae are pink. In addition to instituting prompt therapy with nebulized beta-agonists, IV steroids, & oxygen, stat chest x-ray & arterial blood gas are ordered. ABG reveals pH 7.46, pO2 86 mmHg, pCO2 32 mmHg. 30 minutes later her RR is 25/min. Wheezing not audible on auscultation and her retractions have diminished. Her lips, however, appear blue. Second stat ABG reveals pH 7.38, pO2 84 mmHg pCO2 41 mmHg. Most appropriate next step in management?

*Explain meaning of resp failure to pt, then intubate her* Presented to ED in moderate to severe resp distress - likely due to asthma - first ABG = resp alk via tachypnea induced hypoxia - initial treatment = correct - pt clinically deteriorating - be wary with asthmatic pt who has ABG that appears to be improving --> sign of impending respiratory failure --> best to explain intubation & prepare to do so

31 yo woman smashes her car against bridge abutment. She sustains multiple injuries, including upper and lower extremity fractures. When she is brought to ED, she is fully awake and alert, and she reports that she was not wearing seat belt and that she distinctly remembers hitting her abdomen against steering wheel. Her BP is 92/55 mmHg & pulse is 107/min. Physical exam shows that she has rigid & tender abdomen. There is severe tenderness when external pressure is applied to her abdomen & then suddenly released. She has no bowel sounds. What would be the most appropriate step in evaluating potential intra-abdominal injuries?

*Exploratory laparotomy* Acute abdomen - indication for exploratory surgery & prompt repair of injuries (probz affecting hollow viscera) that have produced signs of peritoneal irritaiton

Successful, 27 yo businesswoman has developed fear of flying after extremely rough landing. She is paralyzed with fear & unable to travel for business. Her doc tried giving her lorazepam to take during flight, but it didn't help. She returns to doc & asks if there is anything else she can do to reduce her fear bc she is not getting a promotion at work due to her inability to travel. Most commonly used treatment for this disorder?

*Exposure therapy* - type of behavioral therapy - most commonly used treatment of specific phobia - forced exposure to feared object/event (flooding) or desensitizes pt by gradual exposure to phobic stimulus (systemic desensitization) - relaxation & breathing control = important parts of systemic desensitization

35 yo woman comes to doc bc of right wrist pain for 1 mo. Pain is worsened by activity & is relieved by rest. She has had difficulty gripping objects with her right hand. She gave birth to her first child 6 mos ago. Exam shows tenderness to palpation of the radial styloid. There is pain with resistance to thumb abduction & extension. Tinel test is negative. Inflammation of what is the most likely cause of this pt's symptoms?

*Extensor pollicis brevis tendon* de Quervain tenosynovitis - common entrapment tendonitis of hand - classically occurs in women shortly after childbirth - caused by repetitive lifting of child - inflammation of tendons of abducto pollicis longus & extensor pollicis brevis - complaints of severe pain during motion of thumb & wrist - firm palpable mass in region of first dorsal extensor comp't of wrist + crepitus over this site - pain may be elicited by resistance to thumb extension & abduction - can also classically be reproduced using Finkelstein test = carried out by passively flexing pts wrist in ulnar direction while having pt grasp thumb within palm of hand - treatment = conservative

In rollover car accident, 42 yo woman is thrown from vehicle. Car subsequently lands on her & crushes her. Physical exam in ED reveal pelvic fracture, which is confirmed by portable x-ray film done as pt is being resuscitated. Her initial BP is 50/30 mmHg & pulse 160/min & barely palpable. Thirty minutes later, after 2 L Ringer's lactate & 2 U packed RBCs have been infused, BP is only 70/50 mmHg & pulse 130/min. Sonogram shows no intra-abdominal bleeding & diagnostic peritoneal lavage confirms no blood in abdomen; recovered fluid is pink, but not grossly bloody. Rectal & vaginal exams show no injury to those organs. There is no blood in pt's urine. Emergency angiogram reports that there is no major arterial bleeding which could be treated by embolization. What is the most appropriate next step in management?

*External fixation of pelvis* Pelvic fractures - can bleed massively (often the source is torn pelvic veins = not easily controlled) - most imp step = attain hemostasis by tamponade or increase pressure in pelvis - can be done quickly in trauma bay by applying pelvic binder (wrapping bedsheet around pelvis, twisting to tighten, & tying off) --> minimizes motion of bone fragments & associated vessels by external fixation - commercial pelvic binds or C clamp can also be used to achieve pelvic stabilization in trauma bay

22 yo woman, gravida 4, para 3, at 38 wks' gestation, comes to labor & delivery ward with gush transvaginal secretion. Sterile speculum exam reveals pool of fluid that is Nitrazine-positive & forms ferns when viewed under microscope. Fetal heart rate is 150/min & reactive. US demonstrates fetus is in breech position. Cesarean delivery performed. During operation, doc, who has received no recent immunizations, is stuck with needle that had been used on pt. What is this doc at greatest risk of contracting?

*Hepatitis B* - essential health care workers be immunized against hep B - immunization schedule = vaccine at 1, 2, & 6 mos

A 24-year-old man is evaluated for severe bleeding following arthroscopic surgery of the right knee 24 hours ago. The patient sustained a sports-related injury 1 year ago and since that time has had repeated swelling of the knee requiring aspiration of bloody fluid. Medical history is significant for compartment syndrome in the left forearm after sustaining an injury. He is an only child. His only medication is acetaminophen. On physical examination, temperature is normal, blood pressure is 100155 mm Hg, pulse rate is 120lmin, and respiration rate is 22/min. The wound dressing shows fresh bleeding from the arthroscopy sites. Lab studies: Platelet count = Normal Prothrombin time = 11 s aPTT = 60 s aPTT mixing study = Corrects Most appropriate next diagnostic study?

*Factor VIII & factor IX measurement* Hemophilia most likely... - absence of clear fam history of X-linked bleeding disorders = may not become apparent until older age - normal PT & prolonged aPTT that fully corrects on mixing with 1:1 ratio of normal plasma

42 yo man with history of IV drug use comes to community outreach clinic complaining of fever, malaise, & cough for last 3 days. Physical exam reveals cardiac murmur, which pt states he has been unaware of. Given his recent use of IV heroin & his chronic symptoms, man is admitted to hospital for blood cultures. Treatment with IV vancomycin & gentamicin initiated. 3 sets of blood cultures grow methicillin-resistant S aureus, & a chest radiograph reveals multiple bilateral nodular densities. Treatment with IV vancomycin continued. Cardiac auscultation most likely to reveal what?

*Faint murmur that increases intensity with inspiration* = characteristic murmur of tricuspid regurgitation = faint holosystolic murmur that increases with inspiration (carvallo's sign) = heard best with diaphragm placed over lower sternal border - murmur increases bc during inspiration, intrapleural pressure becomes more negative = decreased intrathoracic pressure Right-sided endocarditis - injection drug users - septic pulmonary emboli

What type of diverticulum is Zenker's diverticulum?

*False* diverticulum - not all layers of esophageal wall are outpouched - most commonly develops in elderly - outpouching of mucosa through cricopharyngeus muscle / Killian's space - presentation = dysphagia, halitosis, food regurgitation - multiple bouts of aspiration pneumonia common - treatment for lesion = surgical for symptom alleviation & for prevention of aspiration - best seen on lateral view of pharyngeal barium swallow

18 yo woman evaluated during routine office visit. She has 2 yr ho T1DM that is under excellent control with long-acting & bolus insulin. Her most recent hemoglobin A1c value, measured 6 mos ago, was 7%. She has not experienced any hypoglycemic episodes & has no symptoms, including visual changes or numbness or tingling. Med hx otherwise unremarkable, & she has no fam hx of cardiovascular dz or diabetes. On physical exam, vital signs normal. Nondilated funduscopic exam normal, & exam of thyroid gland & feet unremarkable. What screening exams are indicated?

*Fasting lipid panel* Screen for dyslipidemia in pt w/ T1DM

36 yo man develops rapid mental status deterioration two days after sustaining femoral fracture in skiing accident. Physical exam shows multiple petechiae in anterior chest & abdomen. On third day, pt lapses into coma dies. Postpartum exam of brain reveals numerous petechial hemorrhages in corpus callosum & central semiovale. Most likely diagnosis?

*Fat embolism* - mainly affects lungs & brain - clinical pic = dyspnea, tachycardia, mental status changes - rare = death - can be visualized histologically - brain: multifocal petechae in white matter = most common pathologic change

73 yo man with CAD, HT, & hypercholesterolemia admitted to hospital with bright red blood per rectum. He is tachycardic at 100/min & hypotensive with BP 100/40 mmHg. He is started on IV fluids, & blood is sent for typing, cross-matching, & CBC. Gastroenterology team contacted & colonoscopy planned for morning. BP improves to 110/60 mmHg after 2 L of crystalloid, & hemoglobin & hematocrit return with values of 7.5 g/dL & 23%, respectively. Blood transfusion initiated, during which he complains of back pain & is noted to be febrile to 102.3 F, tachycardic at 132/min, & diaphoretic. EKG normal, as are troponin levels. Repeat CBC shows hemoglobin & hematocrit to be 6 g/dL & 19% respectively. Urine from Foley catheter looks reddish. With info available so far, what would be most worrisome problem confronting this man at this time?

*Febrile hemolytic transfusion rxn* - most common transfusion rxn is febrile non-hemolytic transfusion rxn, but most common cause of death by transfusion rxn is from clerical error leading to ABO incompatbility - rxn presented here could be ABO incompatibility with fever, tachycardia, back pain, & decreasing hematocrit = febrile hemolytic transfusion rxn = Ab-mediated hemolysis leads to fever, tachycardia, anemia, & hemoglobinuria - treatment = IV fluids & diuresis, sodium bicarb to alkanize urine, vasopressors when necessary

58 yo woman evaluated during follow-up exam. Pt was evaluated in ED 8 wks ago bc of progressively worsening epigastric pain. Upper endoscopy showed 4-mm duodenal ulcer; biopsy specimens revealed mild gastritis with no evidence of malignancy. Histologic evaluation of tissue showed infection with H pylori. She was treated with 14-day course of omeprazole, clarithromycin, & amoxicillin followed by additional 2 wks of omeprazole alone. Her symptoms resolved at completion of therapy. Med hx otherwise unremarkable, & she is currently taking no meds. On physical exam, vital signs normal. Abdomen soft without midepigastric tenderness. Remainder of exam unremarkable. Most appropriate next step in management?

*Fecal H pylori antigen testing* - verify eradication of infection

44 yo woman, gravida 4, para 3, at 8 weeks' gestation comes to doc for first prenatal visit. She had mild nausea & vomiting but no other complaints. He obstetric history is significant for 3 full-term, normal vaginal deliveries of normal infants. She has no med or surgical history & takes no meds. Physical exam reveals 8-week-sized uterus, but is otherwise unremarkable. She wishes to have chromosomal testing of fetus & wants to have chorionic villus sampling performed, as she did with her last pregnancy. Compared with amniocentesis, chorionic villus sampling may place patient at greater risk for what?

*Fetal limb defects* CVS - chorionic villi sampled through either transabodminal or transcervical approach - can be performed at 10-12 weeks - allows woman to undergo earlier termination than amniocentesis allows for - early 1900s: severe reports linking to limb reduction defects in infants

Jack Nicholson has 5 cm peripheral right lung mass, an enlarged subcarinal lymph node, & a left iliac blastic bone lesion on PET/CT. MRI brain is negative. What must be a part of the diagnostic process?

*IR or surgical biopsy of left iliac bone lesion* - biopsy the lesion that will upstage he cancer unless lesion is inaccessible

A 70-year-old woman undergoes a routine examination. She is asymptomatic and is not taking any medications. On physical examination, her vital signs are normal. Multiple areas of palpable, small, nontender lymphadenopathy are noted in the cervical, axillary, and inguinal areas; these were not present on a previous examination 3 years ago. The rest of the physical examination findings are unremarkable. Lab studies: Hgb = 12.5 g/dL Leukocyte count = 65,000/uL, with 30% neutrophils & 70% lymphocytes Platelet count = 190,000/uL Review of peripheral blood smear reveals numerous small lymphoid cells. What will provide most prognostic inform in diagnostic evaluation?

*Flow cytometry* clinical pic = CLL - absolute increase in mature lymphocytes (>5000/uL) in absence of acute viral illness or other trigger of reactive lymphocytosis & demonstration of clonality of circulating B-lymphocytes on flow cytometry - immunophenotyping = monoclonal proliferation of mature B lymphocytes expressing CD19, CD20, CD5 - most common form of lymphoid malignancy - pt has stage I dz (lymphocytosis & lymphadenopathy w/out splenomegaly or other organomegaly)

A 36-year-old woman is evaluated because of shortness of breath. She describes her symptoms as "difficulty getting air" both at rest and with exertion. Onset of symptoms has been gradually progressive over the last 6 months. She has no cough or wheezing. Medical history is significant for severe injuries sustained in a motor vehicle accident 2 years ago. She had multiple head and chest injuries requiring prolonged mechanical ventilation and multiple corrective surgeries. She has recovered completely and now feels well. She takes no medications. On physical examination, vital signs are normal. Oxygen saturation is 99% on ambient air. The oropharynx is patent, and she has no stridor. The chest shows multiple well-healed surgical incisions; respiratory effort and chest excursion are normal. The lungs are clear to auscultation. The remainder of the examination is unremarkable. Which of the following is the most appropriate next diagnostic step?

*Flow-volume pulmonary function testing* Tracheomalacia via chronic dyspnea + ho multiple intubations - tracheomalacia or tracheal stenosis may be seen in pts with endotracheal intubation, especially when intubation has been repeated or prolonged - best diagnosed on pulmonary function testing = characteristic flattening of curve observed on flow-volume measurements

40 yo man with 1 yr ho HIV comes to ED bc of 4 wk ho fever & headaches. Current meds include raltegravir, tenfovir, & emtricitabine. He has used IV drugs, but he quit 5 yrs ago. His temp is 100 F, BP 140/90 mmHg, pulse 84/min, & respirations 14/min. Pupils are equal, round, & reactive, & there is no papilledema. There is no neck rigidity or lymphadenopathy. Lungs are clear to auscultation. Cardiac exam shows normal S1 to S2; no murmurs are heard. His CD4+ T lymphocyte count is 46 cells/mm^3. Lumbar puncture is performed & CSF analysis shows leukocyte count 20 cells/mm^3. India ink stain is negative. Cryptococcal antigen in CSF is positive. Pt receives 2 wk course of amphotericin B & flucytosine, & he improves significantly. Most appropriate pharmacotherapy for this pt?

*Fluconazole until CD4+ count is >100 cells/mm^3, raltegravir, tenfovir, & emtricitabine* Cryptococcal meningitis = 2 phases Induction phase - combo of amphotericin B & high-dose flucytosine for first 10-14 days Maintenance phase - fluconazole = administered at dose of 400 mg per day for first 2-3 months, followed by 200 mg per day --> should be administered until CD4+ > 100 cells/mm^3 continuously for 1 yr - HAART therapy should be continued

28 yo woman comes to doc bc of 3 mo ho urinating more than 20 times daily & increased thirst. She has had no blurry vision, painful urination, or blood in her urine. She has ho bipolar disorder & hypercholesterolemia. Her temp is 37.2 C (99 F), BP is 115/75 mmHg, & pulse is 76/min. Remainder of exam shows no abnormalities. Her serum sodium level is 132 mEq/L. Urine osmolality is 160 mOsm/kg. Urinalysis shows 2-3 erythrocytes/HPF & 1-2 leukocytes/HPF. After water deprivation, urine osmolality increases to 510 mOsm/kg. Most appropriate next step in management?

*Fluid restriction with medical management of bipolar disorder* Bipolar disorder + new symptoms of polyuria & polydipsia - lithium --> nephrogenic DI --> pts usually hypernatremic, hyperosmolar state - if urine osmolality increases to ~500 mOsm/kg after deprivation test, psychogenic polydipsia most likely cause - treatment = water restriction with review of meds to remove those that cause increased thirst as well as treatment of mental illness

30 yo woman, a model, has 7 year ho binging & purging. She also exercises excessively, often for 4 hours/day, 6 days/week. She does not eat publically, & she hides food. She spends hours in front of the mirror, looking at her body. She is not currently suicidal & does not have ho suicidal ideation. Her BP is 127/77 mmHg, PR is 78/min & regular, RR is 17/min, & BMI is 26. Rest of her physical exam is normal & labs are unremarkable. Pt has been referred to an eating disorders program for behavioral therapy. Of the following, what intervention is most appropriate at this time?

*Fluoxetine* - SSRI - only antidepressant currently indicated for pts with bulimia nervosa Bulimia nervosa - pt's wt normal or slightly above average

21 yo man who was recently diagnosed with asthma comes to see PCP bc of worsening of symptoms. Has been maintained on inhaled albuterol. Patient describes episodes of SOB almost every day. Also reports symptoms of asthma at night, usually 1x/week. Vital signs are temp 36.6 C (97.8 F), pulse 103/min, BP 120/75 mmHg, respirations 22/min, oxygen sat 90% on room air. Physical exam reveals well-developed young man in no distress. Auscultation of chest reveals wheezes bilaterally. Heart sounds normal with no murmurs or gallops. Abdomen soft & nontender, with normoactive bowel sounds. Pulmonary function tests shows FEV1/FVC that is 72% predicted. Most appropriate long-term management?

*Fluticasone & salmeterol* - combo f inhaled corticosteroid & long-acting, beta-2 agonist Moderate persistent asthma - daily asthma symptoms, nighttime symptoms occurring more than once/week, daily use of inhaled, short-acting beta gonists, exacerbations that affect activity, FEV/FVC that is 60-80% predicted

83 yo woman consults doc bc she is "feeling so tired all the time." In-office Hct is 35%. Peripheral blood smear shows many macrocytic RBCs. On questioning, woman, whose finances are limited, admits that she has been living on strictly limited diet consisting mainly of bread. She has been drinking powdered orange juice substitute. She has not been taking vitamin pills bc she feels she cannot afford them. Nutritional def of what is most likely cause of patient's anemia?

*Folate* Tea & toast diet --> more suggestive of folate def - widely found in plant & animal tissues but easily destroyed by over-cooking

Diagnosis of Duchenne muscular dystrophy made by ordering tests in the following sequence:

serum CK (normal level not compatible with diagnosis) & blood sample to show mutation by *PCR* - if this is not conclusive, muscle biopsy with immunohistochemical staining performing = definitive

23 yo primigravid woman comes to doc bc of vaginal bleeding. Her last menstrual period was 6 wks ago. She has no other symptoms. Exam shows 10-wk sized uterus, but is otherwise unremarkable. Pelvic ultrasound reveals snowstorm pattern consistent with complete mole. Serum beta-hCG is markedly elevated over normal pregnant values. Chest x-ray film is negative. Dilation & evacuation performed & pathologic diagnosis is complete hydatidiform mole. Most appropriate next step in management?

*Follow beta-hCG levels to 0* Gestational trophoblastic dz: Hydatidiform mole - typical "snowstorm" pattern on ultrasound & pathologic confirmation after dilation & evacuation - beta-hCG must must be followed weekly until it returns to 0 --> then follow monthly for additional year while on oral contraceptives to ensure that value stays at 0 & that there is no evidence of persistent or metastatic dz

28 yo woman with epilepsy brought to ED by her bro bc of 20 min hx of convulsions. Her temp is 98.6 F, BP 108/88 mmHg, pulse is 102/min, & respirations 28/min. Her oxygen sat is 98% on room air. She is administered glucose, thiamine, and lorazepam IV. Stat serum chemistries are sent, as well as urine tox screen & blood alcohol level. She continues to seize despite lorazepam. Most appropriate pharmacotherapy?

*Fosphenytoin* - less hypotension & phlebitis than phenytoin = preferred Status epilepticus - continuous seizure activity for 30 mins or longer or 2 or more seizures without interval recovery - continues after benzos? --> diff'ts class - *after load of lorazepam, fosphenytoin or phenytoin = most efficacious*

Paraphilic disorder in which sexual arousal achieved by rubbing genitals against women, usually in crowded places where potential victim cannot easily escape

*Frotteuristic disorder*

4 mo old girl brought to doc by her parents bc of problems with constipation. Mother states that infant can go up to 4 days w/out bowel movement, & when she does go, stool is very hard. Prenatal care was appropriate & the infant was born at 39 weeks' gestation without any difficulties except for delayed first bowel movement 2 days after birth. Except for constipation, her first 4 mos of life have been uneventful. Exam shows distended, soft, & nontender abdomen. Immediately after rectal exam, infant passes explosive bowel movement with flatus. After bowel movement, her abdomen is much less distended. What tests will confirm diagnosis?

*Full thickness biopsy of rectal mucosa* Hirschsprung disease (HD) / congenital aganglionic megacolon - more common in boys - migratory arrest of neuroblasts within intestine - mostly limited to rectosigmoid colon - cardinal symptom = constipation - rectal exam may lead to explosive expulsion of stool & flatus, with relief of abdominal distention

52 yo woman comes to ED with increasing fatigue for several weeks. She has ho HT well controlled w/ lisinopril & HCTZ, UC w/ intermittent severe diarrhea, & stable CKD of unknown cause (baseline serum creatinine is 1.8-2 mg/dL). She takes aspirin as needed for intermittent mild headaches. Her vital signs are: temp 96.8 F, BP 148/95 mmHg, pulse 120/min, respirations 24/min, 99% oxygen sat on room air. Heart & lung exams are normal. Abdominal exam reveals mild diffuse tenderness to palpation. There is 1+ edema in both ankles. Arterial blood gases are pH, 7.46; pCO2, 32 mmHg; and pO2, 94 mmHg. Serum chemistries show: Na+ 140 mEq/L K+ 2.6 mEq/L Cl- 114 mEq/L HCO3- 18 mEq/L Creatinine 1.9 mg/dL BUN 20 mg/dL Glucose 92 mg/dL Ca2+ 8.7 mg/dL Urinalysis shows pH5, specific gravity 1.018, negative for glucose & ketones. No cells or casts present. What best explains her acidemia?

*GI bicarbonate losses* Metabolic acidosis + normal anion gap - caused by either diarrhea or renal tubular acidosis - ho UC & of CKD makes either possible - diarrhea causes GI loss of both potassium & proximal & distal (type 1 & 2) RTAs - type 4 RTA = hyperkalemia - pt's urine pH shows acid urine (5) appropriate to systemic acidemia, indicating good distal acidication, & excluding distal RTA

33 yo woman develops bloody nipple discharge from right breast. It occurs intermittently over course of 6 wks. There is no fam hx of breast cancer. Pt denies any trauma, recent pregnancy, prior similar episodes, pain, or fevers. On exam, both breasts are normal in appearance. There are no palpable masses in either breast. Very small amount of blood can be expressed from right nipple. Discharge sent for cytology & results reveal presence of few inflammatory cells & multiple RBCs. Pt is sent for mammography of both breasts, which indicates no masses. Best next step in management?

*Galactography* - may be helpful in guiding targeted limited resection = symptomatic relief Intraductal papilloma - most common cause of unilateral bloody nipple discharge in women b/t ages of 20 & 40 yrs - no palpable findings on physical exam

What is the most likely conseuqence of a proper hepatic artery emboliziation?

*Gallbladder ischemia* - proper hepatic artery = main blood source for gallbladder & biliary tree - often, liver transplant recipients who have complications with hepatic artery will develop problems with biliary system rather than liver itself - cystic artery = only source of arterial blood to gallbladder

23 yo male college student brought to ED complaining of chest pain. Pain had sudden onset this morning after repeated episodes of bilious, nonbloody vomiting that pt attributes to his eating "spoiled Chinese takeout" night before. Pain is not worse with breathing but does radiate to left shoulder. It has not remitted in hour since initial event. He has no significant past med hx. His fam hx & social hx are noncontributory. On exam his vital signs are stable & he is febrile. He is tachypneic but has breath sounds bilaterally. Palpation at base of his neck is suggestive of subQ air. Abdomen is slightly distended & his epigastric region is tender to palpation. Initial lab tests are sent. Next step in management?

*Gastrografin swallow study* Perforated esophagus - Boerhaave syndrome - based on Meckler triad = vomiting, chest pain, subQ emphysema - perforation of esophagus post-vomit usually in left lateral position of distal esophagus, 3-5 cm above GE junction - full-thickness transmural perforation distinguishable from Mallory-Weiss syndrome *diagnosis of esophageal perforation made on gastrografin swallow study* - demonstrates contrast extravasating from esophageal lumen - water-soluble - not toxic to mediastinal & thoracic structures

Frantic mom telephones pediatrician's office. Woman's 7 yo daughter was playing under sink & accidentally spilled strong, corrosive alkaline drain cleaner all over her arms & legs. On phone nurse can hear child screaming in background. Doc's office & nearest hospital are few miles away from woman's home. What is the most appropriate instruction to give mom?

*Get child into shower right away and keep water running over her for 30 mins before bringing her to ED* Caustic chemical burns - wash away caustic agent as soon as possible - massive irrigation

AR syndrome characterized by hypokalemia metabolic alkalosis. Defect due to inactivating mutations in gene for thiazide-sensitive sodium chloride cotransporter in distal convoluted tubule.

*Gitelman syndrome*

55 yo man who was involved in motor vehicle accident was brought into ED by paramedics who reported that patient has not been wearing seat belt & was found slumped on steering wheel, which was deformed. The patient is weak but conscious, & tell you that he feels pain when he breathes. His temp is 37 C (98.6 F), BP 130/80 mmHg, pulse 110/min, respirations 22/min, & oxygen sat 95% on room air. Physical exam shows ecchymosis across chest, with the chest wall tender to touch. Pulmonary exam shows decreased air entry bilaterally with normal resonance. Cardiac exam shows regular rate & rhythm; no murmurs are appreciated. In following minutes patient's BP increases to 145/95 mmHg, respirations increase to 26/min, & oxygen sat decreases to 91%. Most appropriate next step in management?

*Give analgesia & supplemental oxygen* = management of blunt chest injury - appropriate when no evidence of pneumothorax or hemothorax (cardiovascular instability) Chest wall injury - rib fracture, sternal fracture, etc - must secure ABCs initially - moderate hypoxia = inadequate breathing Total ventilation = tidal volume x respiratory rate Alveolar ventilation = tidal volume - dead space (150 mL) x respiratory rate

3 yo boy brought to ED by his mom bc of irritability & lethargy. Child has had progressively worsening diarrhea for past 3 days, which has been treated with oral fluid rehydration. He is afebrile, BP is 70/42 mmHg, pulse is 160/min, & capillary refill is greater than 3 seconds. His weight is 20 kg. Lab studies shows serum sodium level of 163 mEq/L. IV line inserted he is administered 1,200 mL of normal saline over 30 minutes. He requires another 20 mL/kg normal saline bolus to achieve hemodynamic stability. Best fluid management for this pt?

*Give maintenance & solute deficit over first 24 hrs with half free water deficit, then maintenance & the other half of free water deficit over next 24 hrs* Severe dehydration - loss of free water - for management of pt who has hypernatremic dehydration (sodium >150 mEq/L), administer maintenance therapy with solute deficit, but correct sodium slowly over 48 hrs - sodium corrected slowly by administering half of free water deficit in 24 hrs, then the other half in the next 24 hrs

7 yo boy brought to doc by his mom bc he has continuous bleeding since having tooth extracted 24 hours ago. He has taken acetaminophen twice in past 24 hrs. Mother states he is a "very active child who is always getting bruises all over his body." His paternal uncle had ALL. His temp is 37.7 C (99.8 F), BP 90/60 mmHg, pulse 90/min, & respirations 16/min. Exam shows bleeding from site of dental extraction. Lungs are clear to auscultation. 1/6 systolic ejection murmur heard at left sternal border. Petechiae bilaterally on lower extremities & on chest. 4-cm ecchymosis on anterior aspect of right knee. Lab studies show: Hgb = 13.1 Platelets = 300,00/mm^3 WBCs = 8,600/mm^3 PT = 12 seconds PTT = 32 seconds Bleeding times = 10 minutes (normal, 207 minutes) Platelet aggregation studies: Ristocetin = ++++ (normal response) ADP = 0 (no response) Epinephrine = 0 (no response Most likely diagnosis?

*Glanzmann thrombasthenia* - AR - GP IIb/IIIa complex deficient or present but dysfunctional - platelet counts & other coag tests normal - bleeding time prolonged - primary platelet aggregation response to platelet agonists such as ADP, epinephrine, collagen decreased - response to ristocetin normal - bleeding --> platelet transfusion Platelet dysfunction - excessive bleeding after dental extraction - petechiae - ecchymoses

39 yo AA man has had 16 lb weight gain along with progressively worsening massive LE edema & fatigue over last 2 weeks. His urine is normal colored by foamy. He denies any recent skin or throat infections, diabetes, or carpal tunnel syndrome. His temp is 98.6 F, BP 170/70 mmHg, pulse 93/min, & respirations 18/min. Physical exam reveals massive upper & lower extremity edema together with sacral edema. His lungs have decreased breath sounds at bases bilaterally. Cardiac & abdominal exams are within normal limits. He has no retinopathy. Lab studies show: Sodium = 130 mEq/L Potassium = 4.5 mEq/L Chloride = 100 mEq/L Bicarbonate = 24 mEq/L Glucose = 116 mg/dL BUN = 27 mg/dL Creatinine = 1.7 mg/dL Albumin = 1.7 g/dL LDL cholesterol = 450 mg/dL Hemoglobin = 12 mg/dL HCT = 31% WBC = 7700/mm^3 Platelets = 270,000/mm^3 Urinalysis = Negative Leukocyte esterase = Negative Nitrite = ++++ Protein = Negative 24-h protein collection = 8.3 g/24 h Biopsy of kidney would most likely reveal what findings?

*Glomerulosclerosis in some glomeruli with other glomeruli appearing normal* Focal segmental glomerulosclerosis (FSGS) - most common cause of primary nephrotic syndrome in adults in US - can be secondary to: HIV, morbid obesity, reflux nephropathy, heroin use - 5 subtypes - collapsing variant = associated with HIV & heroin use - relatively resistant to treatment - tends to slowly progress to end-stage renal dz

A 58-year-old woman is evaluated for a 3-month history of a nonproductive cough and hoarseness and a 3-week history of worsening shortness of breath. She is otherwise well and takes no medications. On physical examination, temperature is 37.7°C (99.8°F), blood pressure is 160/105 mm Hg, pulse rate is 100/min, and respiration rate is 18/min. Oral mucous membranes are normal. There is scattered lymphadenopathy and mild tenderness to palpation over the anterior aspect of the neck. Diffuse crackles are auscultated. The remainder of the examination is unremarkable. Laboratory studies are significant for a hematocrit of 32% and serum creatinine level ofl.6 mg/dL (141.4 µmol/L). A urinalysis shows 2+ protein, 10-15 erythrocytes/high-power field (hpf), 0-5 leukocytes/hpf, and erythrocyte casts. A chest radiograph reveals right upper and lower lobe pulmonary infiltrates with several cavitary lesions. Which of the following is the most likely diagnosis?

*Granulomatosis with polyangiitis* / Wegender granulomatosis - systemic necrotizing vasculitis - affects upper & lower respiratory tract & kidneys - >70% of patients have upper airway manifestations such as sinusitis - pauci-immune glomerulonephritis in 80% of patients - glomerulonephritis often preceded by respiratory tract manifestations

65 yo male who underwent recent PCI 2 weeks ago, presents with chest pain was started on heparin. Admission plt count was 200K, after 2 days of heparin plt count now 75K.

*HIT* - prior heparin exposure - platelet decrease by 50% - stop heparin - need alternative anticoagulation

35 yo HIV-positive man brought to clinic by partner bc of 6 mo ho progressive memory loss & incontinence. He is taking zidovudine & protease inhibitor. He first noticed difficulties with handwriting. Neuro exam demonstrates deficits in cognitive & fine motor control functions. Lab investigations shows CD4 cell count of 25/mm^3. MRI studies reveal moderate brain atrophy but no focal lesions. Lumbar puncture shows no CSF abnormalities. Most likely diagnosis?

*HIV encephalitis* / AIDS dementia complex - most common - subacute inflammatory infiltration of brain --> direct spread of HIV to CNS - presence of HIV genome can be demonstrated by in situ hybridization in microglia & histiocytes - cognitive impairment + incontinence + impairment of motor skills + confusion

39 yo woman evaluated bc of 1 wk ho painless, blurred vision in right eye. Her only other visual symptoms has been an increased number of floaters in right eye for last 3 months. She reports no discomfort, photophobia, pain with reading, trauma, or recent illness. She has ho IV drug use 9 years ago. She has no other med problems & takes no meds. On physical exam, tem pis 98.2 F. Rest of vital signs are normal. There is no conjunctival injection. Pupils react to light & accommodation. Visual acuity in right eye is 20/30 & in left eye is 20/20. Funduscopic eval shows fluffy yellow retinal lesions with some associated hemorrhage, consistent with CMV retinitis. What is the most likely underlying dz?

*HIV infection* CMV retinitis associated with HIV infection - end-organ dz caused by CMV in pts with HIV infection with CD4 count less than 50/uL - CMV infection in those infected with HIV usually involves eye or GI tract - pts may be asymptomatic or present with floaters, scotomata, or peripheral visual field defects - if macula or optic nerve is involved, pts present with decreased visual acuity - characteristic funduscopic appearance = fluffy yellow-white retinal lesions, with or without intraretinal hemorrhage - treatment = ganciclovir, foscarnet, valganciclovir, depending on location & severity of dz

44 yo man with 2 yr ho rash on his scalp, face, & chest comes for follow-up exam; rash has persisted despite treatment with topical ketoconazole, topical corticosteroids, & crude coal-tar shampoo. Rash is no painful, but has been itchy on occasion. Current meds include topical triamcinolone cream. He is veteran who fought in Gulf War. He has smoked one pack of cigz daily for 25 yrs. Exam shows erythema with waxy scale on scalp, ears, midface, & central chest. What factors is most likely to explain treatment resistance of this pt's dz?

*HIV seropositivity* Seborrheic dermatitis - affects scalp, ears, preauricular face, central face, & central chest - typical eruption = faint erythema, oily skin, waxy scale - via colonization by pityrosporum ovale --> attacked by immune system - treatments = topical antifungals (ketoconazole), topical anti-inflammatories (corticosteroids) - crude coal-tar shampoo effective, but mechanism of action unclear - associated with Parkinson dz, HIV infection, epilepsy, cetrain drugs - if resistant to treatment, testing for HIV seropositivity should be considered, bc seborrheic dermatitis in this pop = generally difficult to treat

24 yo man comes to office for follow-up visit after completing 6 mo course of treatment for active TB that he acquired while traveling. He currently feels well, & has no specific complaints today. Pt's past med history includes new & difficult-to-treat case of seborrheic dermatitis & recent episode of herpes zoster. Other than these conditions, pt states he has no chronic medical conditions. Today, vitals & physical exam are unremarkable, with exception of skin findings consistent with seborrheic dermatitis. Pt is concerned, however, about chances of getting recurrent case of TB. Appropriate test to offer?

*HIV testing* Active TB in immunocompetent = rare

Secondary causes of nephrotic syndrome

*HIV* & hepatitis C DM (most common) Malignancies (lymphoma, GI cancer) Syphilis Chronic NSAIDs

55 yo man with gradual onset of fatigue now complaining of feeling of pressure & fullness on left side of his abdomen. His doc finds that his spleen is 6 cm below left costal margin & firm. In addition, liver edge palpable below right costal margin; there is no adenopathy. CBC has hct of 27% & WBC of 3,800/uL w/ 2,200 neutrophils/uL & 50 monocytes/uL. Lymphocyte count normal. Platelets 60,000/uL. Bone-marrow aspirate inaspirable & subsequent marrow biopsy shows cells that express CD11c & CD22 antigens on immunophenotyping Most likely diagnosis?

*Hairy cell leukemia* - CD11c positive cells - bone marrow aspirate dry = dry tap - cancer of B lymphocytes - middle aged men mostly - gradual onset of fatigue - symptoms related to enlarged spleen or bc of infection - no adenopathy - anemia will always be present - majority of pts = neutropenia, thrombocytopenia - almost all pts have low monocyte count - particular to illness

38 yo man comes to doc bc of restlessness & involuntary jerking movements of his arms for 8 mos. He has also had diffulty remembering things, particularly recent events. He has hx of HT & T1DM. Current meds include lisinopril, HCTZ, & insulin. His bro has similar jerking movements of his arm. BP is 130/84 mmHg & pulse is 76/min. Exam shows choreiform movements of both UEs. He is unable to remember what he ate for breakfast. His hemoglobin A1c is 7.2%. Most appropriate pharmacotherapy for this pt's involuntary movements?

*Haloperidol* - dopamine blocking & depleting agents effective in decreasing involuntary movements - dopamine receptor blocker - commonly used for control of chorea in HD Huntington Dz - AD - via CAG expansion of huntingtin gene on chr 4 - atrophy of caudate nucleus - choreiform / involuntary jerky movements & progressive dementia - other neuroleptics, such as olanzapine, risperidone, aripiprazole = also effective in treating chorea symptoms of HD

68 yo man comes to doc bc of progressive dyspnea over past yr. He states that he has difficulty with exercise. He must sleep on two to three pillows at night, & he has noticed swelling in his ft. He denies chest pain. He occasionally has dry cough but has not had fevers. He has ho heart murmur. Physical exam shows mild jugular venous distention. Crackles heard on auscultation of chest that don't clear with coughing at bilateral lung bases. 3/6 holosystolic murmur best heard at apex that radiates to left axilla. Abdomen slightly distended with positive fluid wave. Mild hepatomegaly also seen. There is 2+ pitting edema, with palpable pulses & no cyanosis. ECG ordered. What will most likely augment this pt's cardiac murmur?

*Hand-grip* Mild regurgitation - reverse blood flow from LV during systole into LA - chronic = dilatation of LA & elevated LA pressures - pulmonary venous congestion & pulmonary edema result - elevated left-sided pressures can eventually causes pulmonary arterial hypertension - management = observational or med if pt is asymptomatic with preserved EF - If EF begins to decrease, or if symptoms occur, surgical repair advised - any maneuver that increases afterload (hand-grip) = favorable pressure gradient for regurgitation = increases murmur

EMS is transporting a patient with a positive prehospital stroke assessment. Upon arrival in the ED, the initial BP is 138/78 mmHg, pulse rate is 80/min, respiratory rate is 12 breaths/min, & pulse oximetry reading is 95% on room air. Lead II ECG displays sinus rhythm. Blood glucose is within normal limits. What intervention should you perform next?

*Head CT scan*

Traditional treatment of perforated viscus

*immediate surgical laparotomy* - prevents further contamination of peritoneum by gastric acid or feces - should also receive IV fluids, broad-spectrum antibiotics, nasogastric tube Perforate gastric or duodenal ulcer - sudden onset of severe abdominal pain that may be generalized - may radiate to back or shoulders - ofter there is ho peptic ulcer dz - free air under diaphragm seen on upright abdominal radiograph

A 78-year-old man was admitted to the hospital 4 days ago because of dyspnea. He has a history of heart failure. On physical examination at admission, he was afebrile, blood pressure was 150/88 mm Hg, pulse rate was 108/min, and respiration rate was 22/min. Jugular venous distention was present, there were bibasilar crackles and dullness to percussion at both lung bases, and there was 2+ lower extremity edema. Chest radiograph showed cardiomegaly, vascular congestion, and moderate bilateral pleural effusions. He was treated with furosemide but continued to have shortness ofbreath. Thoracentesis was performed on hospital day 3 for further relief of dyspnea. Pleural fluid analysis shows a pleural fluid-serum lactate dehydrogenase (LDH) ratio of .52, a pleural fluid LDH level of 46% of the upper limit of the normal level, and a pleural fluid-serum total protein ratio of0.45. Results of pleural fluid cultures and cytology are pending. Which of the following is the most likely cause of this patient's pleural effusions?

*Heart failure* Pleural effusion via HF - presents with decompensated HF - transudate = pleural fluid-serum LDH ratio of less than 0.6; pleural fluid LDH less than 2/3 of upper limit of normal level, & pleural fluid-serum total protein ratio of less than 0.5

58 yo Asian man who is followed for chronic stable hepatitis caused by HCV infection presents with RUQ pain & an acute increase in abdominal size. Abdominal exam reveals diffuse tenderness that is worst at RUQ. Notable fluid wave on exam of abdomen. Paracentesis reveals blood-tinged fluid, & lab exam is significantly elevated alpha-fetoprotein of 435 ng/mL. Potential risk factors for condition affecting this pt?

*Hemochromatosis & nonalcoholic fatty liver dz* HCC - 4th leading worldwide cause of cancer-related death - risk factors = any condition that causes chronic inflammation of liver (chronic viral hepatitis infections (hepatitis B or C), alcoholic cirrhosis, nonalcoholic fatty liver dz, hemochromatosis, Wilson dz, alpha-1 antitrypsin dz, aflatoxin exposure) - AFP typically higher than 400 ng/mL

A 65-year-old man is evaluated in the hospital after undergoing emergent sigmoid colectomy for a perforated diverticulum. Medical history is significant for stage 4 chronic kidney disease due to autosomal dominant polycystic kidney disease. He also has hypertension treated with amlodipine. On physical examination, temperature is normal, blood pressure is 150/95 mm Hg, pulse rate is 102/min, and respiration rate is 18/min. Abdominal examination reveals a clean and dry surgical incision. Postoperative urine output decreases to 50 mL over 8 hours and does not improve following a fluid challenge. Lab studies: Serum creatinine: Current = 6.4 mg/dL (566 umol/L) On admission = 5.4 mg/dL (477 umol/L) Serum potassium: Current = 6.9 mEq/L (6.9 mmol/L) On admission = 4.8 mEq/L (4.8 mmol/L) Electrocardiogram shows tall, symmetric, peaked T waves & a shortened QT interval. IV calcium, insulin, & dextrose given. What is the most appropriate next step in treatment?

*Hemodialysis* - in addition IV calcium, insulin, & dextrose, hemodialysis is appropriate for patient who has significant hyperkalemia with evidence of cardiac conduction abnormalities - hyperkalemia = serum K+ > 5 mEq/L (5 mmol/L) - IV calcium & insulin-dextrose = temporizing meausres to decrease arrythymogenic effect of excessive potassium on myocardium - definitive therapy = potassium removal - presence of concurrent AKI & recent surgery in patient favors use of hemodialysis

45 yo man with ho diabetes mellitus & peripheral vascular disease (PVD) comes to doc bc of increasing pain in his calves when walking. He has had no chest pain or SOB. Current meds include insulin. He has no allergies to meds. His BP is 144/92 mmHg & pulse is 80/min. His low density lipoprotein cholesterol level is 138 mg/dL. The ankle-brachial index (ABI) is 0.5 on left & 0.6 on right. Most appropriate next step in management?

*Hemoglobin A1c levels* PVD = known complication of longstanding diabetes - treatment = intensive risk reduction with glycemic, lipid, & blood pressure control - progressive PVD should be assessed using ABI & angiography

9 yo boy brought to his mom by doc's office bc he complains of feeling tired for last 2 days. He had diarrheal episode 3 days ago. His mom also notes that he has been passing less urine for last few hours, even though he was drinking fluids. Mother reports that he has received all vaccines appropriate for his age. On physical exam, he appears pale, with sunken eyes & dry oral mucosa. Pulse is 120/min, respiratory rate is 16/min, temp is 37.8 C (100 F), & BP is 90/55 mmHg. Lungs clear to auscultation. Cardiovascular exam significant for sinus tachycardia. Abdominal exam shows diffuse tenderness with no guarding or rigidity. Extremities show no pitting edema. Lab workup shows: Hgb = 8.4 g/dL WBC = 6000/mm^3 Platelets = 50,000/mm^3 Sodium = 136 mEq/L K+ = 4.7 mEq/L Chloride = 111 mEq/L Bicarbonate = 17 mEq/L BUN = 30 mg/dL Creatinine = 2.1 mg/dL Glucose = 80 mg/dL Calcium = 9.2 mg/dL LDH = 1,200 U/L (normal: 45-90 U/L) PT = Normal aPTT = Normal Urinalysis reveals plenty of RBCs. Most likely diagnosis?

*Hemolytic uremic syndrome* (HUS) prodrome of diarrhea followed by triad of: - thrombocytopenia - MAHA: weakness, decreased Hb, elevated LDH - acute renal failure: BUN/creatinine ratio <15:1 (renal azotemia) - *decreasing urine volume in adequately hydrated child with diarrhea --> consider new-onset renal injury, particularly due to HUS* - manifestations of CNS inv't = 20% = seizures, coma, stroke, hemiparesis, cortical blindness

63 yo woman arrives in doc's office complaining of profuse, watery diarrhea. She has had this symptoms for past several weeks, & despite using loperamide & changing diet, diarrhea has persisted. She denies travel or camping trips. Even when she does not eat, diarrhea is present. Additionally, she complains of sporadic facial flushing. Her past med history only notable for HT, for which she has been taking HCTZ for many years now. On physical exam, she appears dehydrated & her skin has poor turgor. Other than dry mucous membranes, her exam is unremarkable. She is sent for small bowel follow-through barium exam that demonstrates non-obstructive filling defect in her distal jejunum, which on a CT-scan represents tumor protruding into bowel lumen. Given her history, what most likely coexists with her small bowel tumor?

*Hepatic metastasis* Carcinoid tuor - most frequently arises in small bowel/ileum - carcinoid syndrom eoccurs in hepatic or extrahepatic mets that drain into systemic circulation

19 yo man presents to ED after being shot in abdomen. He is hemodynamically unstable. During emergent exploratory laparotomy, more than 2 L of blood are found in abdomen on entry. All 4 quadrants are packed. When packing is removed, blood is noted to be coming from RUQ. Pringle maneuver is used, but blood continues to flow into field & pt remains hypotensive. What anatomic structure is likely injured?

*Hepatic veins* - drains IVC Pringle maneuver - clamps portal triad in hepatoduodenal ligament intermittently with atraumatic clamp --> controls inflow to liver from hepatic arteries & portal vein, & common bile duct - has no effect on liver's outflow

44 yo woman comes to ED 8 hrs after sudden onset of severe, progressive abdominal pain that radiates to back. Before pain started, she ate lunch at fast-food restaurant. She has had 2 similar episodes, 2 mos ago & during her last pregnancy 3 yrs ago, respectively. Her temp is 100.5 F. Abdominal exam shows RUQ tenderness & cessation of inspiration with deep palpation. Rectal exam shows brown stool that is negative for occult blood. Her leukocyte count is 12,900/mm^3 & her hct is 39%. Total bilirubin is 2.1 mg/dL. RUQ US is ordered, but is read as "poor imaging quality, unable to confirm or reject any diagnosis." Next most appropriate next step in management?

*Hepatobiliary imino-diacetic acid (HIDA) scan* = noninvasive nuclear medicine test that will reveal obstruction of cystic duct Acute cholecystitis - symptoms = fever, RUQ pain, positive Murphy sign (cessation of inspiration w/ deep palpation) - episodes she had 2 mos ago + during pregnancy = biliary colic - US = first-line diagnosis --> shows cholelithiasis, gallbladder inflammation - *if US findings equivocal, HIDA scan performed*

3 wk old boy brought to doc bc of 1 wk ho forceful vomiting. He has been vomiting after almost every feeding. Vomitus contains mostly undigested formula & is nonbilious. Exam shows dry oral mucosa, depressed anterior fontanelle, & capillary refill of 3-4 seconds. Abdominal exam shows 2-cm mass in epigastrium. Remainder of exam is unremarkable. What electrolyte findings will most likely be seen? - pH? - PCO2? - PO2? - bicarb? - chloride?

*High pH, high PCO2, low PO2, high bicarbonate, low chloride* Pyloric stenosis - male mostly - greater in full term infants than preterm infants - projectile nonbilious vomiting shortly after feeding + olive-sized mass palpable in epigastrium - symptoms appear in 2-3rd week of life - as vomiting continues, hydrogen ions & chloride ions begin to decrease in body --> hypochlroemic metabolic alkalosis - infant may also be hypokalemic from repeated vomiting - definite treatment = pyloromyotomy

12 mo old boy brought to ED by his mom bc of bilious vomiting & abdominal distention for past 10 hours. HIs mom states that the infant has been constipated since birth and failed to pass meconium during first 48 hrs of life. She also reports that he often has brown, speckled vomitus. He appears very irritable. His height & weight are both below fifth percentile according to his age. Exam shows moderately distended abdomen. After digital rectal exam, fair amount of stool ejects from anus. There is no stool in ampulla. Most likely diagnosis?

*Hirschsprung disease* / Congenital aganglionic bowel dz - more common in boys - state of chronic contraction - usually limited to rectosigmoid colon - bilious or feculent vomiting + abdominal distention + constipation - might also be hx of failure to pass meconium in first 48 hrs of life

55 yo man presents to doc complaining of mid chest pain. He also had difficulty swallowing solid foods. On further questioning, he has noticed a 10-lb weight loss over past several months. His med history is not well known, bc he has not seen a doc for many years. He does not take any meds. He denies ingestion of excess alcohol. He deos not have a significant smoking history. On physical exam, he is thin-appearing & in no acute distress. His temp is 36.8 C (98.6 F) & BP 125/80 mmHg. Head, neck, & oral exams are normal. Cardiovascular & chest exams are also normal. His abdomen is soft & nontender, & his peripheral exam is also normal. Electrocardiography is normal. He is scheduled for an esophagram, which demonstrates an irregular lesion in his upper to mid esophagus with hanging edges & luminal narrowing that fails to open with peristaltic waves. CT scan of chest demonstrates circumferential mass severely narrowing esophagus. What would explain why this pt developed this lesion?

*History of lye ingestion* = stricture formation Esophageal cancer - 10-lb weight loss & dysphagia for solid foods - imaging = irregular mass compressing lumen of esophagus - mid to upper esophagus populated b squamous epithelium - risk factors = smoking & alcohol, achalasia, another head/neck cancer, *ho lye ingestion*

A 19-year-old female college student presents to your clinic with complaints of a 10-lb unintentional weight loss, intermittent fevers, dry cough, and dyspnea on exertion. She is no longer able to run or jog because of shortness of breath and fatigue. Her symptoms began 6 months ago but have worsened over the past 3 months. On physical examination, her vital signs are normal. She has fullness in the supraclavicular regions and palpable, nontender lymphadenopathy in the bilateral low cervical lymph nodes chains. The rest of her examination findings are unremarkable. Laboratory studies are significant for a leukocyte count of 9500/µL with a normal differential, a hemoglobin level oflO g/dL with a mean corpuscular volume of 85 fL, and a platelet count of 173,800/µL. A left cervical lymph node excisional biopsy shows scattered, very large cells with abundant pale cytoplasm and two or more oval lobulated nuclei containing large nucleoli, with a surrounding mixture of inflammatory cells and bands of fibrosis. Which of the following is the most likely diagnosis?

*Hodgkin lymphoma* = B cell-derived malignancy - malignant cell of origin = Reed-Sternberg cell - weight loss, fever, night sweats = B symptoms - cough & dyspnea = anterior mediastinal mass

Daniel Radcliffe has widely met squamous cell lung cancer with stability of dz on his most recent CT scan after receiving whole brain radiation & then 6 cycles of Taxol/Carboplatin. He sleeps 15 hours/day, has dyspnea with 20 feet of exertion, & has numbness of his fingers & toes. Best at this time?

*Home hospice* - for patients who have ECOG performance status worse than 2 & who have a met cancer that is not highly chemo- or radiosensitive

10 mo old boy brought to clinic by his mother bc of 1 day ho red rash that developed suddenly on the chest & spread to the arms & face last night through this morning. For the past 4 days, the child had a fever up to 104 F, which resolved 1 days ago. His temp is 100 F. Exam shows diffuse, erythematous macular rash on the trunk, face, & limbs. There are no pustules or excoriations. Most likely cause of this child's condition?

*Human herpesvirus 6* - cause of roseola infantum (exanthem subitum, sixith dz) - almost all children infected in first 2 yrs of life - peak at 6-9 mos of age - exists in state of viral latency in monocytes & macrophages throughout life after primary infeciton - first finding = abrupt high fever that lasts 1-3 days --> either decreases gradually or abruptly - faint, pinkish macular rash on trunk that spreads to face & extremities = nonpruritic = lasts 1-3 days - can include variety of upper resp & GI symptoms & irritability - febrile seizures = most common complications

58 yo man with hx of type 1 DM & alcoholism brought to ED bc of SOB & productive cough. He denies chest pain. He has smoked 2 packs of cigarettes daily for past 30 years and he drinks 40 units of alcohol a week. Physical exam shows no chest wall tenderness, & rales are heard on auscultation of chest. There are no murmur or rubs. ECG shows sinus rhythm with no ST_segment depression or elevation. Treatment with IV furosemide, sublingual glyceryl trinitrate, & morphine is begun, but he does not improve. IV dobutamine started, & 10 minutes later, his condition remains unchanged. His BP is 126/79 mmHg. Best next step in pt care?

*Hydralazine* - SM relaxant - works on arteries & arterioles - also reduces afterload --> increases cardiac output - *second-line drug in acute pulmonary edema after use of dobutamine* Acute pulmonary edema - secondary to left ventricular systolic dysfunction - doesn't improve with IV furosemide, nitrates, morphine (all decrease preload) - nor does he improve with dobutamine (positive inotrope - decreases afterload to increase cardiac output) - pts who don't respond to any drugs & have adequate BP can be administered hydralazine

A 71-year-old woman is hospitalized for chest pain. She has type 2 diabetes mellitus, hypertension, hyperlipidemia, and chronic kidney disease. Medications are lisinopril, rosuvastatin, furosemide, carvedilol, insulin, and aspirin. On physical examination, temperature is normal, blood pressure is 118/50 mm Hg, pulse rate is 70/min, and respiration rate is 14/min. Cardiopulmonary and abdominal examinations are normal. There is trace edema of the lower extremities, which is a baseline finding in this patient. Lab studies: Serum creatinine = 2.1 mg/dL (186 umol/L) Electrolytes = Normal Estimated GFR = 19 mL/min/1.73 m^2 Adenosine thallium scan reveals an area of reversible ischemia in the left anterior descending coronary artery distribution. Cardiac catheterization is scheduled. Lisinopril is stopped prior to the procedure. Which of the following interventions will decrease this patient's risk for contrast-induced nephropathy?

*Hydration with intravenous isotonic saline* - indicated to decrease patient's risk for contrast-induced nephropathy (CIN) associated with scheduled cardiac cath - in patients who require contrast studies, use of low osmolar contrast agents & hydration to promote urine flow & avoid volume contraction has been shown to decrease risk for CIN

82 yo woman evaluated in ED for 1 day ho nausea & vomiting. She was discharged from hospital 4 wks ago after exacerbation of COPD & completed glucocorticoid taper 1 wk ago. Pt has had several exacerbations of COPD over past yr requiring similar treatment. Med history otherwise unremarkable, & her only meds are tiotropium & albuterol by metered-dose inhaler. On physical exam, mental status normal. Temp 96.1 F, BP 97/75 mmHg, pulse rate 120/min, & respiration rate 12/min. Oxygen saturation 92% (ambient air). Mucous membranes are dry. Decreased breath sounds & scattered wheezes present. Abdomen diffusely tender without guarding or rebound. Extremities warm & dry. Remainder of exam unremarkable. Lab studies: Random glucose 87 mg/dL (4.8 mmol/L) Sodium 126 mEq/L (126 mmol/L) Potassium 3.9 mEq/L (3.9 mmol/L) Urinalysis >50 leukocytes/high-power field; positive leukocyte esterase She is treated with 1.5 L of 0.9% saline IV & started on empiric broad-spectrum antibiotics. One hour later, her BP is 79/50 mmHg pulse rate is 110/min, & plasma glucose level is 67 mg/dL (3.7 mmol/L). Most appropriate next step in treatment?

*Hydrocortisone intravenous bolus* Secondary adrenal insufficiency management - via decreased ACTH release - often caused by prolonged admin of exogenous glucocorticoids that suppress ACTH release & lead to decreased adrenal gland production of cortisol --> nausea, vomiting, abdominal pain - lab studies = hyponatremia w/ or w/out hypokalemia, infection (UTI)

32 yo woman, gravida 2, para 2 at 33 weeks' gestation is brought to labor and delivery after she began to have generalized jerking movements of extremities & became unresponsive 10 minutes ago. She has been in hospital for last 2 mos on antepartum service with severe preeclampsia on strict hospital bed rest. She is receiving only prenatal vitamin. Her temp is 99 F, BP 145/95 mmHg, pulse 78/min, & respirations 13/min. Recurrent seizure prophylaxis initiated and induction of labor begun. Nurse returns to check on pt 4 hrs later to find pt minimally responsive. BP is 90/50 mmHg, pulse 55/min, & respirations 6/min. Physical exam shows skin to be warm, pink & diaphoretic. Pt emergently intubated by anesthesia team bc of resp failure. What is the most likely cause of this pt's resp failure?

*Hypermagnesemia* Magnesium sulfate = commonly used obstetrics drug that should be used cautiously - acts by blocking neuromuscular transmission mediated by acetylcholine at end plate --> neuronal inhibition controls ongoing seizures & is superior to other forms of therapy (diazepam, phenytoin) for seizure control in eclamptic pts - also suppresses central nervous system --> hyporeflexia = sign of high serum concentrations - normal serum magnesium conc = 1.5 - 2 mg/dL - as magnesium level increases to >4 mg/dL, hyporeflexia occurs - as magnesium approaches 10 mg/dL, respiratory paralysis & death may ensue; heart block may also be observed

thermophilic actinomycetes associated with

*Hypersensitivity Pneumonitis* - moldyhay - restrictive lung pattern - treatment = avoid antigen exposure, steroids for acute symptoms

6 yo boy brought to office bc of fever of 3 days' duration. He has no significant past med hx & is on no med. His younger brother has had similar upper resp symptoms prior week & paretns just want to make sure that nothing serious is going on. On physical exam, pt is in mild distress with temp of 102.2 F & RR of 26/min. His pulse is 110/min. Pharyngeal mucosa is edematous & erythematous & there is clear nasopharyngeal mucous exudate. There is soft, vibratory systolic heart murmur grade 2/6, best heard at left lower sternal border. Murmur was not present at least routine physical exam. Most likely diagnosis?

*Innocent heart murmur* - mostly heard bt 3 & 7 yo - most than 30% of children - never diastolic - soft vibratory or musical systolic ejection murmur best heard at left lower to midsternal border - never greater than 2/6 in intensity

61 yo man brought to ED bc of 6 hour ho burning abdominal pain that radiates to his back. He had nausea exacerbated by eating or drinking. He denies vomiting, diarrhea, constipation, or blood in his stools. He has ho type 2 DM, HT, hypercholesterolemia, hypertriglyceridemia, peptic ulcer dz, & gout. He underwent below-the-left-knee amputation bc of diabetic foot ulcer 2 years ago & a vagotomy & antrectomy (Billroth I procedure) 10 years ago. His BP is 198/110 mmHg & pulse 110/min. Abdominal exam shows diffuse tenderness with no rebound or guarding. Lab studies show: Blood alcohol undetectable Serum amylase 100 U/L Serum lipase 110 U/L Serum glucose 291 mg/dL Urine amphetamines positive The blood sample is cloudy & straw colored. Ultrasound shows diffusely enlarged, hypoechoic pancreas; gallbladder is normal-appearing, & a sonographic Murphy sign is negative. What is the most likely underlying cause of this patient's condition?

*Hypertriglyceridemia* - seen in AD familial conditions or in poorly controlled diabetes --> can cause acute pancreatitis - triglyceride level > 1,000 mg/dL - must be >500 mg/dL to consider diagnosis of triglyceride-induced acute pancreatitis - most common cause of hypertriglyceridemia-induced acute pancreatitis in patients older than 12 yo = DM (type 1 & 2) - can alter measurement of sodium, amylase, & LDL cholesterol

A 72-year-old woman is evaluated in the emergency department for increasing dyspnea on exertion, orthopnea, and bilateral lower extremity swelling over the last week. She has a history of systolic heart failure for which she takes lisinopril, metoprolol, and furosemide. On physical examination, temperature is normal, blood pressure is 100/ 50 mm Hg, pulse rate is 104/min, and respiration rate is 26/min Oxygen saturation is 92% (on 100% oxygen by non-rebreather mask). She has marked jugular venous distention while sitting upright. Cardiopulmonary examination shows a summation gallop and bibasilar crackles. There is 3+ pitting edema of the lower extremities. Lab studies: Serum creatinine = 1.2 mg/dL (106 umol/L) BUN = 25 mg/dL (8.9 mmol/L) Elecrolytes Sodium = 122 mEq/L (122 mmol/L) Potassium = 4.4 mEq/L (4.4 mmol/L) Chloride = 22 mEq/L (22 mmol/L) Glucose, random plasma 110 mg/dL (6.4 mmol/L) Spot urine sodium = 10 mEq/L (10 mmol/L) Urine osmolality = 475 mOsm/kg H2O What best characterizes this patient's hyponatremia?

*Hypo-osmolol hyponatremia with decreased effective arterial blood volume* - hyponatremia most commonly marker of hypo-osmolality - diagnosed by either directly measuring or calculating serum osmolality - most common form of hyponatremia - may occur in patients with normal, increased, or decreased ECF volumes - patient's heart failure, high urine osmolality in relation to her serum osmolality, & spot urine sodium level less than 20 mEq/L (20 mmol/L) consistent with prerenal state due to decreased effective arterial blood volume - decreased effective arterial blood volume consequence of poor cardiac output in setting of decompensated heart failure - serum osmolality = 2[Na+] + ([BUN]/2.8) + [glucose]/18 - this patient: serum osmolality = 259 mOsm/kg = hypo-osmolol hyponatremia

67 yo woman comes to doc bc of pain with urination & frequent urination. She has HT for which she takes beta-blockers, but no other medical problems. She states that she is not sexually active. She does not smoke & drinks cranberry juice daily. Her temp is 98.6 F, BP is 134/84 mmHg, pulse is 84/min, & respirations are 12/min. Physical exam shows mild suprapubic tenderness & genital atrophy but is otherwise unremarkable. Urinalysis shows 50 to 100 leukocytes/high-power field (hpf) & 5-10 erythrocytes/hpf. Most likely cause of the infection?

*Hypoestrogenism* - postmen women not receiving ERT at greater risk for developing UTI vs. women not receiving ERT UTI - 2 major risk factors for uncomplicated UTI = sexual intercourse & hypoestrogenism

In what situations does bradycardia require treatment?

*Hypotension* Acutely altered mental status Signs of shock Ischemic chest discomfort Acute heart failure

33 yo woman comes to doc bc of palpitations, restlesness, sweating, weight loss, & tremor for 3 wks. She does not drink caffeinated beverages or alcohol, & she doesn't smoke cigz. Her temp is 98.6 F, BP 130/80 mmHg, & pulse 90/min. Exam shows fine tremor & pretibial myxedema. Thyroid gland diffusely enlarged, asymmetric, & lobular. Bruit present over gland. Her TSH level is 0.1 mU/L & T4 level is 25 mcg/dL. There is increased radioactive iodine uptake. Pt undergoes radioactive iodine therapy. Pt is at greatest risk for what conditions?

*Hypothyroidism* - radioactive iodine therapy safe & effective treatment for Graves dz - goal of radioiodine therapy = destruction of gland = irreversible hypothyroidism in most cases - less complications of radioactive iodine therapy = Graves ophthalmopathy & radiation thyroiditis

33 yo woman comes to ER for LE weakness. She recovered from GI infection 5 days ago. Yesterday, she began to develop paresthesias in hands & feet. Over next few hours, her legs & arms began to feel week, & she had difficulty standing & lifting objects. She denies any vision loss, hemiparesis, facial droop, & dizziness. Her past med hx is unremarkable, & she does not take any meds. She does not use tobacco, alcohol, or illicit substances. She works as a lawyer in a local firm. On physical exam, her BP is 131/72 mmHg, pulse 79/min, & oxygen sat is 96% on room air. Neuro exam demonstrates bilaterally decreased reflexes, normal Babinski response, & 2/5 peripheral muscle strength. Her sensation is intact. Pulmonary, CV, and abdominal exams are normal. CT of brain is unremarkable. Over next few hours she becomes progressively obtunded, & her oxygen sat falls to 75% on room air. She is intubated & sent to ICU. Most likely explanation for her hypoxemia?

*Hypoventilation* Guillain-Barre syndrome - ascending paralysis that may involve muscles of respiration - resp muscles paralyzed --> no ventilation - no A-a gradient bc alveolar oxygen with be low as well as arterial oxygen - hypoxemia will be corrected with supplemental oxygen

56 to man with long ho smoking & diagnosis of COPD comes to office with increasing SOB with exertion. He denies any fevers or increased sputum production. He denies recent travel. His temp is 37 C (98.6 F), BP 142/88 mmHg, HR 97/min, & resp rate 19/min. Nexk exam reveal distended internal jugular vein. Cardiac exam reveals right ventricular heave & prominent P2. 2/6 holosystolic murmur heard at left lower sternal border. Pulmonary exam reveals prolonged expiratory phase. Abdomen distended with fluid wave, & his peripheral exam notable for 2+ pitting edema in shins. Chest radiograph shows hyperexpansion & enlarged pulmonary arteries with no areas of consolidation or edema. CBC shows WBC 5,400/mm^3, Hct 48%, platelets 254,000/mm^3. Most likely pathophysiology underlying patient's constellation of symptoms?

*Hypoxic vasoconstriction* Right sided HF due to pulmonary HT - elevated jugular venous pressures - ascites - dyspnea - peripheral edema - COPD --> chronic ventilation-perfusion mismatch --> hypoxic vasoconstriction & pulmonary HT *Lung = unique = hypoxia --> hypoxic vasoconstriction*

75 yo man brought to ED by his daughter bc of progressive fever, confusion, & insomnia for 3 days. Recently he has become combative & has reported unusual smells. He has ho HT treated w/ HCTZ & lisinopril. Prior to 3 days ago, he frequently participated in his local bridge club & had no difficulty w/ memory. He appears disoriented & mildly combative. His temp is 101.4 F, BP is 118/72 mmHg, pulse 98/min, & RR 17/min. Oxygen sat is 96% on room air. Head & neck exam shows no abnormalities. Lungs are clear to auscultation. Cardiac exam shows normal S1 & S2; no murmurs heard. Neuro exam shows difficulty following commands. CT scan of brain shows no abnormalities. Lumbar puncture performed & CSF analysis shown: WBC (tube 4) 100/min^3, 68% lymphocytes RBC 200/mm^3 Glucose 40 mg/dL Protein 38 mg/dL Most appropriate next step in management?

*IV acyclovir* Herpes encephalitis - treat immediately with IV acyclovir - high index of clinical suspicion require bc undetected herpes encephalitis is uniformly fatal - reactivation of HSV-1 - temporal lobes --> hemorrhage & swelling - confusion & disorientation - oflactory hallucinations - presence of blood in CSF in absence of traumatic tap should increase suspicion - gold standard for diagnosis = PCR of CSF

9 yo child brought to ED by his grams bc he suddenly developed fever with shallow breathing, vomiting, & mental confusion. She is beside herself bc child has come to visit her over holidays & had been perfectly well before that. He has never had any probz with his health except for skin condition present from birth that she describes as "alligator skin." When asked if she had given child any unusual med or remedy she admits to having applied homemade past to his skin which was supposed to get rid of heavy scale. She states that there have been several affected fam members in previous genz & this remedy has been used to treat them without ever having caused probz. She also insists that it could not have been cause of any illness bc it was really just a bunch of aspirin tablets curhsed & mixed with petrolatum. His temp is 102 F, pulse 12/min, & respirations 35/min. He has vomited twice while in ED & appears to be dehydrated & lethargic. Blood glucose is 45 mg/dL & serum pH is 6.9. Most appropriate next step in management?

*IV bicarbonate* - to enhance excretion of salicyclate - IV route - raise urine pH to 7-7.5 Salicylate intoxication - should never be used in children bc surface-to-volume ratio is very large & even relatively small amount absorbed via large surface area will = significant systemic levels - if salicylate level >100 = hemodialysis indicated

31 yo man with T1DM brouht to ED by his brother bc of strange behavior, nausea, vomiting. Brother reports that the pt recently lost his job. He appears somnolent. His temp is 99.3 F, BP 92/56 mmHg, pulse 118/min, & respirations 34/min. Exam shows dry oral mucosa & decreased skin turgor. There is mild abdominal tenderness. Lab studies are shown: Na+ 134 mEq/L Cl 103 mEq/L K 4 mEq/L HCO3- 8 mEq/L Glucose 855 mg/dL Most appropriate next step in management?

*IV fluids* DKA - nausea, vomiting, abdominal pain, extremely high glucose, anion gap met acidosis - emergency that should be treated with IV fluids, followed by IV insulin drip - real life = both could be started simultanesouly with 2 sep IV lines - K should be added in IV insulin drip when pt's potassium levels are inappropriately in normal to low range - normal anion gap = 10-14 - resp rate = hyperventilation = compensatory mech to met acidosis

14 yo boy dives into shallow end of swimming pool & hits his head on bottom. After he is rescued, he shows complete lack of neuro function below neck. He is still breathing on his own, but he cannot move or feel his arms & legs. Paramedics carefully immobilize his neck for transportation to hospital, & they alert ED of his impending arrival. Next best step for pt?

*IV high dose corticosteroids* - administered as soon as possible after injury --> better outcome - commonly used as initial step in treatment - has not been shown to be detrimental as long as it is administered within 8 hrs from time of injury

23 yo man presents to ED with acutely worsening shortness of breath. He is also nauseous, is having diarrhea, & has vomited twice today. Pt has long ho severe asthma, with multiple hospitalizations & one intubation 3 yrs ago. 2 days ago, he was cleaning out basement. Since that time, he has had progressively worsening SOB. He tried home albuterol & ipratropium nebulizers, as well as his standard cromolyn therapy, but none of these interventions relieved his symptoms. In the hospital, man's peak flow rates are decreased 50% from baseline. What agents should most likely be added to pt's therapy to alleviate his current symptoms?

*IV hydrocortisone* - augments action of bronchodilators by reducing inflammation surrounding airways - IV steroids are important in acute management of asthma --> takes 12-24 hrs for full effect

61 yo man brought to ED for chest pain. He has long-standing ho CAD & HT & s status post a coronary bypass procedure 6 yrs ago. Pt has chronic stable angina that is usually ppted by activity & relieved by rest. His meds include aspirin, captopril, & metoprolol. About 3 wks ago his doc prescribed sildenafil, & he has been using drug with success. His last sexual encounter was 4 days ago. This morning, he developed chest discomfort. Vital signs in ER include: temp 97 F, BP 220/120 mmHg, pulse 100, RR 22/min. Occular exam reveals papilledema. ECG reveals nonspecific changes. Best treatment indicated at this time?

*IV labetalol* - rapid onset = 5 minutes or less - safe in pts with active coronary dz bc does not increase heart rate - can be given as IV bolus or infusion Hypertensive emergency - chest discomfortb + papilledema + BP 220/115 mmHg

In patients who have atrial fibrillation and hemodynamic instability, the treatment of choice is

*immediate synchronized cardioversion* - hemodynamic compromise may be manifested clinically by hypotension & shock & by worsening angina pectoris, SOB, or HF

Thompson test

*inability of prone pt to plantar flex when gastrocnemius muscles are squeezed*, indicating Achielles tendon rupture*

65 yo woman with ho untreated hyperthyroidism presents to ED via ambulence with SOB. For past 8 hrs, she has experienced dyspnea at rest & has been coughing up sputum. She denies chest pain. On physical exam, pt is in distress & is breathing 60% oxygen through facemask. She is unable to complete full sentences. While examining pt, she coughs up sputum. Sputum is bloodstained. There is evidence of jugulovenous distention & pedal edema. There is no chest wall tenderness; however, auscultation reveals fine crepitations throughout chest. There are no murmurs or rubs. ECG normal. Next best step in management?

*IV loop diuretics, nitrates, & morphines* - best management for pt with acute pulmonary edema from congestive heart failure - reducing preload associated with acute pulmonary edema Furosemide - 40-100 mg IV bolus - causes instant venodilation & then diuresis --> mobilizes fluid from lungs into circulation = expelled in urine --> reduces venous return NTG - sublingual tablets or in IV drip (0.4 mg) - relieves pulmonary edema --> produces venodilation - dilates epicardial coronaries --> treatment for ischemia - may be repeated twice at 5-min intervals - should not be given to pt with systolic BP <120 mmHg Morphine - reduces anxiety & decreases sympathetic outflow - causes venodilation - decreases preload --> helps relieve pulmonary edema - should not be given to pts with decreased sensorium or resp drive --> may bring respiratory arrest - in case of resp arrest, give naloxone

39 yo woman comes to doc bc of 2-month ho fatigue, weight loss, nausea, muscle pains. She has ho severe asthma treated with inhaled albuterol. She took prednisone for 4 months but 3 months ago, she stopped taking it bc she felt it was making her gain weight. Her temp is 37 C (98.6 C), BP 95/40 mmHg, pulse 108/min, & respirations 15/min. DIffuse wheezes heard. Cardiac exam shows normal S1 & S2; no murmurs heard. Lab studies show: Na+ = 127 mEq/L K+ = 4.6 mEq/L Cl- = 93 mEq/L HCO3- = 17 mEq/L Glucose = 59 mg/dL BUN = 35 mg/dL Creatinine = 1 mg/dL ACTH = Decreased What is the most likely cause of this patient's condition?

*Iatrogenic* Adrenal insufficiency - secondary adrenal insufficiency caused by chronic prednisone use, followed by abrupt cessation - clues = nonspecific = fatigue, weight loss, muscle aches - K+ normal bc not primary - cortisol low bc ACTH low - most common cause of adrenal insufficiency = prolonged steroid use (iatrogenic) - can be as little as 2-weke exposure to pharm doses of glucocorticoids

45 yo woman comes to doc bc of blurred vision. She states that this symptom started about 2 days ago. She denies any past hx of significant med or neuro probz. She does state that several mos ago she began to have depressive symptoms & several days ago she went to psychiatrist who put her on med for depression. On ROS, she admits to drinking more water over last several days due to dry mouth. She also complains of dizziness when she stands up from lying or sitting. Her temp is 98.6 F, BP lying down is 135/75 mmHg, blood pressure standing is 110/64 mmHg, pulse lying down 84/min, pulse standing is 95/min, & RR is 16/min. Physical exam unremarkable except for mild pupillary dilation which is likely cause of her blurred vision. What antidepressant med most likely accounts for this pt's symptoms?

*Imipramine* = TCA - inhibits NE & serotonin reuptake - antagonistic effects at muscarinic, histaminic, & alpha-adrenergic receptors - *antimuscarinic effects --> blurred vision via pupil dilation; dry mouth* - *alpha1-adrenergic blockade --> orthostatic hypotension*

35 yo woman comes to doc bc of pigmented lesion on palm of her right hand. Her med hx is unremarkable. Exam shows 2-mm light brown macule with well demarcated edges. Skin biopsy specimen shows clustering of pigmented melanocytes at dermoepidermal junction. No clusters of melanocytes in dermis. Most likely diagnosis?

*Junctional nevus* - may be light brown to nearly black - range in size form 1 to 10 mm - may be either flat or very slightly raised - believed that almost all melanocytic nevi may begin as junctional nevi - seen most frequently on palms, soles, & genitalia - clustering of melanocytes at dermal-epidermal junction = characteristic microscopically - common - removal only when nevus exhibits changes in shape or color or become symptomatic

32 yo gravida 2, para 1 Hispanic woman at 38 weeks' gestation by sure last menstrual period & first trimester ultrasound comes to doc for prenatal care. She has had occasional headaches. She does not have right upper quadrant pain, visual changes, uterine contractions, vaginal bleeding, or leakage of fluid. She says there have been decreased fetal movements during last week. Her hx is significant for traveling to US when she was 28 weeks' pregnant with poor follow-up since then. Her prenatal records from Mexico show she has chronic HT & is otherwise healthy. She wask taking labetalol; however, she ran out of the med 5 wks ago. BP is 152/94 mmHg, fundal height is 31 cm. Urine dip is negative for proteinuria. Ultrasoudn with fetal biometry shows fetus in vertex presentation with head circumference consistent with 34 weeks' & an abdominal circumference consistent with 32 weeks. Amniotic fluid index is 4 cm. Non-stress test shows baseline fetal heart rate of 140 with moderate variability. No accelerations or decelerations present. Most appropriate next step in management?

*Immediate admission to hospital for induction of labor* Intrauterine growth restriction (IUGR) - fetus whose estimated weight is less than appropriate for gestational age - usually less than tenth percentile - chronic HT major risk factor - pt is fuller term with decreased amniotic fluid (oligohydramnios) & IUGR --> best next step = induction of delivery

You are evaluating newly admitted patient to critical care unit. Mr Patrick Starr, a 48 yo man with crushing chest pain - with a score of 10 out of 10. Patient is pale, diaphoretic, & is losing consciousness. The BP is 74/32 mmHg, heart rate is 186/minute, respiratory rate is 12 breaths/minute, & his peripheral pulses are very weak. The ECG displays a regular wide-complex tachycardia. What is the action you & the team should perform next?

*Immediate synchronized cardioversion* - patient is in unstable SVT - BP is low - has wide QRS, chest pain, & signs of deterioration & shock

A 30-year-old woman is evaluated for a 2-week history of easy bruising and epistaxis. She had previously been well and takes no medications or supplements. On physical examination, vital signs are normal. There are numerous petechiae, particularly on the lower extremities, and several ecchymoses on her arms and legs. Crusted blood is visible in both nares. There is no lymphadenopathy or liver or spleen enlargement. The remainder of the examination is normal. Lab studies: Hgb = 12.5 g/dL Leukocyte count = 5700/uL Platelet count = 10,000/uL Comprehensive metabolic panel = Normal Peripheral blood smear shows paucity of platelets & several large platelets. Most likely diagnosis?

*Immune thrombocytopenic purpura* (ITP) - acquired autoimmune condition = autoAbs directed against platelet surface proteins = platelet destruction - platelets, when present, may be large bc they typically have recently been released from bone marrow

55 yo man presents to his doc for routine physical checkup. This is his first checkup in several years, & he is relatively asymptomatic. He does admit to 15 lb wt gain over past several years. His past med history is unremarkable. He is currently taking OTC vitamin supplementation & occasional orlistat. He denies drinking alcohol or smoking. On physical exam, the pt is in no apparent distress. Vital signs are: BP 135/90 mHg, pulse 78/min, RR 14/min, temp 97.7 F, height 5 ft 5 in, wt 190 lb. Head, neck, cardiovascular, & abdominal exams are unremarkable. No peripheral clubbing, cyanosis, or edema. Routine lab data obtained & shown below: Sodium = 139 mEq/L Potassium = 4.6 mEq/L Chloride = 104 mEq/L Bicarbonate = 23 mEq/L Creatinine = 1 mg/dL Glucose = 135 mg/dL ALT = 150 IU/L AST = 144 IU/L Alkaline phosphatase = 133 IU/L Total bilirubin = 1 mg/dL TSH = 4.9 mU/L Viral hepatitis battery pending. Ultrasound of RUQ demonstrates heterogeneous echotexture of liver & no gallstones. What is the pt's current condition most likely to be associated with?

*Impaired glucose tolerance test* Non-alcoholic steatohepatitis (NASH) - most pts asymptomatic - discovered based on routine lab tests often - most commonly associated with metabolic syndrome = central obesity, insulin insensitivity, frank type 2 diabetes, hyperlipidemia - better prognosis than alcoholic steatohepatitis but can progress to cirrhosis & end-stage liver dz

25 yo man comes to doc bc of syncope associated with exercise. He states that this symptom began appx a yr ago, while he was playing basketball. He frequently feels light-headed when he exerts himself. Recently, however, he has transiently lost consciousness. He denies chest pain & palpations & he has noticed no leg swelling. He has no hx of any major med illnesses & takes no meds. Review of his records shows that several of his fam members have died suddenly at young ages during exertion. His BP is 125/72 mmHg & his pulse is 78/min. 2/6 crescendo-decrescendo murmur heard on auscultation of chest systole during left sternal border. Carotid pulses are brisk without delay or weakness. There is no clubbing, cyanosis, or edema. Next best step in pt care?

*Implantable cardiac defibrillator* HOCM - symptoms via extent of pressure gradient b/t left ventricle & aorta Criteria for implantable cardiac defibrillator in pts with HOCM - hx of survival of cardiac arrest of sustained ventricular tachycardia in good-prognosis pts - high-risk pts who fit 2 or more of the following risk factors: fam hx of sudden cardiac death, syncope, asymptomatic nonsustained ventricular tachycardia, abnormal BP response to exercise, massive left ventricular hypertrophy

60 yo man with 2 mo hx of T-cell lymphoma comes to doc for follow-up exam. Current meds include cyclophosphamide, doxorubicin, vincristine, & prednisone. He has not received any immunizations over past 10 yrs. Most appropriate immunization to administer at this visit?

*Inactivated influenza vaccine & pneumococcal polysaccharide vaccine* Immunocompromised bc of his T-cell lymphoma & his chemo - annual admin of inactivated influenza vaccine indicated in all oncology pts - pneumoccocal vaccine indicated for adults over 65 yo, adults who have chronic dz, & all immunocompromised pts

4 day old newborn at 39 wks' gestation brought to doc bc of yellow discoloration of skin. Newborn's mom reports that infant has been breastfeeding well, has had 3 wet diapers per day, & has had one stool since discharge. Hemoglobin is 16 g/dL, serum total bilirubin is 15 mg/dL, & direct bilirubin is 1.1 mg/dL. Review of med records shows mom's blood type is A+ & infant is O+. Most likely diagnosis?

*Inadequate caloric intake* - common in first-time breast-feeding moms - dehydration - increased enterohepatic circulation of bilirubin --> indirect hyperbilirubinemia = 2nd-4th day of life - treatment = rehydrate infant, either with formula or IV fluids --> lactation consult to deal with specific issues of breast-feeding

EMS arrives with a patient found unconscious after falling off a ladder. Patient is pulseless & remains in pulseless electrical activity. This prolonged situation continues a CPR continues with 3 more doses of epinephrine given. The team should be discussing possibility of...

*tension pneumothorax* - tension pneumothorax & cardiac tamponade = possible in chest trauma

A 68-year-old man is evaluated for exertional chest pain of 3 months' duration. He describes the chest pain as midsternal pressure without radiation that occurs with walking one to two blocks and resolves with rest or sublingual nitroglycerin. No symptoms have occurred at rest. His medical history is significant for myocardial infarction 3 years ago, hypertension, and hyperlipidemia. Medications are aspirin, metoprolol, simvastatin, isosorbide dinitrate, and sublingual nitroglycerin as needed for chest pain. On physical examination, temperature is normal, blood pressure is lSO/SS mm Hg, pulse rate is 80/min, and respiration rate is 12/min. The lungs are clear. Cardiac examination shows normal S1 and S2 with no extra heart sounds or murmurs. The remainder of the examination is unremarkable. Electrocardiogram shows normal sinus rhythm, no left ventricular hypertrophy, no ST- or T-wave changes, and no Q waves. What is the most appropriate management?

*Increase the metoprolol dosage* - treating continuing angina in patient with chronic stable coronary artery dz - complete beta-blockade typically results in resting pulse rate of appx 55-60/min --> pulse rate of 80/min suggests dosage of metoprolol should be increased Beta blockers - decrease heart rate, myocardial contractility, & systemic BP = decreased myocardial oxygen demand

34 yo primigravid woman at 30 weeks' gestation comes to doc with regular contractions every 6 minutes. Her prenatal course was significant for type 1 diabetes, which she has had for 16 years. Over course of 1 hour, she continues to contract, & her cervix advances from closed & long to fingertip of dilation with some effacement. Pt started on magnesium sulfate, penicillin, & betamethasone. Most likely side effect from admin of corticosteroids?

*Increased maternal insulin requirement* Corticosteroids = more difficult glucose control in diabetics - blood glucose levels should be checked regularly & elevated values treated with insulin *All pts with diabetes will experience hyperglycemia & increased insulin requirements with admin of corticosteroids*

62 yo man with 55-pack-year smoking history comes to urgent care clinic with worsening of his chronic SOB. He has noticed change in his chronic cough. He has also had several episodes of blood-tinged sputum over the past few weeks. His wife states that over the past 2 weeks, he has seemed more hoarse than usual. On physical exam, he has dense rhonchi in right posterior mid-lung field. There are also soft, scattered rhonchi in both lung fields with prolonged expiratory phase. Chest x-ray film reveals a 7-cm, irregularly shaped mass in right middle lob with associated lobar consolidation. What most suggests that the patient has surgically inoperable lung cancer?

*Increasing hoarseness* Patient w/ COPD+ lung cancer - hoarse via metastatic dz to recurrent laryngeal nerve = extrapulmonic spread & incurable by surgical resection Tumor considered unresectable if extrapulmonary spread... - invasion to recurrent laryngeal nerve - evidence of pleural effusion - evidence of contralateral lymphadenopathy - invasion to pulmonary artery

72 yo woman presents to clinic complaining of prob with her right breast. She states that condition has been present for at least several weeks, perhaps mo or two. She has no pain or fever. Vital signs are BP 140/90 mmHg, pulse 86, RR 14/min, & temp 100.2 F. Skin over right breast is edematous. Area is not warm to touch, but on physical exam there is fullness to entire breast with erythema and no discrete mass. Left breast appears normal & no masses are felt. Woman has no fam hx of cancer. Menarche was at age 14 & menopause at age 52. Most likely diagnosis?

*Inflammatory cancer of breast* - age = first tip-off: older pt with any kind of breast prob = most likely cancer - permeation of skin lymphatics = edema, redness, fullness, "orange-peel" appearance - thick, tumor-laden skin masks underlying mass = "fullness" rather than discrete lump

67 yo man comes to doc with complaints of difficulty breathing. He reports that his symptoms started 2 months ago & have been worsening lately. Initially he was SOB only with exertion but now he has frequent bouts of coughing & dyspnea even at rest. He has ho smoking pack/day for 30 years. On physical exam he has distant breath sounds in both lung fields with soft expiratory wheezes. Chest x-ray shows hyperinflation of both lung fields. Pulmonary function test shows FEV1/FVC ratio of 60 & FEV1 of 80, increased RB & TLC & decreased DLCO. Arterial blood gas reveals arterial pH 7.36, pCO2 41 mmHg, & pO2 63 mmHg. Best long-term management of this patient?

*Inhaled ipratropium bromide + inhaled albuterol* COPD: emphysema - GOLD (Global Initiative for Chronic Obstructive Lung Disease) stage 1 - first-line treatment = combo: short-acting inhaled ipratropium bromide (anticholinergic) + inhaled albuterol as needed

45 yo lman who had recent heart transplant has been placed on high doses of immunosuppressant. Five wks later he develops high-grade fever. He is noted to be neutropenic & he fails to improve. At this point, he is noted to have SOB. Chest radiograph reveals right middle lobe infiltrate. Bronchoscopy reveals pulmonary secretions that grow branching septate hyphae. Appropriate initial management?

*Initiate treatment with voriconazole* Neutropenic fever - can be life-threatening - organism most concerning = Pseudonomonas - *If neutropenic pt still febrile after 5-7 days on broad abx or has developed new infiltrates, Aspergillus infection must be considered*

19 yo man brought to ED ater sustaining multiple injuries in high-speed automobile collision. There is pneumothorax on left side, for which he has chest tube placed. Over next several days, large amount of air drains continuously through tube, & daily chest x-rays show that his collapses left lung is not expanding. Pt is not on respirator. All of his other injuries have been treated appropriately. Most likely cause of these findings?

*Injury to major bronchus* - can happen when major blow to chest occurs at time when glottis is closed - if not recognized right away by presence of subQ emphysema --> become evident once air leak persists & lung does not re-expand

42 yo obese woman comes to urgent care clinic complaining of intermittent abdominal pain that has been worsening over past few mos. Pain is described as colicky in nature & often is worse after meals. Pain appears to be epigastric & sometimes located in RUQ. Pt's condition worsened last night after she ate two slices of pizza, & she became severely nauseated. Finally, after woman noted fever of 101.8 F, her daughter persuaded her to come to clinic. She has positive fam hx of gastric adenocarcinoma. She has given birth to five children, all of whom are healthy. Most consistent with her clinical presentation?

*Inspiratory arrest elicited by palpation of abdominal right upper quadrant* Acute cholecystitis - positive Murphy sign - as pt inspires, depressed diaphragm displaces gallbladder toward doc's hand - increased pressure on infamed gallbladder = pain --> pause in inspiration - RUQ ultrasound = gold standard of diagnosis if gallbladder wall thickening & pericholecystic fluid present with or without cholelithiasis

17 yo grl referred for evaluation bc of persistent headaches for past 3 mos. She hit lampposts twice while driving during past 2 wks. She started menstruating 2 yrs ago but has irregular periods. On further questioning, she admits that she has no libido. On physical exam, she has fully developed breasts but no axillary or pubic hair. Absence of libido in this grl is indicative of what conditions?

*Insufficient production of luteinizing hormone* Pituitary adenoma - indicated by neuro complaints of headaches & visual disturbances (bitemporal loss of vision, suggested by lamppost collisions while driving) - impaired vision = most common symptoms that leads pt to seek med attention = via suprasellar extension of adenoma that compresses optic chiasm

64 yo man admitted to medical ICU for treatment of pneumonia & sepsis. IV cefepime & vancomycin are initiated. He has 9 yr ho T2DM treated with metformin. On physical exam, temp is 101 F, BP 160/95 mmHg, pulse rate 100/min, & RR 20/min. Arterial oxygen sat (ambient air) 92%. Plasma glucose level 290 mg/dL. Optimal glucose management for this pt?

*Insulin drip; target plasma glucose level of 140-200 mg/dL (7.8 - 11.1 mmol/L)* Manage hyperglycemia in pt in medical ICU - optimal glucose management for critically ill pt - hyperglycemia in hospitalized pts, w/ or w/out DM, is associated w/ poor outcome - insulin = mainstay therapy for hyperglycemic state in critically ill pts, & oral antihyperglycemic agents, such as metformin, should be stopped

70 yo man who has not seen doc in past 30 years comes to ER with one month ho fatigue & muscle weakness. He was told he had HT >20 years ago, but has never taken med for it. BP is 188/106 mmHg, pulse 80/min. Physical exam shows AV nicking on fundoscopy, but is otherwise normal. Serum studies show: Sodium 140 mEq/L Potassium 6.2 mEq/L Chloride 110 mEq/L HCO3 20 mEq/L Creatinine 3 mg/dL Glucose 397 mg/dL Urinalysis shows 2+ protein & is otherwise normal. ECG normal. Most appropriate initial step in management?

*Insulin* - severe hyperkalemia *without ECG changes* - likely due to chronic kidney disease, most likely due to hypertensive nephrosclerosis from untreated HT - may also have untreated DM *If ECG is abnormal, calcium carbonate IV is first treatment, to stabilize cardiac membrane; if not (as here), an agent should be used to shift potassium into cells* - acceptable agents here are insulin & albuterol - since pt is also hyperglycemic, insulin is preferred - if he were not hyperglycemic, either insulin + dextrose or albuterol would be appropriate

35 yo man evaluated in office for preemployment physical exam. He emigrated to US from Vietnam last year & has been employed by public school system. He is asymptomatic & takes no meds. He does not drink alcohol, smoke cigarettes, or use illicit drugs. At 12 yo, he received bacillus Calmette-Guerin vaccine. On physical exam, vital signs are normal. Remainder of physical exam normal. What is indicated to screen for TB?

*Interferon-gamma-releasing assay* / IGRA - screening for latent TB - CDC endorse use of IGRAs in all clinical settings in which TB skin test (TST) is recommended - preferred to TST in those who have received bacillus Calmette-Guerin vaccine either as treatment for cancer or as vaccine - also preferred when testing ppl who often don't return for follow-up reading of TST (injection drug users, homeless) - more expensive

59 yo woman presents to clinic complaining that yesterday afternoon she had episode of left upper arm weakness that resolved after 6 hours. Over last month, she has experienced increased fatigability, dyspnea on exertion, palpitations, & a low-grade fever. Her vital signs are temp 37.3 C (99 F), BP 115/70 mmHg, pulse 89/min, & respiratinos 14/min. Physical exam discloses clear lungs with regular & rhythmic pulse & a mid-diastolic rumbling murmur on fifth intercostal space at midclavicular line. She is sent for echocardiography. What would this study most likely reveal?

*Intracardiac lesion* Large left atrial myxoma - mid-diastolic rumble heard best at apex = classic of mitral stenosis but can also be caused by large atrial myxoma = most common intracardiac tumor - patient's neurologic finding of left upper arm weakness = via tumor embolization - constitutional complaint of low-grade fever can also point to tumor

19 yo college student visits student health center for persistently itchy eyes & runny nose. She has had these symptoms for last 2 yrs & would like treatment. She states that the symptoms occur around spring season & tend to abate in middle of summer. There have been bouts of sneezing; persistent red, watery eyes; and intractable rhinorrhea. Her past med hx is unremarkable, & she does not take any meds. She denies smoking & occasionally has alcohol at parties. On physical exam, she is normotensive & afebrile. Her eyes are injected, & the nasal mucosa is boggy, pale, & wet. There is no lymphadenopathy. Her lungs are clear to auscultation. Remainder of exam is unremarkable. What agents is most appropriate initial treatment?

*Intranasal corticosteroids* Seasonal allergic rhinitis (severe) - most effective pharm treatment of moderate to severe or refractory allergic rhinitis = intranasal glucocorticoids

8 yo boy brought to ED by his mom bc of fever & decreased activity for 1 day. he reports that he had headache 2 days ago. He has not had any mosquito bites. Boy's fam migrated from Southeast Asia when boy was 3 years old. Med hx unremarkable. Takes no meds. Appears drowsy. His temp is 38.1 C (100.5 F). There is nuchal rigidity. His lungs are clear to auscultation. Cardiac exam shows normal S1 & S2; there are no murmurs. Abdomen is soft & there is no tenderness. There is no rash. Lumbar puncture & CSF analysis shows: Color Cloudy Opening pressure 22 cm WBCs 200/mm^3 Lymphocytes 90% Glucose 39 mg/dL Protein 300 mg/dL Gram stain No organisms Most appropriate next step in management?

*Isoniazid, rifampin, ethambutol, pyrazinamide, & prednisone* Tuberculosis meningitis - hx of being raise din southeast Asia - three phases: first phase = prodrome = malaise, headache, fever, personality change; second phase = meningitic phase = prominent neuro features = meningismus, headache, lethargy, vomiting, confusion; thrid phase = paralytic phase = may progress rapidly to coma, seizures, hemiparesis

28 yo pt who has ESRD on continuous ambulatory peritoneal dialysis (CAPD) for 2 mos is brought to ED with fever, abdominal pain, & cloudy dialysis fluid. There is no diarrhea or vomiting & the pain has been present for appx 12 hours. Pt has ESRD secondary to chronic glomerulonephritis; there is no hx of diabetes, urinary infections, or abx use. Exam reveals temp of 102 F & BP of 110/70 mmHg. Throat is clear, as are lungs. Cardiac exam reveals grade 2/6 systolic murmur. Abdominal exam reveals decreased bowel sounds with diffuse tenderness. There is mild rebound tenderness. There is no edema or skin rash. CBC shows leukocyte count of 14,200/mm^3; hemoglobin of 12.5 g/dL. Peritoneal fluid is cloudy with 1000 white blood cells, 85% of which are polymorphonuclear leukocytes. Gram stain of peritoneal fluid is negative. Cultures of blood & peritoneal dialysis fluid are taken. Most appropriate initial step in management?

*Intraperitoneal admin of cefazolin, together with ceftazidime* Peritonitis in pt on CAPD (continuous ambulatory peritoneal dialysis) - usually caused by S aureus or S epidermidis - diagnosis made on presence of abdominal pain or tenderness, cloudy dialysate with more than 100 WBCs (typically polymorphonuclea leukocytes) in sample of peritoneal dialysis fluid, & by way of isolation of microorganisms from dialysate

6 yo patient brought to doc's office complaining of right knee pain & swelling. Child currently taking amoxicillin for third episode of pneumonia during past 2 months. Mother also concerned bc of decreased appetite of child, & states that he only "eats a little bit of his food bc he gets full very quick." Temp is 39.4 C (101 F), pulse 120/min, & RR 20/min. Child appears acutely ill & pale. Heart: systolic ejection murmur. Lungs: rales over right base. Abdomen: liver & spleen palpated 3 & 2 cm below right & left costal margins, respectively. Skin: petechiae on lower extremities. Neuro exam: confused, no focal defiicts. Lab reports include: Hgb = 9 g/dL Platelets = 100,000/mm^3 WBCs = 4500/mm^3 Peripheral smears = Atypical lymphocytes Bone marrow biopsy = 30% blasts Myeloperoxidase = negative Diagnosis made & immediate treatment initiated. Several weeks later child arrives to ED with confusion & headache. Physical exam relevant for papilledema. What could have prevented this child's new complication?

*Intrathecal methotrexate* ALL - bone & joint pain, especially lower extremities - signs of bone marrow failure = pallor, bruising, epistaxis, petechiae, purpura, mucus membrane bleeding - lymphadenopathy, hepatosplenomegaly, joint swelling = also common - peripheral blood = anemia, thrombocytopenia, WBC <10,000/mm^3 / atypical lymphocytes - characterized by presence of common ALL Ag (CALLA) & terminal deoxynycleotidyl transferase (TdT) Patients with ALL frequently have meningeal leukemia if have relapse - ALL pts must undergo prophylaxis of CNS to prevent relapse there --> best agent = intrathecal methotrexate

39 yo woman, gravida 2, para 1, at 30 wks gestation comes to doc for prenatal visit. Patient's due date was determined by 7-wk ultrasound. Her prenatal course has been unremarkable. She has no complaints of contractions, loss of fluid, or bleeding from vagina, & her baby is moving well. Exam demonstrates fetal heart rate of 150 & a fundal height of 27 cm, which is the same measurement as that determined 4 weeks ago. This patient's fundal height measurement is most suggestive of what?

*Intrauterine growth restriction* - no change in fundal height - fetus not growing appropriately - estimated fetal weight <10th percentile for given gestational age - 3 cm less than expected - should be sent for ultrasound to evaluate fetal size Fundal height - performed by placing measuring tape on pubic symphysis & measuring top of fundus - 26 weeks' gestation = fundal height of 26 cm - 30 weeks' gestation = fundal height of 27 cm

A 32-year-old woman is evaluated in the emergency department because of intermittent palpitations and dizziness for the last week. She has not experienced chest pain, dyspnea, or orthopnea. She was ill 6 weeks ago with fever, fatigue and myalgias, and an associated erythematous rash on her abdomen that resolved over 2 weeks. She has no significant medical history. She works as a landscaper. On physical examination, temperature is normal, blood pressure is 120/70 mm Hg, and pulse rate is 45/min. The cardiac examination shows bradycardia, but findings are otherwise unremarkable. The remainder of the physical examination is normal. An electrocardiogram shows sinus rhythm with a heart rate of 90/min, with complete heart block and a junctional escape rate of 50/min. In addition to hospitalization for cardiac monitoring, which of the following is the most appropriate management for this patient?

*Intravenous ceftriaxone* Reversible heart block via Lyme carditis - acute-onset, high-grade AV conduction defect - AV block can present in any degrees; progression to complete heart block is often rapid - prognosis if good = resolution of AV block within days-weeks - preferred antibiotic regimen = IV ceftriaxone until heart block resolves, followed by 21-day course of oral therapy

39 yo man comes to doc bc of progressive difficulty walking for 1 week. He had episode of right arm weakness 1 year ago that lasted 2 weeks, & he had 10 days of blurry vision & eye pain 6 years ago. He does not drink alcohol. He has smoked one pack of cigarettes daily for 19 years. His temp is 37.1 C (98.8 F), BP is 128/84 mmHg, & pulse is 74/min. Neuro exam shows poor balance, decreased sensation to light touch in upper extremities, & intentional tremor. Flexion of neck produces electric shock-like pain down patient's back. There is nystagmus of both eyes. MRI scan of brain shows multiple lesions in periventricular region & corpus callosum. Most appropriate next step in management?

*Intravenous corticosteroids* MS - clinical diagnosis - demyelinating dz = optic neuritis, radicular pain + sensory abnormalities + white-matter plaques seen on MRI scan - patient has Lhermitte phenomenon = transient electric shock that radiates down spine with flexion of neck - vertigo, nystagmus, motor symptoms - symptoms tend to be worse with increase in body temp - oligoclonal banding = sensitive but nonspecific on CSF - first-line treatment for flares = IV corticosteroids

6 yo boy with ho deafness presents to ED after collapsing at home. He was running after one of his three siblings when he suddenly turned pale & fell to floor. His 'rents dialed 911. He then recovered in ambulance. In ER, he appears pale. Parents are concerned & state that boy is not taking any meds. There was maternal uncle who also experienced similar episodes but died at early age. ECG is performed & reveals marked QT prolongation & morphologic abnormalities of T waves. Within 1 min, pt again loses consciousness & ECG reveals irregular polymorphic ventricular tachycardia that appears to undulate about isoelectric line. Most likely diagnosis?

*Jervell-Lange-Nielsen syndrome* (JLNS) - also has ho deafness - associated with sensorineural deafness Long QT syndrome - recurrent episodes of torsades de pointes at early age - presence of maternal uncle who presented in similar way but died at early age

75 yo man evaluated in ED bc of 2 day ho confusion, falls, urinary incontinence. History includes DM, HT, & CKD, with baseline serum creatinine level of 2.2 mg/dL. Meds are glargine insulin, metoprolol, & lisinopril. On physical exam, temp is 101.3 F, BP 89/55 mmHg, pulse rate 112/min, RR 24/min, & O2 sat 93% on ambient air. Pt is disoriented & has moderate word finding difficulty. Findings of cardiovascular & respiratory exams are normal. There is suprapubic tenderness. Remainder of physical exam is normal. Lab: Leukocyte count = 18,000/uL Serum creatinine level = 3 mg/dL Plasma glucose level = 160 mg/dL BUN level = 48 mg/dL Lactic acid level = 40.5 mg/dL Urinalysis findings = Dipstick results positive for leukocyte esterase & nitrates. Microscopic analysis shows too many leukocytes to count. Blood & urine cultures obtained. What is the most appropriate next step in management of this pt?

*Intravenous crystalloid solution & broad-spectrum abx* - crystalloid solution = normal saline or lactated Ringer solution = to achieve central venous pressure of 8-12 mmHg Severe sepsis - SIRS (altered temp, tachycardia, hyperventilation, abnormal leukocyte count) + suspected infection - associated with systemic effects, including hypotension, confusion, decreased urine output, metabolic acidosis

A 26-year-old man is evaluated for a 2-week history of fever, rapidly enlarging lymph nodes in the head and neck, and abdominal distention. On physical examination, his temperature is 39.0°C (102.4°F), blood pressure is 90/60 mm Hg, pulse rate is 115 beats/min, and respiration rate is 24 breaths/min. He has massive cervical and axillary lymphadenopathy. On abdominal examination, his spleen is palpable 8 cm below the left costal margin and a firm intraabdominal mass is noted. Lab studies: Hgb = 10.5 g/dL Leukocyte count = 65,000/uL with 35% neutrophils & 65% atypical lymphocytes Platelet count = 90,000/uL Creatinine = 2.8 mg/dL Lactate dehydrogenase = 12,000 units/L Phosphorous = 9.9 mg/dL Potassium = 5 meq/L Uric acid = 18.6 mg/dL Biopsy of cervical lymph node confirms Burkitt lymphoma. Most appropriate immediate next step in treatment?

*Intravenous normal saline & rasburicase* - preferred over allopurinol bc uric acid level significantly elevated Tumor lysis syndrome - in pts associated with malignancies associated with rapid cell turnover (leukemia, Burkitt lymphoma) - manifestations = hyperkalemia, hyperuricemia, hyperphosphatemia, hypocalcemia, acute kidney injury, DIC

A 42-year-old man is evaluated in the hospital for dyspnea and pleuritic chest pain. The patient was involved in a motor vehicle accident 3 weeks ago in which he sustained multiple lacerations and a fracture of his right femur. Medical history is otherwise unremarkable and he takes no medications. Physical examination shows a temperature of 38.1°C (100.6°F), blood pressure of l30/78 mm Hg, pulse rate of HO/min, and respiration rate of 22/min. Oxygen saturation is 87% breathing ambient air and 92% on 2 L/min of oxygen by nasal cannula. The lungs are clear and the cardiac examination is significant only for tachycardia. There is a cast in place on the right lower extremity, and there are scattered healing lacerations present. The remainder of the examination is unremarkable. Chest radiograph shows no abnormalities. A complete metabolic profile, including measures of kidney function, is normal. Contrast enhanced CT scan shows pulmonary emboli in the arteries perfusing the lingula and the posterior basal segment of the left lower lobe. Which of the following is the most appropriate treatment for this patient?

*Intravenous unfractionated heparin* Pulmonary embolus - in absence of contraindications, pt should be treated initially with IV or subcutaneous unfractionated heparin, low-MW hepain, or fondaparinux - following initial therapy, pts usually transitioned to warfarin for long-term therapy, with factor Xa & direct thrombin inhibitors being increasingly-available options for this purpose

A 75-year-old woman is evaluated in the hospital because of a 1-day history of swelling of the right leg. Three days ago, she underwent nephrectomy for renal cell carcinoma. Her only medication is unfractionated heparin, 5000 units subcutaneously twice daily. On physical examination, blood pressure is 130 /75 mm Hg, pulse rate is 85/min, and respiration rate is 20/min. Weight is 80 kg (176.3 lb). The right lower extremity is swollen, warm, and tender to palpation of the calf. The nephrectomy incision shows no erythema or bleeding. The remainder of the findings on examination are normal. Lab studies: Hematocrit = 29% Platelet count = 275,000/uL - Creatinine = 2.2 mg/dL Estimated GFR = 23 mL/min/1.73 m^2 Venous duplex ultrasonography shows a right lower extremity femoral and popliteal vein deep venous thrombosis. In addition to cessation of subcutaneous unfractionated heparin administration, which of the following is the most appropriate treatment?

*Intravenous unfractionated heparin* (UHF) - primarily cleared by reticuloendothelial system rather than kidneys = preferable to other choices for acute therapy for DVT - short half-life - completely reversible with protamine - adjusted to achieve therapeutic activated partial thromboplastin time - patient recently underwent major surgical procedure & has CKD

70 yo man comes to ED complaining of nausea, vomiting, & severe headache. He is an Alaskan native & has not sought health-care advice from anyone other than a traditional healer. However, last night he awoke with severe pain & his fam brought him to the nearest ER. He denies any trauma & has never suffered symptoms like this in the past. His headache is mainly retro-orbital, & much of his pain actually seems to originate in his left eye. On exam, the man shields his left eye with his hand. Eye is markedly red & injected and the cornea appears hazy. Pupil is mid-dilated and minimally reactive to light. Right eye appears normal. Visual acuity tested with Snellen chart is 20/40 OD & 20/200 OS. Most likely location of this patient's lesion?

*Iris* Acute angle-closure glaucoma - more prevalent in elderly & in ethnic groups with smaller eyes, such as Asians and Alaskan natives - trabecular meshwork becomes blocked at iridiocorneal junction --> iris creates block at border of lens = obstructs transit & removal of vitreous fluid & rapidly increasing intraocular pressure - definitive treatment = iridotomy to remove relative excess of iris tissue

4 yo grl brought to doc by her mom bc grl recently spent summer wiht her grandfather who was diagnosed with TB 1 wk ago. Her mom denies that pt has had fever, cough, or night sweats. Her med hx is unremarkable. She was born in US & has not traveled outside of county. Her temp is 98.2 F. Physical exam shows no abnormalities. X-ray film of chest within normal limits. TB skin test with PPD shows 4 mm of induration. Most appropriate next step in management?

*Isoniazid* At risk for latent TB infection... - children younger than 5 yo = at high risk for progression of dz --> should start therapy even though her initial tuberculin skin test is negative (>5 mm would be positive given her close exposure)

9 yo girl with ho atopic dermatitis brought to doc bc of worsening pruritis & rash for 1 wk. Current medds include topical corticosteroids & bland emollients. Her popz has herpes labialis. Her temp is 100.8 F. Exam shows eczematous patches on her cheeks, lateral neck, trunk, & antecubital fossae. There are erythematous superimposed vesicles & small, "punched-out" ulcerations. Vesicles have spread beyond edges of eczematous patches onto uninvolved skin. Most likely diagnosis?

*Kaposi varicelliform eruption* Eczema herpeticum (EH) / Kaposi varicelliform eruption - most common in children - most commonly caused by HSV-1 - typically associated with parent affected by recurrent herpes labialis - solitary vesicles & punched-out ulcerations - lesions typically begin in sites with compromised cutaneous barrier function but often spread to uninvolved skin - pts also often complain of fever & malaise - early treatment with systemic antiviral agents (acyclovir, valacyclovir) essential

Genito-pelvic pain/penetration disorder is one of the sexual dysfunctions. It is defined as unexplained pain with sexual intercourse with or without involuntary muscle contraction of outer third of vagina. This disorder interferes with intercourse. It is more common in women who have ho *sexual trauma*, emotional abuse, rigid religion upbringing, or psychosexual conflicts. It is treated with

*Kegel exercises*, vaginal dilators, general relaxation techniques

A 77-year-old woman is evaluated for anemia that has developed over the past year. She is asymptomatic and is active and able to engage in her usual activities without shortness of breath or excessive fatigue. Medical history is significant for hypertension and hyperlipidemia for which she takes lisinopril and atorvastatin. On physical examination, temperature is 36.7°C (98.0°F), blood pressure is 137178 mm Hg, pulse rate is 88/min, and respiration rate is 17 /min. Body mass index is 19. Cardiac examination reveals an S4. The remainder of the examination is normal. Laboratory studies: Hemoglobin = 11.4 Leukocyte count = 6200/uL with normal differential Platelet count = 225,000/uL MCV = 90 fL Reticulocyte count = 0.8% of RBCs Ferritin = 187 ng/mL Iron = 78 ug/dL Iron-binding capacity, total = 356 ug/dL Creatinine = 1.5 mg/dL Peripheral blood smear is compatible with normochromic, normocytic anemia. Most likely cause of patient's anemia?

*Kidney disease* - erythropoietin produced in kidney --> kidney dz associated with underproduction anemia caused by renal cortical loss - inappropriately low reticulocyte count for level of anemia present - pts with minor increases in serum creatinine may have reduced erythropoietin levels

A 67-year-old man is evaluated in the hospital for an increasing serum creatinine level. The patient was hospitalized for pneumonia 2 days ago and is improving on antibiotic therapy. He has experienced no episodes of hypo tension during the hospitalization. His only other medication is tamsulosin for benign prostatic hyperplasia. On physical examination, the patient is afebrile. Blood pressure is 144/75 mm Hg, and pulse rate is 64/min. Cardiopulmonary examination is normal. The abdomen is nontender, with normal bowel sounds and some suprapubic fullness. Urine output was 1200 mL in the past 24 hours. The serum creatinine level is 1.9 mg/dL (168 µmol/L). Urinalysis shows a specific gravity ofl.011; pH 6.0; trace leukocyte esterase; 03 erythrocytes/high-power field; and 0-5 leukocytes/high-power field. Which of the following is the most appropriate diagnostic test to perform next?

*Kidney ultrasonography* - acute kidney injury (AKI) via urinary obstruction

A 69-year-old man is evaluated during a new patient visit. Medical history includes hypertension and several episodes of kidney stones. Family history is significant for chronic kidney disease in his mother, who required dialysis. His only medication is lisinopril. On physical examination, temperature is 36.9°C (98.4°F), blood pressure is 134/72 mm Hg, pulse rate is 72/min, and respiration rate is 14/min. The remainder of the examination is normal. Lab studies: Hemoglobin = 12 g/dL (120 g/L) Serum creatinine = 1.9 mg/dL (168 umol/L); 5 years ago; 1.4 mg/dL (124 umol/L) EGFR = 37 mL/min/1.73 m^2 Urinalysis = 2+ protein; 0-2 RBCs/high-power field; 0-1 leukocytes/high-power field What is the most appropriate diagnostic test to perform next?

*Kidney ultrasonography* - often first imaging choice to assess kidney dz bc it is safe - doesn't require contrast dye = doesn't place patients at risk for contrast-induced nephropathy - can show small echogenic kidneys, elements of obstruction, or other chronic entities such as AD polycystic kidney dz Stage 3 CKD - based on GFR of 37 mL/min/1.73 m^2 - patient's mom has known CKD = raises possibility that there is genetic component to CKD

62 yo man undergoes exploratory laporotomy & repair of bleeding duodenal ulcer. Central line & Foley catheter are inserted before surgery. IV cefazolin & gentamicin are also administered. He is stable throughout procedure, & he makes 400 mL of urine during 3-hr procedure. In recovery room, he is agitated & thrashing until he receives appropriate analgesics. He is then transferred to surgical floor, he is agitated & thrashing until he receives appropriate analgesics. He is then transferred to surgical floor, where his nurse notices that he has had no urine output for 3 hours. Central venous pressure is 12 mmHg & his BP & pulse are stable. What is the most likely etiology of this pt's lack or urine output?

*Kinked Foley catheter* - important to evaluate easiest & most obvious answer first - most likely became kinked while thrashing about in recovery room - in presence of normal perfusion pressure, probz don't suddenly drive urinary output from normal to zero

49 yo man with long ho alcohol abuse is brought to doc by his wife bc of gradually increasing confusion. 2 wks ago, he started to feel drowsy throughout day & had difficulty sleeping at night. Since then, he has become confused & occasionally disoriented as to time & day. He can recognize his wife & neighbors, but cannot maintain casual convos. He denies fever, chills, & abdominal pain. 6 mo ago, he was admitted to hospital with upper GI bleed, which was due to bleeding esophageal varices. His past med history is also significant for HT. He is currently taking enalapril, spironolactone, & propranolol. On physical exam, he is lethargic & disheveled. His temp s 98.4 F, BP 112/64 mmHg, pulse 62/min, & respirations 18/min. Abdominal exam reveals firm liver edge with liver span 7 cm in midclavicular line. No shifting dullness & spleen tip not palpable. On mental status exam, he recognizes doc but cannot name date, reason for visit, or home address. Neuro exam is nonfocal, & asterixis is present. Most appropriate management at this time?

*Lactulose only* - first-line drug for acute HE - lowers blood ammonia - converts lactic acid in gut lumen --> lower pH --> positively charged NH4+ not absorbed; inhibits ammonia-forming bacteria; cathartic = reduces bacterial load in colon

37 yo woman, gravida 3, para 2, comes to doc for follow-up on her ectopic pregnancy. She was diagnosed with ectopic pregnancy 7 days ago & given methotrexate. She now presents with abdominal pain that started this morning. Exam is significant for moderate left lower quadrant tenderness. Lab analysis shows that her beta-hCG value has doubled over the past week. Transvaginal ultrasound shows that ectopic pregnancy is roughly the same size but there is increased amount of fluid in the pelvis. Most appropriate next step in management?

*Laparoscopy* Ectopic pregnancy - when methotrexate given, it is essential to have pt return for follow-up to ensure beta-hCG value is falling - fluid in pelvis on ultrasound likely blood - management of ruptured ectopic = surgical = laparoscopy with salpingostomy or salpingectomy - failure of methotrexate therapy = defined as rise or plateau of beta-hCG by day 7

20 yo woman comes to doc bc of left lower quadrant pain for 2 mos that is now getting worse. She has had no changes in bowel or bladder function. She has had no fever, chills, nausea, vomiting, or diarrhea. Pain is intermittent & sometimes feels like dull pressure. Pelvic exam is significant for left adnexal mass that is mildly tender. Urine hCG negative. Pelvic ultrasound shows 7-cm complex left adnexal mass with features consistent with benign cystic teratoma. Most appropriate next step in management?

*Laparotomy* - surgical management can be accomplished via laparotomy or laparoscopy Dermoid / Benign cystic teratomy - type of ovarian germ cell tumor = most common neoplasm in women <20 yo - most common benign ovarian neoplasm - surgical management = most appropriate next step in management --> as adnexal masses enlarge (>5 cm), risk for ovarian torsion increases - removal of dermoid = indicated to prevent torsion

5 wk old infant brought to doc by her parents bc of 4 wk ho loud breathing. Parents report that loud breathing increases when child is asleep & when she cries. She has also had low-grade fever & rhinorrhea for past 4 days. Physical exam shows infant in mild distress & inspiratory stridor is heard on auscultation of chest. It is loudest in supine positions & lessens in prone. Most likely diagnosis?

*Laryngomalacia* Stridor on exam - inspiratory obstruction that is sensitive to air-flow changes - most common cause of stridor in neonates & young infants - congenital abnormality of laryngeal cartilage - noises on inspiration usually begin in first 2 mos of life but may be present from birth - noise often increased when baby supine, during crying or agitation, & during periods of upper respiratory infection - diagnosis may be confirmed by flexible laryngoscopy - most cases = improvement over first year - severe cases = surgery

At health-fair screening, obese 68 yo woman found to have random blood sugar of 360 mg/dL. Subsequent tests show fasting levels of 240 mg/dL & glycosylated hemoglobin A1c level of 12%. Ophthalmologic eval shows "cotton-wool" spots, microaneurysms, macular edema, & neovascularization. Most appropriate management to prevent vision loss in this pt?

*Laser photocoagulation* - induce regression of proliferative diabetic retinopathy - reduces/eliminates macular edema Nonproliferative (cotton-wool spots, microaneurysms) + proliferative (neovascularization) = indication for laser treatment

64 yo woman who is obese comes to doc bc of chest pain. She states that she has been experiencing progressively worsening dull, retrosternal chest pain exacerbated by climbing stairs and walking more than 2 blocks to the grocery store. She denies dyspnea or syncope. She has smoked one pack of cigarettes daily for past 25 yrs. She appears comfortable at rest. Physical exam shows feeble, slow-rising carotid pulse. There is systolic thrill and forceful apex beat. Breath sounds are clear bilaterally. What is the most accurate diagnostic test?

*Left heart catheterization & angiography* Aortic stenosis - most common cause in elderly = calcification & degeneration of congenitally normal valve - either asymptomatic or present with classic triad = syncope, angina, dyspnea - most accurate test in pts with valvular lesion = cardiac cath & angiography --> accurately delineates position & nature of lesion & determines ejection fraction & left heart pressures

56 yo man evaluated in ED bc of 1 wk ho fever, headache, diarrhea, cough productive of yellow sputum. He also has 2 day ho progressive dyspnea. On physical exam, temp is 38.8 C (101.8 F), BP 110/60 mmHg, pulse rate 110/min, & RR 28/min. Oxygen sat is 85% while breathing 100% oxygen by nonrebreather mask. Bronchial breath sounds heard over left & right lower lung fields. Lab studies show leuckocyte count of 4000/uL, platelet count of 97,000/uL, & serum sodium level of 131 mEq/L. Chest radiograph shows findings consistent with consolidation in left & right middle & lower lobes. Pt intubated, & mechanical ventilation initiated. Blood cultures obtained, empiric antibiotic therapy began, & pt admitted to ICU. In addition to endotracheal aspirate for Gram stain & culture, what is the most appropriate next step in evaluation?

*Legionella & Streptococcus pneumoniae urine antigen assays* Diagnosing severe CAP - CAP in pt who requires admission to ICU or transfer to ICU within 24 hrs of admission - recommendations = blood cultures, Legionalla & Streptococcus pneumoniae urine antigen assays, endotracheal aspirate for Gram stain & culture - Legionella should be suspected in this pt, who is older than 50 yo & presents with severe pneumonia w/ extrapulmonary symptoms (headache, diarrhe,a hyponatremia)

56 yo woman evaluated for 12 mo history of slowly progressive fatigue, weight gain, & constipation. She has no other med problems. On physical exam, vital signs are normal. Thyroid non-tender & diffusely enlarged to appx twice normal size. Ankle deep tendon reflex recovery phase delayed. Serum TSH level is 61.2 uU/mL, & serum free thyroxine level is 0.7 ng/mL. Thyroid peroxidase antibody titer positive. Most appropriate therapy for this pt?

*Levothyroxine* Hypothyroidism: Hashimoto thyroiditis / chronic autoimmune thyroiditis - reduced basal temp, diastolic HT, enlarged thyroid gland, bradycardia, pallor, dry, cold skin, brittle hair, hoarseness, delayed recovery phase of deep tendon reflexes - associated with positive thyroid peroxidase Ab measurement - mainstay treatment = thyroid hormone replacement: oral levothyroxine (T4) = should be taken on empty stomach 1 hr before or 2-3 hrs after intake of food or other meds

5 yo boy brought to doc due to recurrent leg pains. Boy has been complaining for several weeks about pain deep in both lower legs, usually occurring soon after going to bed. Pain is severe enought to interrupt sleep & make child weep in middle of night. He derives relief after taking some analgesics. His parents deny any daytime pain, weight loss, or fever in child. He does not limp, & normal patterns of activity are maintained. Physical exam is unremarkable. Most appropriate next step in management?

*Massage and reassurance* "Growing" pains - affect children between 3-10 yo - lower legs & knees, bilateral - deep pain during rest (bedtime especially) - relieved by massaging or simply analgesics - awake the next morning feeling fine - often have familial predisposition

Baby boy born at term without probz & is discharge home within 24 hrs. Mother is breast-feeding, having done this for her previous child. She takes baby to his pediatrician 2 days after delivery bc of early hospital discharge. At this time the feeding is going well, he is not jaundiced, & he is having normal stools. The next well-child visit is scheduled for 2 wks of age. At this time his cardiovascular exam shows grade IV murmur starting after first heart sound & extending into diastole. It is heard best in left second intercostal space & radiates to clavicle. There is also prominent apical impulse, bounding pulses, & wide pulse pressures. What is the definitive corrective procedure for this anomaly?

*Ligation* Congenital heart lesion not producing cyanosis - left-to-right shunt, obstructive lesion, or regurgitant lesion - this pt: lesion not apparent until 2-wk visit Patent ductus arteriosus *PDA) - loud murmur - associated with thrill (grade IV) - hear best in left intercostal space - systolic murmur that spills well into diastole = "machinery" murmur - wide pulse pressure - includes bounding pulses - definitive surgical correction = ductal ligation

20 yo woman comes to doc bc she has never had period. She has no med probz, has never had sx, & takes no meds. Physical exam shows that she is tall female with long extremities. Breast dev't is normal with pale areolas. Pelvic exam significant for scant pubic hair & short, blind-ended vaginal pouch. Bc of her condition, pt is at risk for malignancy from what?

*Location of gonads* Androgen insensitivity syndrome - normal female phenotype + male genotype (46,XY) - absent or sparse genital hair, absent uterus, normal male testosterone levels Tumors: germ cell tumors & gonadoblastomas - 2% of undescended testes = should be removed after puberty

23 yo gravida 3, para 2 woman at 42 wks' gestation comes to doc bc of decreased fetal movement over last 48 hrs. She has only had 3 prenatal visits - 12 wks, 25 wks, & 34 weeks - all of which revealed normal findings. Her past med hx is positive for use of cocaine, last used 2 wks ago. Her temp is 98.9 F, BP 140/90 mmHg, pulse 90/min, & respirations 16/min. Physical exam shows fundal height measurement is 41 cm. On pelvic exam her cervix is closed, posterior, & firm. Non-stress test with biophysical profile shows variable deceleration with fetal heart (FHR) at 160/min & an amniotic fluid index (AFI) of 3. She is placed on nasal cannula at 5 L, pulse oximeter, & is moved to left lateral decubitus position for 15 minute. Most likely cause of fetal heart tracings?

*Low amniotic fluid index* - can cause compression of umbilical cord seen on fetal heart monitoring as variable decelerations = abrupt decelerations in FHR below baseline of at least 15/min with onset of nadir of <30 seconds on NST Amniotic fluid index (AFI) - calculated by ultrasound - oligohydramnios = AFI<5 cm = can be caused by decrease in placental function

A 65-year-old woman seeks consultation in the office regarding lung cancer screening. She has a 40-pack-year history of cigarette smoking and continues to smoke. Her only active medical problem is chronic obstructive pulmonary disease treated with daily tiotropium inhaler and an albuterol inhaler as needed. On physical examination, her vital signs are normal. Breath sounds are distant with occasional wheezing. The remainder of the physical examination is normal. Which of the following screening tests can be recommended?

*Low-dose spiral chest computed tomography* - inc current or prior smokers with min 30-pack-year smoking history - former smokers who have quit within pas 15 years Lung cancer screening

A 75-year-old man is evaluated in the hospital because of community-acquired pneumonia. He is bedbound. He has heart failure and hypertension. Medications are lisinopril and carvedilol. On physical examination, temperature is 38.6°C (101.4°F), blood pressure is 110/65 mm Hg, pulse rate is 90/min, and respiration rate is 24/min. The patient has right lower lobe bronchial breathing and egophony. Leukocyte count is 17,000/µL (17x 109/L). Chest radiograph shows right lower lobe consolidation. Which of the following is the most appropriate venous thromboembolism prophylaxis in this patient?

*Low-dose subcutaneous unfractionated heparin* - patient immobilized & has at least 2 major risk factors for VTE (age older than 60 yo + acute infectious illness) --> should receive pharm VTE prophylaxis with low-dose unfractionated heparin for at least duration of hospitalization

33 yo woman comes to ED bc of 2 day ho severe headache. Headache occurred suddenly & awoke her form sleep. She has never had headache like this before. She has smoked one pack of cigz daily for 15 yrs & drinks alcohol socially. She admits to occasional cocaine use. Her mother & sister are currently on hemodialysis. What studies is most sensitive test to diagnose this pt's condition?

*Lumbar puncture with spectrophotometry* - most sensitive diagnostic test = yellowing fluid from hemolysis of RBCs = xanthochromia - spectrophotometry detects blood breakdown products as they progress from oxyhemoglobin to bilirubin SAH - worse headache of life - may also have blurry vision - fam hx suggests polycystic kidney dz = aneurysm formation in circle of Willis - smoking = risk factor

12 yo boy presents for eval in office. His mother states that he has been getting bad grades in school. Boy has been attributing it to diminished vision & has been taking a lot of days off from school. Has also been getting frequent throbbing headaches. According to mother, boy has not had any health problems until recently. He was born at 39 weeks by C-section. All immunizations were done on time. He has been doing well at school until recently. He denies any head trauma, weight changes, or history of taking any med. Physical exam remarkable for decreased visual acuity. Boy also has peripheral visual field defects. Fundus exam shows papilledema bilaterally. Left-sided sixth-nerve palsy present. No other neurologic deficits. Remainder of physical exam normal. MRI of head normal. What would be most appropriate next step in management of this patient's condition?

*Lumbar puncture* - increased CSF pressure but normal CSF contents Pseudotumor cerebri / Idiopathic intracranial HT - increased ICP (headache, diminished vision, papilledema) despite normal MRI - initial med therapy = acetazolamide

34 yo woman evaluated for 2 mo ho tremors & hot flashes. During this time she has unintentionally lost 6.8 kg (15 lbs). Her menstrual cycles have been irregular for 3 months. She has no other med problems & takes no meds. On physical exam, temp is normal, BP is 140/90 mmHg, pulse rate 92/min, & RR 20/min. BMI 19. Mild stare present (white sclera noted above iris), but no proptosis or periorbital edema evident. Thyroid normal size. Fine bilateral tremor present. Serum TSH level is 0.11 uU/mL & serum free thyroxine level is 1.9 ng/dL. Serum pregnancy test negative. Radioactive iodine uptake low. Most likely diagnosis?

*Lymphocytic thyroiditis* / chronic thyroiditis - transient destruction of thyroid tissue - hyperthyroidism - increased T4 & T3 + low TSH - usually follows classic course of appx 6 wks of hypothyroidism, & then restoration of euthyroidism

Patient has recurrence of small cell carcinoma of lung following initial systemic chemotherapy & radiation. Cells taken from tumor. In vitro treatment of cells with various chemotherapeutic agents fails to result in growth arrest or death of these cells. What proteins is likely expressed in increased quantities in these cells & accounts for their observed response to chemotherapeutic agents?

*MDR-1* - also known as P-glycoprotein or ABCB1 or multidrug resistance related protein (MRP, ABCC2) - function as efflux pumps - actively transport chemotherapeutic agents out of malignant cells - original function in healthy tissue = protection from harmfuol foreign substances - cell line has grown from recurrent small cell lung carcinoma (SCLC) in patient who has been previously treated with systemic chemo & radiation

Type 1 diabetes is under primary genetic control by

*MHC-HLAs* - most common autoimmune dz seen with T1DM in children are hypothyroidism (most common) & celiac dz

56 yo woman with metastatic breast cancer admitted to hospital bc of back pain & urinary incontinence. Patient was diagnosed originally with lymph node-positive, estrogen receptor-negative, progesterone receptor-negative, Her2-Neu-negative breast cancer 3 years ago. She underwent total right mastectomy & completed adjuvant chemotherapy with Adriamycin, cyclophosphamide, & paclitaxel. Bone scan showed positive radioisotope uptake in T10, L5, L3, & right 5th rib. Pleural tap revealed exudative effusion with cytology positive for adenocarcinoma cells consistent with patient's known primary diagnosis. Appx 2 months ago she started noticing lower back pain that became progressively worse, & this morning she lost control of her bladder function. She decided to come to ED. On physical exam, she is in mild distress from back pain & has indwelling urinary catheter in place, her left UE strength is 5/5, left LE strength is 4/5, & right UE strength is 5/5. In addition to initiating steroid therapy, what is the most appx initial management?

*MRI of thoracic & lumbar spine* = higher resolution - epidural compression of spinal cord - expeditious diagnosis & treatment required - compression at thoracic (70%), lumbar (20%), cervical (10%) - 50% of epidural compression cases arise from breast, lung, or prostate *Stepwise management of suspicious spinal metastatic lesions with epidural compression = immediate IV dexamethasone followed by MRI* --> neurosugical consult

23 yo man known to have type 1 neurofibromatosis (von recklinghausean dz) presents with left lower quadrant abdominal mass & signs of neuro deficits in his left leg. In following workup, it is determined that he has higher than normal levels of metabolites of epinephrine & NE in 24-hr urinary collection. He is currently normotensive. Before invasive step are taken to biopsy & eventually remove his LLQ abdominal mass, what is the most appropriate next step in management?

*MRI scan of his adrenal glands* Even though pt is now normotensive, invasive steps might trigger HT crisis from previously undiagnosed pheochromocytoma - presence of epi metabolites = tumor is in adrenal glands & not at extra-adrenal site - diagnosis of pheo can best be confirmed by MRI scan of adrenals

42 yo man comes to doc bc of lower back pain for 3 days. 3 days ago, he bent over to lift refrigerator, & 2 hrs later, he developed back pain. There is no radiation to buttocks or legs. His med hx is unremarkable. He uses IV drugs. His temp is 103 F, BP 108/65 mmHg, & pulse is 102/min. There is no tenderness along spine; straight leg raise testing is normal. Muscle strength is 5/5 in LEs, & sensation is normal. Most appropriate diganostic study?

*MRI scan of lumbosacral spine* Hx of of IV drug use + low back pain + fever + spinal epidural abscess --> imaging study needed to visualize soft tissues surrounding spine - MRI scan = preferred test = positive early in course of infection & provides best image of inflammatory changes - CT scan with contrast = acceptable alternative Indications for imaging in pts who have back pain - progressive neuro findings - constitutional symptoms - hx of traumatic onset - hx of malignancy - age <18 yo or >50 yo - infectious risks like injection drug use - immunosuppression - indwelling urinary cath - prolonged steroid use - osteoporosis

62 yo woman has hard, 4.5 cm mass under nipple & areola of her rather small left breast. Mass occupies most of breast, but breast is freely movable from chest wall. There is no dimpling or ulceration of skin over mass, & careful palpation of axilla is completely negative. Core biopsy specimen of breast mass establishes diagnosis of infiltrating ductal carcinoma, & mammogram shows no other lesions in either breast. Chest x-ray film & liver function tests are normal. She has no symptoms suggestive of brain or bone mets. What should be offered to this woman?

*Mastectomy & axillary sampling* - any malignant mass >4cm exceeds criteria to perform lumpectomy --> mastectomy indicated - axillary node sampling required in all suspicious lesions to determine postoperative systemic therapy

What is an acceptable method of selecting an appropriately sized oropharyngeal airway (OPA)?

*Measure from the corner of the mouth to the angle of the mandible*

25 yo nulliparous woman at 35 wks' gestation comes to labor & delivery ward complaining of contractions, a headache, & flashes of light in front of her eyes. Her pregnancy has been uncomplicated except for episode of first-trimester bleeding that resolved completely. She has no med probz. Her temp is 98.6 F, BP 160/110 mmHg, pulse 88/min, & respirations 12/min. Exam shows that her cervix is 2 cm dilated & 75% effaced, & that she is contracting every 2 minutes. Fetal heart tracing is in the 140s & reactive. Urinalysis shows 3+ proteinuria. Lab values are as follows: Leukocytes 9,400/mm^3 Hct 35% Platelets 101,000/mm^3 AST 200 U/L ALT 300 UL Most appropriate next step in management?

*Magnesium sulfate* - most effective med for seizure prophylaxis in women with preeclampsia HELLP syndrome - hemolysis + elevated liver enzymes + low platelet count - extreme form of severe preeclampsia - may present with edema, proteinuria, headache that doesn't respond to analgesics, visual changes, seizure, elevated BP, pulmonary edema, elevated liver function tests, severe proteinuria, oliguria, elevated creatinine, thrombocytopenia, hemolysis, intrauterine growth restriction, oligohydramnios - management of severe preeclampsia after 34 weeks = delivery This pt... 35 weeks w/ symptoms --> delivery best option - already in labor = contracting every 2 minutes + cervix dilated & effaced

58 yo woman undergoes preoperative evaluation before coronary artery bypass surgery that is scheduled for trrow. She has been hospitalized in cardiac ICU for 4 days after collapsing & experiencing cardiogenic shock. She was intubated in field & given mechanical ventilation in ICU. She is being treated with both paralytic & sedating meds in addition to PPI & IV nitroglycerin. On physical exam, pt's condition has stabilized & she is afebrile. No attempts are made to wean her from ventilator bc of her impending surgery & her heart condition. What is the most appropriate measure to prevent ventilator-associated pneumonia in this patient?

*Maintain head of bed at angle of greater than 30 degrees* Prevent ventilator-associated pneumonia - develops more than 48-72 hrs after initiation of mechanical ventilation - reduce via "bundle" = maintaining head of pt's bed at angle of greater than 30 degrees; performing daily assessment of pt's reading to wean from ventilator - using chlorhexidine mouthwash

Otherwise 24 yo man, undergoing supraclavicular node biopsy under local anesthesia, suddenly dies after hissing sound heard by staff carrying out procedure. At time of event, target node was under traction, & final cut was being made blindly behind it to free it completely. Pt was inhaling at that moment. What most likely cause pt's death?

*Major vein injury with air embolism* - major veins at base of neck have negative pressure during inspiration &, if injured at that moment, will suck air rather than bleed - air embolism --> sudden death - large bolus of air entering venous system --> air lock in right atrium & ventricle --> outflow obstruction = decreased pulmonary venous return = decreased left ventricular preload & cardiac output Primary causes of air embolism are surgical procedures - surgical procedures: neurosurfical procedures done with pt upright/sitting - obstetric/gynecologic procedures: C section - base on neck dissection: lymph node biopsy - craniofacial surgery - dental implant surgery - vacular procedures - liver transplant - orthopedic procedures (hip replacement, arthroscopy) - central line placement

35 yo man w/ no significant med hx presents to ED with severe chest pain. Pain is worse with ingestion of cold or hot liquids. There is no ho weight loss & no oral lesions. Remainder of physical exam is normal. Cardiac workup is negative. What is the MOST appropriate diagnostic test to confirm diagnosis?

*Manometry* - can confirm diagnosis by revealing intermittent simultaneous contractions Parasternal pain ppted by cold, hot, or carbonate liquids = suggestive of esophageal spasm = simultaneous nonperistaltic contraction of esophagus - intermittent high-pressure peristaltic contractions on manometry diagnostic of "nutcracker esophagus" - CCBs or nitrates before meals are useful for chest pain & dysphagia associated w/ esophageal motility disorders

82 yo woman brought to ED from local nursing home bc of severe constipation for 5 days & 1-day ho lower abdominal discomfort & distention. She has ho HT treated with HCTZ & arthritis of both hips treated with acetaminophen & codeine. Her temp is 98.8 F & BP 148/90 mmHg. Abdominal exam shows mid & lower abdominal distention with mild tenderness. Bowel sounds are normal. Rectal exam shows hard stool in vault. Most appropriate next step in management?

*Manual disimpaction* Severe constipation caused by - prolonged immobilization, bowel hypomotility secondary to narcotic, possibly mild dehydration from diuretic use - when stool occupying rectal vault --> manual disimpaction indicated & will = immediate relief

71 yo man who underwent hemicolectomy of colon cancer 36 hrs ago started to complain of pain at site of his Foley cath. His temp is 100.2 F, BP 123/79 mmHg, pulse 88/min, & respirations 22/min. Narcotics, urinalysis, & urine culture ordered. Nurse called few hrs later & stated that pt was complaining of persistent penile pain. His urinalysis returns as negative for leukocyte esterase, WBCs, & nitrites. Nurse was asked to change cath; however, she was reluctant to do so secondary to "a prob" with pt's penis. There has been on change in his vital signs. His abdomen is mildly distended & soft, with clean dressing in place. On exam of penis, Foley cath is located in meatus. Glans penis exposed, edematous, & dusky, & a penile skin is very edematous with ring of foreskin around portion of penis proximal to glans. Entire penis is tender to palpation. Best course of management?

*Manually reduce pt's foreskin* Paraphimosis painful swelling of foreskin distal to phimotic ring - occur if foreskin remains retracted for prolonged period of time - swelling sufficient to make reduction of foreskin over glans difficult = *emergency* - ring of foreskin (doughnut) very tight around penis & acts as tourniquet --> may lead to penile ischemia & possibly necrosis & gangrene - common when pt has Foley cath inserted & person placing Foley does no replace foreskin over should be glans penis To reduce paraphimosis - gentle, steady pressure must be applied to foreskin to decrease swelling --> may push against glans penis with thumbs = pull foreskin with fingers --> if unsuccessful, dorsal slit may be performed at bedside to relive penile ischemia

65 yo woman consults a doc bc of 3 mo hx of weight loss, burning sensation of tongue, fatigue, anorexia, & poorly localized abdominal pain. Woman appears pale to doc & she does not feel tuning fork that the doc placed on big toe bilaterally. In-office hct is 35%. Upper endoscopy performed that reveals inconspicuous rugae on gross inspection. Multiple stomach & esophageal biopsy specimens are sent & pathology pending. What is most likely to be found on further lab testing?

*Markedly elevated serum gastrin levels* Pernicious anemia - autoimmune gastritis --> lack of intrinsic factor needed to absorb vit B12 - upper endoscopy reveals either complete loss or inconspicuous rugae on gross inspection

28 yo woman with hx of peptic ulcer dz comes to doc bc of watery diarrhea for 5 mos. She has had severe burning sensation in her chest & abdomen following meals. She underwent therapy with amoxicillin, clarithomycin, and omeprazole 2 mos ago without improvement in her chest & abdominal pain. Her temp is 98.6 F, BP is 110/67 mmHg, pulse is 86/min, & respirations are 12/min. Abdominal exam shows no distention, tenderness, or shifting dullness. Upper endoscopy shows 3 ulcers in first & second portions of duodenum. Most appropriate next step in management?

*Measurement of serum gastrin* Virulent & extensive PUD should triggen work-up for gastrinoma (ZES) - multiple ulcers in duod or jejunum - presence of watery diarrhea --> suspicion that gastrinoma present - serum levels should be measured after pt has stopped taking PPIs for at least 1 wk (falsely elevates levels) - level >1,000 pg/dL = diagnostic of gastrinoma - eleavted but <1,000 pg/dL --> perform secretin stimulation test - if gastrin levels increase after injectio nof secretin = confirms gastrinoma

5 yo girl brought to doc by her mom bc of anal itching for 2 wks. Mom reports that girl wakes up at night crying & scratching her buttocks & anus. She has no fever, weight loss, nausea, vomiting, or diarrhea. Girl recently started kindergarten. She appears well nourished. Abodmen is nontender. Genital exam shows no abnormalities. Microscopy of clear scotch tape pressed against perianal skin shows bean-shaped eggs. Most appropriate pharmacotherapy?

*Mebendazole* Anal pinworms / Enterobius vermicularis - common in daycare & schools - mebendazole & albendazole = first-line - treatment done with single dose, followed by second dose 2 weeks later to prevent recurrence from reinfection

18 yo army recruit goes on 24 hr forced march. When he urinates 2 hrs after end of march, his urine is red-tinged. He goes to infirmary where disptick test of urine is positive for hemoglobin. When blood is spun in small hematrocrit machine available in infirmary, overlying serum has red color & hematocrit is 35%. Creatinine kinase serum levels are normal. Peripheral smear shows few odd-shaped RBC fragments. Pt's anemia most likely due to what?

*Mechanical injury to red cells* Traumatic hemolytic anemis - prolonged forced march --> repeatedly compressed tiny blood vessels = fragmentation of some RBCs - triangle & helmet shapes - MCV may be low & RDW high = mixture of normal & fragmented RBCs - rhabdomyolysis could be differentiated from traumatic hemolysis by very high creatinine kinase

A 63-year-old man is evaluated in the emergency department for facial swelling and mild dyspnea. He reports no headache, change in vision, or chest pain. He has a 40-pack-year history of tobacco use. On physical examination, his temperature is 37.0°C (98.6°F), blood pressure is 150/95 mm Hg, pulse rate is 100 beats/min, and respiration rate is 18 breaths/min. Oxygen saturation is 95% with the patient breathing ambient air. He has facial plethora and bilateral jugular venous distention. Wheezing is noted in the left upper lung field, but the lungs are otherwise clear. Cardiac examination findings are normal. There is no peripheral edema and no lymphadenopathy in the head or neck. Chest radiograph reveals a widened mediastinum and a left upper lobe infiltrate. A computed tomography scan of the chest demonstrates a left upper lobe mass with impingement on the superior vena cava and mediastinal lymphadenopathy. Which of the following is the most appropriate next step in management?

*Mediastinoscopy & biopsy* Most appropriate initial management of pts with SVC syndrome depends on histopathology - necessary to obtain tissue diagnosis

10 yo boy brought to ED bc of difficulty walking, headache, nausea, & vomiting for past 3 days. Neuro exam reveals nuchal rigidity & papilledema. CT scan reveals infiltrating cerebellar tumor, which is located in the midline (vermis), with plaque-like extensions onto the cerebellar surface. There is no cystic component. Fourth ventricle compressed, & third & lateral ventricles are dilated. His 3 siblings are all healthy. Most likely diagnosis?

*Medulloblastoma* - grows from celebellar vermis - hydrocephalus via obliteration of fourth ventricle - gait abnormalities prominent - sheets of undiff cells with scanty cytoplasm & immunohistochemical features of neuronal or astrocytic differentiation - extension of cerebellar surface = sugar coating / drop metastasis to spinal cord through CSF = mode of spread of tumor - rapidly growing - highly responsive to radiation & chemotherapy - primary brain tumors = second most common malignancy of childhood

34 yo woman comes to doc bc of 6 mo ho ringing in her ears, feeling of spinning, & progressive hearing loss in her left ear. Spinning sensation is episodic & lasts 30-60 minutes. During these episodes, she has had nausea & vomiting. She denies fever, chills, cough, & ear or throat pain. She has ho hypothyroidism & fibromyalgia. Current meds include levothyroxine & ibuprofen. Her father died of MI at age 54 yo. Her BP is 130/70 mmHg, pulse is 62/min, & respirations are 15/min. Exam shows left-sided hearing loss. MRI scan of head shows no abnormalities. Most likely diagnosis?

*Meniere disease* - relatively severe vertigo attacks accompanied by prominent tinnitus, fluctuating hearing loss, sensation of ear fullness or pressure - diagnosis made only if pts have episodic vertigo & sensorineural hearing loss - associated with endolymphatic hydrops - chronic - treatment = symptomatic

A 35-year-old woman is evaluated for a 1-week history of right knee pain that began when she jumped from a 4-foot height and twisted her knee. At the time she felt a popping sensation; her knee became swollen over the next several hours. She has continued to have moderate pain, particularly when walking up or down stairs. There is no locking or "giving way" of the knee. She reports no previous knee injury. On physical examination, vital signs are normal. The right knee has a minimal effusion. There is full range of motion. The medial aspect of the joint line is tender to palpation. Maximally flexing the hip and knee and applying abduction (valgus) force to the knee while externally rotating the foot and passively extending the knee (McMurray test) results in a palpable snap. What is the most likely diagnosis?

*Meniscal tear* - typical = twisting injury with foot in weight-bearing position = popping or tearing sensation often felt, followed by severe pain - swelling over several hours - locking or clicking of knee secondary to loose cartilage in knee - often have pain only on walking, particularly going up or down stairs - audible pop or snap on McMurray test = 97% for such a tear

Young mom complains of pain along radial side of wrist and first dorsal comp't. She relates that pain is often caused by position of wrist flexion & simultaneous thumb extension that she assumes to carry head of her baby. On physical exam, pain is reproduced by asking her to hold her thumb inside her closed fist, & then forcing wrist into ulnar deviation. Most likely diagnosis?

*Tenosynovitis of abductor or extensor tendons of thumb* / de Quervain's tenosynovitis - diagnosis via hx & physical - characteristic pain on radial side of wrist & first dosral comp't - via pain being reproduced by Finkelstein test - via palpation over dorsal radial comp't of bone-hard thickening

A 45-year-old man is brought to the emergency department after being found unresponsive in an alleyway. Medical history is unknown, although his breath smells of alcohol. On physical examination, he is obtunded and responds only to noxious stimuli. Temperature is normal, blood pressure is 95/70 mm Hg, pulse rate is 115/min, and respiration rate is 12/min. General physical examination is unremarkable. Except for his altered mental status, the neurologic evaluation is nonfocal. Lab studies: Electrolytes: Sodium = 135 mEq/L (135 mmol/L) Potassium = 3.8 mEq/L (3.8 mmol/L) Chloride = 92 mEq/L (92 mmol/L) Bicarbonate = 12 mEq/L (12 mmol/L) Arterial blood gas studies (ambient air): pH = 7.08 PCO2 = 42 mmHg (5.6 kPa) What acid-base disorders is most likely present?

*Metabolic acidosis, metabolic alkalosis, & respiratory acidosis* - low arterial pH = acidosis - low serum bicab = metabolic acidosis Expected PCO2 = (1.5x[HCO3] + 8) +/- 2 = 26 +/- 2 - confirms measured PCO2 is inappropriately elevated for degree of expected compensation for metabolic acidosis - mixed acid-base disturbances are common in patients with multiple medical issues affecting metabolic & resp systems

A 39-year-old man is evaluated in the emergency department because of the acute onset of severe right flank pain. The pain is described as sharp and radiates to the groin. He vomited six times prior to presentation. Med history unremarkable, & he takes no meds. On physical examination, the patient is in distress because of the pain. Temperature is normal, blood pressure is 148/88 mm Hg, pulse rate is 110/min, and respiration rate is 30/min. There is tenderness to palpation over the right flank. The remainder of the examination is unremarkable. Lab studies: Electrolytes: Sodium = 141 mEq/L (141 mmol/L) Potassium = 4 mEq/L (4 mmol/L) Chloride = 100 mEq/L (100 mmol/L) Bicarb = 34 mEq/L (34 mmol/L) Arterial blood gas studies (ambient air): pH = 7.60 PCO2 = 36 mmHg (4.8 kPa) PO2 = 59 mmHg (7.8 kPa) Computed tomographic scan of kidneys demonstrates nonobstructing kidney stone at ureteropelvic junction on right. What best describes patient's acid-base disorder?

*Metabolic alkalosis & respiratory alkalosis* - metabolic alkalosis = high serum bicarb = arterial pH > 7.4 - PCO2 has decreased to 36 mmHg (4.8 kPa) = presence of concurrent respiratory alkalosis - met alk probz result of vomiting - resp alk probz due to pain-induced hyperventilation - both effect of patient's kidney stone

44 yo man complains of vague right upper abdominal discomfort that he has had for appx 1 mo. He describes no other symptoms &, except for enucleation of one eye at age 21 "for a tumor," he has been in excellent health all his life. He exercises regularly & does not smoke or drink. The only findings on physical exam include artificial eye & a tender, enlarged, & nodular liver. Viral hepatitis serology is negative. CT scan of upper abdomen demonstrates multiple masses within liver. Biopsy specimens of these masses will most likely reveal what?

*Metastatic malignant melanoma* 2 malignant tumors of eye for which enucleation would be performed - retinoblastoma & melanoma Melanoma - unique timeline: 20+ years elapse b/t primary tumor & metastatic manifestations - pt + glass eye & liver full of multiple tumors = 1 of 2 classic examples given (other one has missing toe) to illustrate unpredictable behavior of melanoma - can be followed clinically by monitoring tumor marker tyrosinase

A 47-year-old woman is evaluated for a 4-month history of a sensation of "thumping" in her chest. She reports feeling as if her heart stops when these episodes occur. The symptoms occur frequently throughout the day but are more noticeable at night. She finds them bothersome and notes that her symptoms appear to decrease with exercise. She reports no chest pain, dyspnea, orthopnea, or edema. She is healthy and active and takes no medications. On physical examination, the patient is afebrile, blood pressure is 110/67 mm Hg, and pulse is 72/min with occasional ectopy. Cardiac auscultation is normal except for occasional extra beats. There are no murmurs, gallops, or clicks. The remainder of her examination is unremarkable. Electrocardiogram shows sinus rhythm with normal intervals and occasional premature ventricular contractions with varying morphologic patterns that correspond to her symptoms of palpitations. Echocardiogram shows a structurally normal heart. Which of the following is the most appropriate treatment for this patient?

*Metoprolol* - suppress premature ventricular complexes Treating symptomatic premature ventricular complexes - spontaneous depolarizations originating in ventricles - beats usually followed by compensatory pause = patients may feel as if their heart is stopping - in absence of structural heart dz, prognosis is benign

24 yo student brought to ED bc of sudden change in behavior. His friends report that he has been acting "weird" and confused & has been talking about "flying above floor" since being at party night before. Student laughs loudly without reason & then bursts into tears. He appears hot & has uncoordinated movements. On physical exam, he has horizontal nystagmus, ataxia, & muscular rigidity, & becomes very agitated & combative during exam. What agents should be administered at this time to treat agitation?

*Midazolam* - benzos preferred (antipsychotics can amplify hyperthermia, dystonic rxns, anticholinergic effects, & can even lower seizure threshold) PCP intoxication - treated with benzos = diazepam, midazolam, lorazepam OR antipsychotics = haloperidol - cranberry juice or ascorbic acid can be useful to acidify urine & speed up drug elimination

23 yo gravida 1, para 0 woman at 32 weeks' gestation who has dichorionic, diamniotic twin gestation comes to doc for routine prenatal check-up. She has some epigastric pain that has been progressive over last 3 days that has been unrelieved with Tums. Her prenatal course has been uncomplicated thus far. Vital signs on her last visit include temperature 37 C (98.6 F), BP 164/104 mmHg, pulse 87/min, respirations 13/min. Physical exam shows 2+ pedal edema, fundal height of 37 cm, & mild epigastric tenderness. Urinalysis shows 4+ proteinuria, negative leukocyte esterase, negative blood, & negative glucose. Serum lab testing shows: Sodium = 136 mEq/dL Potassium = 3.6 mEq/dL Chloride = 100 mEq/L Bicarbonate = 18 mEq/L BUN = 55 mg/dL Creatinine = 0.8 mg/dL WBCs = 9,000/mm^3 Hemoglobin = 10 mg/dL Hematocrit = 31% Platelets = 175,000/mm^3 AST = 32 U/L ALT = 28 U/L Most likely diagnosis?

*Mild preeclampsia* - sustained BP >140/90 mmHg & proteinuria 1-2+ on urine dipstick or >300 mg in 24 hours after 20 weeks' gestation

35 yo man comes to PCP for annual appointment. Feeling fine & does not have any complaints. Past med history significant for only GERD, for which he takes omeprazole. He works as engineer & does not smoke or drink alcohol. Vitals are normal & his physical exam does not reveal any abnormalities. His complete blood count & BMP within normal limits. Chest x-ray shows 0.90-cm solitary pulmonary nodule that has popcorn calcifications. No previous x-ray available for comparison. Most appropriate next step in management?

*Serial CT scans every 3 months for 2 years* Pt <35 yo + no smoking hx + calcified lesion in lung <1cm - low risk --> followed up with serial CT scans - benign lesions = coarse, popcorn-like, diffuse, central, laminar, concentric calcifications

42 yo HIV-positive woman presents to ED with abdominal pain & fever. She has noticed increasing pain in her RUQ. Her husband has noticed that her eyes appear "yellow." Her past med hx is unremarkable. She does not smoke or consume alcohol, nor does she take any meds. On physical exam, vital signs are: temp 101.2 F, HR 102/min, BP 110/72 mmHg. She is obese, & she has scleral icterus. Palpation of abdomen elicits mild to moderate pain over RUQ. Rest of physical exam is normal. An ultrasound of her RUQ is limited due to her body habitus but demonstrate dilated intrahepatic ducts. Lab data are: WBC 13,100/mm^3 Hct 42% Hb 14 g/dL Platelets 255,000/mm^3 Na 138 mEq/L K 4.2 mEq/L Cl 105 mEq/L HCO3 22 mEq/L Creatinine 1.1 mg/dL Total bilirubin 5.33 mg/dL Conjugated bilirubin 4.3 mg/dL ALT 92 U/L AST 88 U/L Alkaline phosphatase 250 IU/L After abx started, pt is taken for ERCP, which demonstrates smooth tapering of common hepatic duct & an abrupt termination of cystic duct with large filling defect & nonvisualization of gallbladder. What is responsible for this patient's presentation?

*Mirizzi syndrome* - via large stone impacted within cystic duct that externally compresses adjacent common hepatic duct --> obstruction of common hepatic duct & intrahepatic bile duct dilatation - ERCP = filling defect in cystic duct caused by stone - smooth tapering of common hepatic duct via stone pressing against & narrowing common hepatic duct - treatment = cholecystectomy - clinical pic = ascending cholangitis = triad of fever, jaundice, RUQ pain - ascending cholangitis frequently caused by superinfection of static bile, often result of biliary obstruction

19 yo man who is a college football player comes to doc for routine physical exam. He states that he feels well and has no specific physical complaints. A soft sytolic murmur is heard on auscultation of the chest. What is the most likely finding?

*Mitral valve prolapse* - most common valvular dz = MVP - mostly among young women - often asymptomatic and goes undiagnosed in population - many cases present similar to anxiety disorder = chest pain, palpitations, lightheadedness - common = normal variant

19 yo obese grl comes to doc bc she often feelstired & sleeps throughout the course of the day. She says she sleeps for about 7 hrs each night, & snores while sleeping. Few wks ago, she collapsed to the floor when she met her dad for the first time after he had a stroke. She remained awake during this episode. She notes that she sometimes finds that she cannot move for few minutes when she first wakes up. She has no significant med hx & denies substance use. Her vital signs are within normal limits. Her physical exam is normal except for obesity. Most appropriate management for this pt's condition?

*Modafinil* - stimulant - less likely to increase risk of addiction that amphetamine Narcolepsy - excessive daytime sleepiness - abnormal REM sleep - cataplexy = pathognomonic = sudden loss of muscle tone ppted by loud noise or intense emotion - inability to move for short period when one first awakens - sleep attacks - hypnagogic & hypnopompic hallucinations

45 yo woman who regularly wears high-heeled, pointed-toe shoes complains of pain in forefoot after prolonged standing or walking. Occasionally she also experiences numbness, burning sensation, & tingling in area. Physical exam shows no obvious deformities & very tender spot in third interspace, between third & fourth toes. There is no redness, limitation of motion, or sign of inflammation. Most likely diagnosis?

*Morton neuroma* / Benign neuroma of third plantar interdigital nerve - diagnosis made at exam by eliciting exquisite pain on palpation of that area - conservative treatment = avoiding high-heeled shoes

21 yo woman comes to doc bc of profuse, malodorous vaginal discharge. She has also experienced burning with urination. She has no past med hx. Physical exam shows greenish-gray, malodorous discharge & petechial lesions on cervix. There is no cervical motion tenderness. Her temp is 99.4 F, BP is 120/80 mmHg, pulse 60/min, & respirations 16/min. Microscopic evaluation of discharge most likely to show what?

*Motile, flagellated organisms* Trichomoniasis - via Trich vaginalis - symptoms = copioius, malodorous/fishy, greenish-gray, "frothy" discharge - vulvar & vaginal epithelium may be erythematous & edematous - colposcopy --> petechial cervical lesions / strawberry cervix - wet mount of discharge --> PMNs & motile trichomonads

68 yo man brought to doc by his wife bc of gait abnormalities & forgetfulness for 2 yrs. 2 yrs ago, he had difficulty with his memory & walking that improved gradually. 2 mos ago, there was sudden deterioration in cognitive function. At that time, his memory & walking worsened. He has 25 yr hx of HT controlled with HCTZ. His BP is 134/84 mmHg & pulse is 78/min. Cardiac exam shows normal S1 & S2; no murmurs heard. Neuro exam shows wide-based, unsteady gait. MMSE shows score of 27/30. Hemoglobin level is 15.4 g/dL. Most likely cause of pt's condition?

*Multi-infarct dementia* / Vascular dementia - prominent gait + motor + visual abnormalities - abrupt stepwise deterioration in mental function - MRI scan more sensitive than CT scan for vascular dementia = cortical & subcortical ischemical changes

Recognize *multifocal atrial tachycardia* Case: A 68-year-old man is evaluated in the emergency department for shortness of breath and palpitations that have worsened over the last 3 days. His medical history is significant for chronic obstructive pulmonary disease. He has a SO-pack-year smoking history and continues to smoke 1 pack of cigarettes daily. His medications include tiotropium and albuterol metered-dose inhalers. On physical examination, temperature is 37.8°C (100°F) and pulse rate is 122/min. Oxygen saturation on ambient air is 89%. The patient is in moderate respiratory distress. Chest examination shows decreased airflow with diffuse expiratory wheezing. Cardiac examination shows distant heart sounds and an irregular rate with a loud S2 and no murmurs. Laboratory studies show normal electrolytes. The electrocardiogram is shown. Which of the following is the most likely electrocardiographic diagnosis

*Multifocal atrial tachycardia* (MAT) - commonly seen in ill patients, most often in setting of pulmonary dz (such as exacerbation of COPD with associated hypoxia) + electrolyte abnormalities - electrocardiogram = discrete P waves + at least 3 diff't morphologic patterns with varying P-P, P-R, & R-R intervals - morphologic features of P waves generally best seen in leads II, III, & V1 - treatment should be directed toward pulmonary dz & correction of electrolyte imbalances, especially magnesium - treatment = oxygen, inhaled bronchodilators, antibiotics, corticosteroids

Most appropriate management for pt with prostatic abscess

*transrectal ultrasound* - acute prostatitis --> IV abx --> no clinical improvement after 36-72 hrs --> prostatic abscess --> further evaluation with transrectal ultrasound or abdominal/pelvix computed tomography --> prostatic abscess identified --> ultrasound-guided or surgical drainage indicated

A 70-year-old woman is evaluated for a 1 week history of progressive fatigue and anorexia. Medical history is significant for hypertension. Her only medication is hydrochlorothiazide. On physical examination, temperature is normal, supine blood pressure is 150/95 mm Hg and pulse rate is 80/min with orthostatic changes noted on standing, and respiration rate is 20/min. The remainder of the examination is unremarkable. Lab studies: Hct = 29% BUN = 62 mg/dL Creatinine = 4.6 mg/dL Electrolytes: Sodium = 134 mEq/L K+ = 5 mEq/L Cl- 114 mEq/L Bicarb = 15 mEq/L Ca2+ = 12.5 mg/dL Phosphorous = 8.5 mg/dL Urinalysis = Specific gravity 1.010; trace protein; no glucose or ketones Most likely diagnosis?

*Multiple myeloma* - may cause AKI, anemia, hypercalcemia decreased anion gap - AKI = initial presentation in 50% of MM = may result via myeloma proteina on renal tubule or myeloma-associated hypercalcemia = via osteoclast activation *Hypercalcemia in presence of kidney failure should raise suspicion for MM* - kidney injury usually associated with hypocalcemia via hyperphosphatemia & decrease in kidney 1-alpha hydroxylation of 25-hydroxycholecalciferol - high calcium --> vasoconstriction --> prerenal azotemia secondary to volume depletion

27 yo ski instructor complains of nonproductive cough for 10 days. He has also developed low-grade fever & diffuse muscle aches. 2 weeks ago he went to instructors' convention & he thinks that air conditioner in his room was cause of his symptoms. He has been able to work 6 hours per day but has become increasingly dyspneic on long skin runs. He has no prior med hx & does not smoke or drink. He has temp of 100.9 F & has scattered bilateral crackles. He has regular heart rhythm. Remainder of physical exam is normal. Chest radiograph reveals faint bilateral interstitial infiltrates. Most likely diagnosis?

*Mycoplasma pneumonia* - atypical = gradual onset, absence of high fevers & rigors + nonproductive cough - most common bacterial agent causing atypical pneumonia in young pts - suggested on bilateral infiltrates on chest radiograph + mild symptoms

75 yo man has widely disseminated prostate cancer. He is being followed at home bc he has refused any further specific anti-cancer therapy. His hct decreases from previously stable 42% to 25% over 2 mo period. Review of the peripheral blood smear demonstrates normochromia, anisocytosis, poikilocytosis, and nucleated RBCs. Rare immature myeloid cells are also seen in smear. This pt's anemia is best classified as what?

*Myelophthisic anemia* / Leukoerythroblastic picture - via replacement of marrow by other constituents = abnormal hematopoietic cells or nonhematpoietic cells - pushes out normal marrow constituents --> anemia - underlying process = end-stage cancer or granulomatous dz - peripheral blood smear = fragmented & nucleated (immature) RBCs

32 yo woman brought to ED by her husband, who states that his wife suddenly developed severe right back pain appx 3 hours ago. Pain is sharp in nature, radiates toward her groin, & "comes and goes." What pain is most severe, she is unable to catch her breath. She denies any fever, chills, or prior similar episodes. She does complain of urinary urgency & frequency but denies dysuria or hematuria. Her last bowel movement was yesterday & was normal. She does not remember date of her last menses. She is tossing & turning on stretcher & is unable to get comfortable. Her temp is 100 F, BP 125/85 mmHg, & pulse 75/min. Heart & lung exam within normal limits. Abdominal exam reveals decreased bowel sounds diffusely with mild right-sided abdominal pain. There are no peritoneal signs. There is severe costovertebral angle tenderness on right side. Pregnancy test negative. Most appropriate next step?

*NSAIDs & fluids* Renal colic - pain via stretching of collecting system (ureter) or distention of renal capsule - urinary obstruction (usually via calcification) = main cause of renal colic - as stone moves down ureter, local pain is referred to distribution of ilioinguinal nerve & genital branch of genitofemoral nerve

62 yo man brought to ED bc he has been seizing frequently for last hour without regaining consciousness. He has ho small-cell lung cancer. He has no ho HT, diabetes, thyroid disease, or CHF. His temp is 37.4 C (99.3 F), BP is 130/90 mmHg, pulse is 86/min, & respirations are 14/min. Physical exam including fundoscopic exam shows no abnormalities. Lab studies show: Na+ = 112 mEq/L K+ = 4 mEq/L Urea nitrogen = 10 mg/dL Creatinine = 0.8 mg/dL Head CT scan shows no abnormalities. Radiograph of chest shows right perihilar mass unchanged from radiograph 1 month ago. What is the most appropriate next step in management?

*NaCl 3%* Hypertonic saline (NaCl 3% or 5%) Patient = hyponatremia & seizures = acute decrease in serum sodium levels - SIADH via lung cancer Additionally... - furosemide administered with hypertonic saline to promote water loss - corrections should not be faster than 0.5 - 1 mEq/L every hour or 12 mEq/day

15 yo boy brought to doc bc of 3-month ho episodic tingling of his hands, followed by blue discoloration, then red discoloration. Entire lasts appx 5 minutes & usually occurs when he is cold. He has had occasional headaches. He denies fever, weight loss, weakness, rash, arthritis, or SOB. He has ho exercise-induced asthma treated with albuterol. His popz has ho HT. He plays rugby for his school team. He does not smoke cigarettes, drink alcohol, or use illicit substances. His temp is 37.2 C (99 F), BP is 110/70 mmHg, pulse is 70/min, & respirations are 12/min. His O2 sat is 99% on room air. Physical exam shows no abnormalities. Most appropriate next step in management?

*Nail fold microscopy* - drop of oil placed on periungual area --> examined by ophthalmoscope - enlarged, distorted, or paucity of capillary loops = increased risk of CT disease Raynaud phenomenon - sudden onset of cold fingers or toes - lasts up to 20 minutes - erythematous blushing after - starts in one finger & spreads to other fingers - first step in evaluation = complete history & physical exam - must distinguish b/t primary & secondary - history & physical exam not indicative of secondary cause --> next step = nail-fold microscopy

64 yo homeless woman brought to ED bc she complains of bleeding from her breast. Physical exam shows large, fungating, ulcerated mass that occupies entire right breast & is firmly attached to chest wall. Right axilla contains multiple immobile, hard masses. Core biopsy specimens of breast reveal highly undifferentiated infiltrating ductal carcinoma, and assays for estrogen and progesterone receptors are negative. Most appropriate next step in management?

*Neoadjuvant chemotherapy followed by mastectomy* Inflammatory carcinoma - associated with poor prognosis - can be expected to shrink significantly with preoperative chemotherapy = allows resection via modified radical mastectomy = should be considered palliative given advanced nature

5 day old infant brought to ED by his mother bc of poor feeding & irritability for past 2 days; he has had irregular breathing & blue hands & feet for past 4 hrs He was delivered at term to 19 yr old woman, gravida 1, para 1. Mother says that pregnancy was uneventful, but labor was prolonged & membranes had ruptured 20 hrs before neonate was delivered. He appears irritable & is grunting. His temp is 96.1 F, pulse is 85/min, & respirations are 75/min. Exam shows bulging anterior fontanel. There is cyanosis of hands & feet. Most likely diagnosis?

*Neonatal sepsis* - early onset = first week of life - late onset = between age 8 & 28 days - risk factors = maternal infection during pregnancy, prematurity, rupture of membranes >18 hours - signs & symptoms = grunting, tachpnea, cyanosis, poor feeding, irritability, apnea, bradycardia, jitters, tremors, seizures - bulging fontanel may be palpated on physical exam

27 yo woman comes to doc complaining of fever & back pain. She states that 5 days ago she developed burning with urination, progressing to fever with chills & pain on the right side of her back. She has a ho kidney stones, last passing one 10 years ago. She takes no meds. Her temp is 102 F, BP is 110/70 mmHg, pulse is 102/min, & respirations are 16/min. Exam shows pt in mild distress with shaking chills & right costovertebral angle tenderness. Leukocyte count is 18,000/mm^3. Serum BUN & creatinine are normal. Urinalysis shows 100 leukocytes/high-power field. CT scan shows mild right hydronephrosis with 1.5 cm stone in right renal pelvis. She is admitted to hospital & given IV saline & ciprofloxacin. Most appropriate next step in management?

*Nephrostomy tube placement* Complicated pyelonephritis with renal obstruction due to stone - back pain, fevers, chills, dysuria, nausea, vomiting - urine sediment = WBCs, RBCs, white cell casts - if there is evidence of renal obstruction (hydronephrosis) on CT or ultrasound as seen here, nephrostomy tube should be placed

45 yo man comes to ED bc of shaking, palpitations, sweating, & anxiety for 15 mins. He ate lunch 5 hours ago. He has had no chest pain or SOB. His med hx is unremarkable & he takes no meds. He works in hospital as nurse. His temp is 97.7 F, BP is 105/65 mmHg, pulse is 104/min, & respirations are 14/min. His blood glucose is 35 mg/dL, & both serum insulin & C-peptide levels are elevated. Most likely cause of pt's symptoms?

*Neuroendocrine tumor* Insulinoma - seizures, diaphoresis, diplopia, palpitations, syncope - low blood glucose + increased insulin + *C-peptide* - diagnosis via abdominal ultrasound, CT, MRI, octreotide scan

12 yo boy brought to doc by parents bc of "changing spot on his scalp." Patient was born with 1x1-cm bald spot near crown of head that enlarged as he grew. It always had yellowish color never grew hair. Over past few months, parents noted that lesion had become warty & more intensely yellow in color, & they are concerned about these changes. Patient is otherwise healthy & has not significant medical problems. He has not received any medication in previous 6 months & has no known drug allergies. Exam of scalp shows well demarcated 2x3-cm yellow, verrucous plaque with no hair. Surrounding scalp hair appears to be of normal quality & density. What is the most likely diagnosis?

*Nevus sebaceous* (of Jadassohn) = hamartoma = always presents at birth = most often near vertex of scalp = changes = at onset of puberty --> verrucous surface & increases in thickness = increased risk of benign or malignant tumors - treatment = excision at early age

A 34-year-old woman is evaluated for increasing bone pain, dyspnea, and fatigue for the past 2 days. The patient has sickle cell anemia. She was hospitalized 7 days ago for an elective cholecystectomy for which she received 2 units of matched erythrocytes. The operation was uneventful, and she was discharged home in 24 hours. Current medications are hydroxyurea and folic acid. On physical examination, the patient is in pain and has jaundice. Temperature is 37.4°C (99.4°F), blood pressure is 146/85 mm Hg, pulse rate is 116/min, and respiration rate is 12/min. The cardiopulmonary and neurologic examinations are normal. Lab studies: Current value - Hgb = 7.4 g/dL - Leukocyte count = 12,000/uL - Platelet count = 187,000/uL - Reticulocyte count = 2.3% of RBCs - Bilirubin, total = 4.8 mg/dL - Bilirubin, direct = 0.6 mg/dL Values at hospital discharge - Hgb = 9.9 g/dL - Leukocyte count = 8000/uL - Platelet count = 207,000/uL - Reticulocyte count = 5.3% of RBCs - Bilirubin, total = n/a - Bilirubin, direct = n/a Lab findings that would best explain this pt's current clinical presentation?

*New alloantibodies* - tend to occur in pts who receive multiple blood transfusions over time, such as those with sickle cell anemia Delayed hemolytic transfusion rxn (DHTR) - severe pain crisis occurring 5-10 days after receiving transfusion = classic - jaundice, elevated serum indirect bilirubin, current hemoglobin lower than recent value - caused by amnestic minor, non-ABO RBC Ab - *following transfusion, there is 1-1.6% chance of developing minor non-ABO alloantibodies* --> DHTR occurs when pt re-exposed to same Ag with subsequent transfusion

49 yo obese man comes to doc for follow-up visit. He has longstanding hx of retrosternal burning sensation that initially resolved with OTC antacids. After persistent symptoms, his PCP places him on PPI. He receives some relief with this med therapy, but his symptoms progress. He then undergoes an endoscopy that shows severe peptic esophagitis with no dysplastic changes. pH monitoring confirms diagnosis of esophageal reflux. Further, manometry, gastric emptying study, & barium swallow are normal. What should be offered to this pt?

*Nissen fundoplication* - indicated when pts who have GERD develop damaged to lower esophagus, when symptoms persist even with med therapy or if long term med therapy undesirable to younger pt - can be performed laparoscopically - wraps fundus of stomach 360 degrees around lower esophagus to "replace" incompetent lower esophageal sphincter - treatment of choice in all pts who have normal length & motility of esophagus

22 yo woman evaluated for 1 day ho dysuria & urinary urgency & frequency. She had episode of cystitis 2 yrs ago. She has sulfa allergy. On physical exam, temp is normal, BP is 110/60 mmHg, pulse rate is 60/min, & RR is 14/min. There is mild suprapubic tenderness, but no flank tenderness. Remainder of findings on exam are normal. Urine dipstick analysis shows 3+ leukocyte esterase. Pregnancy test is negative. Treatment with what abx is most appropriate in this patient?

*Nitrofurantoin* Acute, uncomplicated cystitis in woman - preferred initial therapy = 3-day course of trimethoprim-sulfamethoxazole if local resistance rates of urinary tract pathogens don't exceed 20% or if infecting organism is known to be susceptible - this pt has sulfa allergy --> should be treated with nitrofurantoin for 5 days = excellent coverage fo rcommon organisms responsible for cystitis & has minimal propensity to select for drug-resistant organisms = should not be used if early pyelonephritis suspected

35 yo man is seen for follow-up evaluation. He is scheduled to have dental work, including several extractions & placement of implants. Medical history is significant for heart murmur, but is otherwise unremarkable. He takes no meds & has no known allergies. On physical exam, vital signs are normal. Heart exam shows normal S1 & physiologically split S2. There is grade 2/6 midsystolic murmur heard best at second right intercostal space that radiates to right carotid artery. Remainder of exam is normal. Previous transthoracic echo demonstrated bicuspid aortic valve w/ normal left ventricular function. What is the most appropriate antibiotic prophylaxis for this pt before his dental procedure?

*No antibiotic prophylaxis* W/hold infective endocarditis prophylaxis in pt w/ heart murmur associated w/ native valve abnormality - bacteremia associated w/ dental procedures much less likely to cause endocarditis than bacteremia resulting from normal, daily activities - extremely small # of cases of infective endocarditis prevented by prophylaxis

A 62-year-old man is evaluated following the incidental discovery of a 3-mm left lower lobe lung nodule on a recent computed tomography (CT) scan of the abdomen performed to evaluate for kidney stones. He has never smoked and has an otherwise unremarkable medical history. He takes no medications. On physical examination, his vital signs are normal. The physical examination is unremarkable. A dedicated CT of the chest shows only the 3-mm left lower lobe nodule and is otherwise normal. There are no other chest images available for comparison. Which of the following is the most appropriate next step in management of this patient?

*No follow-up imaging* Manage small pulmonary nodule in pt at risk for lung cancer Fleischner Society & American College of Chest Physicians - no follow-up necessary for nodules smaller than 4 mm in ever-smokers with no other known risk factors for malignancy - nodules smaller than 4 mm + current or former smokers or have other risk factors --> follow-up CT at 12 months recommended

70 yo man evaluated for placement in extended care facility. Other than dementia, pt has no med problems, including fever, cough, or recent weight loss. He is retired army officer who served in logistics & supply. He has no ho previous TB infection or exposure to person w/ TB. He does not smoke cigarettes, drink alcohol, or use illicit drugs. His only med is donepezil. On exam, vital signs are normal. His score on Mini-Mental State Exam is 23. Tuberculin skin test is applied & shows 8 mm of induration 48 hrs later. What is the most appropriate management?

*No further evaluation or therapy*

22 yo pt comes to doc with her sister, who has noticed a greenish tinge to her eyes. She has ho depression treated with sertraline & was diagnosed with ADHD 5 yrs ago. Neuro exam shows bilateral dysmetria & mild hand tremor at rest. Slit lamp exam shows brown-green pigment surrounding iris. Lab studies show: Alkaline phosphatase 75 U/L Serum studies show: AST, GOT 90 U/L ALT, GPT 73 U/L Ceruloplasmin 15 mg/dL What is most likely to establish diagnosis in this pt?

*No further testing needed to establish diagnosis* Wilson Dz/Hepatolenticular dz - abnormally reduced hepatic excretion of Cu - initial workup = liver function test, serum ceruloplasmin, 24 hr basal urinary Cu excretion, slit-lamp exam for Keyser-Fleischer rings - serum ceruloplasmin <20 mg/dL in pt who also has Kayse-Fleischer rings = diagnotic --> no further testing needed to establish --> start on chelation therapy with penicillamine

25 yo woman comes to ED complaining of SOB & wheezing. She reports ho mild episodic asthma & usually has these symptoms 1x or 2x a week. She also admits having a couple of nighttime symptoms over past six months. Current symptoms began 5 hours ago & have become gradually more severe. She takes no meds. On physical exam the lungs have loud expiratory wheezing bilaterally. Expiratory phase is mildly prolonged & air movement is fair. Her respiratory rate is 28/min. Peak expiratory flow rate is 120 L/min. Oxygen sat at room air is 94%. She is given a short-acting beta-adrenergic agonist which resolves symptoms within 10 minutes. FEV1 after stabilization is 85%. What is the most appropriate long-term management for this patient?

*No long-term pharmacotherapy is necessary* Mild asthma = SOB not more than 2x/week + 1-2 nighttime symptoms in month & normal FEV1 (>80%) - no long-term pharmacotherapy needed - albuterol should be used for symptomatic episodes only

3 yo grl with HIV brought to doc by her mom before starting daycare. Child is able to speak sentences of 3-4 words, follow commands, feed herself, & draw circles. She is currently practicing toilet-training with her parents. She has had all of the recommended vaccinations. Current meds include efavirenz, tenofovir, emtricitabine, & a multivitamin. Most appropriate reason to exclude child from attending daycare?

*No reason for exclusion* Other than through blood exposure, HIV has not been transmitted through daily contact that occurs in daycare centers, including saliva & tears - only modes of HIV transmission = blood exposure, vaginal secretions, semen, breast milk

65 yo male pt comes to office for routine exam. He recently recovered from episode of pneumonia for which he was treated with levofloxacin for 5 days. He states that besides intermittent episodes of constipation, for which he takes docusate, he has not had any other major medical problems. He denies fevers, cough, SOB, or history of abnormal bleeding. His temp is 37.1 C (98.7 F), BP is 120/80 mmHg, pulse 82/min, & respirations 16/min. Bilateral adenopathy in cervical & supraclavicular chain. Lymph nodes hard & nontender, largest is appx 4 cm. Heart: RRR, no murmurs; Lungs: clear to auscultation; Abdomen: soft, nontender; neuro exam: pt oriented in person, time, & place; no focal deficits; pelvic: bilateral inguinal adenopathy present; rectal exam: no fecal occult blood. Lab reports include: Hgb = 14 g/dL Platelets = 170,000/mm^3 WBCs = 130,000/mm^3 Granulocytes = 15% Lymphocytes (mature) = 80% Monocytes = 5% Smear = Smudge cells CD19 = Positive Most appropriate intervention?

*No therapy needed* CLL - older: 90% > 50 Staging: Stage 0 = lymphocytosis alone Stage 1 = lymphadenopathy Stage 2 = splenomegaly Stage 3 = anemia Stage 4 = thrombocytopenia *No therapy needed in early stage ((0-1) in which there is just lymphocytosis or enlarged nodes*

A 38-year-old man is evaluated during a follow-up examination. An abnormal serum uric acid level of 7.9 mg/dL (0.47 mmol/L) was obtained at a health screening performed at his place of employment. All other measures from the comprehensive metabolic profile were normal. He drinks two alcoholic beverages each weekend and eats meat several times weekly. Medical history is otherwise unremarkable, and he takes no medications. Family history is notable for his father who has gout. On physical examination, vital signs are normal. Body mass index is 24. The remainder of the examination is normal. Which of the following is the most appropriate treatment at this time?

*No treatment is required* - asymptomatic hyperuricemia - moderately elevated serum uric acid level without evidence of gout - decrease consumption of high-purine foods (meat & seafood), alcohol, high-fructose foods - increase in dairy + weight loss = lower serum uric acid

32 yo gravida 2, para 1 woman at 28 wks' gestation comes to doc for prenatal checkup. She is concerned that he baby is not moving as much as normal over last 48 hrs. She has hx of chronic HT for which she takes methyldopa. Her temp is 98.6 F, BP 118/78 mmHg, pulse 87/min, & respirations 14/min. Physical exam shows lungs clear to auscultation bilaterally & heart exam reveals no murmurs. There is no edema, clubbing, or cyanosis bilaterally. Her fundal height is 27 cm (2 wks ago her fundal height was 25 cm). Fetal heart tones are in the 140s. Most appropriate next step in management?

*Non-stress test* = external fetal monitoring = method of choice to screen fetal status when pt reports decreased fetal movement - quickening, or feeling of fetal movement, typically begins in second trimester - fetal movement used as means for maternal fetal monitoring - decreased fetal movement = common cause of maternal concern during pregnancy - less than 10 movements over 2 hrs while mother concentrating on sensation warrants further evaluation (most women experience 10 movements after 20-30 minutes of focused observation)

A Sl-year-old man is evaluated for left-sided flank pain and a lowgrade fever of several days' duration. He reports no nausea or vomiting. He has not experienced urinary changes such as hesitancy or frequency. Medical history is unremarkable, and he takes no medications. On physical examination, temperature is 37.8°C (100.0°F), blood pressure is 1S9/93 mm Hg, pulse rate is 92/min, and respiration rate is 12/min. Abdominal examination is significant for mild discomfort to palpation across the left flank but is otherwise normal. The remainder of the examination is unremarkable. Results of laboratory studies are significant for a leukocyte count of 11,SOO/µL (11.S x 109/L) and a urinalysis showing a pH of S.S; 2+ blood; trace protein; 1 + leukocyte esterase; S-10 erythrocytes/highpower field; 2-S leukocytes/high-power field; and no nitrites. Which of the following is the most appropriate test to perform next?

*Noncontrast abdominal helical computed tomography* - most frequently used method for diagnosing kidney stones - identifies urinary tract obstruction with hydronephrosis - detects stones as small as 1 mm in diameter - helps evaluate other potential causes of abdominal pain & hematuria - expensive relative to plain radiography - higher radiation exposure than other imaging studies - new-onset gradual abdominal & flank pain + urinalysis revealing hematuria with low-grade pyuria = associated with kidney stones

A 56-year-old man is evaluated in the emergency department because of a 3-day history of increasing dyspnea, fever, and cough with purulent sputum. He has severe chronic obstructive pulmonary disease with a history of exacerbations requiring hospitalization. Medications are ipratropium, salmeterol-fluticasone, and albuterol. On physical examination, temperature is 38.0°C (100.4°F), blood pressure is 134/84 mm Hg, pulse rate is 88/min, and respiration rate is 30/min. He is awake and alert but is dyspneic and uses the accessory muscles to breathe. Pulmonary examination shows bilateral expiratory wheezes but no crackles. An arterial blood gas study performed while breathing 2 L of oxygen via nasal cannula shows pH of7.31, Pco2 of53 mm Hg (7.0 kPa), and Po2 of 55 mm Hg (7.3 kPa). Oxygen saturation is 89%. Chest radiograph shows hyperinflation but no infiltrates. In addition to antibiotics, glucocorticoids, & bronchodilators, what is the most appropriate management?

*Noninvasive positive pressure ventilation* (NPPV) - reduces mortality rate, need for intubation, length of hospital stay - improves respiratory acidosis & decreases respiratory rate & severity of breathlessness in pts who are candidates for therapy - can benefits pts with: moderate to severe dyspnea, moderate to severe acidosis (pH<7.35) or hypercapnia, respiration rate greater than 25/min Management of exacerbation of COPD with noninvasive positive pressure ventilation -

78 yo woman treated in ICU for 24-hr ho altered mental status that has been progressively worsening. On arrival to ED< she was disoriented. Temp was 101.7 F. BP was 82/40 mmHg & heart rate was 115/min. Lab studies showed leukocyte count of 33,000/uL & a hemoglobin level of 11 g/dL. Urine dipstick was positive for nitrites & leukocyte esterase. Chest radiography was normal. Results of blood & urine culture are pending. Central venous access was obtained, & treatment with broad-spectrum abx was initiated. 1000-mL normal saline fluid challenge was administered over 30 minutes. Current exam in ICU shows BP of 85/45 mmHg & pulse rate of 100/min. Findings on physical exam are unchanged. What is the most appropriate immediate next step in management?

*Norepinephrine* Septic Shock Management - start vasopressor therapy w/ NE - likely via UTI - goals = treat infection & optimize tissue perfusion - accomplished by starting early & appropriate antibiotic therapy & using crysalloids to maintain adequate preload - if initial fluid challenge of 1000 mL crysalloid solution doesn't achieve adequate BP, defined as mean arterial pressure of 65 mmHg or greater or central venous pressure of 8 to 12 mmHg, initiation of vasoactive agent indicated to ensure that tissue perfusion maintained - MAP = ([2xdiastolic BP] + systolic BP) / 3 - despite initial 1000-mL normal saline bolus, pt's mean arterial pressure remained less than 65 mmHg --> recommended vasopressor for initial treatment = NE adminsitered centrally

24 yo woman, gravida 3, para 1 (1 prior abortion), at 34 weeks' gestation by last menstrual period comes to doc for her first prenatal visit. She denies any past med hx. Her temp is 98.8 F, BP 155/95 mmHg, pulse 70/min, & respirations 16/min. Repeat exam 10 minutes later shows BP 158/98 mmHg. Physical exam reveals fundal height 30 cm. Urine dipstick negative for protein. Ultrasound with fetal biometry will likely show what?

*Normal head and small abdominal circumference* - corresponds to asymmetric intrauterine growth restriction (IUGR) - related to decrease in placental perfusion caused by chronic maternal disease (HT, DM, SLE, cardiovascular dz) - most likely suffering from gestational HT; absence of proteinuria helps support this diagnosis - pt should be monitored with serial sonograms & biophysical profiles

52 yo man comes to doc bc of widespread pruritic coin-shaped lesions on his skin for 2 mos. Lesions begin as itchy patches of vesicles & papules that later ooze serum & crust over. He states that some of the lesions have appeared to heal & then reappear at same sites. Pt has hx of chronically dry skin. Physical exam shows crusted erythematous patches & plaques on extensor surfaces of extremities & on buttocks. Most likely diagnosis?

*Nummular dermatitis* - common & chronic skin dz of unknown etiology - mainfests as coin-like (nummular) lesions of eczematous dermatitis - head typically spared - microscopically = localized spongiosis (corresponding to edema) of epidermis - treated with high-potency corticosteroids or calcineurin inhibitors

55 yo man comes to ED complaining of recent palpitations & fatigue. He reports that his cough has gotten worse over last few days & his palpitations are worse when he is winded. He has a ho COPD & DM treated with ipatropium, albuterol, & metformin, respectively. He does not drink alcohol, but continues to smoke one pack of cigz per day. His vitals are temp 97.5 F, BP 100/70 mmHg, pulse 118/min, & respirations 18/min. His BMI is 28.5 kg/m^2. Exam reveals decreased breath sounds, scattered rhonchi, no wheezing, & hyper-resonance to percussion; his cardiac exam shows apical impulse with irregular pulse & distant heart sounds. LEs reveals 1+ pedal edema. 12-lead EKG is done in clinic, showing varying P-R intervals & discrete P waves that have different morphologies on leads I, III, & VI. What would be the most appropriate next step in management of this pt?

*O2 saturation* Multifocal atrial tachycardia (MAT) - arrhythmia found in pts with decompensated chronic lung dz - hypoxic complication - other causes = electrolyte abnormalities, CHF, sepsis, methylxanthine toxicity - varying P-R intervals & at least 3 diff't P-wave morphologies - initial step = obtain O2 sat to rule out hypoxia bc if hypoxia were present, it could be easily corrected - best way to manage = correct underlying cause

18 yo man comes to doc bc of painful finger for 5 days. He has hx of asthma & occasional cold sores. Current meds include albuterol & fluticasone. He works part-time as carpenter & frequently inquires his hands and fingers. Exam shows grouped & coalescing vesicles on erythematous base on distal phalanx of pt's right index finger. There is exquisite tenderness to palpation. Most appropriate next step in management?

*Observation and analgesics* Herpetic whitlow - infection of soft tissue of distal finger with HSV - can be caused by either HSV-1 or HSV-2 by inoculation of virus onto wounded skin of finger during outbreak of oralherpes (cold sores) or genital herpes

A SO-year-old man is evaluated in the emergency department for a 3-day history of dyspnea, fever, productive cough, and left-sided pleuritic chest pain. He has been in good health previously and takes no medications. On examination, temperature is 39°C (102.2°F), blood pressure is 140/80 mm Hg, pulse rate is 105/min, respiration rate is 22/min, and oxygen saturation is 94% on ambient air. Pulmonary examination shows crackles on the left side. Chest radiograph shows a patchy left lower lobe infiltrate with blunting of the costophrenic angle. Left lateral decubitus film shows freeflowing fluid that layers out to 8 mm. Treatment with empiric oral antibiotics is initiated for communityacquired pneumonia. Which of the following is the most appropriate next step in management of the pleural effusion?

*Observation* Uncomplicated parapneumonic pleural effusion = noninfected effusion occurring in pleural space adjacent to bacterial pneumonia - in 50% of pts who are admitted to hospital with bacterial pneumonia - most are small - can resolve without specific therapy - 10% become complicated or progress to empyeme

2 yo boy diagnosed with hydrocephalus shortly after birth has ventriculo-peritoneal (VP) shunt placed at 3 mos of age. Fam has been instructed in proper care of shunt, but over last 3 days child has become irritable, complains of headache, and has developed nausea & vomiting. This morning fam notes impairment of the boy's upward gaze. On exam, his temp is 100.6 F, BP is 111/62 mmHg, pulse is 68/min, & respirations are 18/min. Most likely explains boy's condition?

*Obstruction of shunt* - increased intracranial pressure - impaired upward gaze = ballooning of suprapineal recess - can happen even when pumping is done regularly - treated by replacement of device - obstruction & infection = 2 main complications of VP shunts

49 yo woman arrives in ED with persistent epigastric pain. She had been taking oral antacids for past 6 hours bc she thought she had heartburn. Initial BP is 118/72 mmHg, heart rate is 92/min & regular, nonlabored respiratory rate is 14 breaths/min, & pulse oximetry reading is 96%. Most appropriate intervention to perform next?

*Obtain 12-lead ECG*

Pediatrician seeing a 12 yo boy for first time for a school physical exam. Boy's parents state that he has never had any significant illnesses, takes no meds, & has no known allergies. Boy is in sixth grade & does very well in school. He spends most of his free time reading and working on the computer. He & his fam eat a lot of fast food. Both parents appear to be overweight. On exam, his height is 4 ft 10 inches & his weight is 169 lb. Pediatrician calculates boy's BMI to be significantly greater than 95% of boys for his age. BP in left arm while seated is 135/88 mmHg. BP repeated later in visit is essentially the same. Boy has purple striae on his abdomen & darker pigmented skin in his axillae & inguinal regions. Next step in management of this pt?

*Obtain fasting plasma glucose* - abnormal screen should be followed with oral glucose tolerance test T2DM - insulin resistance & secondary hyperinsulinemia - over time, hyperglycemia worsens & is accompanied by hyperlipidemia - fasting plasma glucose > 126 mh/dL

16 yo boy evaluated for excessive urination & thirst. He has been drinking almost 5 liters of fluid daily for past 2 mos. Pt's mother has T2DM. On physical exam, vital signs are normal. BMI 35. Results of general physical & neurologic exams are unremarkable. He is not dehydrated, & no ketones are detected on his breath. Lab studies: Hgb A1c 8.7% Glucose, random 324 mg/dL Electrolytes Normal Urine ketones Negative What diagnostic studies is most likely to identify cause of pt's findings?

*Obtain islet cell & glutamic acid decarboxylase Ab titers* Differentiate type 1 from type 2 DM - should check pt's blood from pancreatic autoAbs, such as islet cell Abs & glutamic acid decarboxylase Abs - pt is obese & his mom has T2DM, but he is young, so T1DM more likely to be present

27 yo man evaluated in clinic 6 mos after initiation of antiretroviral therapy for newly diagnosed HIV infection. He is asymptomatic. At time of diagnosis, his HIV-RNA (viral load) was 500,000 copies/mL & CD4 count was 298/uL. Meds are emtricitabine, tenofovir, & efavirenz, & omeprazole, which he takes on occasion for heartburn. On physical exam, temp is 98.6 F. Remainder of vital signs & physical exam are normal. Today's lab results show viral load of 200,000 copies/mL & CD4 cell count of 225/uL. What is the most appropriate management?

*Obtain viral resistance testing* Manage unsuccessful anti-retroviral regimen in pt with HIV - obtain viral resistant test = genotype +/- phenotype - consult infectious disease specialist - suppression of HIV viral load to less than 50 copies/mL should occur by 24 wks of effective therapy - virologic failure suspected when suppression of viral replication to less than 200 copies/mL cannot be achieved or maintained - potential causes for virologic failure = poor adherence to regimen, med intolerance, pharmacokinetic issues, suspected drug resistance

30 yo primigravid woman who is at 18 weeks' gestation comes to doc for routine prenatal visit. She has had regular prenatal care since 6 weeks' gestation was confirmed by obstetric ultrasound, & her pregnancy has been uncomplicated thus far. She has hypothyroidism, for which she takes thyroxine, but otherwise has no medical or surgical hx. Her temp is 99.3 F, BP is 118/78 mmHg, pulse is 82/min, & respirations are 16/min. Physical exam shows her uterus at her umbilicus with fetal heart rate at 150/min. Urine disptick shows no protein or glucose. A 17-week anatomic ultrasound was normal. Her maternal triple-marker serum screen returned as positive for Down syndrome with risk slightly greater than that of a 35 yo. Most appropriate next step in management?

*Offer amniocentesis now* - low AFP & unconjugated estriol + high hCG (& inhibin A in quadruple screen) = increased risk for fetus that has Down syndrome - pt should be counseled regarding risk of amniocentesis, including fetal loss rate of 0.5%, vaginal spotting or amniotic fluid leakage in 1-2%, & chorioamnionitis in <0.1% - definitive diagnosis can only be made by obtaining fetal karyotype = chorionic villus sampling & amniocentesis

29 yo woman, gravida 3, para 2 at 39 wks' gestation, comes to doc for prenatal visit. She feels good fetal movement & has had no contractions, bleeding from vagina, or loss of fluid. Pt had hyperemesis in first trimester, but her pregnancy has been otherwise uncomplicated. Her obstetric hx is significant for normal spontaneous vaginal delivery of 9 lb 13 oz grl 5 yrs ago, & a normal spontaneous vaginal delivery of 10 lb 5 oz boy 3 yrs ago. She has no med probz & has never had sx. She takes prenatal vitamins & has no known drug allergies. Physical exam shows fetal HR in 150s per minute. Her fundal height is 42 cm & fetus feels large on abdominal exam. Pt state that this fetus feels bigger than did her other children. Her cervix is long, closed, & posterior in location. Ultrasound shows vertex fetus with estimated fetal weight of 5,100 g. Most appropriate next step in management?

*Offer cesarean delivery* Macrosomic fetus - fetal weight exceeds 4,000 g = 1.5% of fetuses - increased risk for cesarean delivery, postpartum hemorrhage, vaginal lacerations - most feared risk = shoulder dystocia = fetal head delivered but there is delay in delivery of fetal shoulders --> clavicle fracture, brachial plexus injury, paralysis, death *ACOG, 2000: pts with estimated fetal wt > 5000 g should be offered cesarean delivery to prevent shoulder dystocia (4,500 g if pt has diabetes)*

81 yo man with Alzheimer dz who is in nursing home undergoes sx for fractured femoral neck. On fifth postop day, his abdomen is grossly distended & tense, but non-tender with occasional bowel sounds. Rectal vault is empty on digital exam, & there is no evidence of occult blood. Vital signs are normal. X-ray films show few distended loops of small bowel & very distended colon. Cecum measures 9 cm in diameter, & gas pattern of distention extends throughout entire large bowel, including sigmoid & rectum. No stool seen on x-ray film. Most likely diagnosis?

*Ogilvie syndrome* - colonic dysfunction or "pseudo-obstruction" often seen in elderly pts who are not very active & further immobilized by extra-abdominal sx - often associated with electrolyte abnormalities - non-mechanical - management = electrolyte correction, endoscopic decompression, IV neostigmine - surgical resection indicated in presence of ischemia

Treatment of choice for Tinea capitis caused by Trichophyton tonsurans (common among black and Hispanic school-aged children)

*Oral admin of griseofulvin* for 6-12 wks - discontinued only after repeat fungal cultures are negative Tinea capitis - severe small patches of alopecia, where hairs are broken off close to follicle (black-dot ringworm) - can be confirmed by fungal culture on Sabouraud medium

69 yo woman comes to doc bc of right-sided back pain for 6 mos. She has felt burning & tingling over her upper right back. 6 mos ago, she had low-grade fever, muscle aches, & painful rash on right side of her back that lasted for 10 days & then resolved. She has ho HT & hypercholesterolemia. Current meds include HCTZ, lisinopril, & pravastatin. Her temp is 98.8 F, BP is 136/88 mmHg, & pulse is 82/min. Exam shows decreased sensation to pain in T4 dermatome on right side. Most appropriate next step in management?

*Oral desipramine* - tricyclic antidepressants (TCAs) such as desipramine & anticonvulsants such as gabapentin are commonly used agents Postherpetic neuralgia - postinfectious inflammation & nerve damage = persistent pain after resolution of herpes zoster

A 22-year-old woman is evaluated for a 6-month history of decreased exercise tolerance, particularly with activities such as running. She is otherwise healthy and eats a normal diet. Medical history is unremarkable. She notes no menstrual abnormalities and takes no medications. On physical examination, temperature is 36.7°C (98.0°F), blood pressure is 110/72 mm Hg, pulse rate is 88lmin, and respiration rate is 161min. Body mass index is 22. The patient has pale conjunctivae. Examination of the heart and lungs is normal. There is no splenomegaly. The neurologic examination is normal. Lab studies: Hemoglobin = 7.9 g/dL Leukocyte count = 5600/uL MCV = 62 fL Platelet count = 625,000/uL RBC distribution width = 22% (normal range: 14.6-16.5%) Peripheral blood smear notable for microcytic, hypochromic RBCs with marked abisopoikilocytosis. Most appropriate treatment for this patient?

*Oral ferrous sulfate* Iron def in menstruating woman - increased RDW often associated with nutrient def such as iron, folate, vit B12 - mild thrombocytosis

A 65-year-old man is evaluated for a 3-week history ofnonradiating left hip pain that worsens with walking or lying on his left side. He reports no locking symptoms or paresthesia. His only medication is ibuprofen as needed, which provides partial pain relief. On physical examination, vital signs are normal. Full range of motion of the left hip is present. There is tenderness over the lateral aspect of the hip with direct palpation. Results of a straight-leg-raising test are normal, and reflexes are normal.

*trochanteric bursitis* - pain when lying on their side or swinging their leg into car

22 yo woman comes to doc bc of burning during urination and vulvar itching over past 3 days. She is sexually active & she and her partner use condoms inconsistently. Her temp is 99.2 F, BP 118/70 mmHg, pulse 74/min, & respirations 20/min. Abdominal & costovertebral exam shows no tenderness. Pelvic exam shows mild vulvar erythema & a thick, white discharge on the vaginal walls. The cervix is normal-appearing & nontender. Microscopy of vaginal discharge shows epithelial cells with multiple adherent bacteria as well as budding yeast and hyphae. Addition to KOH to slide produces amine odor. pH of discharge is 5. Urinalysis is within normal limits. Gonorrhea & Chlamydia screening tests sent. Most appropriate pharmacotherapy for this pt?

*Oral fluconazole & tinidazole* Bacterial vaginosis & concomitant vaginal candidiasis - 2 most common causes of symptomatic vaginal discharge - candidiasis = vaginal errythema, dysuria, curdy thick discharge, edema; hyphae may be seen on vaginal smear but don't always appear - BV = thin, white-gray vaginal discharge with strong "fishy" or amine odor, especially with KOH (whiff test) - treatment with antifungal & treatment for vaginosis with either metro or tinidazole (newer drug with fewer side effeccts)

48 yo man evaluated for 3 day history of LLQ abdominal pain. He rates pain a 6 on scale of 1 to 10. His appetite is decreased, but he is able to tolerate oral intake. He is otherwise healthy & has no previous GI problems. On physical exam, temp is 38.2 C (100.8 F), BP 138/78 mmHg, pulse rate 103/min, & RR 14/min. Abdominal exam discloses focal tenderness in LLQ. Perirectal fullness. Lab studies reveal Hgb level of 13.5 g/dL & leukocyte count of 14,000/uL. Urinalysis normal. CT scan of abdomen & pelvis discloses moderately dense diverticula in descending colon & proximal sigmoid colon; focal bowel wall thickening (5 mm) in midsigmoid colon with associated inflammation of pericolic fat; & no evidence of ileus, obstruction, abscess, or perforation. Most appropriate initial management for this patient?

*Oral metronidazole & ciprofloxacin* Acute uncomplicated diverticulitis - oral antibiotic therapy - via obstruction at diverticulum by fecal matter = mucus production & bacterial overgrowth - LLQ pain = most common clinical manifestation, often accompanied by fever

2 yo boy brought to doc by his parents bc of 3 day ho diarrhea & vomiting. He is able to tolerate small amounts of fluids, although he has been vomiting 3 or 4x / day & has frequent loose stools. His temp is 98.6 F, BP 88/42 mmHg, pulse 145/min, & respirations 20/min. Exam shows dry mucous membranes. Next best step in management?

*Oral rehydration therapy at home followed by normal diet* Dehydration via total body loss of water & sodium - acute infectious gastroenteritis = most common causes of dehydration in infants & young children - mild & moderate dehydration may be managed at home with oral rehydration therapy, event if child continues to have intermittent vomiting

59 yo white male presents to outpatient clinic with chief complain of palpitations. Pt says that for past two weeks his heart has been "feeling funny." He says that it feels like his heart "skips a beat sometimes." Pt has past medical ho HT managed by metoprolol 50 mg twice daily. He also has COPD managed with albuterol & ipratopium. Pt admits to drinking 4-6 beers/day for past couple of months. Pt also reports increased amount of stress in his life from his employer. On exam pts is in no acute distress. Vital signs are temp 98.8, pulse rate 65 bpm, respirations 14/min, BP 135/78 mmHg, pulse oximeter 93% on room air. EKG done & shows normal sinus rhythm. Next step in diagnosing pt?

*Order 72 hr holter monitor* Premature atrial contractions (PACs) - best way to make diagnosis = 72 hour holter --> records all of pt's heart beats; pt can press button when symptoms arise to allow for doc to determine what rhythm is occurring - extra impulses that can originate from anywhere in right or left atria - most pts are asymptomatic - pts with underlying lung condition = more susceptible due to oxygenation status - also associate with caffeine, nicotine, stress & alcohol

47 yo alcoholic man arrives at hospital with unremitting abdominal pain. He was brought in by his wife after pain became unbearable. He has had bouts of abdominal pain in past, but none as severe as current one. He drinks appx 6 alcoholic beverages/day. On physical exam, he is afebrile & his BP is 105/62 mmHg. His pulse is 103 beats/min. Head & neck exam reveals no scleral icterus. His chest is clear. His jugular veins are flat. No murmurs are auscultated. Diffuse abdominal tenderness appreciated. No clubbing, cyanosis, or edema noted. CT of abdomen demonstrates peripancreatic fluid, pancreatic edema, & necrosis of appx 1/3 of pancreas. Pt is resuscitated aggressively & is started on abx. Pt fails to improve significantly over next 2 days. Next step in management of pt?

*Pancreatic aspiration* Pancreatic necrosis - most dreaded consequence of pancreatitis - biggest risk = superinfection - tissue should be sampled

24 yo woman comes to office for evaluation 2 days after visit to ED. She says that she went to ED bc of "allergic rxn" that consisted of itching in the throat after eating ice cream, followed by nausea & vomiting, a sensation of flushing & hives. Same kind of problem happened to her last year after eating chocolate candy & once before that in a Thai restaurant. Her friend suggested that this might represent a peanut allergy but pt does not recall eating peanuts when she had these rxns. When she is in your office, all manifestations of allergic rxn have resolved. Pt seems healthy & has no significant past med history. Her only med is oral contraceptives. Physical exam in your office is normal. Appropriate next step in evaluating & managing pt?

*Order skin-prick test or radioallergosorbent test for peanut allergy* = 95% likelihood Peanut-induced food allergy - IgE-mediated rxn - if history does not clearly indicate peanut allergy, confirmation of diagnosis can be made either with skin-prick test or blood radioallergosorbent test = both positive if IgE Abs against peanuts

25 yo medical student comes to student health clinic bc of 2 mo history of epigastric pain that started 1 wk before taking Step 2 of USMLE. Pain becomes more severe 30 min after meals, & she has been awakened from sleep by pain several times weekly. Ranitidine has improved her symptoms transiently. She has ho asthma & seasonal allergies. Current meds include albuterol & loratidine. Most likely cause of pt's symptoms?

*Organisms colonizing gastric antrum* Peptic ulcer dz - pt's chronic epigastric pain severe enough to awaken her at night - temporarily relieved by ranitidine - worsened by eating H pylori - secretes toxins & lipopolysaccharide & ammonia produced by urease activity - ammonia binds to protons to reduce acidic anv't in stomach - treatment = amoxicillin, clarithromyin, omeprazole

33 yo woman presents with blurred vision. She has had acute onset of nausea, dizziness, diarrhea, severe abdominal cramps. There is no past med hx. On exam, she is sweating, anxious, & restless. Her temp is 99 F, BP 86/54 mmHg, pulse 52/min, & respirations 26/min. There is increased oral secretion. Eyes are watery & pupils are 2 mm on both sides. There are scattered fasciculations, but no sensory loss. Most likely diagnosis?

*Organophosphate poisoning* Organophosphates - absorbed via skin & lungs - irreversibly inhibit acetylcholinesterase --> parasympathetic symptoms = nausea, vomiting, abdominal cramps, incontinence, increased secretions, blurred vision, miosis, fasciculations, anxiety, restlessness, tremor, convulsions

59 yo man who is homeless is brought to ED bc of confusion & weakness. It is a bitterly cold night & there is snow on the ground. His temp is 89.6 F, BP is 80/40 mmHg, pulse is 53/min, & respirations are 10/min. An ECK would most likely show what?

*Osborn waves* Hypothermia - core body temp below 95 F - early signs & symptoms = shivering, tachycardia, HT, hyperglycemia, cold diuresis, mental confusion - signs & symptoms of severe = difficulty speaking, amnesia, paradoxical undressing, decreases in pulse, BP, & RR ECG - upward deflection following R wave (lead II) = Osborn wave (or J wave of Osborn)

Morning stiffness that resovles + worsening pain with activity + no evidence of swelling or inflammation.

*Osteoarthritis* PE - tenderness to palpation of invovled joints without signs of inflammation - join effusions - creptius - osteophytes palpable as bony enlargements along lateral edge of joint - Heberden & Bouchard nodes Heberden = DIP Bouchard = PIP

29 yo woman comes to ED bc of abdominal distention & SOB that has been progressive over last 2 days. Appx 1 wk ago, she underwent fertility treatment with ovulation induction & oocyte retrieval. She has hx of polycystic ovarian syndrome but no other med problems. She has no known drug allergies. Her temp is 98.6 F, BP is 80/40 mmHg, pulse is 130/min, & respirations are 28/min. Physical exam is remarkable for crackles at lung bases bilaterally & a distended, nontender, abdomen with fluid wave. Ultrasound demonstrates bilaterally enlarged ovaries (each >10 cm) & free fluid in abdomen. Urine hCG is negative. Most likely diagnosis?

*Ovarian hyperstimulation syndrome* (OHSS) = combo of ovarian enlargement caused by multiple ovarian cysts & acute fluid shift out of intravascular space - most often occur in pts undergoing ovulation induction with gonadotropins but can also occur with use of clomiphene citrate - treatment = supportive care + prevention of thromboembolic dz associated with endothelial dysfunction Mild (grade I) OHSS - ovaries <5 cm - pts has mild weight gain & pelvic discomfort Moderate (grade II) OHSS - ovaries can be up to 12 cm in diameter - pt has at least a 10-lb weight gain, nausea, & vomiting Severe (grade III) OHSS - ovaries >12 cm with ascites, hydrothorax, hemoconcentration, & oliguria

6 mo old infant brought to doc by her parents bc of a delay in development of gross motor skills. She has past med hx of meconium aspiration at birth. At that time she received treatment with supplemental oxygen, IV fluids, & abx for 7 days in NICU. Upon discharge from NICU she was able to tolerate oral feedings. Her current physical exam shows poor head control & relative hypotonia of lower extremities. There is also abnormal persistence of 2 primitive reflexes. What two of the primitive reflexes are most likely present in this pt?

*Palmar grasp & rooting reflex* - palmar grasp is first to develop ~ 28 weeks' gestation = full developed by 32 weeks' gestation = lasts about 2-3 months = would be abnormal if still present in 6 mo old - rooting reflex starts at about 32 weeks' gestation = fully developed by 36 weeks = fades over first mo of life = would also be abnormal in 6 mo old

50 yo man comes to doc for routine health maintenance exam. His med history is unremarkable, & he takes no meds. He smoked 2 packs of cigarettes daily for 2 years, but quit 27 years ago. His brother died of squamous cell lung cancer at the age of 56 years. His BP is 122/84 mmHg, pulse is 74/min, & respirations are 12/min. Physical exam shows no abnormalities. Because of his brother's recent death from cancer, he is very anxious about his risk for cancer. This patient is at greatest risk for what malignancies?

*Prostatic carcinoma* - highest incidence in men - risk factors = age, black race, fam history of prostate cancer Incidence of cancer: men #1 = Prostate #2 = Lung #3 = Colorectal

Thin 7 yo boy lost control of bicycle he was riding & fell to the ground, sustaining deep abdominal contusion as he landed on handlebar. He is evaluated at ED & found to be stable & relatively asymptomatic. CT scan without contrast is negative. Boy is sent home, but next day he returns with diffuse, constant abdominal pain. He is lying on stretcher without moving, & his abdominal exam reveals generalized tenderness & muscle guarding. There is deep ecchymotic area over LUQ, where he was hit by handlebar. His temp is 98.6 F, pulse is 110/min, BP 110/80 mmHg, & RR 28/min. Lab studies show hemoglobin is 14 g/dL, leukocyte count 9,500/mm^3, serum amylase level of 550 U/L, & serum lipase level of 260 U/L. Second CT scan, this time with double contrast, shows fluid accumulation in pelvis & no free air. Additiona diagnostic findings most likely to be revealed by most CT scan?

*Pancreatic injury* - typically thin pts + epigastric blunt trauma = at rsk for pancreatic injury via risk of compressing pancreas against spine --> parenchymal hemoarrhage, ductal injury, or complete pancreatic transection - *elevated amylase & lipase* - collection of pelvic fluid in second CT scan = pancreatic ascites

62 yo woman comes to doc bc of progressive urine leakage over last 2 years. She has had episodes during which she feels immediate need to void & is not always able to make it to restroom in time, requiring use of adult diapers. This need to urinate occurs at all times of day & night, & she often awakens with need to urinate. She has ho acute-angle glaucoma requiring surgical intervention & untreated HT. Most appropriate therapy?

*Pelvic floor exercises & bladder training* Urge incontinence - destrusor hyperactivity = unexpected, immediate voiding - first-line therapy = conservative, non-pharm management with pelvic floor exercises & bladder training - Kegel exercise = 80% decrease in symptoms - patients should keep voiding diary & return to office for evaluation

16 yo boy brought to urgent care clinic with temp of 101 F & low back, wrist, & knee pain. He had sore throat 1 mo earlier. His arthritis is diffuse. Pea-sized swellings are noted over skin on his knees. He has serpigionous erythematous area on his anterior trunk. His blood & throat cultures are negative, & his CBC is unremarkable. His ASO titer is high. Most appropriate therapy?

*Penicillin and aspirin* Acute rheumatic fever from group A strep - migratory polyarthritis, erythema marginatum, subQ nodules - other features absent in this pt = chorea & carditis - ASO titer = recent infection with Strep = penicillin - arthritis managed with salicylates (not indicated in viral infections bc of potential to cause Reye syndrome)

76 yo man recovering from emergency CABG in cardiac care unit. His past med hx significant for DM, HT, hyperlipidemia, & chronic tobacco use. He came to ED w/ acute-onset chest pain & was found to have STEMI. Urgent cardiac angiography revealed multiple vessel dz. Hemodynamic instability prompted insertion of intra-aortic balloon weaned & extubated on post-op day 5. On post-op day 7 he complains of abdominal pain & vomits once. He is noted to be febrile to 101.8 F. Lab studies notable for WBC count 16,000/mm^3, hgb 9.2 g/dL, & creatinine level 1.8 mg/dL. Abdominal x-ray film unremarkable. Ultrasound of RUQ reveals normal intra- & extrahepatic bile ducts, a dilated gallbladder w/ no stones but thickened wall. There is also a small amount of fluid surrounding gallbladder. Next step in management of pt?

*Percutaneous cholecystostomy tube placement* Acalculous cholecstitis - presence of cholecystitis symptoms = fever, leukocytosis, thickened gallbladder wall with pericholecystic fluid, in absence of gallstones - 5-10% incidence of cholecystitis - stasis phenomenon = typically presenting in hospitalized pts who are in critical condition - contributing factors = hypovolemia, absence of alimentary nutrition, multiple blood transfusions, narcotic use, prolonged ventilator dependence

A 54-year-old man is evaluated in the emergency department for an acute coronary syndrome that began 30 minutes ago. His medical history is significant for hypertension and type 2 diabetes mellitus. Medications are lisinopril and glipizide. On physical examination, he is afebrile, blood pressure is 160/90 mm Hg, pulse rate is 80/min, and respiration rate is 12/min. Cardiovascular examination shows a normal S1 and S2 without an S3 and no murmurs. Lung fields are clear. An initial serum troponin level is pending. Electrocardiogram shows 3-mm ST-segment elevation in leads V 2 through V4 and a 1-mm STsegment depression in leads II, III, and a VF. Treatment is initiated with aspirin, clopridogrel, a P-blocker, and unfractionated heparin. His symptoms of chest pain improve. Which of the following is the most appropriate next step in management?

*Percutaneous coronary intervention* (PCI) - preferred bc it is associated with lower mortality rate compared with thrombolytic therapy - should be performed within 90 minutes of presentation to a facility with PCI capability or within 120 minutes if patient requires transfer from non-PCI-capable hospital - also indicated in patients with contraindication to thrombolytic therapy & in patients with cardiogenic shock - most effective if completed within 12 hours of onset of chest pain STEMI via electrocardiographic changes - patients who present within 12 hours of symptoms onset should undergo either primary PCI or thrombolytic therapy

When the patient has a confirmed advanced airway in place what is the correct way to do compressions & ventilations?

*Provide continuous chest compressions with 1 breath every 6 seconds (10 breaths/minute)* - slowing the ventilations rate down will prevent oxygen toxicity which causes reduced cardiac output

60 yo woman explains to her PCP that she has been having daily temp elevations to 100 F (37.8 F). In addition, for past 3 weeks, she has had no energy, & now, over past week she has been waking up at night sweating. On exam, she has sternal tenderness on palpation & her spleen is palpated 4 cm below left costal margin. CBC shows 70,000 WBCs with predominance of mature myeloid cells. There are 1% blasts seen. Hematocrit is 38% & platelets are 400,000/uL. What is the most appropriate next step in management?

*Perform FISH on peripheral blood to find bcr-abl protein* CML - predominance of myeloid cells - stable often remains stable for years before transforming to higher-grade malignancy - most commonly seen in elderly - fatigue, night sweats, low-grade fever, splenomegaly - on exam, may be sternal tenderness from marrow overexpansion - Philadelphia chromosome = reciprocal translocation b/t long arms of chr 9 & 22 - fusion gene = bcr-abl - gold standard = FISH or cytogenetic studies

62 yo man with HT & hyperlipidemia comes to ED complaining of severe headache & high fever. Further hx reveals neck pain, photophobia, nausea, & vomiting. He has no HIV risk factors. His temp is 102.2 F, BP 100/70 mmHg, pulse 123/min, & respirations 16/min. He is no respiratory distress. Light bothers his eyes, & he has painful neck to elicited lateral movements. There is no edema of optic discs. Cranial nerve exam is normal. Mental status is appropriate. His heart is tachycardic & regular without any murmurs. His lungs are clear. His abdomen is soft. He has no edema. He has 5/5 strength in all 4 extremities with normoactive reflexes. Most appropriate sequence of management?

*Perform LP & begin treatment with ceftriaxone, vancomycin, ampicillin, & dexamethasone* Meningitis - via hx & physical exam - most appopriate = LP --> then immediately start empiric abx - inds > 50 yo at substantial risk of LIsteria monocytogenes meningitis = ampicillin should be added to treatment regimen - adjunctive dexamethasone given shortly before or at same time as first dose of abx in ALL adults with suspected or proven pneumococcal meningitis (according to Infectious Diseases Society of America (IDA) guidelines)

22 yo woman, gravida 2, para 1 at 38 wks gestation, comes to labor & delivery floor bc of contractions. She has uncomplicated prenatal course. Her previous obstetric hx is significant for normal spontaneous vaginal delivery at term 3 years ago. She has no med hx & has never had surgery. She takes prenatal vitamins & has no known drug allergies. On pelvic exam, her cervix is 3 cm dilated & 75% effaced, & the fetus is at -2 station. She is contracting every 2 minutes & fetal heart rate is in 140s w/ accelerations & no decelerations. Few minutes later, pt experiences large gush of fluid from vagina & fetal heart rate becomes bradycardic to 70s per minute. On exam, cervix feels appx 5 cm in diameter & a pulsating segment of umbilical cord can be felt in vagina. Most appropriate next step in management?

*Perform an emergency cesarean delivery* Prolapsed umbilical cord - true obstetric emergency - compression of cord --> decreases supply of oxygen to fetus --> fetal distress (bradycardia) - main risk factor = malpresentation (breech presentation) - proper management = bring pt immediately to STAT cesarean delivery - person who performed exam in which prolapses umbilical cord was palpated should maintain his or her hand in vagina

29 yo woman, gravida 2, para 1, comes to doc at 12 weeks' gestation for her second prenatal visit. She is feeling well except for some mild nausea. Her past obstetric hx is significant for term vaginal delivery following uncomplicated pregnancy 3 yrs ago. She has no med probz & has never had surgery. She takes prenatal vitamins & is allergic to penicillin. Physical exam shows her BP is 100/70 mmHg & weight is 120 lb. Fetal pulse is in 160s. Review of her prenatal lab studies shows that her Pap smear is reported as high-grade intraepithelial lesion (HGSIL). Most appropriate next step in management?

*Perform colposcopy* Pap smears routinely performed during pregnancy for purpose of screening for cervical cancer HGSIL - may progress to cervical cancer if not treated - next step = colposcopy

37 yo firefighter injured while rescuing young child from house fire. Firefighter hemodynamically stable & oxygenating well in ED. On physical exam he is noted to have first-degree burns to chest & abdomen, & second-degree burns to forearms & upper arms. Topical silver sulfadiazine applied to burns & they are loosely dressed with Vaseline gauze. He is started on IV fluids, & Foley catheter is inserted. Initially he does not complain of pain; however, the following morning he complains of significant forearm pain, worse on the right. The dressings are removed & the right forearm is noted to have significant edema. He is able to grasp with 5/5 strength but has decreased sensation in high fifth digit. both radial and ulnar pulses are palpable. Next step in management?

*Perform forearm escharotomy* Compartment syndrome = forearm pressures greater than 30-40 mmHg - 4 Ps = paresthesias, poikilothermia, pulselessness, pallor - neuro loss before loss of pulses - pain & paresthesias present before loss of pulses = pain on passive flexion

32 yo gravida 2, para 1 woman comes to labor & delivery with large gush of fluid that soaks through her pants. Her prenatal course is significant for being Rh negative, for which she received RhoGAM at 28 weeks. She is admitted & delivers a healthy infant boy after long & difficult delivery complicated by uterine atony & mild postpartum hemorrhage. There is suspicion for fetomaternal hemorrhag.e Most appropriate next step in management?

*Perform rosette test* - all RhD-negative pregnant women should undergo Ab screen at first prenatal visit & again at 28 weeks of gestation - at 28 weeks gestation, 300-mcg prophylactic dose of anti-D immun globulin (RhoGAM) administered - *If fetomaternal hemorrhage is suspected, the next step should be to perform a rosette test* --> negative = standard 300 mcg dose; positive = follow up with Kleihauer-Betke stain = estimates fetal cells in maternal blood in 15-mL increments --> for every 15 mL of fetal blood entering maternal circulation, 300-ug dose should be administered IM up to max of 5 shots

71 yo man complains that over past 2 weeks his weak urine stream has become even weaker. Over last 24 hours he has been unable to urinate at all, & it is becoming extremely uncomfortable. He has ho BPH, for which he takes tamsulosin. There is no ho dysuria, hematuria, fever, or chills. He takes diltiazem for HT, & had a cholcystectomy 20 years ago. He denies any use of OTC meds. His temp is 37.4 C (99.3 F), pulse 86/min, BP 164/88 mmHg, pulse 86/min, & he is in moderate distress. Abdomen is soft & there is lower abdominal distention with suprapubic discomfort on palpation. On rectal exam prostate is enlarged, nontender, & without nodularity. When attempt is made to place urinary catheter, resistance is met & no urine comes out. Blood begins to ooze from urethral meatus. Best next step in management?

*Perform suprapubic tube placement* - least invasive & most expeditious - performed 4 cm above pubic symphysis under local anesthesia - spinal needle used to locate bladder by aspirating urine & then inserting tube in same location Urinary retention with bladder outlet obstruction via BPH - must drain bladder

47 yo man with PUD comes to doc for followup exam; he has persistent epigastric pain. He was diagnosed w/ duodenal ulcer & H pylori infection on endoscopy 2 mos ago. He has decreased size of his meals & has stopped drinking coffee & alcohol. He completed 2-wk course of amoxicillin, clarithromycin, & omeprazole. There has been no improvement in his symptoms. Most appropriate next step in management?

*Perform urea breath test* - 1st step = treat w/ PPI, amoxicillin, & clarithromycin twice daily for 7-14 days (metronidazole instead of amoxicillin if penicillin-allergic) --> cures 75% of H pylori - symptoms persist? --> perform urea breath testing (confirms eradication of H pylori) --> if test positive, repeat antibiotic treatment w/ diff't antibiotic combo

23 yo man sustains multiple stab wounds to his left chest. At ED, his BP is 70/45 mmHg, pulse 110/min, & central venous pressure 4 mmHg. He is diaphoretic, anxious, & notably pale. It is quickly determined in initial assessment that he has left hemopneumothorax, & a chest tube is inserted. Total of 380 mL of blood recovered initially, & another 120 mL is suctioned during next hour. He is also administered 2 L of Ringer's lactate, followed by 2 units of blood. Reassessment at end of first hour shows that his lung is expanded & his central venous pressure has increased to 22 mmHg, but BP is only 85/70 mmHg, pulse is 115/min, & he remains diaphoretic. Most likely diagnosis?

*Pericardial tamponade* - shock w/ muffled heart sounds + hypotension + distended neck veins (Beck's triad) + high central venous pressure in chest trauma victim = pericardial tamponade or tension pneumothorax --> latter ruled out by re-expanded lung

61 yo woman comes to doc's office for steadily increasing abdominal girth & fatigue with mild exertion. She has noticed this symptom for past few months. She reports a 5-kg (11-lb) increase in her weight without making any change in her regular diet. Her past medical history is unremarkable, although she has not seen a doc for many years. She denies smoking, but admits drinking glass of wine with meals on weekends. On physical exam, she is afebrile & normotensive. Exam of her abdomen reveals shifting dullness & fluid wave, with clear distention. Bedside ultrasound performed, which demonstrates large amount of ascitic fluid. What conditions is most likely cause of this patient's current condition?

*Peritoneal carcinomatosis* - new-onset ascites = broad diagnosis - new-onset diagnosis of ascites in elderly female = ovarian cancer possible Ovarian cancer = 2nd most common gynecologic malignancy in US - most common cause of death among gynecologic malignancies - 5th most common cause of cancer deaths in women - late complication = peritoneal carcinomatosis = when ovarian cancer metastasizes in peritoneal cavity

70 yo Asian man presents for evaluation of weight loss & "heartburn" symptoms. Pt states that he has slowly been losing weight for appx last year, & he states that he has had pain in his upper central abdomen & a feeling that he is regurgitating his stomach contents for a few years. Exam reveals thing-appearing man with temporal wasting, a small palpable mass in his periumbilical region, & a positive fecal occult blood test. Upper endoscopy reveals friable mass in gastric fundus, & biopsy demonstrates gastric adenocarcinoma. What is a risk factor for this pt's disease?

*Pernicious anemia* Gastric adenocarcinoma - risk factors = H pyloria, pernicious anemia, high intake of N-nitrosocompounds found in salted & preserved foods (common cause in Asia)

35 yo woman comes to doc for periodic health maintenance exam. She has no physical complaints, but she is concerned that she hardly every feels happy. She says that she has basically been "down" for at least 3 years. She rarely goes out with friends, & basically keeps to herself at work. She states that her work performance has been stable but uninspired and that she usually feels tired and "blah." Most likely diagnosis?

*Persistent depressive disorder* Persistent depressive disorder - chronic form of depression - diagnosis requires at least 2 yrs of depressed mood - usually functional but at suboptimal level - treatment = psychotherapy or antidepressant therapy

55 yo man with non-Hodgkin lymphoma admitted to hospital for admin of chemotherapy. He is administered cyclophosphamide, vincristine, & prednisone. One day later, he develops paresthesias, muscle weakness, & fatigue. Two days after adminof chemotherapy, ECG shows peaked T waves, widened QRS, & prolonged QT. What findingsis most likely in this patient?

*Phosphate level of 5 mg/dL* Tumor lysis syndrome - complication of high-grade lymphomas - hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia - nausea, vomiting, diarrhea, anorexia, lethargy, hematuria, heart failure, dysrhythmias, seizures, muscle cramps, tetany, syncope, possible sudden death - aggressive IV hydration prior to admin of chemo = most important preventative measure

44 yo man comes to ED 4 hrs after onset of left lower back pain that began shortly after he lifted heavy box out of his car & carried it into his home. He has had no leg weakness & on incontinence. He has ho HT that is controlled with HCTZ. His temp is 98.4 F, BP 138/85 mmHg, & pulse 85/min. Pain is reproduced when pt leans to right. No tenderness to palpation & no deformities in low back or pelvis. Straight leg raising test does not produce symptoms. Neuro exam shows no abnormalities. Most appropriate next step in management?

*Physical therapy* Lumbosacral muscle straing - imaging not indicated in management of new-onset, low back pain in absence of neuro signs, such as radiating pain, weakness, diminished reflexes, regional anesthesia or loss of bowel & bladder control

Venous insufficiency can result in edema, ulceration, & dermatitic skin changes, & can be quite symptomatic. It is the result of venous insufficiency secondary to valvular incompetence, often caused by post-thrombotic state of obstruction. Diagnosis made with

*ultrasound* imaging

68 yo man evaluated in ED bc of fever, SOB & productive cough. He felt ill a week ago, & his symptoms have progressively worsened. A month ago, he was hospitalized in ICU bc of resp failure. He has ho COPD & uses an ipratropium & albuterol inhaler. He has 45 pack yr ho smoking & continues to smoke. On physical exam, temp is 38.4 C (101.1 F), BP 110/68 mmHg, pulse rate 114/min, RR 24/min, O2 sat 90% on ambient air. BMI 19. Pulmonary exam shows crackles at right base. Leukocyte count 19,000/uL w/ 70% segmented neutrophils & 10% band forms. Chest radiograph shows right lower lobe consolidation. Blood cultures obtained, & treatment with IV fluids initiated. Most appropriate empiric antibiotic treatment?

*Piperacillin-tazobactam & amikacin* Pseudomonas aeruinosa pneumonia - ho smoking & COPD - other risk factors = broad-spectrum antibiotic use in previous month, recent hospitalization, malnutrition, neutropenia, glucocorticoid use - treatment = beta-lactam + aminoglycoside initially

Pt complains to doc of chronic pain & tingling of buttocks. Pain is exacerbated when buttocks are compressed by sitting on toilet seat or chair for long periods. No lumbar pain noted. Pain elicited when doc performs Freiberg maneuver, in which there is forceful internal rotation of extended thigh. Most likely diagnosis?

*Piriformis syndrome* - piriformis = small muscle that crosses greater sciatic foramen, cutting into 2 spaces as muscle passes from edge of sacrum to greater trochanter - bicycle riding & running may set off symptoms = nagging ache, pain, tingling, numbness - treatment = avoid maneuvers that set off symptoms - some pts improve with corticosteroid injection near site where piriformis muscle crosses sciatic nerve - therapy believed to work by reducing fat around muscle & thereby increasing available space in that area

Mother of a newborn is concerned bc he has not had a wet diaper during the first 24 hours of his life. Boy is third child for this 26 yo mother & 29 yo father. His siblings have no significant hx. Prenatal care was appropriate & mother says that the infant's kidneys were "a little bit swollen" on prenatal ultrasound. There was no birth trauma and no abnormalities were seen on initial exam at birth. Currently the infant appears comfortable & there is no fever. Significant findings on physical exam include a palpable mass in the suprapubic area. The remainder of the GU exam is normal. Most appropriate next step in management of this infant?

*Place a urethral catheter* Posterior urethral valves (PUV) - most common reason newborn boy not urinating during first day of life - mucosal folds that look like thin membranes - may cause varying degrees of obstruction when child attempts to void - first step = drain bladder so renal function may be preserved = immediately place catheter (usually feeding tube bc regular Foley too large) per urthera & into bladder - VCUG = single best imaging to detect PUV = valves will cause elongation & dilatation of posterior urethra with prominent bladder neck

64 yo man has 6 mo ho progressively worsening urinary symptoms, including hesitancy, intermittency, & sensation of incomplete bladder emptying. Over past 3 days, his symptoms have become markedly worse. Yesterday, he could barely general urine stream & today he has dribbled only little bit of urine. He also has developed lower abdominal pain radiating to back, lethargy, fatigue, nausea, & vomiting. Before this he was otherwise healthy, with no significant med or surgical hx. His only med is aspirin 1x/day. His temp is 98 F, BP 125/80 mmHg, pulse 65/min, & respirations 14/min. He is awake but obviously weak, with soft voice. His abdomen is soft with moderate infraumbilical tenderness & suprapubic distention to umbilicus. Genital exam is significant for circumcised phallus & bilaterally palpable testes in scrotum. Prostate is extremely enlarged but without nodules or tenderness. Lab studies show: K+ 5.4 mEq/L Bicarb 21 mEq/L BUN 71 mg/dL Creatinine 5.6 mg/dL Abdominal & pelvic ultrasound shows distended bladder with moderate bilateral hydronephrosis. What steps is most appropriate at this time?

*Placement of foley catheter and admit him to hospital* Pt has urinary retention + complete bladder outlet obstruction - most likely from prostatic hyperplasia - progressively worsening obstructive voiding symptoms --> urinary retention with some overflow dribbling or incontinence --> bladder outlet obstruction secondary to prostatic enlargement - azotemia --> nausea, vomiting, fatigue, lethargy - pts ARF should be reversible following bladder decompression - serum K+ must be monitored closely for post-diuresis hypokalemia - method to relieve obstruction: simplest, most efficient, & least uncomfortable = Foley cath

38 yo woman, gravida 3, para 2, at 32 wks' gestation comes to doc bc of bleeding from vagina. She states that this morning she passed 2 quarter-sized clots of blood from her vagina. Otherwise, she states that she is feeling well. Baby has been moving normally & she has had no contractions or gush of fluid from vagina. Her obstetrical hx is significant for 2 low-transverse cesarean deliveries for nonreassuring fetal heart rate tracings. Ultrasound performed that demonstrates complete placenta previa. What condition is this pt at highest risk of having?

*Placenta accreta* - abnormal attachment of placenta to uterin ewall - decidual basalis is absent - placenta is attached to myometrium (accreta) or invades into myometrium (increta) or perforates through myometrium (percreta) - may pts with previa & accreta will require hysterectomy at time of delivery Placenta previa - placenta located over cervical os - 3 major types - 3 major risk factors = maternal age, minority race, previous cesarean delivery

60 yo policeman complains of intense, disabling, sharp heel pain every time his foot strikes the ground. Pain is worse in mornings, preventing him from putting any weight on heel. On physical exam, his BP is 132/90 mmHg, pulse is 87/min, respirations are 14/min, & BMI is 30 kg/m^2. He shows exquisite tenderness to direct palpation over anteromedial aspect of heel. Furthermore, pain is exacerbated when toes are dorsiflexed. X-ray films look normal. Most likely diagnosis?

*Plantar fasciitis* - may be multifactoria - may be due to repetitive microtrauma - possible risk factors = obesity, occupations requiring prolonged standing, heel spurs, pes planus, reduced dorsiflexion of ankle - spur caused by pull of fascia = not the cause of plantar fasciitis - spontaneous resolution can be expected in 12-18 mos = symptomatic treatment too

Clint Eastwood has 7 cm right lung EGFR & ALK negative adenocarcinoma with hilar & mediastinal adenopathy, a large right pleural effusion, & bone metastases in his right pelvis & left scapula without pain. He sleeps 8 hours a day & does his own cooking & cleaning. Best treatment option?

*Platinum based chemotherapy + denosumab + Pleur-x catheter* - platinum based chemo & palliative measures = treatment for met lung cancer that is EGFR mutation negative & ALK gene rearrangement negative - pleural effusion related to cancer - bone mets - need help feeling better, not cure - don't need to radiate yet because no pain - Pleur-x catheter = inserted & drained by patient = no SOB bc able to drain themselves - denosumab = reduces risk of fractures with bone mets

A 54-year-old woman is evaluated in the emergency department because of a 7-day history of cough and dyspnea. She had fatigue at the onset of symptoms. She reports feeling feverish, with nonproductive cough and progressive shortness of breath. Medical history is otherwise unremarkable. She takes no medications. On physical examination, temperature is 37.9°C (100.3°F), blood pressure is 105/70 mm Hg, pulse rate is 106/min, and respiration rate is 32/min. Oxygen saturation is 92% on ambient air. Lung examination shows dullness to percussion, decreased tactile fremitus, and decreased breath sounds at the right base. The remainder of the findings on physical examination are unremarkable. Which of the following is the most likely diagnosis?

*Pleural effusions* - secondary to right lower lobe pneumonia with parapneumonic effusion - fluid accumulation in pleural space blocks transmission of sound b/t lung & chest wall = dullness to percussion on exam - decreased-absent breath sounds over effusion bc of separation of aerated lung from chest wall

6 yo girl with ALL admitted to hospital bc of rash & fever. Her mom reports that grl has had fever & runny nose for past 6 days, & rash developed on child's face 3 days ago. Her temp is 99.5 F, BP 110/60 mmHg, pulse 90/min, & respirations 16/min. Exam shows 10-15 small, translucent vesicles on erythematous base. There are pustules with central umbilication, erythematous macules, & crusted lesions on face, upper chest, & abdomen. Most serious possible complication of pt's condition?

*Pneumonia* Varicella / Chickenpox - primary infection with varicella zoster virus - in immunocompromised pts, grl with ALL, varicella can be serious & life-threatening complication = *varicella pneumonia* Varicella pneumonia - poor prognosis in pts with ALL = mortality rate of 25% - rapid deterioation - pts can die within 3 days - IV acyclovir indicated

56 yo man admitted to hospital bc of respiratory distress. Endotracheal tube placed for mechanical ventilation at tidal volume of 900 mL, respiratory rate of 12/min, & fraction of inspired oxygen of 50%. Positive end-expiratory pressure is 10 cm of water. Current meds include subcutaneous heparin & aspirin. Two days later, he develops tachycardia & has a BP of 110/70 mmHg. Cardiac exam shows multiple premature contractions. His arterial blood gas shows a pO2 of 40 mmHg. What is the most likely cause of this patient's condition?

*Pneumothorax* - sudden onset of tachycardia + hypotension = acute - mechanically ventilated with high positive end-expiratory pressure (PEEP) = increased risk for bullous rupture from barotrauma --> pneumothorax Complications of PEEP = barotraumas --> pneumothorax, pneumomediastinum, subcutaneous emphysema - ventilator-associated lung injury - increased intrathoracic pressure --> decreased venous return (preload) --> decreased CO --> systemic hypotension *This patient = tidal volume was set too high = pneumothorax* - tidal volume should be set at 10 mL/kg

Newborn transferred to neonatal ICU for observation & evaluation bc of need for resuscitation in delivery room. On physical exam, baby has low-set ears, small mandible, & short philtrum. On cardiac exam, there is loud second heart sound & grade IV systolic ejection murmur along left sternal border. Chest radiograph shows right-sided aortic arch, normal-size heart, clear lung fields, & no thymic shadow. What would confirm underlying cause of cardiac defect?

*Polymerase chain rxn-based genotyping* DiGeorge syndrome - dysmorphic facial features - evidence of sign cardiac lesion - no hypoplastic thymic shadow seen on chest x-ray - via developmental failure of 3rd & 4th pharyngeal pouches --> congenital absence or anomalies of parathryoid, thymus, lower face, cardiac structures - underlying gene defect = 22q11 deletion --> PCR-based genotyping

5 yo grl brought to doc by her mom bc of dev't of axillary hair & breast budding for 2 mos. She began to bleed from her vagina 1 day ago. She had tibial fracture 1 yr ago. She takes no meds. She is in 60th percentile for both height and weight. Breast & axillary & pubic hair dev't are Tanner stage 2. Skin exam reveals cafe au lait spot. Pelvix exam shows blood at introitus. Most likely diagnosis?

*Polyostotic fibrous dysplasia* / McCune-Albright syndrome - autonomous stimulation of aromatase enzyme production of estrogen by ovaries - prevocious puberty + multiple cystic bone lesions + cafe au lait skin spots

26 yo woman undergoes follow-up evaluation after completing appropriate antibiotic course for UTI that was diagnosed 3 days ago. She is currently asymptomatic. She has had five similar episodes in the last year. In all cases, the symptoms began after sexual intercourse and responded well to antibiotic treatment. She has increased her fluid intake & routinely voids after sexual intercourse. She is otherwise healthy, with no medical problems and no ho sexually transmitted infections. She currently takes no meds and does not use spermicides. Physical exam, including vital signs, are normal. What is the most appropriate next step to reduce this pt's risk of UTI?

*Postcoital antimicrobial prophylaxis* Most appropriate next step in preventing recurrent UTIs in this pt ... postcoital ciprofloxacin - recurrent UTIs in young, sexually active women more commonly reinfection rather than relapse = often associated with sexual intercourse - recommended prophylaxis against recurrent UTIs = liberal fluid intake & postcoital voiding - symptoms of UTI often related to use of spermicidal agents bc spermicides decrease number of healthy vaginal lactobacilli & predispose women to UTIs

49 yo man has had persistent PUD for 7 yrs. He was originally diagnosed by upper GI series 6 yrs ago, & he was poorly compliant w/ med management. For past yrs he has also been complaining of watery diarrhea. All tests for H pylori are negative. Upper GI endoscopy at this time confirms presence of 2 duodenal ulcers. Most appropriate next step in management of this patient?

*Serum gastrin levels* Zollinger-Ellison syndrome - tumor of gastrin-producing cells = excessive acid production - persistent PUD + multiple ulcers + negative H pylori + watery diarrhea = ZES gastrinoma - fasting serum gastrin should be measured in any pt suspected of having ZES - serum gastrin level greater than 1000 pg/mL & gastric pH <5 = diagnostic of ZES

43 yo man consults doc bc of progressively severe fatigue that has developed over period of appx 3 months. On physical exam his skin & mucous membranes show waxy pallor. In-office hematocrit is 18% & peripheral blood smear shows cells of normal morphology in all cell lines, but band-form neutrophils & reticulocytes nearly absent. On specific questioning about possible toxic exposures, patient reports using benzene frequently to clean his hands after working on old house he recently bought & is remodeling. Marrow biopsy specimen would most likely show what?

*Predominance of fat & stroma* Aplastic anemia - panhypoplasia - half of cases = idiopathic - contributors = exposures to chemicals (benzene, inorganic arsenic), radiation, some drugs (antineoplastic agents, antibiotics, NSAIDs, anticonvulsants)

56 yo woman comes to doc bc of 2 year ho burning sensation in her legs. She has occasional sharp, lancinating pains that shoot up her legs, for which hydrocodone & acetaminophen provide some relief. She has had no weakness, headaches, confusion, or memory loss. She has a 22 yr ho HT, CKD, & type 2 DM with retinopathy & diabetic gastroparesis. Current meds include insulin, metformin, lisinopril, & HCTZ. She had MI 4 years ago. Serum creatinine is 2.8 mg/dL & Hb A1c is 11.6%. What is the most appropriate pharmacotherapy for this patient's leg pain?

*Pregabalin* Peripheral neuropathy = complication of diabetes = numbness, burning, tingling of extremities - first-line agents = tricyclic antidepressants, duloxetine, pregabalin, controlled-release oxycodone - other meds = carbamazepine, gabapentin, lamotrigine, tramadol

A 48-year-old woman is evaluated in the emergency department for fatigue, diffuse weakness, and lightheadedness. Her symptoms developed after attending an outdoor music festival, where she was exposed to the sun most of the day. Medical history is significant for hypertension, which is treated with hydrochlorothiazide. She took a single dose of ibuprofen 3 hours ago. On physical examination, temperature is normal, supine blood pressure is 97/52 mm Hg, supine pulse rate is 98/min, and respiration rate is 12/min. When standing, blood pressure is 90/ 45 mm Hg, and the pulse rate is 108/min. The remainder of the examination is normal. Lab studies: Serum creatinine = 1.1 mg/dL (97.2 umol/L) (baseline: 0.7 mg/dL [61.9 umol/L]) Electrolytes = Normal Fractional excretion of sodium = 1.2% Fractional excretion of urea = 27.4% Urinalysis = Specific gravity 1.035; pH 6.5; trace protein; no cells; 3-5 hyaline casts What is the most likely diagnosis?

*Prerenal azotemia* - mean arterial pressure below 60 mmHg - may occur at higher pressures in patients with chronic kidney dz or in those taking certain meds, such as NSAIDs, glomerular hemodynamics - although her fractional excretion of sodium (FENa) is greater than 1%, she is on diuretic, which can increase FENa even in patients with prerenal azotemia - her urine is concentrated, with hyaline casts & high urine specific gravity

43 yo woman has fatigue & poor exercise tolerance. She normally goes to gym every night on her way home from work. For past 8 mos, however, she has been able to go only once or twice a week. She is "exhausted" throughout the day & can barely stay awake until 10 PM. She has joint stiffness in morning that subsides as day progresses. She takes oral contraceptive pills, & does not drink alcohol or smoke cigz. Her menstrual periods are regular & flow is light. Her temp is 98.6 F, BP is 125/85 mmHg, pulse is 80/min, & respirations are 16/min. Physical exam shows wollen, erythematous wrists & metacarpophalangeal & proximal interphalangeal joints. She has increased ESR & a positive rheumatoid factor. Her hemoglobin is 10 g/dL, hematocrit is 31%, & a MCV is 74 fl. She has reticulocyte count of 0.5%. Iron studies show decreased iron & total iron-binding capacity &increased ferritin. Urinalysis normal. Most appropriate next step in management of anemia?

*Prescribe oral methotrexate* Anemia of chronic dz - via RA - primary treatment of anemia of chronic dz = via controlling underlying dz process --> if ineffective or impossible, treatment with erythropoietin injections for target of hgb of 12 g/dL appropriate

21 yo woman, gravida 2, para 2 comes to doc for 6 wk postpartum visit with feelings of depression most of time & crying spells. Her prenatal course was uncomplicated & resulted in normal spontaneous vaginal delivery at 39 wks' gestation. She says that she has not been feeling so well emotionally since birth of baby. She is having trouble sleeping & has little appetite. She has no suicidal or homicidal ideation and no strange thoughts or hallucinations. She did not experience these emotions after her first delivery. She has no med probz & takes no meds. Her physical exam is normal for a woman who is 6 wks' postpartum. Most appropriate next step in management?

*Start antidepressant therapy* Postpartum blues affects 80% of women Potpartum depression affects 10% of postpartum women - treatment = psychosocial therapy & support - antidepressants = first-line therapy

62 yo woman comes to doc bc of lethargy, weakness, & depression for 4 mos. She started taking paroxetine 3 mos ago & has had no change in her mood. Her past med hx is otherwise unremarkable. Her BP is 100/60 mmHg, pulse 80/min, & respirations 12/min. Lungs are clear to auscultation. Cardiac exam shows normal S1 & S2; no murmurs heard. No pedal edema. Lab studies show: Na 134 mEq/L K 5.5 mEq/L Cl- 101 mEq/L HCO3- 22 mEq/L BUN 20 mg/dL Creatinine 0.9 mg/dL Glucose 82 mg/dL Cortisol (AM) 4 ug/dL (normal, 5-23 ug/dL) 30-min cosyntropin stimulation test 8 ug/dL 60-min cosyntropin stim test 8 ug/dL Plasma adrenocorticotropin 75 pg/mL (normal, 9-52 pg/mL) Most likely diagnosis?

*Primary adrenal insufficiency* - low morning cortisol level = adrenal insufficiency --> next step = perform cosyntropin (ACTH) stim test - normal response to ACTH stim test = increase in serum cortisol conc to peak of *>18 ug/dL* after 30-60 mins - when cortisol level don't sufficiently increase with ACTH stim, adrenal insuff is the cause

47 yo man comes to doc for routine health maintenance exam. His med history is unremarkable & he takes no meds. his temp is 36.7 C (98 F), BP 125/70 mmHg, & pulse 88/min. X-ray of chest shows no abnormalities. Exam shows no abnormalities. Lab studies: Hematocrit = 42% Leukocytes = 6,000/mm^3 Na+ = 141 mEq/L K+ = 4.1 mEq/L Cl- = 102 mEq/L HCO3- = 24 mEq/L Protein, total = 7 g/dL Albumin = 4.1 g/dL BUN = 10 mg/dL Creatinine = 0.8 mg/dL Phosphate = 1.8 mg/dL Calcium = 11.4 mg/dL Alkaline phosphatase = 45 U/L Uric acid = 7.3 mg/dL What is the most likely cause of this patient's hypercalcemia?

*Primary hyperparathyroidism* - asymptomatic hypercalcemia & hypophosphatemia - phosphate levels low because PTH inhibits reabsorption of phosphate = more phosphate secreted

65 yo man admitted to hospital for worsening headache, light-headedness, blurry vision & fatigue over last 3 months. He also reports weakness & generalized itching. On exam, he is in no apparent discomfort. His BP is 137/84 mmHg, pulse rate is 98/min, & temp is 37 C (98.6 F). There is facial plethora & diffuse linear scratch marks that don't appear to have secondary infection. His spleen is 4 cm below left costal margin. Lab studies reveal the following: Hematocrit = 62% Hemoglobin = 18 g/dL WBC count = 18,000/mm^3 Platelet count = 550,000/mm^3 Serum erythropoietin = 1 mU/mL (normal = 5-20 mU/mL) Leukocyte alkaline phosphate = 90 U/L Most likely diagnosis?

*Primary polycythemia* / Polycythemia vera - acquired myeloproliferative disorder = overproduction of all 3 hematopoietic cell lines - erythrooietin level low - serum leukocyte alkaline phosphates increased - most frequently diagnosed in ppl 60-75 yo - pruritus, especially after hot bath - facial plethora & splenomegaly common

Commonly associated with UC. Should be considered in pts who have inflammatory bowel disease who have otherwise unexplained abnormal liver function tests, particularly elevated alkaline phosphatase levels. Characterized by inflammation, fibrosis, & strictures of intra- & extrahepatic biliary ducts. May cause jaundice, pruritis, steatorrhea, malabsorption, fat-soluble vitamin deficiencies, & metabolic bone dz.

*Primary sclerosing cholangitis (PSC)*

Initial management for Wolf-Parkinson-White syndrome

*Procainamide* - if procainamide doesn't show results, amiodarone should be tried - definitive treatment = radiofrequency catheter ablation

Russell Crowe has completed six cycles of cisplatin & etoposide & chest radiation for his limited stage small cell lung cancer with a good response. Next most appropriate step?

*Prophylactic brain radiation* - 1/3 of time, it comes back in brain

48 yo man brought to ED by his wife bc of burns on his hands after spilling coffee on himself. He has had episodes of shaking hands & bobbing head. He has had no weakness, loss of consciousness, or change in vision. He takes no meds. He has had recent promotion at work. His father's hands also shook. Cardiac exam shows normal S1 & S2; no murmurs heard. When asked to reach out to grab a pen, his hands begins to shake. There is no tremor at rest. Muscle strength is 5/5 inn all extremities. Sensation normal. Most appropriate next step in management?

*Propranolol* Benign essential tremor - usually found in middle-aged men - genetic component - usually limited to arms, legs, face - head bobbing = characteristic = not seen in pts who have Parkinson dz - treatment = small amounts of alcohol, propranolol, primidone

63 yo woman comes to ED bc of 45 min ho palpitations, nausea, sweating, & feeling sense of impending doom. She has anxiety, restlessness, & tremors. She also reports feeling hot. Her BP is 148/90 mmHg & pulse is 103/min. Lab studies show TSH level of 0.1 uU/mL. Serum CK & troponin enzymes are negative. Most appropriate next step in management?

*Propranolol* Hyperthyroidism - pts should be started on beta-blockers immediately to ameliorate symptoms & prevent cardiac arrhythmias caused by increased beta-adrenergic tone = event before obtaining 24-hr radioiodine uptake result

52 yo man evaluated bc of nasal congestion, frontal headache, & rhinorrhea. He was well until 4 days ago, when rhinorrhea developed. Two days ago, nasal discharge increased & has become dark green. He has frontal headache that worsens when he bends over & right upper maxillary tooth pain. He has no other med problems & takes no meds. On physical exam, vital signs are normal. Nasal exam shows red, swollen mucosa & green discharge. He has no lymphadenopathy. He has no pain with palpation over maxillary sinuses. Best management plan?

*Provide symptomatic therapy* Acute sinusitis - common symptoms = headache ,facial pain & pressure that increases when bending forward, fever, toothache - physical exam findings that add diagnostic value = purulent rhinorrhea w/ unilateral predominance, local pain w/ unilateral predominance, bilateral purulent rhinorrhea, pus in nasal cavity - 3 or more symptoms = positive likelihood ratio of 6.75 for presence of bacterial sinusitis - initial treatment = largely symptomatic = systemic histamines, intranasal glucocorticoids, topical decongestants

Indication for use of magnesium in cardiac arrest

*Pulseless ventricular tachycardia-associated torsades de pointes* Magnesium sulfate - for torsades de points - loading dose 1-2 g IV/IO diluted in 10 mL (D5W normal saline) given as IV/IO bolus - typically over 5-20 minutes - can be classified as sodium/potassium pump agonist - suppression of atrial L- & T-type calcium channels - ventricular depolarizations

35 yo woman comes to doc bc of red lesion on her index finger that developed after minor injury 2 wks ago. Woman reports that lesion is not uncomfortable, although its cosmetic appearance it bothersome. Exam shows 1-cm red, vascular, raised papule with thin collarette of scale. Lesion bleeds easily and does not blanch with pressure. There are no changes in surrounding skin. Most likely diagnosis?

*Pyogenic granuloma* (PG) - most commonly develop at sites of previous minor injuries - manifest as friable, rapidly enlarging, erythematous, vascular-appearing papulaes with collarette of scale - commonly occur during pregnancy - neither pus-containing nor granulomatous = common name is misnomer - best referred to as lobular capillary hemangiomas - proliferation of small blood vessels in fibrous stroma resembling granuloma tissue - neutrophils & crust commonly observed in superficial parts of lesion - treatment = surgical excision, curettage, or electrodesiccation

42 yo gravida 1, para 1 woman comes to doc bc of nausea, vomiting, & abdominal fullness. She is 12 weeks' postpartum & has not stopped having vaginal bleeding as of yet, using 2-3 maxi pads per day. She delivered a term male fetus weighing 3,500 g without complications. She has no other medical problems. Her temp is 98.6 F (37 C), BP is 118/76 mmHg, pulse is 67/min, & respirations are 12/min. Physical exam shows her abdomen is nontender & slightly distended with palpable 10-week-sized uterus. Pelvic exam reveals scant dark to bright red blood in vagina without signs of cervical motion tenderness or purulent discharge. Urine beta-hCG obtained & returns positive. What is the most appropriate next step in management?

*Quantitative beta-hCG* Gestational trophoblastic neoplasia = either choriocarcinoma or placental site trophoblastic tumor - 2 main risk factors = advanced maternal age & previous ho molar pregnancy - most common presentation after delivery of term fetus = irregular vaginal bleeding lasting greater than expected postpartum time (4-6 week = normal) + nausea, vomiting, abdominal fullness

37 yo woman undergoes lumpectomy & axillary node sampling for 3-cm infiltrating ductal carcinoma that was diagnosed by core biopsies & is located on upper outer quadrant of her left breast. Pathology report of surgical specimen is received 3 days after operation. It indicates that all margins around tumor are clear & that all 4 of removed sentinel nodes have metastatic tumor. Tumor is reported to be estrogen & progesterone receptor-negative. What should further therapy most likely include?

*Radiation therapy & chemotherapy* - presence of metastatic dz in axillary nodes requires systemic therapy

44 yo woman has palpable nodule in right lobe of her thryoid gland. Nodule measures 2 cm & is firm. Rest of thyroid gland cannot be felt & is not tender. Pt also describes palpitations, heat intolerance, & weight loss depsite her ravenous appetite. She is thin, fidgety, & constantly moving, with moist skin & a spule of 105/min. She has no exophthalmos or pretibial edema. Her TSH is reported as much lower than normal, & she has elevated levels of free T4. Most appropriate next step in diagnosis?

*Radionuclide thyroid scan* Thyroid nodules - first test = always TSH - low TSH? --> hyperfunctioning nodules --> subclinical hyperthyroidism --> thyroid nodule hyperfunctioning --> thyroid scintigraphy - thyroid cancer is *never* hyperfunctioning - "hot" or hyperfunctioning nodules --> observe or treat for hyperthyroidism

26 yo pregnant woman at 16 weeks' gestation comes to doc bc of palpitations & anxiety. She has had no complications thus far. Her temp is 37 C (986 F), BP 110/80 mmHg, pulse 83/min, & respirations 18/min. Physical exam shows no tremor, exophthalmus, or myxedema. Her thyroid gland is palpable but not enlarged. Lab studies show: TSH = 3 uU/L Total T4 = High Free T4 = Normal What is the most appropriate intervention at this time?

*Reassurance* Euthyroid - easily recognized by *normal TSH value* - total T4 elevated bc increased estrogen in body during pregnancy = increased thyroid-binding globulin - oral contraceptives also increased thyroid-binding globulin

Patient with pulseless ventricular tachycardia is defibrillated. Next action?

*Start chest compressions at rate of at least 100/min*

Required to diagnose spontaneous bacterial peritonitis (SBP)

*ultrasound-guided paracentesis* - ascitic fluid polymorphonuclear leukocyte count >250 cells/mm^3 = diagnostic SBP - presents with fever, abdominal pain, mental status change, increasing ascites in pts who have known liver dz Hepatic encephalopathy - confusion & asterixis - can be ppted by spontaneous bacterial peritonitis - treated with lactulose - give cefotaxime & albumin infusion to treat SBP

71 yo man comes to ED with fever & cough. He has known hypercholesterolemia & is status post-right hemicolectomy for colon cancer 2 weeks ago. Patient states he has had 3 days of fever to 38.9 C (102 F), cough productive of green sputum, & general malaise & weakness. Physical exam is remarkable for decreased breath sounds at left base, left basilar egophony, & dullness to percussion. Complete blood count reveals leukocyte count 15,000/m^3. Chest radiograph reveals left lower lobe infiltrate. He has not received any immunizations in the past 10 years. What is the most important part of the history to ascertain before initiating therapy?

*Recent hospitalization* Pneumonia - absolute requirement for diagnosis = chest radiography + clinical findings - question stem hints toward possible RECENT HOSPITALIZATION for hemi-colectomy - anyone who has been hospitalized 48-72 hours in last 90 days = at risk for multi-drug resistant organisms = must cover patient for nosocomial pneumonia, NOT community-acquired pneumonia

24 yo woman comes to ED bc of abdominal pain & vaginal spotting. She states that pain began yesterday morning & has continued, & at the moment it is mild. Pain is in her left lower quadrant & doesn't fluctuate or radiate. Nothing that she does seems to make it better or worse. She has depression, for which she takes sertraline. She has ho smoking 1 ppd of cigarettes since age 19, but has no med problems & has never had any surgeries. She is allergic to penicillin. On physical exam her temp is 37 C (98.6 F), BP 110/70 mmHg, pulse 84/min, & respirations 12/min. Abdominal exam reveals mild abdominal tenderness. Speculum exam shows scant dark blood in vaginal vault with closed cervical os. Bimanual exam demonstrates mild left lower quadrant tenderness. Remainder of physical exam normal. Lab evaluation: Urine hCG = + Serum hCG = 420 (Normal hCG = 5-25 mIU) Leukocytes = 9,000/mm^3 Hematocrit = 38% Platelets = 230,000/mm^3 Blood type = A-positive Pelvic ultrasound reveals no intrauterine or ectopic pregnancy & is subsequently read as normal. What is most appropriate next step in management?

*Recheck serum hCG in 2 days* - if hCG increasing appropriately, she may be followed every 2 days until it is 1,500 mIU --> intrauterine pregnancy should be visible - no elevation of hCG? = complete abortion - any young woman who presents with abdominal pain, pelvic pain, vaginal bleeding = ectopic pregnancy needs to be ruled out = pregnancy test - patient has + pregnancy test, but based on ultrasound, pregnancy cannot be located - intrauterine pregnancy usually not seen by vaginal-probe ultrasound until hCG reaches 1,500 mIU - may have intrauterine pregnancy, ectopic pregnancy, or impending miscarriage

23 yo college student comes to student health clinic complaining of burning, itchy red eyes. Appx 3 days ago, he noticed that one of his eyes appeared pink. Since then, his other eye also has become involved. He has noticed morning crusting of his eyelids & a watery discharge throughout the day. Review of symptoms reveals additional complaints of low-grade fever, malaise, diffuse myalgias, & a sore throat, lasting appx a day. He is concerned, as he had "pink eye" as a child, and is worried about spreading an eye infection. He is hoping you will prescribe appropriate antibiotic, as he does not want to infect his friend and family. Exam os his eyes reveals bilateral injected conjunctivae reveals "bumpy" appearing epithelium by gross exam. There is bilateral, tender preauricular adenopathy. Exam of oropharynx reveals mild erythema. Rest of physical exam is unremarkable. Most appropriate next step in management?

*Recommend hand-washing and supportive care* Viral conjunctivitis - benign + self-limited - highly contagious --> prevent spread to others

2 mo old boy brought to office bc of chronic constipation & failure to thrive since birth. He has had infrequent small bowel movements since birth, usually no more than once a week & with great difficulty & crying. Mother tried changing to formula instead of breastfeeding, hoping it would help, but this seemed to make the boy's problem worse. Her pregnancy was uneventful & she delivered vaginally at full term without complications. He weighed 2,900 g at birth & currently weighs 3,500 g. Infant did not pass meconium until third day & had several episodes of vomiting in first few weeks of life. On physical exam, infant is not in distress & is in thirtieth percentile for length and fifth percentile for weight. His abdomen is mildly distended and nontender to palpation. Anal sphincter tone is normal & rectal vault is empty of stool. Upon performing digital exam, there is sudden release of dark stool. Next best step in management?

*Rectal biopsy* Short segment Hischprung dz or Aganglionosis of colon - 75-80% of cases --> aganglionic segment limited to rectosigmoid area - begins at internal anal sphincter = most cases present in immediate newborn period with failure or delay (consider after 36 hrs) of passage of meconium - short segment dz = meconium just above rectum --> dilation of internal anal sphincter during digital exam --> sudden explosive release of stool

64 yo man evaluated in ED bc of marked dehydration, tachypnea, & thirst. He has type 2 DM, which has been poorly controlled for 3 yrs. Meds are glyburide & metformin, although he has been only moderately compliant in taking these drugs. On physical exam, BP in supine position is 160/95 mmHg & pulse rate is 100/min, & when standing is 125/78 mmHg w/ pulse rate of 118/min. RR is 20/min. Mucus membranes are dry, nut remainder of physical exam is unremarkable. Lab studies: Creatinine = 2.9 mg/dL Glucose, random = 1196 mg/dL Potassium = 4.3 mEq/L Bicarbonate = 24 mEq/L Serum ketones = Negative Urine ketones = Negative Pt receives 3 L of 0.9% (normal) saline over 3 hrs. What insulin regimen is most appropriate?

*Regular insulin, by intravenous infusion* - most appropriate for pt w/ T2DM & presents w/ HHS - he is being appropriately treated w/ rapid volume resuscitation --> will counteract several of pathophysiologic processes that maintain & progressively worsen HHS - also requires insulin to treat underlying hyperglycemia

69 yo man admitted to ICU with respiratory failure as result of exacerbation of HF. He is intubated & mechanically ventilated. Treatment with IV diuretic & ACEI is initiated. Urinary catheter placed. In addition to meticulous hand hygiene, what is the most effective in preventing catheter-associated UTI?

*Removing urinary catheter immediately* Prevent cath-associated UTI / CAUTI - decrease cath use = 97% of hospital-acquired urinary tract infections - caths should be used for specific indications, not for convenience = removed as soon as possible

2 yo girl seen by pediatrician for fever of 101.4 F & "fussiness" for past two days. Her mother noticed nausea, two vomiting episodes & crying during urination past two days. Child was born 2 weeks premature, is up to date with her immunization, & has reached all her developmental milestones. On physical exam, her temp is 102.3 F, BP 101/60 mmHg, & pulse 110/min. Physical exam unremarkable. She has no rash, petechia, or edema. Her abdominal exam is normal. She cries when her left flank is percussed. Lab studies reveals: WBCSs: 14,000/mm^3 Hct 42% Urinalysis 20-25 WBCs/high power field, many bacteria Child is admitted to hospital for IV hydration & abx. Next step ipn management of this pt?

*Renal ultrasound* - best initial step to evaluate children with UTIs diagnosed from urinalysis - voiding cystourethrogram (VCUG) indicated ater UTIs successfully treated Pyelonephritis Indications for imaging (RUS & VCUG) in children - girls <3 yo with first UTI - boys of any age with first UTI - children of any age with febrile UTI - children with recurrent UTI - first UTI in child of any age with abnormal voiding pattern, poor growth, anatomical abnormalities of urinary tract, fam hx of renal dz

46 yo woman comes to doc for routine exam. She states that her BP was checked a wk ago at health fair & it was 190/120 mmHg. She has no hx of any major med illnesses & takes no meds. She has smoked one pack of cigz daily for past 20 yrs but does not drink alcohol. Her temp is 98.3 F, BP 196/118 mmHg, pulse 80/min, & respirations 16/min. Ophthalmoscopic exam shows arteriovenous nicking but no hemorrhage. Physical exam shows mid-abdominal bruit. Lab studies shown: Na 140 mEq/L K 3 mEq/L Cl 100 mEq/L HCO3- 31 mEq/L pH 7.5 PCO2 33 mHg PO2 100 mmHg Urinalysis shows no abnormalities. Most likely cause of her HT?

*Renovascular HT caused by fibromuscular dysplasia* - low serum K+ levels & metabolic alkalosis = hyperaldosteronism - abdominal bruit = clue - renal artery stenosis & state of high renin - commonly affects middle-aged Caucasian women - may be unilateral or bilateral - various tests confirm presence = captopril renal scan, MRA of renal arteries, CT angiogram, renal artery angiogram - once presence confirmed, revascularization procedure like angioplasty most likely = improvement in BP - non-inflammatory, non-atherosclerotic

A 35-year-old woman undergoes evaluation following the incidental detection of thrombocytopenia. The patient has no evidence or history of bruising, nosebleeds, menorrhagia, or upper gastrointestinal or genitourinary bleeding and no family history of bleeding disorders. Medications are an oral contraceptive pill and occasional ibuprofen for menstrual discomfort. On physical examination, vital signs are normal. Examination of the skin discloses no bruising or hematomas. Abdominal examination is normal, with no splenomegaly. Lab studies: Hct = 35% Hgb = 12.9 g/dL Leukocyte count = 6500/uL MCV = 85 fL Platelet count = 55,000/uL Peripheral blood smear shows large platelets, slightly decreased in number. Most appropriate management?

*Repeat complete blood count in 1 week* - counsel pt about potential bleeding symptoms & repeat CBC at designated interval such as 1 week ITP treatment - repeat complete blood count in 1 week - new-onset thrombocytopenia with otherwise normal complete blood count = diagnosis of exclusion

46 yo woman evaluated during routine exam. She has 6 yr ho HT treated w/ amlodipine & atenolol & is currently asymptomatic. Her father had MI at age 50 years, & her mom developed T2DM at age 64 years. On physical exam, BP is 138/89 mmHg, pulse rate is 76/min, & RR is 18/min; BMI 33. Central obesity noted, but all other findings unremarkable. Results of lab studies show hgb A1c value of 6.6% & fasting plasma glucose level of 114 mg/dL. What diagnostic tests should be performed next?

*Repeat measurement of hemoglobin A1c value* Diagnose T2DM - pt is at high risk, & hgb A1c should be remeasured - has fam hx of T2D & CAD, is obese, & has HT - *according to American Diabetes Association, in absence of unequivocal symptomatic hyperglycemia, diagnosis of diabetes must be confirmed on subsequent day by repeating same test suggestive of diabetes* - bc pt had 2 diff't tests w/ discordant results, test that is diagnostic of diabetes should be repeated to confirm diagnosis

A 35-year-old woman is evaluated for thrombocytopenia. This finding was identified on a complete blood count obtained as part of an insurance application. The patient feels well and has no history of bleeding symptoms. Her medical history is unremarkable, and she takes no medications. On physical examination, vital signs are normal. Examination of the skin discloses no petechiae or ecchymoses. The remainder of the examination is normal. Hemoglobin is 13.5 g/dL (135 g/L), the leukocyte count is 8000/µL (8.0 x 109/L) with a normal differential, and the platelet count is 12,000/µL (12x109/L). A peripheral blood smear is shown. Which of the following is the most appropriate management?

*Repeat platelet count* Pseudothrombocytopenia - platelets drawn into EDTA-anticoagulated test tube clump & fail to be counted accurately by automated counter = spuriously low platelet count = lab artifact --> requires no therapy - can be confirmed when platelet count normalizes after count is repeated in tube containing citrate or heparin as anticoagulant

75 yo woman evaluated during routine physical exam. She reports moderate fatigue that she believes has worsneed over past 6 months but has not other symptoms, such as nervousness, weight gain or loss, joint discomfort, constipation, palpitations, or dyspnea. Pt has ho HT. Her only med is daily lisinopril. On physical exam, she appears healthy. BP is 132/75 mmH; all other vital signs normal. Thyroid gland is not palpable; no cervical lymphadenopathy noted. Cardiac & pulmonary exam findings normal. Deep tendon reflexes normal. Lab studies: CBC Normal Comprehensive metabolic panel Normal Thyroid function tests (repeated & confirmed): Thyroid-stimulated hormone 6.8 uU/mL Thyroxine, free 1.1 ng/dL Thyroid peroxidase Ab titer Normal Most appropriate management?

*Repeat thyroid function testing in 6 months* Subclinical hypothyroidism - TSH greater than reference range + T4 in reference range - typically has no symptoms or mild symptoms - may have mild elevations in serum total cholesterol, LDL, & even C-reactive protein levels - increased risk for atherosclerosis & cardiac events - treatment recommended when TSH > 10 uU/mL

25 yo man comes to ED with progressive lower back pain for 3 wks. He has had intermittent episodes of night sweats, fevers, & chills. He has had difficulty walking & difficulty controlling his bowel movements. His med hx is unremarkable. His temp is 102 F, BP is 100/60 mmHg, & pulse is 120/min. Grade 3/6 systolic ejection murmur that radiates to carotid arteries is heard over right sternal border. There is tenderness over L4. Leukocyte count is 32,000 cells/mm^3 & erythrocyte count sedimentation rate is 100 mm/h. Most likely causal organism?

*Staphylococcus aureus* Spinal cord compression - most likely via epidural abscess: leading bacterial pathogens = S aureus - hx of fever, chills, night sweats indicates that pt's back pain most likely associated with infection - heart murmur = bacterial endocarditis - one of most common predisposing factors to spinal epidural abscess = IV drug abuse

A 28-year-old man is evaluated for hematuria. Blood in the urine was found on testing related to an insurance physical examination. Medical history is unremarkable, and the patient takes no medications. His father died of metastatic bladder cancer at the age of 55 years. On physical examination, temperature is 36.9°C (98.4°F), blood pressure is 138/8S mm Hg, pulse rate is 72/min, and respiration rate is 12/min. The remainder of the examination is normal. Urinalysis reveals no protein, 5-10 erythrocytes/high-power field (all of which are isomorphic), and 0-2 leukocytes/high-power field. Which of the following is the most appropriate diagnostic test to perform next?

*Repeat urinalysis* - appropriate for low-risk patient with possible hematuria - in patient age younger than 40 yo, greater than 3 erythrocytes/high-power field on two or more occasions constitutes hematuria & is common finding on urinalysis - urinalysis should be repeated before further evaluation, despite fam history - fam history of bladder cancer does not increase patient's risk of developing malignancy unless both fam members have been exposed to similar toxins - if hematuria established after repeat urinalysis, patient should then be evaluated for its cause

25 yo man of Eastern European Jewish descent being evaluated for right hip fracture & splenomegaly. He reports recurrent acute episodes of bone pain for past 5 yrs. Blood chemistry Erythrocyte count: 2,000,000/mm^3 Leukocyte count: 3300/mm^3 Platelet count: 60,000/mm^3 Radiographic films demonstrate multiple osteolytic lesions in vertebral column & femurs. Bone marrow aspirate reveals clusters of histiocytes showing fibrillary cytoplasm with finely uniformly vacuolated appearance. Fibrillary material in cytoplasm in PAS-positive. Most effective treatment available for this condition?

*Replacement therapy with imiglucerase* Gaucher dz - via def of glucocerebrosidase --> accumulation of glucocerebroside within lysosomes of histiocytes - most common adult variant (type I) --> affects bone marrow, liver, spleen --> pancytopenia, bone fractures; thrombocytopenia, anemia - diagnosed established by determination of glucocerebrosidase levels in circulating leukocytes - most characteristic = Gaucher cells, large histiocytes with their cytoplasm engorged with glucolipid - US: dz most common among Ashkenazi Jews (of Eastern European origin)

60 yo man comes to clinic for physical exam. His company's health-insurance provider has changed, and the new insurance company is requiring all health plan members to have full physical exam, including a chest radiograph. The man reports smoking one to 2 packs of cigarettes per day since his mid-20s. He has no complaints, reports being quite healthy, & jogs 5 miles a day. Review of systems is negative for chest pain, hemoptysis, chronic cough, weight loss, & melena. Physical exam is unremarkable. His chest radiograph, however, reveals a solitary pulmonary nodule in the periphery of his left mid lung zone. No old radiographs are available for comparison. CT scan of chest reveals 2.8 cm mass with no calcifications. Most appropriate next step in management?

*Resection* Large pulmonary nodules (>1 cm), especially if older in age (>60 years) + underlying risk factors (smoking) = extremely high risk of cancer - high-prob nodules should be excised

44 yo man comes to doc (video of fasciculations shown) bc of 1-year ho progressive weakness in his extremities & one side of his face. Recently he has had difficulty swallowing & has had slurred speech. He has had no bowel or bladder incontinence, pain, difficulty with memory, or numbness. His BP is 132/88 mmHg, pulse is 75/min, & respirations are 16/min. Exam shows 3/5 muscle strength in upper & lower extremities & tongue fasciculations. Deep tendon reflexes are brisk. Sensation is normal. Electromyogram shows widespread axonal disease. Most appropriate counseling about patient's prognosis?

*Respiratory failure & death within 3-5 years is common* ALS - combo of lower & upper motor neuron findings - lower = muscle weakness, fasciculations, atrophy - upper = spasticity, increased deep tendon reflexes - limited to corticospinal & motor nerve pathology - EMG = widespread axonal death

A 63-year-old man is evaluated for progressive dyspnea on exertion for the last several months. He can walk two to three blocks on a flat surface but becomes short of breath when going upstairs or uphill. He has a 10-pack-year history of smoking but quit 20 years ago. He takes no medications. On physical examination, vital signs are normal except for a respiration rate of 22/min. No jugular venous distention is noted. Pulmonary examination shows reduced breath sounds at the lung bases. Findings on cardiac examination are normal. There is no leg edema. Pulmonary function tests show forced expiratory volume in 1 second (FEV1) of75% of predicted, forced vital capacity (FVC) of 68% of predicted with no change after administration of a bronchodilator, total lung capacity of 68% of predicted, and residual volume of125% of predicted. The FEV1/FVC ratio is 82%. Chest radiograph shows low lung volumes with suggested bibasilar atelectasis. Which of the following is the most likely diagnosis?

*Respiratory muscle weakness* - progressive dyspnea w/out other associated respiratory syptoms - pulmonary function tests = restrictive pattern w/out evidence of obstruction & with increased residual volume = typical for resp muscle weakness - residual volume increased via pt's inability to exhale fully

What condition is a contraindication to therapeutic hypothermia during post-cardiac arrest period for patients who achieve ROSC?

*Responding to verbal commands*

24 yo woman comes to ED after motor vehicle accident. She is conscious & complains of abdominal pain. Her BP is 123/86 mmHg, pulse 102/min, & respirations 18/min. On physical exam, multiple lacerations & bruises seen all over body, but there is no obvious deformity. There is tenderness & instability of pelvic girdle. Initial assessment shows no vaginal or rectal injuries, but when a Foley cath is inserted blood urine is recovered. Best next step?

*Retrograde cystogram including post-void films* - injecting dye + taking x-ray --> extravasation - important to include post-void films bc extravasation at bladder neck can be obscured by dye that is filling bladder Bloody urine + pelvic facture = presence of tenderness & instability of pelvic girdle = bladder injury in either gender, or bladder or urethral injury in male - bladder in this case

25 yo man has headache & mild photophobia. Symptoms have been ongoing for past 3 hrs. He denies nausea, vomiting, or prior symptoms. He denies any head trauma. His past med hx is notable for hydrocephalus for which he has indwelling ventriculoperitoneal shunt. This was manipulated few days ago during neurosurgical clinic visit. Pt's shunt series films reveal no kinking in shunt tubing. Head CT scan reveals no increased hydrocephalus. CSF obtained via cisternal tap reveals several white cells consistent with infection. Pt started on abx. What pathogens is most likely responsible for pt's presentation?

*Staphylococcus epidermidis* - colonizes skin - pt had recent manipulation of shunt --> shunt was infected during procedure --> pathogen = S epidermidis - treatment = nafcillin

22 yo man involved in motocycle accident & sustains serious injuries. He is brought by ambulance to ED, where he is noted to have injuries to head, chest, pelvis, & legs. His HR is 110/min, with BP of 100/60 mmHg. In addition to bruises along his body, blood is noted at urethral meatus. Pelvic radiograph demonstrates significant separation of pubic symphysis with fracture of pelvis. CT scan demonstrates active extravasation of arterial contrast in pelvis. Pt is taken to interventional radiology suite, where several embolization coils are placed in branches of internal iliac artery. His BP improves to 125/75 mmHg & pulse improves to 90/min. Next step in management of his potential urethral injury?

*Retrograde urethrogram* - to confirm diagnosis - place cath in distal urethra --> inject contrast - urethral injury diagnosed by irregular appearance or by extravasation of contrast above &/or below urogenital diaphragm Diastatic pelvic fracture - high risk of pelvic & venous bleeding - associated with urethral & bladder disruption - blood noted in urethral meatus = high suspicion of urethral injury

65 yo woman evaluated 1 wk after undergoing upper endoscopy for persistent abdominal pain. Study showed 1-cm, clean-based ulcer in duodenum. Biopsy specimens from stomach showed no evidence of H pylori infection, & serum Ab test for H pylori was also negative. PPI therapy was started, & pt's symptoms were alleviated. She has ho mild osteoarthritis & osteoporosis. Meds are nonprescription analgesic for arthritis & calcium supplement, vitamin D, & alendronate. On physical exam, vital signs are normal. Abdominal exam reveals no tenderness, hepatomegaly, or palpable masses. CBC normal. Most appropriate next step in this pt's management?

*Review the nonpresciption arthritis analgesic* - 2 most common causes of PUD = NSAIDs & H pylori - pt has ho arthritis, for which she takes OTC analgesic

63 yo white man who recently retired after working as plumber for over 30 years returns to his fam doc, saying that he has been feeling "very down" lately & has been having decreased appetite & loss of interest in activities that used to give him pleasure. He is a smoker, drinks no alcohol, & is being treated by his fam doc for moderate essential HT. His physical exam is unchanged from his previous visits. What is the most appropriate next step in management?

*Review the patient's medication history* - many meds used to control HT, such as propranolol, & in past, reserpine = depressive symptoms - changing antiHT meds could possibly improve depressive symptoms without need to start antidepressant

Should be considered in patients with serum creatinine kinase level above 5000 U/L who demonstrate blood on urine dipstick testing in absence of significant hematuria

*Rhabdomyolysis* - *treatment = rapid infusion of IV 0.9% saline* - fluids adjusted to maintain hourly urine output of at least 300 mL until urine negative for myoglobin - most commonly develops after exposure to myotoxic drugs, infection, excessive exertion, or prolonged immobilization - complications = hypocalcemia, hyperphosphatemia, hyperuricemia, metabolic acidosis, acute muscle compartment syndrome, limb ischemia - AKI via acute tubular necrosis in appx 1/3 of patients

5 yo girl from Connecticut brought to fam clinic with 3 day ho fever & intermittent joint pain. She is generally healthy, but according to her mother, she had a "cold" about 1 mo ago. On physical exam her temp is 103.2 F, BP 94/60 mmHg, pulse 114/min, & respirations 22/min. Knees & elbow joints are swollen, warm, & tender to palpation. There is grade III/VI diastolic murmur heard best at apex. Multiple fine, pink macules noted on her trunk. These macules blanch in center. Most likely diagnosis?

*Rheumatic fever* - inflammatory - possibly autoimmune - immune response to group A streptococcal Ags during pharyngitis = Ab cross-rxns with myocardial Ags - involves many tissues = heart, joint, skin, CNS - initially: fever, dyspnea, chest pain, cardiac murmur

A 68-year-old woman underwent a right hemicolectomy 2 years ago for stage III colon cancer. She received 6 months of adjuvant chemotherapy after surgery. On a recent routine follow-up visit, a serum carcinoembryonic antigen level was found to be elevated to 43 ng/mL (upper limit of normal, S ng/mL). She has no other medical issues and takes no medications. On physical examination, her vital signs are normal. Her abdomen is soft with no distention or masses, the liver edge is palpable just below the right costal margin, and bowel sounds are normal. No supraclavicular lymph nodes are palpable. Computed tomography (CT) scans of the chest, abdomen, and pelvis demonstrate a single, LS-cm-diameter hypodense lesion in the right lobe of the liver. No other abnormalities are seen on the scan. Which of the following is the most appropriate management?

*Right hepatectomy* Manage oligometastatic colorectal cancer - pt has potential for curative resection --> should undergo right hepatectomy if no other sites of dz identified during explorative surgery = limited # of metastatic foci of cancer confined to one organ

72 yo man brought to ED bc of progressive weakness, headaches, difficulty with memory, & an inability to perform simple activities of daily living for 3 days. He states that he no longer knows how to dress himself or brush his hair, and he has had difficulty using his left hand. He has hx of CAD, transient ischemic attack 2 yrs ago, & atrial fibrillation. Current meds include warfarin. His temp is 98 F, BP 145/90 mmHg, & pulse 85/min. Neuro exam shows left-sided. Muscle strength is 2/5 in left UE & 3/5 in left LE. There is left-sided homonymous hemianopsia. Sensation is normal. His INR is 1.2. What is the most likely location of this pt's lesion?

*Right parietal lobe* - contralateral weakness = parietal, and memory deficits - contralateral hemianopsia = interruption of optic fibers that have already crossed at optic chiasm - neglect points towards lesion in right parietal lobe - may have had hemorrhagic stroke = embolic event from atrial fibrillation or ischemic event from severe vascular dz

Mom brings 18 mo old daughter to ED 20 minutes after child had episode of choking & gasping while eating potato chips. Mom doesn't think child went blue during episode, & child returned to playing with her toys shortly after episode. On exam, child has had intermittent cough but is otherwise playful & in no apparent acute distress. Physical exam is normal, except for expiratory wheeze noted in right lung fields. BP is 95/58 mmHg, respirations 27/min, pulse 107/min, & O2 sat 97%. Chest radiograph appears normal but expiratory films are unable to be performed. Next step in management?

*Rigid bronchoscopy* - under general anesthesia - greater access to subglottic airways - ensures oxygenation & easy passage of telescope & grasping forceps during extraction - children, ages 1-3, at greatest risk for aspirating foreign objects

25 yo man presents to doc's office bc people have told him that his eyes appear "yellow." Pt has been told this for several years now, & he has noticed this appearance himself. He denies any other symptoms, including weight loss, malaise, or abdominal pain. He drinks alcohol occasionally with meals. His past med hx is unremarkable, & he takes no meds. On physical exam, vitals are: temp 98 F, BP 120/80 mmHg, HR 86/min, RR 13/min. He has obvious scleral icterus. Head & neck are within normal limits. Chest is clear to auscultation. Heart shows normal S1 & S2 with no rubs or gallops. Abdominal exam is normal with no megalies. Extremities are normal. Following lab data obtained. WBC 8,000/mm^3 Hb 13 g/dL Hct 39% Platelets 450,000/mm^3 ALT 33 IU/L AST 22 IU/L Alkaline phosphatase 100 IU/L Total bilirubin 6 mg/dL Conjugated bilirubin 3.5 mg/dL Lactate dehydrogenase 130 U/L Urinary exam positive for bilirubin & a 500% greater-than-normal urinary coproporphyrin. What conditions is most likely diagnosis?

*Rotor syndrome* - asymptomatic jaundice + direct hyperbilirubinemia - AR - defect in hepatocytes' ability to store bilirubin - elevated urinary coproporphyrins - at least 50% of bilirubin conjugated or direct = can be found in urine - benign - no specific treatment

A 70-year-old man is evaluated in the emergency department for severe lower back pain that began suddenly 2 days ago and was associated with an episode of syncope. Since that time, he has had vague lower abdominal and back discomfort. He has had no change in bowel or urinary habits and no fever or chills. Medical history is significant for hypertension, hyperlipidemia, and a 40-pack-year smoking history. Medications are atorvastatin, aspirin, and lisinopril. On physical examination, temperature is 37. 7°C ( 99 .8°F), blood pressure is 100/60 mm Hg, pulse rate is 98/min and regular, and respiration rate is 18/min. Results of cardiac and neurologic examinations are normal. Abdominal examination shows moderate tenderness to palpation in the infraumbilical and suprapubic regions, but without guarding or rebound tenderness. Findings on rectal examination are unremarkable, with guaiac-negative stool. Laboratory results include hematocrit of32% and leukocyte count of 12,000/µL (12.0x 109/L). Results ofliver chemistry studies and urinalysis are normal. Electrocardiogram shows normal sinus rhythm and evidence ofleft ventricular hypertrophy. Plain abdominal radiograph shows no free air or air-fluid levels. Which of the following is the most likely diagnosis?

*Ruptured abdominal aortic aneurysm* - severe abdominal or back pain with syncope, followed by vague discomfort - locally contained - prevent immediate death - leukocytosis & anemia common - CT should be performed for diagnosis

4 yo boy with congenital hydrocephalus is brought to ED bc of fever, headaches, irritability, lethargy, photophobia, & vomiting for 2 days. He underwent surgery for placement of ventriculoperitoneal shunt 1 yr ago. His childhood immunizations are up to date. His temp is 103.2 F. Exam shows nuchal rigidity. Kernig & Brudzinski signs are present. Skin overlying shunt tract is erythematous. Lumbar puncture & CSF analysis shows leukocyte count of 40,000/mm^3, with 85% neutrophils, glucose level of 48 mg/dL, & protein level of 169 mg/dL. Most likely cause of this pt's condition?

*S epidermidis* - causes 40-60% of CSF infections in ppl with ventriculoperitoneal shunts (S aureus = 2nd) - *unlike meningitis occurring in normal children, ventriculoperitoneal shunt infections most common caused by coagulase-negative Staphylococcus*, such as S epidermidis

55 yo woman of South Asian descent presents to her doc's office with vague RUQ pain that has been ongoing for several months. She describes pain as dull, w/ no association with food intake. She denies fever, although she has noticed 11-22 lb weight loss. Her pas med hx remarkable for gallstones. She immigrated to US appx 10 yrs ago. She denies hx of IV drug use, & she has never received blood transfusion. She doesn't take any meds. On physical exam, vital signs are: temp 98 F, HR 86/min, BP 120/72 mmHg. Her head, neck, pulmonary, & CV exams are within normal limits. Palpation of RUQ elicits moderate tenderness, w/ no rebound or guarding. CT of abdomen performed, & reveals mass arising from gallbladder wall & invading liver parenchyma, as well as several stones within gallbladder lumen. What organisms has been implicated in dev't of this lesion?

*Salmonella typhi* Gallbladder cancer - usually has grave prognosis due to advanced stage at which it presents - chronic carriers of Salmonella = increased risk for dev't of gallbladder cancer - ind's of gallstones have higher Salmonella carrier rates (stones act as *nidus* for infection)

35 yo man falls on hand & comes to urgent care clinic complaining of wrist pain. He relates that he was not able to break fall, & that the heel of his hand took brunt of his full weight as it hit the pavement. On physical exam, he is distinctly tender to palpation over anatomic snuffbox. Anteroposterior & lateral x-ray films are negative. Most likely diagnosis and most appropriate next step in management?

*Scaphoid bone fracture; thumb spica cast* Nondisplaced fracture of carpal navicular (scaphoid bone) - notorious for not showing up on x-ray films at time of injury - failure to correctly diagnose --> can lead to avascular necrosis of scaphoid = more invasive intervention

22 yo woman, gravida 2, para 1 at 28 weeks' gestation, comes to physician for prenatal visit. She states that fetus is moving very well & she has no bleeding, contractions, or loss of fluid. She had nausea & vomiting throughout firs trimester, but her pregnancy has been otherwise uncomplicated. Her obstetric history is significant for term vaginal delivery after normal prenatal course. She has asthma, for which she occasionally uses inhaler, & has no other med problems. Her BP is 106/66 mmHg & pulse is 78/min. Physical exam shows fetal heart rate is in 150s & her fundal height is 29 cm. Lab studies show glucose-loading test is 148 mg/dL & urine dip is negative for protein & glucose. What is the most appropriate next step in management?

*Schedule a 3-hour, 100-g oral glucose tolerance test* Gestational diabetes mellitus - screening = use 50-g, 1-hour oral glucose-loading test - screening test administered between 24 & 28 weeks' gestation - normal value < 140 mg/dL - next step = schedule 3-hour, 100-g oral glucose tolerance test

69 yo woman comes to doc bc of exertional chest pain for past 18 mos. She says that her chest pain always occurs after she walks 2 blocks at fast pace. She does not have pain any other time. She has hx of non-insulin-dependent diabetes & HT, & has smoked one pack of cigz daily for past 35 yrs. Vital signs are within normal limits. Physical exam shows no abnormalities. Exercise stress test shows ST-segment depression in leads V1, V2, V3 after 4 minutes of exercise that is reversible with rest. Cardiac cath shows 80% stenosis of proximal left main coronary artery. Most appropriate treatment for pt?

*Send her for coronary artery bypass grafting* Indications for CABG - significant left main coronary stenosis - significant stenosis (>70%) of proximal LAD & proximal left circumflex artery - 3-vessel dz - 2-vessel dz in diabetic pts - significant proximal LAD dz with 1 or 2 vessels affected, with left ventricular ejection fraction <50% &/or risk for infarction during noninvasive testing

26 yo woman, gravida 4, para 0 at 28 weeks' gestation, comes to doc for prenatal care visit. She says that sometimes she feels fetus movign and not at other times. She has had no bleeding, loss of fluid, or contractions. Her past obstetric hx is significant for spontaneous abortions at 9, 12, & 15 weeks. She has no past med hx & has never had surgery. This pregnancy has been uncomplicated thus far. On physical exam, fetal heart tones are not appreciated so she is sent immediately for an ultrasound. Ultrasound shows 23-week fetal demise. After discussion, pt states that she desires an autopsy to be performed on the fetus & that she does not want expectant management. What is the most appropriate next step in management?

*Schedule induction of labor* - pt has experienced fetal demise = fetal death after 20 weeks' gestation and before birth = difficult emotional experience - several risk factors for fetal demise = fetal aneuploidy, maternal diabetes, antiphospholipid syndrome, other "thrombophilias," maternal trauma, fetal infection - for pts who desire autopsy or are past 20 weeks' gestation, most appropriate management = induction of labor

21 yo student states that he feels very anxious around ppl & fears that something will happen to him bc he has noticed other ppl watching him & talking about him. He has difficulty focusing during class, thinking that his peers are watching his every move. He has recently dropped out of classes & taken medical leave of absence. Student vehemently denies using any drugs bc he heard stories that they make people "go crazy." These specific symptoms have been present over past 3 mos. He usually stays at home in his room & has recently started covering mirrors in house. He occasionally mumbles things to himself. Student denies any other symptoms, & his physical exam & lab testing are within normal limits. During the interview, his responses are short but organized & goal-directed & he has restricted affect. Most likely diagnosis?

*Schizophreniform disorder* - symptoms must meet criteria for schizophrenia = 2 or more of the following: delusions, hallucinations, disorganized speech, catatonic behavior, negative symptoms - lasts at least 1 mo but less than 6 mos

Philosophy graduate student notes that she has always felt diff't from others & believes in supernatural powers. She thinks that at time she hears voice of God. She believes that there is evil in the form of witchcraft in the world but feels protected bc she "can spread an energy shield around" her body. She has tried to be a medium for communicating with the deceased based on what she thought was one communication with her dead grandmother. She states that some of her friends think she is a little bit odd, but she feels that is okay because nothing is really wrong with her. She supports herself and is otherwise functional. Most likely diagnosis?

*Schizotypal personality disorder* - pervasive pattern of social & interpersonal deficits & eccentric behaviora 5 or more of the following characteristics - odd beliefs - unusual perceptual experiences - lack of close friends, suspiciousness - odd speech - inappropriate affect - odd appearance

19 yo male college student visits college infirmary with complaint of severe right eye pain, photophobia, tearing, and decreased vision. He is immediately referred to ophthalmologist. Student tells doc that he wears contact lenses but has not taken them out for 10 days bc he has been up late every night studying for final exams. On exam, doc finds hazy cornea, central corneal ulcer, and adjacent stromal abscess. What is the appropriate next step in management?

*Scrape the ulcer for Gram stain & culture* Corneal ulcer - sensitivity before topical abx therapy started

55 yo man reevaluated during follow-up exam. He slipped in his driveway 2 wks ago & sustained right wrist fracture. Radiography showed evidence of cortical thinning of bone of wrist & forearm. Med hx is unremarkable, & he takes no meds. His age-appropriate preventive health interventions are current. On physical exam, vital signs are normal. BMI is 19. Other than a cast on his right wrist, all other findings are normal. Results of lab studies are significant for hemoglobin level of 11.9 g/dL & a serum 25-hydroxyvitamin D level of 17 ng/mL. Results of comprehensive metabolic panel, urinalysis, & stool exam for occult blood are normal. DEXA scan shows T-scores of -1.6 in lumbar spine, -2.2 in femoral neck, & -1.9 in total hip. What is the most appropriate next step in management?

*Screen for celiac disease* - calcium malabosrption may occur in pts with celiac disease and may cause secondary osteoporosis - part of evaluation for secondary causes of his low bone mass & fracture - pt has ho fragility fracture = sustained in fall from standing height - bone density scan shows low bone mass - in otherwise healthy 55 yo man, these findings raise concern for secondary cause of low bone mass & fragility fracture - screening guided by history & physical exam findings may include testing for hypogonadism, vitamin D def, primary hyperparathyroidism, calcium malabsorption, & multiple myeloma

Alcoholic 56 yo man gives hx of several yrs of intense epigastric pain that is present at all times & is exacerbated by eating. He also reports that for past 3 yrs, he has had diagnosis of diabetes & oily spots on surface of his stool. He began to have acute episodes of severe upper abdominal pain in his 30s & has continued to have intermittent attacks of pain at unpredictable intervals. He has been smoking one pack of cigz & drinking half bottome of vodka per day for past 30 yrs. On physical exam, he has BMI of 18 kg/m^2, BP of 120/76 mmHg, pulse of 86/min, respirations of 18/min, & upper abdominal tenderness. Most accurate test for diagnosis?

*Secretin stimulation test* - most accurate test for chronic pancreatitis --> directly measures pancreatic function & has 90% specificity - healthy person --> releases large volume of bicarb-rich pancreatic fluid in response to IV injection of secretin (chronic pancreatitis = nah) Chronic pancreatitis

Patient has rapid irregular wide-complex tachycardia. Ventricular rate is 138/min. He is asymptomatic, with BP of 110/70 mmHg. He has history of angina. Action recommended next?

*Seeking expert consultation* Adult Tachycardia with Pulse Algorithm: Assess appropriateness for clinical condition. Heart rate typically >150/min if tachyarrhythmia --> Identify & treat underlying cause --> No wide QRS --> IV access & 12-lead ECG if available Vagal maneuvers Adenosine (if regular) beta-blockers or CCB Consider expert consultation

25 yo man sustained multiple stab wounds to abdomen when he was mugged while jogging in park. Assault took place in evening. He was dumped by attackers behind thick vegetation and was not found until next morning. Exploratory surgery reveals multiple small bowel and colonic lacerations, all of which are repaired. In postoperative period pt has persistent hypotension, even though he has received adequate fluid infusion & his central venous pressure is 12 mmHg. Further studies done with help of pulmonary artery cat reveal high cardiac output & low peripheral resistance. Most likely diagnosis?

*Septic shock* - high cardiac output + low peripheral resistance - via massive peritoneal bacterial contamination

33 yo man comes to doc for physical exam & to have chest x-ray done, as required by his new employer, an asbestos removal company. He is feeling well & has no complaints. He takes no meds. He does not smoke cigz or use drugs. He has no ho previous potentially toxic exposures. His temp is 98.6 F, BP is 100/70 mmHg, pulse is 63/min, & respirations are 18/min. His lungs are clear to auscultation. He has no clubbing of his fingers. Remainder of exam is unremarkable. Chest x-ray shows 0.9-cm nodule in left lower lobe w/ large, coarse, dense calcifications. Most appropriate management regarding evaluation of this mass?

*Serial CT scans* Solitary pulmonary nodules - low risk for malignant lesion due to benign appearance of lesion (coarse calcifications) - <35 yo - nonsmoker - has not had either extensive exposure to asbestos or time for nodule to develop - just started working with asbestos - malignancy requires time to dev'p - low-risk = looks for previous chest x-ray for comparison & following w/ serial CT scans every 3 months for 2 yrs

26 yo woman evaluated during follow-up exam. HBV detected as part of health exam following her recent emigration from Southeast Asia to the US. Pt has no known history of hepatitis. Med history unremarkable. She does not smoke, drink alcoholic beverages, or take any meds. On physical exam, vital signs are normal. There is no evidence of jaundice. Abdominal exam discloses normal liver. There is no splenomegaly or stigmata of chronic liver dz. Lab studies: Aspartate aminotransferase Normal Alanine aminotransferase Normal HBV serology: Hepatitis B surface Ag Positive Ab to hepatitis B surface Ag Negative Hepatitis B core Ab Positive Hepatitis B e antigen Positive Ab to hepatitis B e Ag Negative HBV DNA Positive Most appropriate next step in management?

*Serial aminotransferase monitoring* - every 3-6 months Chronic hepatitis B virus infection - based on presence of circulating HBV DNA - appears to immune-tolerant via circulating viral level in absence of markers of liver inflammation = typically occurs in pts born in hepatitis B-endemic areas such as Southeast Asia or Africa in whom HBV was likely acquired prenatally - as long as pts maintain normal serum aminotransferase levels, they are at low risk for progression of liver dz - as pt ages, she is at increased risk for active hepatitis

6 yo boy brought to doc by his mom bc of pain in his left knee for 2 days. One week ago, he had pain in his right ankle. Mom reports that he had red rash on his leg about 2 mos ago in association with low-grade fever, fatigue, muscle pain, & headache, that resolved after 2 wks. His past med hx is otherwise unremarkable. Mom states that the fam went camping & hiking in wooded areas of Wisconsin appx 2-1/2 mos ago. His temp is 98.8 F, HR is 80/min, RR 20/min, & BP normal for age. Exam shows edema & mild tenderness of left knee; ROM is within normal limits. Most appropriate next step in management?

*Serologic testing* - when erythema migrans rash not seen or described in pt with suspected Lyme dz, diagnosis must be confirmed using ELISA followed by Western blot --> should be reported to CDC Late Lyme dz - hx of rash - hx of hiing in woods - migratory polyarthritis (arthritis) - treatment of early localized Lyme dz in children younger than 8 yo = amoxicillin - treatment of inds older than 8 yo = doxycycline

54 yo woman evaluated in ED bc of fever, muscle stiffness, & altered mental status. Pt was well until 2 days ago, when she had fever & myalgia. Today, she also had muscle stiffness, restlessness, & difficulty remembering things. She reports no respiratory infection, headache, GI symptoms, or rash. She has HT treated with lisinopril & depression treated with sertraline. Dose of sertraline was increased to 200 mg daily last week. On physical exam, temp is 38.9 C (102.1 F), BP 144/74 mmHg, pulse rate 112/min, respiratory rate 18/min, & O2 sat 96% on ambient air. She is agitated, diaphoretic , & shivering. Her gait is ataxic, muscle tone is increased, & deep tendon reflexes are increased. Myoclonus present. Most likely diagnosis?

*Serotonin syndrome* - SSRIs, SNRIs alone or + opiates, triptans, OTC meds - can develop as little as 24 hrs or several weeks after initiation - unique findings = shivering, hyperreflexia, myoclonus, ataxia

A 34-year-old woman is evaluated during a follow-up examination. Fibromyalgia was diagnosed 1 year ago. At that time, she received intensive education about her condition, and an aerobic exercise program was prescribed. Pregabalin was also initiated but was discontinued when she developed hives. She continues to have fatigue, widespread pain, and difficulty sleeping. She currently takes an over-the-counter nonsteroidal anti-inflammatory drug intermittently without relief of pain. On physical examination, vital signs are normal. Musculoskeletal examination reveals multiple tender points but no synovitis or muscle weakness. Screening for mood disorders is negative. The remainder of the examination is normal. Repeat laboratory studies since her initial diagnosis, including erythrocyte sedimentation rate and serum thyroid-stimulating hormone level, are normal. Which of the following is the most appropriate class ofpharmacologic treatment for this patient?

*Serotonin-norepinephrine reuptake inhibitors* - duloxetine & milnacipran approved by FDAf Fibromyalgia - widespread pain & tenderness of at least 3 months' duration - patient has at least 1-year history of widespread pain & tenderness along with fatigue & difficulty sleeping - tried pregabalin = discontinued bc of allergic rxn --> SNRI warranted

29 yo, previously successful woman was climbing stairs in her new home about a month ago, when the staircase collapsed. She was taken to the hospital with fractured left femur. Psychiatry team was consulted bc pt complained of nightmares & flashbacks & was afraid to go to sleep as result of accident. During interview, she is tearful, & afraid that her fear of falling is preventing her from fully participating in her rehabilitation, for which she fears team will discharge her from hospital. Most appropriate next step in management?

*Sertraline* PTSD - first-line treatment = SSRI

35 yo woman presents to outpatient clinic for evaluation. She reports that the apartment building in which she lives had a serious fire appx one year ago, & she narrowly escaped. Many other tenants were injured and had to be taken to the hospital for medical care. Since that time, the woman has hade nightmares about being trapped in her apartment and unable to escape. She cannot concentrate at work because she often thinks of the fire, and she feels fearful when she sees someone light a match. She has not been participating in her usual hobbies and feels detached from her friends and fam. She reports difficulty falling asleep, because she is afraid she will have more nightmares about the fire. She also reports a poor appetite and a "short fuse" with coworkers and friends. Most appropriate intervention for this pt?

*Sertraline* = first-line med treatment for ind.s who have PTSD PTSD - symptoms must last longer than 1 mo

During evaluation of patients with proximal muscle weakness of 4 months duration, the following tests will most likely give a clue to the diagnosis:

*Serum CPK & aldolase*

52 yo man brought to ED after being found unconscious at bus stop near hospital. Pt's med history unknown. Pt appears malnourished & poorly dressed. His temp is 96.1 F, BP 96/65 mmHg, pulse 120/min, respirations 24/min, & O2 sat 94% on 2L oxygen via nasal cannula. Pt responds only to pain. Head is atraumatic. Pupils are equal to slightly reactive to light. Skin dry with decreased turgor. Physical exam reveals decreased breath sounds bilaterally with no crackles or wheezes. Heart sounds are normal with no murmurs. Abdomen soft & nondistended, with normoactive bowel sounds. There is 3x4-cm wound on left foot with purulent discharge. Neuro exam normal except for altered mental state. Serum studies show: Na+ = 141 mEq/L K+ = 4.5 mEq/L Cl- = 111 mEq/L HCO3- = 13 mEq/L BUN = 15 mg/dL Creatinine = 0.9 mg/dL Calcium = 8.7 mg/dL Glucose = 310 mg/dL Foley catheter placed. Urinalysis shows 3+ glucose with no protein, blood, ketones, or cells. Pt remains hypotensive & confused after IV admin of 1 L of normal saline. What tests would best diagnose the cause of the pt's lab abnormalities?

*Serum lactic acid level* Elevated anion gap metabolic acidosis - MUDPALES Lactic acidosis - most often due to shock, sepsis, metformin, or aspirin overdose - may accompany any severe illness with hemodynamic compromise - his lack of response to normal saline suggests sepsis with lactic acidosis

55 yo man comes to clinic four routine physical exam. He has not seen a doc in years & states that had it not been for a case of "tennis elbow" some years back, he probz would not have seen one at all. Aside from baby aspirin, he doesn't take any meds. He has never smoked or used illicit drugs, has at most a glass of wine a day, & exercises regularly. A review of systems is unremarkable for any cardiac complaints. Although his med history is unremarkable, the rest of his fam has not been so lucky. Fam history includes mother with stroke, brother with MI at age 50, & father who died of MI at age 58. Vital signs are: temp 37 C (98.6 F), BP 142/78 mmHg, pulse 88/min, respirations 12/min. Physical exam unremarkable. What is the most appropriate screening test for this patient?

*Serum lipid studies* - one major cardiac risk factor of patient = fam history of heart dz - USPSTF recommends all men undergo routine screening for dyslipidemia starting at age 35 & that all women start screening at age 45 in normal population in absence of risk factors

32 yo woman evaluated after missing several menstrual periods. She also reports vaginal dryness & several episodes of non-bloody bilateral breast discharge. Pt otherwise feels well. She has not had heat or cold intolerance or changes in appetite but does not decreased libido over past several months. Med hx unremarkable, & she takes no prescription or OTC meds. On physical exam, pt appears healthy. Vital signs normal. BMI 25, which is a stable management. No skin rash or visual field defects present. There is expressible nonbloody discharge from both nipples. Remainder of exam normal. Urinary pregnancy test negative. Most appropriate next diagnostic study?

*Serum prolactin measurement* Central/Secondary Hypogonadism secondary to Prolactinoma - galactorrhea w/out evidence of elevated serum hCG level extremely suggestive of prolactinoma

A 62-year-old woman evaluated for weakness of 1 week's duration. Patient has 35-year history of Crohn dz. Two months ago, she underwent resection of the distal ileum and right colon because of entero-enteric fistula formation. After the resection, she developed profuse diarrhea while on enteral feedings and also had significant weight loss amounting to 15% of her body weight. Home intravenous total parenteral nutrition was started 1 week ago. Since the initiation of intravenous nutrition, her diarrhea has resolved completely, but she has developed new muscle weakness and mild dyspnea on exertion. On physical examination, temperature is normal, blood pressure is 106/68 mm Hg, pulse rate is 78 min, and respiration rate is 18/min. Body mass index is 17. Cardiopulmonary examination is normal. The abdomen is soft with well-healed surgical scars. There is generalized muscular weakness and symmetrically diminished reflexes throughout. Laboratory studies: Electrolytes: Sodium = 136 mEq/L (136 mmol/L) Potassium = 3.3 mEq/L (3.3 mmol/L) Chloride = 96 mEq/L (96 mmol/L) Bicarbonate = 18 mEq/L (19 mmol/L) Random glucose = 122 mg/dL (2.1 mmol/L) Calcium = 8.3 mg/dL (2.1 mmol/L) Phosphorous = 1.1 mg/dL (0.36 mmol/L) Magnesium = 1.2 mg/dL (0.50 mmol/L) Albumin = 2.7 g/dL (27 g/L) What is the most immediate cause of this patient's recent symptoms?

*Shift of phosphorous into intracellular space* Refeeding syndrome - shift of extracellular phosphorous into intracellular space - hypophosphatemia = serum phosphorous < 2.5 mg/dL (0.81 mmol/L) - most common in patients with ho chronic alcohol use, critical illness, or malnutrition - most patients asymptomatic - symptoms of weakness may manifest at serum phosphorous levels less than 2 mg/dL (0.65 mmol/L) - levels less than 1 mg/dL (0.32 mmol/L) may = respiratory muscle weakness, hemolysis, & rhabdomyolysis

Patient in respiratory failure becomes apneic but continues to have strong pulse. Heart rate is dropping rapidly & now shows sinus bradycardia at rate of 30/min. What intervention has highest priority?

*Simple airway maneuvers & assisted ventilation*

Which of the following has the best description for Pulseless Electrical Activity (PEA) listed?

*Sinus bradycardia without a pulse is PEA* Any rhythm without a pulse - often the rhythm will deteriorate by slowing down & then convert to asystole is CPR & other treatments not initiated

35 yo woman comes to ED complaining of SOB since awakening this morn. She denies any cough, chest pain, or fever & denies ever feeling this way before. She has significant past med history of deep venous thrombosis 2 years ago. She takes oral contraceptives. She states that she smokes one pack of cigarettes per day. Her vital signs include pulse of 110/min, resp rate of 24/min, BP of 110/60 mmHg, oxygen sat of 95%, & temp of 36.7 C (98 F). Ventilation-perfusion scan is reported as "high prob" of pulmonary embolism. Most likelely electrocardiographic finding?

*Sinus tachycardia* - 70% of pts with pulmonary embolus have ECG abnormalities --> most common = nonspecific ST segment-T wave abnormalities & *sinus tachycardia*

Abnormal findings on Schirmer test consistent with what dz?

*Sjogren syndrome* - Schirmer test measures moisture under lower eyelids - xerophthalmia + xerostomia + anti-Ro/SSA & anti-La/SSB Ab positivity & abnormal findings on Schirmer test = 94% sensitivity & specificity - 50% of patients antinuclear antibody positive - 60-75% of patients anti-Ro/SSA Ab positive - 40% of patients anti-La/SSB Ab positive - 60-80% of patients have rheumatoid factor positivity

Parents bring their 13 yo son to doc bc he has been limping & has complained of persistent knee pain for several weeks. Since age 3 he has had known diagnosis of moderate asthma, treated chronically with inhaled steroids & salmeterol. He has been taking oral steroids for last 10 days for recent asthma attack. He sits on examining table with sole of foot on affected side pointing to other leg. Physical exam is normal for knee but shows limited hip motion. As hip is flexed, leg goes into external rotation & cannot be rotated internally. His BP is 132/85 mmHg, pulse 72/min, respirations 17/min, & BMI 31 kg/m^2. Diagnosis?

*Slipped capital femoral epiphysis* (SCFE) - orthopedic emergency Clinical picture = classic - obese (or tall & lanky) boy in early teens who is limping, cannot rotate leg internally, &, when sitting, points sole of affected limb toward other leg - knee normal on physical exam Epiphyseal dislocation --> twisting & kinking of lateral epiphyseal vessels = compromise to blood flow to epiphysis = Avascular necrosis as complication

38 yo man evaluated for 3 mo ho abdominal bloating & increased frequency of defection. He has 4-6 loose bowel movements/day, including nocturnal bowel movements, without abdominal pain. Med hx significant for Roux-en-Y gastric bypass procedure 2 yrs ago for severe obesity; his wt loss stabilized 1 yr ago, although he has lost an additional 10 lbs in the past few months. Meds are daily iron & vitamin B12 supplements & a multivitamin. On physical exam, vital signs are normal. Cardiopulmonary exam is normal. Abdomen is not distended or tender, & bowl sounds are normal. Lab studies are normal. Stool cultures are negative. Upper endoscopy & colonscopy are unremarkable except for expected altered anatomy. What is the most likely diagnosis?

*Small intestinal bacterial overgrowth* Pts who undergo bariatric surgery at risk for specific early & late complications of procedure - SI bacterial overgrowth = late complication that can manifest with bloating, diarrhea, & features of malabsorption

A 4,196 g (9 lb, 4 oz) male infant is delivered at 38 weeks' gestation via vaginal delivery to a 31 yo G1P1 woman who has diabetes. Delivery was complicated by shoulder dystocia. Initial lab studies show a serum glucose of 20 mg/dL & hematocrit of 65%. What is most likely associated with this infant's condition?

*Small left colon* Infant of diabetic mother (IODM) - exposure to maternal hyperglycemia in utero = hyperinsulinism in fetus = macrosomnia bc insulin is perinatal primary growth factor --> affects size of every fetal organ except the brain - common features = polycythemia, hypocalcemia, hypomagnesemia jaundice, asymmetric septal hypertrophy, respiratory distress syndrome in term infant - severe congenital anomalies = small left colon = can cause meconium plugging, CNS & cardiac anomalies, sacral agenesis (caudal regression syndrome), renal vein thrombosis (usually with polycythemia)

Obese, 40 yo white woman reports repeated episodes of RUQ abdominal pain. Pain is brought about by ingestion of fatty foods & radiates to right shoulder & around to back, & is sometimes accompanied by nausea & occasional vomiting. Pt has no pain at this time but is anxious to avoid further episodes. She is afebrile, & her physical exam is unremarkable. Most appropriate next step in management?

*Sonogram of biliary tract & gallbladder* Biliary colic - via gallstones - intermittently impacted at cystic duct - diagnostic study of choice to confirm presence of gallstones = sonogram

Baby in neonatal intensive care unit born at 26 weeks' gestation & had difficult course. At 2 months of age, he has just been extubated to nasal cannula oxygen. At 1 wk of age, cranial ultrasound through anterior fontanel documented a grade III intraventricular hemorrhage-i.e., blood in ventricles-that did not reabsorb, leading to obstructive hydrocephalus. Bc of persistent generalized hypotonia, computerized tomography of brain is performed & currently shows extensive periventricular leukomalacia (white-matter necrosis). Most likely prognostic outcome for this pt?

*Spastic diplegia or quadriplegia* Preterm infants at risk for intraventricular hemorrhage (IVH) - choroid plexus, in ependymal lining of lateral ventricles, doesn't mature until at least 35 weeks' gestation = highly vascularized & hemorrhages easily with changes in brain blood flow --> blood fills lateral ventricles & may obstruct flow of CSF = hydrocephalus = grade III IVH - most damage done with hypoxic-ischemic episodes = periventricular white matter undergoes liquefaction necrosis = periventricular leukomalacia (PVL) / periventricular white-matter necrosis - most severe result = cerebral palsy (CP) = motor problem = spasticity - types of CP w/ PVL = spastic diplegia (either upper or lower extremity; most commonly lower) or spastic quadriplegia

66 yo woman complains of severe chest pain & SOB. She underwent laparotomy for pancreatic cancer appx 1 wk ago. When examined today, she is found to be anxious, diaphoretic, & tachycardic, with BP 90/55 mmHg, pulse 112/min, & respirations 24/min. Her BMI is 31 kg/m^2. She has loud S2 click, with prominent distended veins in neck & forehead. Blood gases show hypoxemia & hypocapnia. Chest x-ray shows few atelectatic changes near base. EKG is normal. Nurses place her on supplemental oxygen by face mask. What is the most appropriate next step to establish diagnosis?

*Spiral CT scan of chest* Pulmonary Embolism (PE) - chest pain, SOB that started 1 wk after massive surgery - tachycardiac, tachypnea, anxiety, diaphoresis, loud S2 - arterial blood gas = hypoxemia, hypocapnia, resp alkalosis - normal EKG

Previously healthy 70 yo man comes to doc for routine health maintenance exam. His BP is 155/95 mmHg & pulse 75/min. Lab studies show: Na+ 138 mEq/L K+ 3.3 mEq/L Cl- 95 mEq/L HCO3- 32 mEq/L BUN 14 mg/dL Creatinine 0.9 mg/dL Aldosterone-to-renin ratio 28 CT scan of adrenal glands shows bilateral adrenal hyperplasia. Most appropriate pharmacotherapy?

*Spironolactone* Hyperaldosteronism - via bilateral adrenal hyperplasia - treatment of choice = aldosterone antagonist

61 yo man presents to PCP bc he noticed a neck mass appx 3 mos ago, which has been growing since then. His past med hx is significant for HT, well controlled with a CCB, & osteoarthritis, managed with NSAIDs. He has 40 yr smoking hx & quit drinking recently, after many years of frequent alcohol abuse. He denies IV drug use. He is married & is a retired police officer. He denies fevers, chills, night sweats, SOB, palpitations, or changes in his appetite or weight. On physical exam he is afebrile with normal vital signs. Head & neck exam significant for palpable mass appx 3 cm in diameter just medial to sternocleidomastoid muscle at level of hyoid. Mass is nontender, firm, & nonfluctuant. No other masses are palpated in neck or supraclavicular area. Visual exam of oropharynx reveals no visible lesions. He undergoes fine-needle aspiration of mass. Most likely histologic finding?

*Squamous cell carcinoma* Painless masses in neck in older pt = cancer until proven otherwise - older adults: 80% of painless, firm, persistent masses = metastatic in origin --> most of these masses are SCC arising from resp or digestive tract - needs triple endoscopy to evaluate larynx (laryngoscopy), esophagoscopy, bronchoscopy to localize primary origin of lesion

58 yo man presents to hospital after vomiting "cupful" of blood. Patient reports that he was watching TV when happened. This is his first time he has experienced such an event. His past med history is remarkable for gallstone pancreatitis, which was diagnosed & treated appx 6 months ago, & he underwent elective cholecystectomy 2 months later. He denies alcohol consumption, & admits smoking two packs per day for 20 years. On physical exam, vital signs are: temp 98 F (36.7 C), BP 110/70 mmHg, HR 88/min, RR 13/min. Head & neck exam are normal, without scleral icterus. Skin exam is also normal, without evidence of spider angiomata or palmar erythema. Chest is clear to auscultation . Heart shows normal S1 & S2 & nor rubs or gallops. On abdominal exam, there is mild epigastric tenderness to palpation. Nasogastric lavage reveals presence of blood clots. Ultrasonography of liver demonstrates normal echotexture & a normal-sized portal vein with forward flow. Patient has upper endoscopy, which reveals several gastric varices treated with local sclerosis. What underlying conditions is most likely responsible for this man's condition?

*Splenic vein thrombosis* - bleeding from gastric varices in grater curvature + past history of pancreatitis - splenic vein passes just posterior to pancreatic body & tail to join superior mesenteric vein at portal confluence - chronic inflammation from pancreas -- thrombus formation within adjacent splenic vein - treatment = splenectomy

A 28-year-old woman is evaluated during a follow-up visit. A recent life insurance examination revealed proteinuria on dipstick urinalysis. She is otherwise healthy and has no pertinent personal or family medical history. On physical examination, temperature is 36.1°C (97.0°F), blood pressure is 110/64 mm Hg, pulse rate is 72/min, and respiration rate is 12/min. Body mass index is 23. The remainder of the examination is normal. Lab studies: Serum creatinine = 0.8 mg/dL (70.7 umol/L) Estimated GFR = >60 mL/min/17=.73 m^2 Urinalysis = 1+ protein; 0-2 RBCs/high-power field; 0 leukocytes/high-power field 24-Hour urine collection for protein = 200 mg/24 h (normal, <150 mg/24 h) What is the most appropriate next step in management?

*Split urine collection* = appropriate initial evaluation for sustained, isolated proteinuria - protein excretion may vary based on time of collection, & in small % of children & young adults, may also vary with changes in posture Orthostatic/postural proteinuria - protein excretion that increases during day but decreases at night during recumbency - diagnosis established by comparing urine protein excretion during day with findings from separate urine collection obtained during night - 8-hour nighttime urine collection containing <50 mg of protein required for diagnosis typically, urine protein excretion in patients with orthostatic proteinuria < 1 g/24 h btu can rarely be greater than 3 g/24 h - benign

45 yo man evaluated in ED bc of abdominal pain. He describes pain as diffuse & constant. For past month, he has had yellow discloration of his eyes & skin, abdominal distention, & a 9.7-kg (20 lb) weight gain There has been no fever, nausea, vomiting, or change in bowel habits. Med hx otherwise unremarkable & he takes no meds. He drinks 6 cans of beer daily. On physical exam, temp is 37.7 C (99.9 F), BP 110/75 mmHg, pulse rate 90/min, & RR 12/min. Sclerae are icteric & skin is jaundiced. Abdomen is distended & diffusely tender. Shifting dullness & a fluid wave are present. Diagnostic paracentesis performed. Lab studies: Ascitic fluid Leukocytes: 450/uL, w/ 90% neutrophils, 5% lymphocytes, 5% macrophages Albumin: 1 mg/dL Serum albumin: 3.2 mg/dL What is the most likely cause of this pt's abdominal pain?

*Spontaneous bacterial peritonitis* - hx & physical exam strongly suggesting cirrhosis & ascites likely based on chronic alcohol use SAAG/Serum Ascites-Albumin Gradient = serum albumin level - ascitic fluid albumin concentration = 3.2 - 1 = 2.2 > 1.1 = ascites related to cirrhosis or portal HT Neutrophil counts > 250/uL diagnostic of spontaneous bacterial peritonitis

A 59-year-old woman is evaluated during a routine follow-up visit. Type 2 diabetes mellitus and hyperlipidemia were recently diagnosed. She feels well. Medications are metformin, atorvastatin, and aspirin. Physical examination findings, including vital signs, are normal. Results of laboratory studies show a serum creatinine level of O. 9 mg/dL (79.6 µmol/L), an estimated glomerular filtration rate of greater than 60 mL/min/l. 73 m2, and a normal urinalysis. Which of the following is the most appropriate diagnostic test to perform next?

*Spot urine albumin-creatinine ratio* - testing for moderately increased albuminuria (microalbuminuria) appropriate - National Kidney Foundation & American Diabetes Association recommend annual testing to assess urine albumin excretion in patients with type 1 diabetes of 5 years' duration & in all patients with type 2 diabetes starting at time of diagnosis by measuring urine albumin-creatinine ratio - microalbuminuria defined as albumin-creatinine ratio of 30-300 mg/g - diagnosis requires elevated albumin-creatinine ratio on 2 of 3 random samples obtained over 6 months - use of ACEIs or ARBs delays progression of CKD in patients with proteinuric kidney dz or in patients with diabetes & microalbuminuria.

55 yo, HIV-positive man has fungating mass growing out of anus. He can feel it when he wipes himself after having bowel movement, but it is not painful. For past 6 mos, he has noticed blood on toilet paper, & from time to time there has also been blood coating outside of stools. Pt has lost weight, & he looks emaciated. On physical exam, mass is easily visible, measures 3.5 cm in diameter, is fixed to surrounding tissues, & appears to grow out of anal canal. He also has hard, enlarged lymph nodes on both groins. Most likely diagnosis?

*Squamous cell carcinoma of anus* - palpable anal mass could be benig, such as condyloma, or malignant, such as anal SCC - anal cancer metastasizes to inguinal lymph node basin

51 yo white man comes to doc complaining of weight loss & difficulty eating. His doc has been counseling pt for many years to stop drinking & smoking, but man has continued to do both regularly. Pt states that he noticed he was having some difficulty swallowing his dinner over past couple of months. Initially he had trouble with roasted potatoes, but now it seems that even the mashed potatoes are not "going down smoothly." Bc he is not doing well, he has also begun losing weight, at least 15 lbs since his last visit. On exam, pt appears weak & his skin is pale. There are no palpable lymph nodes. His abdomen is soft with normal bowel sounds & without mass or tenderness. Stool is guaiac-negative. Most likely diagnosis?

*Squamous cell carcinoma of esophagus* Cancer of esophagus... - classic progress of dysphagia starting with meat --> solids --> soft foods --> liquids --> saliva - smoking & drinking = risk factors for SCC - blacks more common than whites

25 yo man undergoes elective inguinal hernia repair. Operation initially proceeds according to plan. First incisions made without complication, & surgical mesh is placed appropriately. There is minimal blood loss & no technical complications. Appx 30 minutes into operation, however, pt develops muscle rigidity. Some cyanosis & mottling noted on man's extremities. Anesthesiology resident reports that pt has temp of 103 F & pulse 128/min. Before starting operation, pt's temp had been 98.6 F & pulse 70/min. Past med hx significant for schizoaffective disorder treated with haloperidol & fluoxetine for 4 yrs. Most appropriate treatment?

*Start dantrolene* Malignant hyperthermia - rare - complication of general anesthesia & muscle relaxants - via uncontrolled release of intracellular calcium from skeletal SR - within 30 mins --> muscle rigidity (often with masseter stiffness), sinus tachycardia, hypertherma, skin cyanosis, mottling - treatment = dantrolene with supportive care including rapid cooling of pt & immediate cessation of all inhalation anesthetics

A 35-year-old woman is evaluated for follow-up of heart failure secondary to peripartum cardiomyopathy. Symptoms began in the third trimester, and therapy was initiated at that time. The patient gave birth to a healthy baby 3 weeks ago but remains symptomatic. She can walk approximately one block on level ground. Medical history is otherwise unremarkable. Medications are carvedilol, spironolactone, and hydrochlorothiazide. On physical examination, the patient is afebrile, blood pressure is 100/70 mm Hg, and pulse rate is SO/min. No jugular venous distention is present. Lungs are clear to auscultation. Cardiac examination shows a regular rhythm and a normal S1 and S2, without an S3• No peripheral edema is present. Electrocardiogram shows normal sinus rhythm with a QRS complex duration of 110 msec and nonspecific ST-segment changes. Echocardiogram shows left ventricular ejection fraction of 25%. Which of the following is the most appropriate management?

*Start enalapril* Systolic HF via peripartum cardiomyopathy - euvolemic - NYHA class III HF Treatment - beta-blocker & diuretic - ACEIs & ARBs excluded until after delivery

50 yo obese man brought to ED by paramedics after his wife found him on floor at home. Wife reports that patient had "cold" for past week. She informs you that her husband is a diabetic & has high BP, though she can't remember which meds he takes. His temp is 36.6 C (97.8 F), BP 105/65 mmHg, pulse 102/min, respirations 18/min, & urinary output for past 30 minutes is 50 mL. On physical exam patient is unresponsive to touch or voice. Head & neck exam show low jugular venous pressure, dry oral mucosa, & decreased skin turgor. Patient is given a 1 L bolus of normal saline. Lab studies: Na+ = 142 mEq/L K+ = 3.2 mEq/L Cl- = 106 mEq/L CO2 = 16 mEq/L Glucose = 1260 mg/dL BUN = 35 mg/dL Creatinine = 2.8 mg/dL What is the most appropriate next step in management?

*Start half normal saline together with potassium replacement IV* - serum K+ <3.3 mEq/L on labs --> give 20-30 mEq IV K+ in 1/2 normal saline before starting IV insulin - if you start insulin first, you are at risk for causing severe hypokalemia Hyperosmolar hyperglycemic state / HHS / Nonketotic hyperglycemia - little or no ketoacid accumulation - serum glucose exceeds 1,000 mg/d: (56 mmol/L) - plasma osmolality may reach 380 mOsmol/kg - neurologic abnormalities frequently present = 25-50%: comas - mostly pH > 7.30, serum bicarb > 20 mEq/L, serum glucose >600 mg/dL (33.3 mmol/L) - most common ppting events = infection (pneumonia or UTI - first step in management = hydration - patient should be given 1 L bolus of NS while waiting for labs - patients with HHS at presentation have potassium deficit averaging 3-5 mg/kg - If 40 mg of K+ is added to each liter, one-half isotonic saline should be used if patient is hemodynamically stable (solution contains 117 mEq of cation / 77 mEq of sodium & 40 mEq of potassium & is equivalent to appx 3/4 isotonic saline)

66 yo man brought to ED with acute onset of pleuritic chest pain & dyspnea. He was just collecting his baggage at airport when pain & SOB began. His exam in ED shows pulse of 122/min & cast on his left leg. He admits to having skiing injury 8 days earlier, & states that, unfortunately, he has had to spend much of his vacation on the couch. There is right-sided segmental ventilation/perfusion mismatch. What management strategies most likely to reduce risk for recurrent thromboembolic event?

*Start heparin & warfarin; once INR is therapeutic, stop heparin & continue warfarin for 6 months after discharge* Pulmonary embolus --> needs prolonged oral anticoagulation - heparin & warfarin started at same time (unless known protein C def exists) - once pt achieves therapeutic INR of 2-3 --> heparin can be stopped - 3-6 months of anticoagulation necessary

59 yo woman had diverticulectomy. During observation period, resident notices that pt's vital signs are all increased & she seems confused, disoriented, & delirious. She starts having seizures. On review of her chart, the intern notices that the woman has a past hx of HT, DM, anxiety, & PID. She is on thiazide, metformin, alprazolam, & allopurinol. Her father has bipolar disorder & is on lithium. She is hepatitis B positive. She is a smoker, & drinks only socially. Most appropriate next step?

*Start lorazepam* Benzo withdrawal - anxiety, diaphoresis, irritability, insomnia, fatigue, headache, myalgia, nausea, perceptual disturbances, tremors, seizures - managed appropriately with parenteral admin of short-acting benzo, such as lorazepam

54 yo woman comes for routine health maintenance exam. She has hx of HT & hypercholesterolemia. In addition, her father, sis, & bro have T2DM. She exercises by walking for 30 mins 4-5 weekly. Current meds include aspirin, simvastatin, & lisinopril. She denies increased urination, increased thirst, & any change in vision. Menopause occurred yr ago. She smoked 1 pck of cigz daily for 32 yrs but quit 2 mos ago. She drinks 2 glasses of wine on weekends. She weighs 185 & is 160 cm (63 in) tall. Her BP is 122/82 mmHg. Two recent fasting serum glucose levels are 115 & 121 mg/dL, respectively. Hemoglobin A1c level is 6.2%. Most appropriate next step in management?

*Start metformin* = small but significant delay in progression to dz = most useful in pts who are obese - impaired glucose tolerance = at risk for progressing to T2DM, particularly if obese & with fam hx of diabetes (impaired glucose tolerance = fasting glucose of 100-125 mg/dL) - A1c of 5.7-6.4 = prediabetes = increased risk for diabetes

33 yo woman found to have palpable thyroid nodule during routine med checkup. Sonogram confirms presence of solid, 1.5-cm nodule in right lobe of thyroid gland. FNA cytology is reported as "follicular tumor, otherwise unspecified." At surgery, frozen section shows follicular carcinoma. With pt's neck open, surgeon looks for enlarged jugular & paratracheal lymph nodes, but finds none. Most appropriate treatment?

*Total thyroidectomy plus postoperative radioactive iodine* Follicular cancers - can met hematogenously to liver, lung, brain, bones - rudimentary functional capability = can be traced with & ablated by radioactive iodine - after entire gland removed, tumor becomes most effective iodine trapper in body - radioactive iodine therapy should be continued until no further uptake noted - pt will also require thyroid replacement therapy with levothyroxine

70 yo woman present to PCP with diarrhea. She describes watery stools associated with abdominal cramping for last week. There has been no fever, nausea, or vomiting. She was hospitalized 1 mo ago for CAP, which was treated with ceftriaxone & azithromycin. She also has ho watery diarrhea with abdominal cramps when she consumes milk products. Physical exam reveals lower abdominal tenderness. Initial lab evaluation of stool is significant for presence of fecal leukocytes. Most useful step in diagnosing this pt?

*Stool C difficile toxin assay* C difficile-associated diarrhea - loose, watery stools + fecal leukocytosis & abdominal cramping several weeks after treatment with antibiotics - cytotoxin assay --> shows presence of toxin = most useful in establishing diagnosis of C difficile colitis - treatment = stop offending antibiotic & initiating metronidazole - vanc indicated in severe dz or after more than 2 treatment courses with metronidazole (on 3rd recurrent episode of C difficile)

59 yo man who lives in southeastern US taken to ED by his wife in middle of summer bc of sudden onset of severe right flank pain accompanied by nausea & vomiting. He tells doc that he has been jogging outside recently in hot weather & has been on low-carb, high-protein diet to lose weight. By time he is seen by doc, pain has now moved downward toward right testis, than abates. Doc exam is normal. Urinalysis shows numerous RBCs. Serum studies are normal, including normal calcium & uric acid level. CT scan shows multiple stones in right kidney. He is discharged with recommendation to increase his hydration. However, in the next two months he develops similar symptoms three times, each time resolving spontaneously. Best next step in management?

*Strain urine for stone analysis* Nephrolithiasis of unknown cause - initial management = identify type of stone via stone analysis or urine analysis if no stones available - ppl who have recurrent stone formation encouraged to increase water intake & eat low-sodium, low-protein diet - presenting symptom = usually renal colic, with pain frequently radiating to groin and pelvis - spiral CT scan = now the first-line tool for locating stones

67 yo woman comes to ED bc of constant, watery nasal discharge & headache for 5 days. She has had no cough, fever, chills, or sneezing. She took loratadine for past 4 days, which did not improve her condition. She has hx of HT, osteoporosis, & depression. Current meds include HCTZ, calcium supplements, & venlafaxine. Her temp is 98.6 F, BP is 138/76 mmHg, pulse is 88/min, & respirations are 18/min. Exam shows clear, thin nasal discharge. Beta-2-transferring test of nasal discharge positive. Most likely complication of this pt's condition?

*Streptococcus pneumoniae meningitis* CSF leak - via beta-2-transferring (CSF-specific marker protein) in nasal discharge - rare cases: pts may have spontaneous CSF leak - low CSF headache = orthostatic headache = may be associated with changes in hearing or vision & symptoms of nausea/vomiting or vertigo/dizziness - meningitis most frequent & severe complication of CSF leak; S pneumoniae = most common pathogen

45 yo man who has been admitted to hospital for hip fracture undergoes total replacement of left hip. 48 hrs later he complains of increased SOB & palpitations. He denies cough, fever, chills, shakes, & hemoptysis. He has ho HT, for which he takes amlodipine 5 mg daily. He has no medical allergies. He does not smoke. BP is 100/70 mmH & pulse 120/min. Oxygen sat is 87% on 3 L oxygen. Physical exam is notable for tachycardia. Lungs are otherwise clear. Spiral T of chest is positive for multiple pulmonary emboli in right lung. What is the most appropriate next step in management?

*Subcutaneous low-molecular-eight heparin* - on basis of spiral CT scan, pt has multiple pulmonary emboli --> given recent surgery & acute onset of SOB & tachycardia, he is clinically at risk - when pts are hemodynamically low-molecular-weight heparin to treat pulmonary embolism --> subQ low-molecular-weight heparin largely preferred over IV unfractionated heparin

What is the appropriate procedure for endotracheal tube suctioning after appropriate catheter is selected?

*Suction during withdrawal but for no longer than 10 seconds*

19 yo college student comes to urgent care clinic after having developed whitish discharge with crusting in his eyes this morning. The pt is very concerned bc he has to take important exam later today. The pt's personal & med hx is unremarkable. He does not smoke & does not drink alcohol. He is sexually active with his girlfriend & uses condoms. Exam of eyes reveals moderate amount of whitish discharge & conjunctival injection bilaterally. His visual acuity is 20/20. Extraocular muscle function & fundoscopic exam are normal. Most appropriate next step in management?

*Sulfa ophthalmic drops* - preferred rather than ointments, which blur vision for 20 minutes after admin Whitish eye discharge + conjunctival injection = bacterial conjunctivitis - Staph, Strep, H influenza, Pseudomonas, Moraxella - more often unilateral - topical abx (erythromycin ointment) or sulfa ophthalmic drops

45 yo man comes to clinic with firm, nontender, 2-cm mass in front of his left ear. Mass has been present for 4 mos; it has limited mobility but is not fixes to deep tissues or to overlying skin. Pt has normal function of facial nerve & there are no enlarged lymph nodes in neck. FNA is done, but pathologist is unable to provide cytologic diagnosis. Most appropriate next step in management would be what?

*Superfiial parotidectomy, sparing facial nerve* Clinically, assumed to be parotid tumor - statistically = probz pleomorphic adenoma (mixed tumor) or adenoid cystic tumor - only formal parotidectomy can = complete removal with permanent cure & sparing of facial nerve - whether superficial or total = depends on final pathology of tumor (high or low grade?)

Causes acidosis in Renal tubular acidosis type 4

*Suppression of renal ammoniagenesis by hyperkalemia* Hyperkalemia - suppresses renal ammoniagenesis --> reduces net acid excretion = acidosis Causes - aldosterone def of any cause - adrenal insensitivity to ang II - diabetes - Addison dz - SC dz - renal interstitial dz

48 yo man goes to doc bc of 4 mo hx of progressive weakness that is worst in his legs. There are no alleviating or exacerbating factors. He has had no viral or diarrhea illnesses. He has hx of HT, hypercholesterolemia, gout, & asthma. Current meds include simvastatin, colchicine, metoprolol, & prednisone. He has had no changes in his meds for 2 yrs. Exam shows proximal muscle atrophy. Muscle strength is 4/5 in lower extremities & 5/5 in upper extremities. Sensation normal. Lab studies show CK 80 mU/mL (normal, 25-145 mU/mL) & troponin 0.0 ng/mL (normal 0.0 - 0.6 ng/mL). EMG shows no abnormalities. Most appropriate next step in management?

*Taper the dose of prednisone* Corticosteroid-induced myopathy - presents with LE weakness & proximal muscle atrophy - muscle enzymes usually within normal limits - EMG usually normal - confirmed iwth improvement in muscle strength 3-4 wks after dose reduction of steroid

22 yo man presents to his doc complaining of intermittent abdominal pain that has been present for the past yr. He says that the pain is occasionally associated with eating. He denies nausea or vomiting. He is not taking any meds. His past med history is unremarkable. Vital signs are: BP 126/80 mmHg, HR 86/min, RR 14/min, temp 37.5 C (99.5 F). On physical exam, pt appears to be in no distress & is holding his arm against his abdomen. Chest & heart exams are normal. Mild tenderness is elicited while palpating the RUQ. There is no rebound, guarding, or ascites. Peripheral exam is normal. Liver function tests are obtained & are found to be normal. A RUQ ultrasound demonstrates a fusiform dilatation of common bile duct, & a subsequent cholangiography confirms diagnosis. What is the next step in management of this pt?

*Surgical excision* Choledochal cyst - congenital cyst of biliary tree - rare = 1:100,000 - carry increased risk of developing cholangiocarcinoma --> current rec = remove as much of cyst & its epithelium as surgically possible Five types - Type 1 = fusiform dilations of common bile duct - Type 2 = saccular diverticula of common bile duct - Type 3 = choledochoeceles, or dilatations at sphincter extending into duodenum - Type 4 = multiple cysts of intra- & extrahepatic ducts - Type 5 = intrahepatic ductal cysts = Caroli dz

25 yo man shot with .22-caliber revolver. Entrance wound is anteromedial aspect of upper thigh, while exit wound is appx 3 inches lower, in posterolateral aspect of thigh. He has large, expanding hematoma in upper inner thigh. There are no palpable pulses in foot. Bone is intact by physical exam & x-ray film. What is the most appropriate next step in management?

*Surgical exploration* - with proximal & distal control - once hematoma is safely entered, extent of injuries can be ascertained & proper repair performed Femoral artery injured via absence of pulses & expanding hematoma

10 day old newborn-male brought to ED bc of grossly bloody stools, vomiting, & poor feeding for past 12 hours. He was born at 34 weeks' gestation to healthy 29 yo G1P1 woman via a normal vaginal delivery without complications. Birth weight was 2,030 grams. Apgar scores were 3 & 8 at 1 & 5 minutes, respectively. Passage of meconium occurred within 24 hours. He has been nippling formula from a bottle well. His temp is 100 F, BP is 60/35 mmHg, pulse is 170/min, & respirations are 38/min. Physical exam shows abdominal distention, a large area of erythematous, warm, indurated abdominal wall, & decreased bowel sounds. Abdominal x-ray film shows multiple dilated loops of bowel l& gas in a linear pattern along the thickened bowel wall. Free air is seen on lateral decubitus view. Most appropriate next step in management?

*Surgical resection* Necrotizing enterocolitis - requires surgical resection of necrotic bowel and reanastomosis after 6 wks - most common acquired GI emergency in newborn infants - more common in premature infants - mortality rate >50% in infants weighing <1,500 g - incidence is inverse to gestational age & birth weight & correlated to severity of neonatal illness - absolute indication for surgery = perforation = free air present on left lateral decubitus or free air under diaphragm - relative indications for surgery = single, fixed loop of bowel seen on serial abdominal x-ray films, palpable mass, abdominal wall cellulitis, progressive clinical deterioration despite appropriate medical management - radiographic hallmark = accumulation of gas in submucosa of bowel = pneumatosis intestinalis --> can progress to total bowel necrosis, perforation, peritonitis, sepsis, death

26 yo single, unemployed Caucasian man who has hx of schizophrenic presents to outpatient clinic. He reports that his previous psychiatrist prescribed risperidone, 2 mg/d, but he does not take it regularly. He states that it makes him tired and occasionally stiff, & he does not think he needs to take med on a daily basis. He is mildly disorganized and somewhat disheveled but denies acute psychotic symptoms or thoughts of self-harm. What intervention should be tried next?

*Switch to depot med* - long-acting, neuroleptic meds = haloperidol, fluphenazine, risperidone adminitered IM every 2 wks or monthly - side effects occur less frequently with injectable long-acting form Schizophrenia + noncompliance with oral antipsychotic drugs

You are evaluating a 48 yo man with crushing substernal chest pain. Patient is pale, diaphoretic, cool to touch, & slow to respond to your questions. BP is 58/32 mmHg, heart rate is 190/min, respiratory rate is 18 breaths/min, & pulse oximeter is unable to obtain a reading because there is no radial pulse. Lead II ECG displays regular wide-complex tachycardia. What intervention should you perform next?

*Synchronized cardioversion*

64 yo man has been having bloody bowel movements for 2 days. He reports to ED, & while waiting to be seen, he has another large evacuation of dark red blood. His BP is 90/70 mmHg & pulse 110/min. Hemoglobin level is 9 mg/dL. In initial evaluation a nasogastric tube is inserted & aspiraiton produces clear, green fluid without blood. Digital rectal exam & anoscopy shows blood in rectal vault but don't identify source. Most appropriate diagnostic study at this time?

*Tagged red blood cell study* - should provide idea of region where blood is pooling - should set stage for arteriogram if active extravasation is demonstrated - clear aspirate at time when pt is actively bleeding = source distal to ligament of Treitz - colon = most likely site but could also be small bowel Rate of bleeding... - >2 mL/min = angiogram - < 0.5 mL/min = wait until bleeding stops & then do colonscopy - 0.5-2 mL/min = tagged RBC study

27 yo man undergoes exploratory laparotomy for stable wound through midline excision. Five days later large amounts of clear, pink fluid begin soaking through wound dressings. When seen by surgical staff, pt is lying in bed in supine position, with dressings removed. Incision appears intact & not particularly red or inflamed, but there are indeed traces of the clear pink fluid on his skin. He has no specific complaints. He is still NPO & on IV fluids, but has already been passing gas per rectum, & plans had been made to feed him today. Abdomen is not distended, & bowel sounds are normal. He is afebrile. Most appropriate initial step in management?

*Tape the wound securely & bind the abdomen* Dehiscence - has not yet progressed to evisceration - can be dealt with conservatively by taping wound securely, maintaining moist env't, reducing pain, & promoting granulation tissue - will eventually require re-closure of fascia or repair of subsequent hernia

3 mo old girl born to a couple from Nicaragua brought to doc for well-child visit. Infant appears well nourished and her weight is at forty-fifth percentile of normal growth curve. Physical exam shows blue-black pigmentation over buttocks. When questioned further, parents say that it was present from time of birth. Next best step in management?

*Tell the parents that this is normal finding* Mongolian spot - area of hyperpigmentation in 66% of all infants of Hispanic, Asian, & Native American ethnic background - sometimes mistaken from bruise caused by trauma

33 yo woman involved in high-speed automobile collision. She arrives at ED gasping for breath. Her lips are cyanotic and she has flaring nostrils. There are bruises over both sides of chest & tenderness to palpation of chest wall. Her BP is 60/45 mmHg, pulse is 160/min & feeble. Her neck & forehead veins are distended. She is diaphoretic, & subcutaneous emphysema in lower neck & upper chest is present. Her left himthorax has no breath sounds & is hyper-resonant to percussion with tracheal deviation to right. Most likely diagnosis?

*Tension pneumothorax likely caused by lung puncture from broken ribs* - on left --> pushing heart, mediastinum, & right lung to right side - to decompress --> large bore needle should be inserted in second intercostal space, midclavicular line, followed by tube thoracostomy placement - blunt injury can also produce lung puncture when jagged edges of broken ribs driven in at time of impact = emergency condition that requires urgent intervention - pt = cyanotic & hypotensive

10 hrs after fistulectomy, 31 yo man develops fever, confusion, & severe abdominal pain. He vomits five times & passes 3 loose stools. His med hx is significant for T2DM & Crohn's dz for several yrs. Current meds include metformin, mesalamine, & corticosteroids. Prior to fistulectomy he had lost 10 lbs, & workup had revealed fistula b/t proximal jejunum & terminal ileum. On exam, his temp is 102 F, BP is 100/52 mmHg, pulse 122/min, & respirations 18/min. Lab studies reveal: Hgb = 14 g/dL Leuckoytes = 11,400/mm^3 Neutrophils-segmented = 57% Eosinophils = 5% Lymphocytes = 50% Serum sodium = 130 mEq/L Serum potassium = 5 mEq/L Serum glucose = 60 mg/dL Chest x-ray normal. Most likely cause for pt's condition?

*Tertiary adrenal insufficiency* Chronic steroid therapy --> suppresses HPA via suppression of CRH & thus ACTH secretion = tertiary adrenal insufficiency - atrophic glands incapable of producing high steroid secretion needed to survive stress = adrenal crisis if stress-dose steroids not administered IV during sx

A 24-year-old woman is evaluated for a 3-week history of pain and swelling of the right knee and left ankle. The patient also reports mild burning with urination. She has no history of tick exposure, skin rash, diarrhea, or abdominal pain. She has not been sexually active in the past month. She takes no medications. On physical examination, vital signs are normal. Musculoskeletal examination shows swelling, tenderness, warmth, pain on range of motion, and an effusion of the right knee; the left ankle is also swollen and tender. Serologic studies for Lyme disease are negative. Urinalysis reveals 18 leukocytes/high-power field and 2+ leukocyte esterase but is otherwise normal. Aspiration of the right knee shows a synovial fluid leukocyte count of7500/µL (7.5x109 IL) and negative Gram stain. Synovial fluid culture results are pending. Which of the following is the most appropriate next step in management?

*Testing for Chlamydial trachomatis infection* Reactive arthritis - should have NAAT for Chlaymdia trachomatis infection - absence of recent history of sexual activity = more suggestive of reactive arthritis that can develop after C trachomatis infection - symptoms typically develop 2-4 weeks after infection - NSAIDs = first-line therapy for musculoskeletal symptoms - antibiotics do not effectively treat reactive arthritis

45 yo woman comes to doc for follow-up exam; she was bitten on left foot by her cat 2 days ago. Cat recently gave birth to litter & attacked her when she tried to pick up one of the kittens. She has had progressive swelling & redness of foot despite treatment with oral amoxicillin & clavulanic acid. She has had no fever. Patient reports that cat is not immunized against rabies. Cat has had no change in her behavior recently. Her temp is 36.7 C (98 F), BP 114/82 mmHg, & pulse 82/min. Exam of left foot shows 3-cm area of erythema & edema surrounding 4 clean bite marks. No fluctuance. Wound is cleaned & irrigated, & IV antibiotics started. Patient's last tetanus vaccine was 7 years ago. Most appropriate next step in management?

*Tetanus toxoid & observation of cat for 10 days* - domestic cat - patient needs tetanus vaccine bc last tetanus vaccination was 5+ years ago AND she has serious wound - wound serious bc contaminated with saliva - *any wound contaminated with dirt, feces, soil, or saliva, such as bite, requires tetnus vaccination if last one was >5 years*

50 yo man + ho HT presents for regular health maintenance visit. His only med has been HCTZ fo rhis HT. He denies every using alcohol. On physical exam, vital signs are within normal limits. Exam of lungs is normal. Cardiac exam shows grade II/VI flow murmur over aortic area. Chest x-ray normal. Lab studies show WBC count of 6,200/mL, hematocrit of 30%, & platelet count of 253,000/mm^3. MCV is 65 fl. RBC count & RDW are within normal limits. Most likely cause of patient's anemia?

*Thalassemia* - microcytic anemia + normal RBC & RDW - degree of microcytosis out of proportion to level of anemia - MCV low with mildly decreased hematocrit - peripheral blood smear = microcytosis & hypochromia, often with target cells - hemoglobin electrophoresis required to confirm diagnosis

50 yo man w/ ho HT presents for regular healthy maintenance visit. His only med has been HCTZ for his HT. He denies ever using alcohol. On physical exam, the vital signs are within normal limits. Exam of the lungs is normal. Cardiac exam shows grade II/VI flow murmur over aortic area. Chest x-ray is normal. Lab studies show WBC count of 6,200/mL, hematocrit of 30%, & platelet count of 253,000/mm^3. MCV is 65 fl. RBC count & RDW are within normal limits. What is the most likely cause of this pt's anemia?

*Thalassemia* - microcytic anemia + normal RBC count & RDW - peripheral blood smear = microcytosis, hypochromia, target cells

74 yo woman with long history of type 2 DM undergoes SBO surgery. After surgery, she develops acute renal failure. She refuses to undergo dialysis despite advice of her doc. Her doc calls for psychiatry consult. Patient tells psychiatrist that she has lived long life & does not want to be kept alive by or attached to machine, even if it means she will die. Mental status exam shows that she is not psychotic, that she is fully oriented & alert, & that she has no fluctuations of cognition or level of consciousness. Patient's fam is insistent that she be dialyzed immediately. What is the most appropriate statement psychiatric consultant could make?

*The patient is aware of consequences of her decision & shows no signs of major psychiatric illness* - role of psychiatrists = solely advisory in determining competency

Combination of *hemangioblastoma* & an angiomatous lesion of retina is diagnostic of

*von Hippel-Lidau syndrome* - AD - via mutation of gene in short arm of chr 3 Hemangioblastoma - may also develop sporadically - frequently located in cerebellum - cyst-mural nodule characteristic of hemangioblastoma - rich vascular network admixed with interstitial cells (true neoplastic elements) Typical brain tumors of cyst with nodular lesion = hemangioblastoma & pilocystic astrocystoma in cerebellum = ganglioma in cerebral hemisphere = craniopharyngioma in suprasellar region

Screening test for lupus

+ANA - don't have it = don't have lupus - sensitive - most specific = smith or dsDNA

33 yo woman comes to doc for her first prenatal visit. Her last menstrual period was 7 weeks ago. She has had no bleeding or abdominal pain. She has no med problems & takes no meds. She has no fam ho congenital anomalies. Her husband is 55 yo. He is in good health & also has no fam ho birth defects. Patient is concerned that her husband's age may place their fetus at increased risk of a chromosomal anomaly. She wishes to know paternal age above which amniocentesis or chorionic villus sampling should be considered? What is most appropriate?

*There is no age cutoff for paternal risk* - paternal age has not been shown to be related to chromosomal anomalies - evidence that paternal age is linked to increased risk of AD mutations (neurofibromatosis, achondroplasia, Apert syndrome, Marfan syndrome) - suggested amniocentesis or chorionic villus sampling in women 35 yo or older at time of delivery

57 yo diabetic man with past med hx of GERD arrives at ED complaining of pain. Four hours ago he had been sitting down, eating his daily meal with his family, when he suddenly felt severe, epigastric pain with associated nausea. His vital signs are temp 100 F, pulse 124/min, & BP 159/95 mmHg. On physical exam pt is sweating excessively. There is no chest tenderness & breath sounds are clear bilaterally. There are muffled heart sounds with regular rate. EKG reveals ST-segment elevations in leads II & aVF. Twenty-four hours after percutaneous coronary intervention, pt's BP drops to 98/62 mmHg. Pulse is 54/min. Most likely diagnosis?

*Third-degree block* Hypotension + *Bradycardia* shortl after MI... - most likely diagnosis = thrid-degree heart block / complete heart block - occurs via direct lesion of AV node

A 62-year-old man is evaluated for a persistent cough of 9 months' duration and a 4.5-kg (10-lb) unintentional weight loss over the past 6 weeks. The patient has a 30-pack-year history of smoking cigarettes and continues to smoke. On physical examination, his vital signs are normal. His body mass index is 24. There are decreased breath sounds and dullness to percussion at the right base. The remainder of the physical examination is normal. Chest radiography confirms a right pleural effusion. Chest computed tomography (CT) confirms a right pleural effusion and a 2.1-cm spiculated nodule in the right middle lobe. Which of the following is the most appropriate next diagnostic test?

*Thoracentesis & pleural fluid cytology* - would both diagnose & stage lung cancer as advanced Lung cancer diagnosis - by the time cancer causes symptoms, appx 3 of 4 lung cancers are advanced - when advanced dz is suggested by CT or PET-CT, diagnosis & staging best accomplished with single invasive test, usually of location that would confirm most advanced stage

53 yo man presents to hospital with SOB & right-sided chest pain. He describes pain as sharp & worsening with inspiration. He has noticed SOB progressing over past wk. His past med hx is notable for liver cirrhosis, which was diagnosed appx 3 yrs ago. Cirrhosis secondary to hep C infection. On physical exam, he is saturating 91% on room air, BP 105/65 mmHg, & pulse 95/min. He appears uncomfortable. Head & neck exam unremarkable. He has scattered spider angiomata. Markedly decreased breath sound noted on right. He has no murmurs. No appreciable abdominal fluid wave demonstrated. Peripheral exam reveals 2+ pretibial edea. Chest radiograph shows large, right-sided pleural effusion. Next step in management?

*Thoracentesis* - known cirrhotic + right-sided pleural effusion - in absence of any cardiopulmonary dz --> effusion likely a hepatic hydrothorax - mechanism thought to be secondary to peritoneal ascites passing through holes that vary in sizes ranging from microscoppic to less than 1 cm, in diaphragm - negative pressure generated by inspiration though to be driving force behind formation of pleural effusion - initial management = thoracentesis = both diagnostic & therapeutic - no more than 1 L should be removed to prevent re-expansion pulmonary edema

68 yo man with ho COPD presents to ED complaining of SOB. He states that he has developed progressively severe SOB over past 2 weeks, & complains of chest pain that is worse on inspiration & while coughing. On physical exam, patient appears dyspneic, with respiratory rate of 18 breaths/min. Heart sounds are distant. Chest wall movement is reduced on right. Right side of stony dull to percussion. There are absent breath sounds on right lung field with decreased vocal resonance. Chest x-ray reveals obliterated costophrenic angle on right side with mediastinal shift. Best next step in management?

*Thoracentesis* Pleural effusion - symptoms of pleuritic chest pain - right side: dullness to percussion, absent breath sounds, decreased vocal resonance - chest x-ray confirms suspicion: opacification of right lung field w/ mediastinal shift & obliteration of costophrenic angle - single-sided effusion best managed by thoracentesis

22 yo G1P0 woman comes to ED complaining of vaginal bleeding. SHe is 12 wks pregnant & has had uneventful course so far. This morning, while in bathroom, she noticed moderate amount of vaginal bleeding. There were no associated contractions, pain, or abdominal cramping. Her BP is 128/72 mmHg, pulse is 72/min, respirations are 20/min, and temp is 98.6 F. Speculum exam reveals small amount of clotted blood in vaginal vault & surrounding os. There is no active bleeding or abnormal tissue, & the cervix is closed. Bimanual exam is unremarkable. Most appropriate description of woman's current condition?

*Threatened abortion* - bleeding during first trimester of pregnancy - heghtened risk of proceeding to complete abortion - 50% of women proceed to spontaneous abortion

1 1/2 grl sent to children's hospital for evaluation following nosebleed which was so severe as to require nasal packing & transfusion of platelet concentrates. When blood sample had been drawn in ER for serum chemistry studies, local hospital lab had noted that clot that formed was unusual in that it failed to retract. Peripheral blood smear obtained by finger puncture showed an appropriate number of normal-sized platelets, all of which were individual, without clumping. At the children's hospital, it was noted that the child's parents were cousins. Special platelet studies showed that child's platelet's failed to aggregate with any physiologic aggregating agent, including high concentrate of exogenous ADP. Most likely diagnosis?

*Thrombasthenia* - AR - lack of platelet membrane glycoprotein GPIIb-IIIa - absence of protein --> platelet aggregation/clot retraction cannot occur - prob with severe bleeding from mucosal surfaces

Milestones consistent with 24 months old

- *pick up objects while standing without losing balance* - running well - jumping up with both feet off the groun - kicking ball forward - throwing ball overhead - climbing stairs or going down stairs one foot at a time with support - *builds tower of seven blocks* - feeds self with fork and spoon - mimics horizontal stroke - scribbles circle (not closed) - 50+ words - uses three words together - points to named body parts and uses "I, me, and mine"

Things to do during a seizure episodes

- *place pt on side* - put pillow or other soft object under pt's head - loosen tight clothing around neck - remove sharp objects from surroundings

8 yo grl brought to doc bc of patchy hair loss & scalp itching for 3 wks. Mom reports that grl has had extra dandruff for past 2 mos, followed by hair thinning in patches. Symptoms didn't improve with antidandruff shampoo. She has had no fever or weight loss. Her med hx is unremarkable. Exam shows multiple circular patches with hairs broken off at level of scalp. There is scaling at edge of patches. Occipital lymph nodes are enlarged & tender. Remainder of exam shows no abnormalities. Most likely diagnosis?

*Tinea capitis* / Ringworm of scalp - dermatophyte infection of scalpm - most common via Trichophyton tonsurans & sometimes via Microsporum canis - Woods lamp may be helpful in diagnosis - hairs infected with Microsporum fluoresce blue-green; Trichophyton = don't - extensive infection + fever + pain + regional lymphadenopathy - treatment = oral griseofulvin --> continue until fungal culture is negative = 2-3 mos sometimes

66 yo African American woman brought to ER by her husband for severe headache. She describes pain as unilateral, one of the worst of her life, & associated with excruciating eye pain. Light has been very painful, & she has vomited several times in past 2 hours. Her vision has been blurred, & she has also noticed excessive tearing. She does not notice foreign-body sensation. Her past medical history is remarkable for DM, for which she takes metformin. On physical exam, her BP is 150/82 mmHg, HR is 97 beats/min, & temp is 98.3 F (37 C). She is saturating 100% on room air. She is holding her hand over her right eye & will not permit extensive evaluation; however, the eye appears injected. Rest of physical exam is unremarkable. What is most likely to reveal diagnosis?

*Tonometric testing* - will detect elevated intraocular pressures >21 mmHg Acute angle-closure glaucoma - iridocorneal angle acutely becomes closed --> blocks outflow of aqueous humor --> intraocular pressure rises rapidly - blindness can develop if condition left untreated Treatments - increasing aqueous outflow = cholinergics, epinephrine, alpha-adrenergic agonists - decreasing aqueous production = alpha-adrenergic agonists, beta-adrenergic blockers, carbonic anhydrase inhibitors - definitive therapy = surgical or laser treatment

21 yo man comes to doc bc of 2 mo hx of frequent episodes of abdominal cramping & loose stools. He has had 2-3 episodes daily. Stools have become increasingly bloody during last month. He has had sensation of rectal fullness but has been unable to pass any fecal matter. He has not traveled outside of country. His temp is 98.4 F, BP is 118/75 mmHg, & pulse is 66/min. Sigmoidoscopy shows inflammation in circumferential pattern from anal verge to mid-sigmoid colon, where transition to normal mucosa is seen. Most appropriate pharmacotherapy?

*Topical mesalamine* - hydrocortisone enemas - reduces inflammation - active ingredient = 5-aminosalicylic acid (5-ASA) - available in rectal suspension, suppositories, delayed-release oral tablets, & controlled-release oral capsules - usually well tolerated but can cause allergic rxns related to sulfite sensitivity - other forms that don't contain sulfa compounds = mesalamine, olsalazine, balsalazide - no improvement or if pt cannot tolerate enemas = oral -ASA preps as alternative UC / Ulcerative proctosigmoiditis - confined to distal colon -

22 to man comes to ED bc of acute onset of right knee pain while playing soccer 1 day ago. He hyperextended his knee & heard a "popping" sound. He immediately stopped playing. He has had swelling & pain. Exam shows edema around right knee. There is increased anterior mobility with knee fixed at 20 degrees. What is the most likely diagnosis?

*Torn anterior cruciate ligament* - ACL injury = most likely diagnosis in patient who sustained significant knee injury - knee pain + instability + "popping" sound at time of injury - physical exam = knee flexed 90 degrees + leg pulled anteriorly, like drawer being opened (anterior drawer sign) - can be elicited with knee fixed at 20 degrees by grasping thigh with one hand & pulling leg with other hand = Lachman test

Term male infant found to be cyanotic shortly after birth & requires endotracheal intubation. On physical exam, his BP is 68/34 mmHg (equal in all four extremities), pulse is 180/min, & respirations are 32/min. His precordium is dynamic, has a grade III systolic murmur, & single S2. Chest radiography shows normal heart size & increased pulmonary vascular markings. EKG shows right ventricular hypertrophy, with peaked P waves. Arterial blood gas on FiO2 of 100% shows pH 7.34; paCO2, 47 mmHg; PaO2, 46 mmHg. What diagnoses is most consistent with these findings?

*Total anomalous pulmonary venous return* (TAPVR) - pulmonary veins form confluence behind left atrium --> drains into right atrium - complete mixing takes place in right atrium = right-to-left shunt through foramen ovale to left side of heart - ECG often reveals right atrial enlargement & right ventricular hypertrophy, with spiked P waves - chest roentgenogram often shows normal heart size with pulmonary edema - chest x-ray = large supracardia shadow with large heart shadow = snowman - definitive treatment = surgical anastomosis of pulmonary vein to left atrium

63 yo man in apparent good health convinced by what he has read in news that he will live longer if he takes one aspirin tablet every day. After appx 3 weeks of doing so (325 mg/day), he begins to notice bright red blood on toilet paper after his bowel movements. This does not occur every time - only when he has to strain more than usual. He has never had any discomfort referable to hemorrhoids, or nay bowel pathology of which he is aware. Anoscopy & digital rectal exam show external and internal hemorrhoid, none of which are bleeding at the time of examination. Most appropriate next step in management?

*Total colonoscopy* - bleeding lesions in this case could be internal hemorrhoids that were diagnosed; however, malignant source must be ruled out before making this assumptoms - since pt > age 50, he should be screened for colon cancer - differential = colonic adenocarcinoma, hemorrhoids, arteriovenous malformation, diverticulosis, benign polyps

19 yo man undergoes colonscopy bc of fam hx of multiple polyps in his siblings. His brother underwent total proctocolectomy at age 13 years, and his sister underwent total proctocolectomy at age 29 years. Colonscopy shows 150 to 200 small colonic polyps within rectosigmoid; biopsy specimens of 5 of polyps all show benign adenomas. Most appropriate next step in management?

*Total proctocolectomy* FAP - presence of more than 100 polyps in colon = diagnostic - via germline mutation in APC gene - flexible sigmoidoscopy or colonscopy should be done in first-degree relatives of FAP pts starting at age 12 yrs

Synovial Fluid Analysis: WBC Count - >50K - 2-50K

- *septic joint* - inflammatory

Prerenal azotemia

- BUN to Cr > 20:1

In a postoperative pt, it is important that pt's internal function be evaluated before pt can be discharged. This includes...

- able to ambulate - *able to tolerate adequate oral intake* - have stable vital signs - have satisfactory bowel & urinary tract function

15 yo girl brought to pediatrician with 2 day hx of pain & swelling in her left knee. She plays soccer regularly on her school team. There is no hx of trauma. On physical exam, there is marked swelling & tenderness over her anterior tibial tuberosity. Radiograph of her left knee reveals soft tissue swelling with loss of sharp margins of the patella & fragmentary ossification of tibial tubercle. Most likely explanation for her symptoms?

*Traction apophysitis* = inflammation at insertion of muscle group of repetitive tensile action, especially during active growth Osgood-Schlatter - common cause of anterior knee pain in children 10-15 yo - when girls present, it is generally up to 2 yrs earlier than boys - repetitive tensile microtrauma to tibial tuberosity from patellar ligament

35 yo gravida 2, para 1 woman at 38 wks' gestation comes to labor & delivery bc of painful contractions & vaginal bleeding. Her temp is 98 F, BP 170/115 mmHg, pulse 96/min, & respirations 16/min. Fetal heart monitoring shows baseline 130 with deep, late decelerations & no accelerations. Soon after initial assessment, pt complains of pelvic pain & becomes confused. Repeat vital signs show BP 80/40 mmHg. Pt is intubated, 2L of Ringer's lactate is infused, & an emergency C section is performed. Infant is transferred to neonatal ICU; however, mom remains hypotensive to 60/40 mmHg with pulse 18/min. Most appropriate next step in management?

*Transfusion of packed red blood cells* Placental abruption - painful, dark vaginal bleeding in term pregnancy followed by hypotension - treatment = C section - persistent hypotension & tachycardia with this sequence most likely secondary to intrauterine blood loss & resultant hypovolemic shock = class IV hemorrhagic shock + profound hypotension & tachycardia via loss of >40% of pt's total body blood volume - treatment = control of surgical bleeding (if still present) & transfusion of packed RBCs

A 48-year-old woman is evaluated in the hospital for shortness of breath, chills, and fever. These findings developed during transfusion of a single unit of packed erythrocytes that she received following an uncomplicated left total hip arthroplasty. On physical examination, temperature is 38.9°C (102.0°F), blood pressure is 116/68 mm Hg, pulse rate is 111/min, and respiration rate is 22/min. Oxygen saturation is 86% (breathing oxygen, 2 liters/min by nasal cannula). There is no jugular venous distention or peripheral edema. Cardiopulmonary examination discloses tachycardia but is otherwise normal. Results oflaboratory studies indicate a hemoglobin level of9.3 g/dL (93 g/L), a leukocyte count of9600/µL (9.6 x 109/L), and a platelet count of198,000/µL (198x109/L). Diffuse bilateral infiltrates are seen on a chest radiograph. An electrocardiogram shows sinus tachycardia but no ST changes. Which of the following is the most likely diagnosis?

*Transfusion-related acute lung injury* (TRALI) - fever, dyspnea, diffuse pulmonary infiltrates, hypoxia during blood transfusion - rxn caused by antileukocyte Abs in donor blood product directed against recipient leukocytes --> sequest in lungs, usually during 6 hours of transfusion - can occur with any blood product, even RBCs & platelets Treatment - supportive - within several days to 1 week

30 yo East Asian woman comes to clinic complaining of chest pain. For last 2 years, she has had intermittent nocturnal chest pain that lasts up to 10 minutes. Pain is substernal & is described as heavy pressures that radiates to her throat. Pain is a 6/10 on pain scale & awakens her from sleep. It is associated with mild nausea & clammy sensation. In past, she has tried antacids & PPI, neither of which seem to help. Occasionally, significant aerobic exercise induces pain. Aside from this complaint, she reports being quite healthy; her only medical problem is Raynaud phenomenon, severe during winter months, & a hx of migraine headaches treated with sumatriptan. Social hx remarkable for occasional use of cocaine. Vital signs & physical exam are unremarkable; pt appears young & healthy. ECG unremarkable. Holter monitor study arranged. Given this pt's likely diagnosis, what is the most likely finding on Holter monitor during episode of chest pain?

*Transient ST-segment elevation in inferior leads* Variant angina - via coronary vasospasm --> induces transient & ST-segment elevations - younger, typically women - occurs at night - hyperventilation from exercise may induce symptoms via alkalosis - can be worsened by agents such as cocaine or serotonergic agents - vasospasm most commonly in right coronary artery

4,000-g male neonate develops severe cyanosis that begins within minutes of birth. Blood drawn 1 hr after birth shows metabolic acidosis with resp acidosis. Chest radiograph shows narrow mediastinum, narrow heart base, & absence of pulmonary artery. ECG normal. ECG ordered & report pending. Most likely diagnosis?

*Transposition of great arteries* - absence of pulm artery with narrow med on chest radiograph = egg of string apperance - 5% of congenital cardiac anomalies - affected infants present within minutes of birth with severe cyanosis & metabolic acidosis secondary to inability to oxygenate tissues - only exchange of blood b/t pulmonic & circulatory systems typically occurs via PDA - chest radiograph = narrow mediastinum, narrow heart base, absence of pulmonary artery = via superposition of great vessels - surgical repair usually within 7-10 days of life

A 52-year-old man requests prostate cancer screening during a routine office visit. He feels well, with no weight loss, fatigue, bone pain, or urinary symptoms. He has no other medical problems. After a discussion of risks and benefits, he desires prostate screening with a digital rectal examination that reveals a nontender normal-sized prostate with a firm peripheral nodule. A prostate-specific antigen (PSA) level is 3.8 ng/mL. Which of the following is the most appropriate next step in management?

*Transrectal prostate biopsy* - definitive diagnostic study - should be done in all pts with asymmetric induration or nodularity - prostate cancers discovered on digital rectal exam often higher clinical stage than those found using PSA testing alone - low PSA (less than 4 ng/mL) does not exclude prostate cancer *If abnormalities found on digital exam, transrectal ultrasonography should be done to evaluate anterior & medial portions of prostate that are difficulty to assess by physical exam*

16 yo girl comes to doc bc of 2 yr ho "pimples" on her face, back, & chest that don't improve with OTC benzoyl peroxide. She states that # of red, tender nodules on cheeks & chin increases during menses. Her menses are irregular, & her last menstrual period was 7 wks ago. She takes no other meds. She weighs 106 kg (234 lb) & is 170 cm (67 in) tall. Physical exam shows deep inflammatory nodules, pustules, & comedones on face., chest, & back. There are sparse, coarse, pigmented hairs on upper lip & chin & thinning of hair at temples. Urine pregnancy test is negative. Most appropriate next step in diagnosis?

*Transvaginal ultrasound* PCOS / Stein-Leventhal syndrome: 2 of 3 criteria - oligomenorrhea/amenorrhea - clinical or biochemical signs of hyperandrogenism - polycystic ovaries on ultrasound exam = >12 follicles in at least 1 ovary, each 2-9 mm in diameter or total ovarian volume >10 cm^3

67 yo restrained driver involved in motor vehicle accident. Stabilized by paramedics at scene & is brought to trauma center on backboard with cervical collar in place. Complains of left-sided chest pain with SOB. His pulse is 87/min, BP is 110/56 mmHg, respirations are 24/min, & oxygen sat is 91% on room air. Physical exam reveals seat-belt abrasion over left hemithorax; auscultation reveals decreased breath sounds on left chest & rough gurgling sounds. His abdomen is nondistended & soft, without peritoneal signs. His pelvis is stable, but there is deformity of left lower extremity consistent with femur fracture. Initial chest x-ray film shows elevation of left hemidiaphragm; a second chest x-ray film is pending. What is the most likely diagnosis?

*Traumatic diaphragmatic rupture* - diagnosed by x-ray film & physical exam - almost always occurs on left side - abdominal viscera protrude through rupture & can be seen on x-ray film as air-filled bowel loops in chest - may also show elevation of hemidiaphragm or nasogastric tube curling up into chest - sometime hemothorax = only findings - treatment = surgical repair, usually by abdominal approach in acute setting

21 yo woman, gravida 2, para 1 at 10 wks' gestation, comes to doc for her first prenatal visit. She says she has been experiencing some fatigue, nausea, & occasional episodes of vomiting, but is otherwise doing well. She has had no bleeding, loss of fluid, or any urinary symptoms. Her first pregnancy was cesarean delivery at term for breech fetus, after uncomplicated prenatal course. She plans for trial of labor. She has no med probz &, other than cesarean, has never had surgery. She takes prenatal vitamins & has no known drug allergies. Physical exam normal for woman at 10 wks' gestation. Initial lab studies sent, including urine culture that shows >100,000 organisms/mL of E coli, which is sensitive to all tested abx. Most appropriate next step in management?

*Treat with oral nitrofurantoin* Asymptomatic bacteriuria + pregnancy - via kidney's decreased ability to concentrate urine & progesterone's relaxing effect on ureteral smooth muscle - bacteriuria has been associated with increased risk for preterm birth, low birth wt, & perinatal mortality - screening for asymptomatic bacteriuria sould be performed at 12-16 wks' gestation

A 24-year-old man is evaluated for a 6-month history of episodic substernal chest pain. Episodes occur four to five times per week and are accompanied by palpitations and sweating. They resolve sponta neously after approximately 30 minutes. His symptoms are unrelieved with antacids, can occur at rest or with exertion, and are nonpositional. There are no specific precipitating factors. Lipid levels were obtained last year and were normal. The patient is a nonsmoker. He has no personal or family history of coronary artery disease, diabetes mellitus, hyperlipidemia, or hypertension. He is not taking any medications. On physical examination, vital signs are normal. He has no cardiac murmurs and no abdominal pain. Complete blood count, serum thyroid-stimulating hormone level, and electrocardiogram are all normal. Which of the following is the most appropriate management of this patient?

*Treatment with SSRI* Panic disorder - somatic symptoms: chest pain, palpitations, sweating, nausea, dizziness, dyspnea, numbness - symptoms usually last from 5-60 minutes - diagnosis based on clinical description & setting - treatment options = meds & psychotherapy - CBT most effective psychotherapeutic intervention in controlled trials

A SO-year-old woman is evaluated for a 1-year history of recurrent left-sided chest pain. The pain is poorly localized and nonexertional and occurs in 1-minute episodes. There is no dyspnea, nausea, or diaphoresis associated with these episodes. The patient has not had dysphagia, heartburn, weight change, or other gastrointestinal symptoms. She has no other medical problems and does not smoke cigarettes. On physical examination, vital signs are normal. The patient's chest pain is not reproducible by palpation. The cardiac examination is unremarkable, as is the remainder of the physical examination. Results of a lipid panel, a fasting plasma glucose test, and a chest radiograph are normal. An echocardiogram shows a normal ejection fraction, with no wall motion abnormalities. Results of an exercise stress test are normal. Which of the following is the most appropriate next step in management?

*Trial of proton pump inhibitor* - should receive twice-daily PPI therapy for 8-10 weeks - pain associated with gastroesophageal reflux can mimic ischemic chest pain - patient has nonanginal chest pain, no additional risk factors, & normal findings on exercise stress testing

A 63-year-old man is evaluated because of increased dyspnea and wheezing of S days' duration. New lower extremity edema has also developed over the last 6 weeks. On physical examination, the patient is afebrile, blood pressure is 162/92 mm Hg, pulse rate is 116/min, respiration rate is 24/min, and oxygen saturation is 90% on ambient air. He has jugular venous distention and an early 2/6 systolic murmur isolated to the lower left sternal border. The murmur increases in intensity with inspiration. The liver is enlarged to palpation. Pedal edema is present bilaterally. What is the most likely diagnosis?

*Tricuspid regurgitaiton* - systolic murmur at lower left sternal border that may increase in intensity with inspiration - murmur does not radiate well - right-sided murmurs = augmentation in intensity with inspiration - most often caused by left-sided heart dz that causes pulmonary HT, which leads to right ventricular enlargement & annual dilation

35 yo woman evaluated before initiation of infliximab treatment for RA. She was diagnosed w/ rheumatoid arthritis 5 yrs ago, & her dz is inadequately controlled on methotrexate & naproxen. She has no other symptoms or medical problems. She has no ho known exposure to TB or other risk factors for TB. Findings on physical exam are unremarkable except for changes compatible with active RA involving hands & feet. What studies should be performed before initiation of therapy?

*Tuberculin skin test or interferon-gamma-releasing assay* Evaluate for latent TB - evaluation done w/ tuberculin skin test or interferon-gamma releasing assay (IGRA)

66 yo man comes to clinic complaining of progressively worsening SOB & nonproductive cough over past 2 yrs. He has also lost 15 lbs over past 3 mos. He retired 1 yr ago, after working as rock miner for more than 30 yrs. He has no other significant past med hx. On physical exam he is a thin man who appears tachypneic at rest. His lungs have reduced chest expansion & dry inspiratory rales in upper lobes bilaterally. Remainder of his exam is normal. Chest x-ray reveals multiple round opacities in upper lobes accompanied by hilar lymphadenopathy with lymph node calcification. What is a serious complication of the condition with which the pt presents?

*Tuberculosis* = high association rate with silicosis - pt should be tested for TB at time of diagnosis & annually thereafter Pt presents with silicosis... - hilar LAD + eggshell calcifications - treatment = supportive

To prepare for emergencies, what would be the correct steps for operating an AED?

*Turn on the AED, apply pads, analyze the rhythm, clear the patient, delivery shock*

Baby born with translucent cystic structure covered by thin membrane over lower lumbosacral vertebrate. Through covering, neural tissue visualized. Further exam reveals flaccid paralysis of LEs, no deep tendon reflexes, & no response to pinprick. Baby also has bilteral clubfeet. Baby taken to neonatal intensive care unit & lesion is covered with sterile saline-soaked gauze. Neurosurgical consult requested. Prior to surgery, neurosurgeon requests a computerized tomographic exam of brain to assess for what conditions?

*Type II Chiari malformation* - majority of patients with have obstructive hydrocephalus - fourth ventricle elongated & brain stem kinked - associated with meningomyelocele Myelomeningocele: most located in lumbosacral region but may occur anywhere along neuraxis - flaccid paralysis with no deep tendon reflexes of LEs - no response to touch or pain - lesion may be associated with deformations such as clubfoot or congenital hip dysplasia

62 yo man with ho long-standing HT, DM & hypercholesterolemia presents to ED with retrosternal chest pain for last few hrs. He also complains of SOB that is started about same time as his chest pain. His initial ECG & cardiac enzymes are within normal limits. Diagnosis of unstable angina made & he is given oxygen (by nasal cannula), morphine, aspirin, & beta-blockers. He is started on heparin drip & admitted to telemetry unit & his symptoms subside. On fourth hospital day, he develops pain in his right lower extremity. Physical exam reveals absent dorsalis pedis & posterior tibial artery pulses on right side. Stat lower-extremity Doppler ultrasound exam confirms diagnosis of acute arterial thrombosis in popliteal artery. Lab evaluation reveals: Hemoglobin 14 g/dL Hematocrit 42% WBC 5,300/mm^3 Platelets 60,000/mm^3 PT 18 sec PTT 50 sec Most likely diagnosis?

*Type II heparin-induced thrombocytopenia* - immune-mediated disorder - dev't of Abs against heparin-platelet factor IV complex - dev't of platelet arterial thrombosis - 4-10 days after exposure to heparin - decreased platelet count = 30,000-55,000 - stop heparin immediately! HIT: 2 subtypes - most serious = HIT type II

65 yo white man brought to ER after he collapsed while shopping at local mall. His wife, who was with him when he collapsed, states that he has hx of HT, hypercholesterolemia, & chronic renal insufficiency. He has been taking his meds regularly & has never before had such an episode. On arrival pt is found to be unresponsive, with shallow breathing. He is orally intubated. His HR is 110/min, respirations 16/min, BP 180/100 mmHg, & temp 98.9 F. Ventilator settings assist control with rate 12, tidal volume 500 mL, & PEEP 5. Eye exam shows that right-sided pupil dilated & nonreactive to light. Left pupil normal & reactive to light. Doll's eye reflex is intact. Lungs are clear to auscultation, with no wheezes or crackles. CVS exam shows no rub or gallops. Abdomen is soft, nontender, & nondistended. Bowel sounds present & active. Extremities show no pitting edema. Pt withdraws his extremities on painful stimulation. Lab tests show: Sodium 142 mEq/L K 4.4 mEq/L Cl 101 mEq/L Bicarb 27 mEq/L BUN 60 mg/dL Creatinine 2.6 mg/dL Glucose 90 mg/dL Calcium 9.2 mg/dL Most likely diagnosis?

*Uncal herniation* Expanding mass in supratentorial region of brain --> eventual herniation through tentorium - can be lateral (uncal) or central Lateral / uncal herniation - compresses oculomotor nerve = ipsilateral dilated pupil - most likely has expandign subdural hematoma or intracranial hemorrhage = expanding

When is a transcutaneous pacemaker recommended?

*Unstable 3rd degree heart block* When patient is experiencing symptoms & is becoming unstable due to a brady-arrhythmia - 2nd degree, type II, or 3rd degree heart block where atropine has not been effective

What rhythm requires synchronic cardioversion?

*Unstable supraventricular tachycardia*

What do guidelines recommend for dyspepsia and alarm features?

*Upper endoscopy* - 70% of pts with dyspepsia don't have physiologic explanation for their symptoms - alarm features = onset after 50 yo, anemia, dysphagia, odynophagia, vomiting, weight loss, fam history of upper GI malignancy, personal hx of PUD, gastric surgery, GI malignancy, abdominal mass or lymphadenopathy

58 yo man evaluated in ED for painless red blood per rectum that began 3 hrs ago. Bleeding was accompanied by presyncopal episode. Med hx unremarkable. He doesn't smoke, drink alcoholic beverages, or use illicit drugs. He is on no prescription meds but has been taking OTC ibuprofen recently for knee sprain. On physical exam, temp is 99 F, BP is 88/58 mmHg, pulse rate is 132/min, & RR is 24/min. Abdominal exam is normal. Rectal exam discloses bright red blood in rectal vault. Lab studies reveal hemoglobin level of 7.3 g/dL. Nasogastric tube aspirate shows no evidence of blood or coffee-ground material. IV fluid resuscitation is begun. What is the most appropriate diagnostic test to perform next?

*Upper endoscopy* - this pt has hematochezia, significant anemia, & hemodynamic instability - his use of ibuprofen for his knee injury increases chance of upper GI source of bleeding - absence of blood or coffee-groun material in nasogastric tube aspirate doesn't rule out upper GI bleeding source - nasogastric tube placement can miss up to 15% of actively bleeding lesions, especially if no bile is noted on aspirate - brisk upper GI source of bleeding can cause hematochezia & can be life threatening if not acted upon early - upper GI source suspected? --> urgent upper endoscopy should be performed

Next step in pt w/ GERD that does not respond to empiric trial of PPI therapy

*Upper endoscopy* - required for pts with symptoms of weight loss, dysphagia, odynophagia, bleeding, or anemia & in pts with long-standing symptoms (>5 yrs) or symptoms refractory to acid-suppression therapy - to identify possible complications or alternative diagnoses such as eosinophilic esophagitis, stricture, malignancy, or achalasia

71 yo man brought to OR for elective repair of growing AAA. Aneurysm has been followed closely for 3 yrs but has grown 1 cm over past yr, to 5.8 cm. Operation is uncomplicated & the pt is extubated & brought to surgical ICU postoperatively for management. He remains hemodynamically stable & his lower extremities remain ward & well perfused. On postop day 1 his creatinine increases from 1.1 mg/dL to 1.3 mg/dL but his urine output remains appx 40 mL/h. On postop day 2, he complains of abdominal pain & has episode of bloody diarrhea. Stat CBC shows that hemoglobin has dropped from 10 g/dL to 9 g/dL, & WBC has elevated from 12,000/mm^3 in morning to 15,000/mm^3. Next step in management?

*Urgent colonoscopy* Ischemic colitis - well-recognized complication of AAA repair, open or endovascular - origin often the inferior mesenteric artery covered by aortic graft = pts don't have adequate collateralization via marginal artery of Drummund = at risk for ischemia of descending & sigmoid colon - blood diarrhea & leukocytosis = diagnostic of condition - gold standard = endoscopic visualization of cyanotic or shedding mucosa = via either colonoscopy or flexible simgoidoscopy - management also exclusively requires colonic resection with colostomy - lack of prompt intervention could result in sepsis & death

A 26-year-old man is evaluated for a 6-month history of fatigue. He is subsequently diagnosed with hypokalemic metabolic alkalosis. Medical history is unremarkable, and he takes no medications. On physical examination, temperature is 36.6cC (97.9°F), blood pressure is 110/64 mm Hg and pulse rate is 78/min without orthostatic changes; respiration rate is 14/min. Cardiopulmonary examination is normal. There is no edema. The remainder of the examination is unremarkable. Lab studies: Serum creatinine = 0.8 mg/dL (70.7 umol/L) Electrolytes: Sodium = 142 mEq/L (142 mmol/L) Potassium = 2.9 mEq/L (2.9 mmol/L) Chloride = 100 mEq/L (100 mmol/L) Bicarbonate = 32 mEq/L (32 mmol/L) What is the most appropriate diagnostic test to perform next?

*Urine chloride measurement* - most appropriate test to determine cause of patient's hypokalemic metabolic alkalosis - metabolic alkalosis caused by net loss of acid or retention of bicarb - diagnostic evaluation via clinical assessment of volume status & BP - patient who doesn't have HT & has normal or slightly decreased effective arterial blood volume, urine chloride level can help distinguish b/t various causes of metabolic alkalosis Low urine chloride levels = <15 mEq/L - normal for men = 25-371 mEq/L - usually either vomiting or have decreased effective arterial blood volume

Recognize *acanthocytes* Case: A 34-year-old woman is evaluated for urinary frequency. She has no dysuria, fever, chills, or excessive sweating. She is otherwise healthy, and her only medication is a daily multivitamin. On physical examination, temperature is 37 .1°C ( 98. 7°F), blood pressure is 149/9S mm Hg, pulse rate is 72/min, and respiration rate is 18/min. The remainder of the examination is normal. Dipstick urinalysis shows a pH of S.S, 1+blood, 1 + protein, and negative leukocyte esterase. Urine microscopy findings are shown. Which of the following diagnostic tests is most appropriate to perform next?

*Urine protein-creatinine ratio & serum creatinine measurement* - to determine degree of proteinuria & level of kidney function - patient has microscopic hematuria that appears glomerular in origine - glomerular hematuria on urine microscopy characterized by presence of dysmorphic RBCs or acanthocytes

74 yo comes to his PCP for annual exam. Pt reports that he has had significant probz with maintaining erection. He is able to achieve erection but is not able to sustain it for sufficient time to complete intercourse. His past med hx is significant for HT, CAD, CHF, osteoarthritis, & GERD. He takes atenolol, isosorbide dinitrate, lisinopril, furosemide, ibuprofen, & omeprazole. He denies tobacco & alcohol use. His temp is 98.3 F, BP 124/72 mmHg, pulse 72/min, & respirations 16/min. His weigh is 180 lb, heigh 6 ft 2in, & BMI is 24. Physical exam of heart reveals regular rate & rhythm. Lungs are clear to ausucltation. Abdomen soft & nontender. CBC, basic metabolic panel, & lipid profile within normal limits. Testosterone level 435 ng/dL. Most appropriate recommendation for this pt?

*Vacuum device* - this pt cannot receive sildanafil bc of concurrent use of nitrates as well as hx of CHF --> second-line therapy for ED = vacuum device

35 yo woman presents with chief complaint of palpitations. Patient in sinus tachycardia. She has no chest discomfort, SOB, or light-headedness. Her BP is 120/78 mmHg. What intervention is indicated first?

*Vagal maneuvers*

17 yo gravida 1 para 0 girl at 35 weeks' gestation comes to doc bc of foul-smelling vaginal discharge for 7 days. She has had no fever, frequency, urgency, painful urination, or blood in her urine. She is sexually active w/ new male partner. Her temp is 98.4 F, BP is 110/75 mmHg, & pulse is 75/min. There is fetal movement & no contractions, & fetal heart tones are 140/min. Pelvic exam shows erythematous cervix w/ punctate hemorrhages & a frothy, green discharge. There is no cervical motion tenderness. Gonorrhea & chlamydia nucleic acid testing was negative 3 days ago. Most appropriate next diagnostic test?

*Vaginal discharge microscopy* Trichomonas vaginalis - foul-smelling discharge & punctuate hemorrhages (strawberry cervix) - most appropriate way to diagnose = microscopy --> motile trichomonads can be seen on wet mount - vaginal pH > 4.5 - increase in neutrophils on saline microscopy - in pregnant pts, trichomonas vaginalis have been linked to premature rupture of membranes & preterm labor - treatment = metronidazole

4 yo grl brought to doc by her mom bc of vaginal discharge. 2 days ago, child began scratching vulva & complaining of burning with urination. She is otherwise healthy & has never had similar prob. Exam shows normal structural anatomy without evidence of atrophy. Medial aspects of labia majora are erythematous & excoriated. There is mucous discharge with streaks of admixed blood. Most likely diagnosis?

*Vaginal foreign body* - often stool or toilet paper - most common cause of vaginitis in 4 yo grl - may be compounded by child's scratching --> excoriations - inflammation of vulvar & vaginal mucosa may be treated with topical estrogen cream for 1 wk

61 yo woman with ho HT & COPD comes to doc bc of SOB. She states that she has had 6 mo ho progressively worsening dyspnea while climbing stairs in her house. She denies both chest pain & dyspnea at rest. She appears to be comfortable at rest & has barrel-shaped chest. Physical exam shows prolonged expiratory phase & wheezes on forced exhalation. Heart sounds are regular in rate & rhythm with absence of murmurs or rubs. Transthoracic echo shows diastolic left ventricular dysfunction. Next best step in pt care?

*Verapamil* Diastolic left ventricular dysfunction - advanced hypertrophy via long-standing HT - concentric hypertrophy --> heart that cannot relax during diastole = dyspnea on exertion - administer negative inotropic agent --> relax heart during diastole = improves filling pressures - beta blockers contraindicated in this pt bc of ho COPD

66 yo man with hx of bacterial endocarditis comes to doc bc of SOB. He says that for past 2 mos he has been waking up in the middle of the night gasping for breath. His solution has been to open window & stick out his head. He admits to using four pillows to fall asleep & occasionally feels dyspneic on climbing stairs at his home; however, he is quick to remark that such breathlessness is "nowhere near as severe as it is at night." Physical exam shows absence of jugular venous distention & pedal edema. There are scattered wheezes throughout both lung fields. Pansystolic murmur heard best at apex & radiating to axilla is audible. ECG shows no abnormalities. Echocardiogram shows ejection fraction 55%. Next best step in patient care?

*Valve repair* - suitable bc ejection fraction <60% on echo = cut-off relatively high - bc pts who have mitral regurg can decompensate into fulminant heart failure very rapidly, threshold EF for surgery is higher - either mitral valve replacement or mitral valve repair Continuing left hear failure - paroxysmal nocturnal dyspnea + orthopnea + occasional dyspnea - mitral regurg = pansystolic murmur at apex radiating to axilla

29 yo woman, gravida 2, para 1, at 38 weeks' gestation comes to labor & delivery ward with frequent painful contractions that have been progressive over last 6 hours. She has hx of asthma for which she uses an albuterol inhaler. Pt has hx of anaphylactic rx after admin of penicillin. Physical exam shows that she is contracting every 2 minutes & her cervix is 5 cm dilated & 100% effaced. Her prenatal urine culture shows 100,000 colony-forming units/mL of group B streptococci. Sensitivities were not done. Most appropriate pharmacotherapy?

*Vancomycin* GBS - colonization occurs in 10-40% of women - cause of early-onset GBS infection in neonate less than age 7 days - cultures should be obtained at 35-57 weeks of gestation - in women who don't have penicillin allergy, penicillin G is preferred drug for prophylaxis - if minor allergy is noted, cefazolin can be subbed - if severe allergy, pt must be treated with vancomycin if susceptibility to clindamycin not known

42 yo gravida 1, para 0 woman comes to labor & delivery for induction of labor for postdate pregnancy. Pelvic exam shows her cervix to be closed & thick. She is administered intravaginal prostaglandins for cervical ripening. Four hours later, cervix is dilated 2 cm & an oxytocin infusion is started. Once regular contraction pattern is established, amniotomy is performed. Immediate painless vaginal bleeding occurs. Fetal heart rate is in 90s. Most likely diagnosis?

*Vasa previa* = triad of: ruptured membranes, painless vaginal bleeding, fetal bradycardia (fetal HR <100/min) - via abnormal traversin of fetal vessels across cervical os - either via velamentous insertion of umbilical cord or joining an accessory placental lobe - true obstetric emergency = immediate C section indicated - fetuses have little intravascular volume & exsanguinate quickly

32 yo woman comes to psychiatrist bc she cannot enjoy her social life. She states that over the past 7 mos she has experienced extreme fatigue, muscle tension, & irritability. She has difficulties falling asleep, partly bc she is unable to control thoughts that something bas is going to happen to her husband & children. In past mo she has had episodes of SOB, dizziness, & restlessness, & has avoided going to work bc she "Couldn't take stress." Her physical exam & lab tests, as well as her ECG are unremarkable. What psychoactive agents should be the next step in management?

*Venlafaxine* GAD - unrealistic worry about life events most days for period longer than 6 mos - impairment in everyday functioning - treatment = SNRI such as venlafaxine or SSRI

What action minimizes risk of air entering victim's stomach during bag-mask ventilation?

*Ventilating until you see chest rise*

A 54-year-old man is evaluated in the emergency department for a 1-hour history of chest pain and shortness of breath. He had been hospitalized 1 week ago for a colectomy for colon cancer. His medical history is otherwise significant for hypertension complicated by hypertensive nephropathy. His medications include amlodipine, ramipril, and as-needed acetaminophen for postoperative pain. On physical examination, temperature is 37.5°C (100°F), blood pressure is 110/60 mm Hg, heart rate is 115/min, and respiration rate is 24/min. Oxygen saturation is 89% with the patient breathing ambient air and 97% on oxygen, 4 Umin by nasal cannula. The lungs are clear. Cardiac examination shows tachycardia but is otherwise normal. There is a surgical incision in the left lower quadrant that is healing well. The remainder of the examination is unremarkable. Chest radiograph is negative for infiltrates, widened mediastinum, and pneumothorax. Serum creatinine concentration is 2.1 mg/dL (185.6 µmol/L). Empiric intravenous unfractionated heparin therapy is begun. Which of the following is the most appropriate study to confirm the diagnosis in this patient?

*Ventilation-perfusion scanning* - detect abnormalities of blood flow in comparison to pattern of ventilation Acute pulmonary embolism in pt with kidney failure - both CT angiography & ventilation-perfusion scans able to reliably diagnose large pulmonary emboli

A 70-year-old woman is hospitalized for an ST-elevation myocardial infarction involving the anterior wall. Her symptoms initially began 3 days before admission. The pain resolved spontaneously before she reached the hospital. Two hours after presentation to the emergency department, she has acute onset of dyspnea and hypotension and requires emergent intubation. A portable chest radiograph shows cardiomegaly and pulmonary edema. Vasopressor therapy is initiated to support her blood pressure. On physical examination, blood pressure is 90 I 60 mm Hg, pulse rate is 120/min, and respiration rate is 12/min. She has a grade 4/6 harsh holosystolic murmur at the right and left sternal borders associated with a palpable thrill. No S3 or S4 is heard. Crackles are heard bilaterally at the lung bases. Which of the following is the most likely diagnosis?

*Ventricular septal defect* Postinfarction ventricular septal defect - shunting of oxygenated blood from left ventricle to right ventricle occurs - acute volume overload to right ventricle --> cardiogenic shock = rapidly fatal unless emergent surgical or possibly percutaneous intervention can be performed - she initially presented with delayed anterior wall ST-elevation MI (STEMI) --> then had acute respiratory distress & was found to have new holosystolic murmur at left sternal border on physical exam

Medicine consult requested on 32 yo woman with schizophrenia who is pt in closed psychiatric unit. Several days after pt's admission, she developed polyuria, vomiting, stupor, diarrhea, & restlessness. She is currently taking risperidone, 6 mg given at bedtime, but no other meds. She has no other medical conditions. Most likely diagnosis?

*Water intoxication* / Psychogenic polydipsia - excessive intake of water via psychiatric disorder --> symptoms

46 yo man admitted to hospital bc of fever, bakc pain, & leg weakness for 3 wks. He has had no headache or loss of consciousness. He has had fatigue & malaise. He has hx of T1DM & renal failure. He had renal transplant 4 yrs ago. Current meds include insulin, cyclosporine, prednisone. His temp is 100.6 F & pulse 90/min. Grade 3/6 holosystolic murmur heard at apex. Muscle strength in LEs bilaterally. Blood cultures grow S viridans. Echo shows vegetations on mitral valve. What is the most likely explanation for this pt's back pain & leg weakness?

*Vertebral osteomyelitis* - most commonly occurs via hematogenous spread of bacteria to vertebral bodies (richly vascularized) - epidural abscess --> compresses spinal cord = neuro symptoms Immunosuppressed + DM + anti-rejection meds

69 yo man comes to ED bc of dizziness, blurry vision, & slurred speech for 30 minutes. Earlier in day, he suddenly lost his balance, felt like the room was spinning, & had difficulty with his vision & speech. Symptoms resolved 30 minutes later. He denies headache, fever, or loss of consciousness. He hs ho HT & hyperlipidemia. Current meds include HCTZ. He smoked one pack of cigarettes daily for 30 years, but he quit 12 years ago. His BP is 130/85 mmHg & pulse is 75/min. Exam shows no abnormalities. ECG shows sinus rhythm, & carotid ultrasound shows no abnormalities. Abnormality in what arteries is most likely cause of this patient's symptoms?

*Vertebrobasilar artery* Vertebrobasilar ischemia (VBI) - dizziness = most common presenting complaint of TIA in this area - feeling of heaviness - eyelid drooping - diplopia - drowsiness - bilateral leg & arm weakness - numbness - dysarthria

30 yo man being evaluated in ED. Has long ho fever, diarrhea, abdominal pain, weight loss, & fatigue. He was evaluated in ER bc of 2 episodes of right lower abdominal pain. Appendicitis was ruled out & pt was sent home with meds. He is scheduled to see gastroenterologist for evaluation of perianal fistula. When asked about other signs & symptoms he states he has noted multiple bruises all over his body, as well as nasal & gum bleeding, & he noted some blood in his urine yesterday in morning. On physical exam, he has multiple ecchymoses on abdomen & LEs. Anal exam discloses perianal fistula. 10 minutes after blood drawn oozing is still evident. Lab report: Hgb = 12 g/dL Platelets = 180,000/mm^3 WBCs = 6500/mm^3 PT = 30 seconds PTT = 45 seconds Most likely cause of pt's bleeding?

*Vitamin K deficiency* Crohn's Disease - malabsorption of vit K --> decreased production of factors 2, 7, 9, 10 - bleeding may mimic hemophilia = may occur at any site - both PT & PTT elevated; PT usually more severely - severe bleeding treated with infusions of FFP

5 day old boy who was born at home is being evaluated in urgent care for bruising & GI bleeding. Lab findings include PTT & prothrombin time, greater than 2 minutes; serum bilirubin, 4.7 mg/dL; alanine aminotransferase, 18 mg/dL; platelet count, 330,000/mm^3; & hemoglobin, 16.3 g/dL. His mother has Factor V Leiden deficiency. Most likely cause of boy's bleeding?

*Vitamin K deficiency* Hemorrhagic disease of newborn - via vit K def - now uncommon bc of routine admin of vit K at birth - still encountered when babies born outside hospital - normal newborn has moderate def of vit K-dependent coag factors --> plasma levels of factors fall even further during first 2-5 days --> rise again when infant is 7-14 days old --> attain normal adult levels at ~ 3 mos old - all newborns should receive 0.5-1 mg of vit K IM within first hour after birth

A 16-year-old girl is evaluated because of fatigue for the past 3 to 4 months. She reports a history of heavy menstrual bleeding since onset of menarche at 13 years, requiring several pads each day during her menstrual cycle. Her mother and sister also have a history of heavy menstrual bleeding. She has no known medical problems, but recalls continued bleeding for 2 to 3 days following an uncomplicated tooth extraction 1 year earlier. She takes no prescription or over the-counter medications. On physical examination, temperature is normal, blood pressure is 108/68 mm Hg, pulse rate is 90/min, and respiration rate is 10/min. There is mild conjunctiva! pallor. The remainder of the examination is normal. Lab studies: Hemoglobin = 8.5 g/dL Leukocyte count = 6800/uL with normal differential Platelet count = 260,000/uL MCV = 68 fL Exam of peripheral blood smear shows microcytosis & hypchromia but is otherwise normal. Most appropriate diagnostic test to perform next?

*Von Willebrand factor antigen determination* vWD - hx of bleeding - normal platelet count - suggestive fam history - most common inherited bleeding disorder = 1% of pop - easy bruising or mild to moderate nasal or gingival bleeding or heavy menstrual flow - excessive bleeding following surgical procedures - desmopressin = releases vWF & factor VIII from endothelial cells = first-line therapy for most subtypes of vWD = administered IV or intranasally

67 yo Caucasian male comes to clinic complaining of weakness, fatigue, & paresthesias. He is asking doc to prescribe him something that could increase his appetite since he has lost almost 12 pounds in last 4 weeks. He has also had two episodes of nasal bleeding, blurred vision & headaches during past week. Past history significant for HT & diabetes for which he is taking HCTZ & glimepiride, respectively. His temp is 39.4 C (101.1 F), BP is 130/80 mmHg, pulse is 94/min, & respirations are 16/min. Patient appears confused. HEENT: pale conjunctiva. Heart: regular rate & rhythm, S1 & S2 normal, displaced apical impulse. Lungs: clear to auscultation. Abdomen: liver & spleen palpated 4 & 3 cm below right & left costal margins, respectively. Neuro exam: impaired vibration & proprioception in LEs, bilaterally. Lab reports include: Hemoglobin = 9 g/dL Platelets = 100,000/mm^3 WBCs = 4,500/mm^3 MCV = 88um^3 MCHC = 32% Peripheral smear = Plasmacytoid lymphocytes & rouleaux formation Bone marrow biopsy = >10% infiltration by small lymphocytes showing plasma cell differentiation Creatinine = 1.1 mg/dL BUN = 18 mg/dL Serum protein electrophoresis = Monoclonal spike (IgM) What is the most likely diagnosis?

*Walderstrom macroglobulinemia* - malignant monoclonal gammopathy - high levels of IgM - lymphoplasmacytic infiltrate in bone marrow - monoclonal IgM = hyperviscosity syndrome, cryoglobulinemia, coagulation abnormalities, sensorimotor peripheral neuropathy, anemia, primary amyloidosis, tissue deposition of amorphous IgM in skin, GI tract, kidneys, other organs - neoplastic lymphoplasmacytic cells >10% infiltrate the bone marrow, spleen, lymph nodes - dz of elderly ind.s - 7th or 8th decades of life - weakness, anorexia, fever, weight loss, hemorrhagic manifestations, mental status changes, peripheral neuropathy, skin changes (purpura, papules) - peripheral smear = plasmacytoid lymphocytes & roleaux formation - unlike multiple myeloma, there are no lytic bone lesions & serum calcium levels don't increase

A 35-year-old woman is evaluated preoperatively before undergoing a complex orthopedic procedure. Her medical history is significant for IgA deficiency and a severe anaphylactic reaction during an erythrocyte transfusion that she received for postpartum hemorrhage at age 25 years. On physical examination, temperature is 37.4°C (99.3°F), blood pressure is 128/78 mm Hg, pulse rate is 82/min, and respiration rate is 16/min. The remainder of the examination is unremarkable. Results of laboratory studies indicate a hemoglobin level of13.6 g/dL (136 g/L), a platelet count of186,000/µL (186 x 109/L), and normal prothrombin and activated partial thromboplastin times. Previous laboratory study results showed an undetectable serum IgA level but otherwise normal immunoglobulin levels and no other abnormalities on serum protein electrophoresis. Which of the following is the most appropriate erythrocyte product for this patient if transfusion is needed?

*Washed* - may remove plasma proteins Hx of transfusion-associated anaphylaxis - washed RBCs - diagnosis of severe IgA def should be considered in any pt with hx of anaphylaxis during blood transfusion - anti-IgA Abs --> may lead to anaphylactic rxn when blood products containing IgA used in transfusion - RBC & platelet products contain small amounts of plasma (with IgA present)

51 yo man is unrestrained front-seat passenger in motor vehicle collision. Physical exam reveals multiple facial lacerations & shortened * adducted right lower extremity. Vital signs are temp 100 F, BP 155/75 mmHg, pulse 110/min, & respirations 16/min. Neuro tests intact & CT can of head, chest, & abdomen are normal. Additional imaging study indicated?

*X-ray of both hips* Unrestrained front seat passenger at risk for knees impacting dashboard - femurs can be driven backward & out of acetabulum = *posterior dislocation of hips* - bc of tenuous bloods supply of femoral heads, injury must be promptly recognized & treated bc it may cause avascular necrosis of femoral head - posterior dislocation of hip can sometimes be recognized on physical exam, as affected lower extremity may be shortened, adducted, & internally rotated

70 yo woman comes to doc bc of recurrent head and neck pain for 6 mos. She has had episodes of sensation of spinning that occur after turning her head. She has had no chest pain, diaphoresis, nausea, or SOB. She had hysterectomy with bilateral oophorectomy for endometriosis 30 years ago. She takes no meds. Her temp is 97.7 F & BP 132/70 mmHg. Exam shows decreased ROM of neck Flexion of neck to right side produces pain to right upper extremity. Most appropriate next step in diagnosis?

*X-rays of head and neck* - indicated in pts who have nontraumatic neck pain who are older than 50 yo Degenerative joint disease involving cervical column (cervical spondylosis) - may cause neck pain & headaches - may represent underdiagnosed cause of headache - osteophytes may impinge on cervical roots & cause pain radiating along upper extremities Classic signs - Spurling sign = increased radicular pain by extension & lateral bending of neck toward sign of lesion - L'hermitte sign = feeling of electrical shock with neck flexion - Reduced ROM of neck = most frequent objective finding

72 yo man brought to ED after sustaining fall. His med hx is significant for coronary artery disease, chronic kidney disease, & osteoarthritis. He is hemodynamically stable, but his pulse is 121/min until IV morphine is administered & his heart rate is normalized. On physical exam he is found to have severe right hip tenderness that is worse on abduction and external rotation, with significant soft-tissue edema & ecchymosis but no open wounds. Next step in management?

*X-rays of right hip & femur* Fracture of femur - age & medical comorbidities - initial first step = x-ray imaging in ED

56 yo nulliparous woman comes to doc bc she is concerned about breast cancer, as her maternal aunt was recently diagnosed with advanced breast cancer. She wishes to take a med she read about on the Internet to prevent breast cancer. Her past history includes cholecystectomy at age 38 & obesity with BMI 32 kg/m^2. She smokes & does not exercise regularly. She has been menopausal since age 51. Her meds include gemfibrozil for hyperlipidemia, aspirin, & beta-blocker for HT. Breast exam reveals normal breast tissue without palpable lumps or lymph nodes. What is the most appropriate next step in management?

*Yearly mammography* - more accurate in detecting small breast lesions that cannot be felt during physical exam - USPSTF & ACOG = routine mammogram screening begin at age 50... - can find nearly 1-3 years before lymp in breast - risk factors breast cancer = increasing age, first-degree relative with breast cancer, nulliparity, obesity

69 yo women evaluated following routine dual-energy x-ray absorptiometry scan. Pt's T-score is -2.8, & a diagnosis of osteoporosis is established. Med hx significant only for GERD treated w/ omeprazole. Additional meds are calcium citrate & vitamin D. She does not smoke cigarettes or drink alcoholic beverages & does not have postmenopausal symptoms. In addition to weight-bearing exercise, what is the most appropriate therapy for this pt?

*Zoledronic acid* Treat osteoporosis w/ IV bisphosphonate - IV preferred for women w/ postmenopausal osteoporosis who are unable to take oral bisphosphonates or who deisre less frequent dosing

A 50-year-old man undergoes follow-up examination. He was evaluated in the emergency department 2 days ago for right flank pain and was found to have a 4-mm stone in the distal right ureter on noncontrast computed tomography (CT). Results oflaboratory studies at the time, including kidney function tests, were normal. He was treated with low-dose opioid medication and was discharged home with follow-up scheduled today. The patient continues to report mild pain that is controlled with the medication. On physical examination, vital signs are normal. There is mild tenderness to palpation over the right costovertebral angle, and the remainder of the examination is normal. Which of the following is the most appropriate next step in management?

*alpha-blocker* Kidney stone appx 4 mm - 90% of stones less than 5 mm pass spontaneously - to increase chance of stone passage, medical expulsive therapy using agents such as alpha-blocker (such as tamsulosin) or CCB (such as nifedipine) should be employed - off label but common practice for patients with stones less than 10 mm & well-controlled symptoms - now recommended by American Urologic Association & European Association of Urology

A 36-year-old man is evaluated because of progressive shortness of breath over the last 3 years. He has episodic wheezing and decreased exercise capacity when he climbs stairs or walks quickly. He has a 10-pack-year history of smoking, but has not used tobacco for the past 5 years. His father is 60 years old and has severe emphysema. On physical examination, vital signs are normal. Oxygen saturation is 95% on ambient air. Body mass index is 22. There is wheezing in the posterior and lower lung fields. The remainder of the findings on physical examination are normal. Chest radiograph is shown (flip for pic) Spirometry shows Forced expiratory volume in 1 second (FEV1) of 53% of predicted and an FEV1/forced vital capacity ratio of 64%. Diffusing capacity of carbon monoxide is 67% of predicted. A sixminute walking test shows no significant oxygen desaturation while breathing ambient air. In addition to smoking cessation, which of the following is the most appropriate next step in management?

*alpha1-antitrypsin level measurement* alpha1-antitrypsin deficiency - circulating inhibitor of serine protease - considered in pts diagnosed with COPD at younger age (younger than 45 yo), nonsmokers, pts with predominantly basilar lung dz, & in pts with concurrent liver dz - pt's young age, severity of dz, finding of radiolucency (absence of lung markings) in lung bases on chest radiograph all consistent with diagnosis of alpha1-antitrypsin def

First-line treatment of wounds from cat bites

*amoxicillin-clavulanate* - most organisms isolated from cat bite wound = Pasteurella multocida & Staph aureus - based on nature & location of wound, it may be sutured or allowed to heal by secondary intention - tetanus status should be reviewed

First-line treatment for animal bites

*amoxicillin-clavulanate* in non-penicillin allergic pts - rabies vaccination & immunoglobulin indicated in situations in which animal exhibits abnormal behavior or animal in question cannot be observed or tested

First step in management of Congenital diaphragmatic hernia (CDH)

*nasogastric suction* - for bowel decompression = to prevent further lung compression - & immediate intubation - infant should be ventilated w/ low pressure to minimize lung injury CDH - should be suspected in any full-term infant w/ respiratory distress, especially in absence of or decreased breath sounds on left - infant's abdomen = scaphoid & ipsilateral chest prominent bc of intrathoracic, air-filled intestine - cardiac impulse displaced to side & breath sounds diminished on affected side - diagnosis confirmed by chest radiography showing herniation of abdominal contents into hemithorax - via fusion defects or muscularization defects - most often occur on left & bowel located in chest - prognosis related to degree of pulmonary hypoplasia - after delivery, respiration accompanied by air-swallowing that distends intestine --> exacerbates displacement of abdominal viscera into thorax

Most important prognostic factor of breast cancer

*nodal status* - usually spreads locally to axillary lymph nodes

Optic neuritis causes acute unilateral decreased visual acuity and eye pain. Optic neuritis manifests with decreased color vision, central scotoma, decreased visual acuity, & afferent pupillary defect. Most common finding on fundoscopic exam is

*normal optic disc* seen in two third of pts who have optic neuritis - other one third of pts = papillitis

Complicated pyelonephrosis includes that associated with

*obstruction*, renal emphysema (air), DM, or renal structural abnormalities/stones - complicated pyelonephritis = hospitalization with IV abx & radiologic evaluation - pyelonephritis + obstruction = *nephrostomy tube placement in addition to IV abx*

Pt with adrenal incidentaloma should receive what initial lab tests?

*overnight dexamethasone suppression test, 24-hr urine collection for metanephrines, & measurement of plasma renin activity & serum aldosterone level*

Only treatment options that decrease morbidity and mortality in patients with COPD

*oxygen therapy & smoking cessation* Criteria for home O2 therapy - pO2 < 55 mmHg with O2 sat <88% - pO2 < 60 mmHg if cor pulmonale develops

A 31-year-old woman is evaluated for a 4-week history of left anterior knee pain. The pain developed insidiously and has progressively worsened, especially with prolonged sitting and walking up and down stairs. There is no morning stiffness. The patient has no history of trauma. She is taking acetaminophen as needed for the pain. On physical examination, vital signs are normal. The pain is reproduced by applying pressure to the surface of the patella with the knee in extension and moving the patella both laterally and medially. There is no effusion, swelling, or warmth. Range of motion of the knee is normal, without crepitus or pain. Which of the following is the most likely diagnosis?

*patellofemoral pain syndrome* - most common cause of knee pain in patients younger than age 45 years - more common in women - anterior knee pain worsened by prolonged sitting & with going up & down stairs - pain reproduced by applying pressure to patella with knee in extension & moving patella both medially & laterally

A 38-year-old woman is evaluated for left knee pain that has been present for the past 3 weeks. Before onset, she had been preparing for a 5-kilometer race by running approximately 2 miles each day, 6 days each week, for the past 6 months. Walking up stairs makes the pain worse; she also notes pain at night. She has never had this pain before. On physical examination, vital signs are normal. There is tenderness to palpation located near the anteromedial aspect of the proximal tibia. A small amount of swelling is present at the insertion of the medial hamstring muscle. There is no medial or lateral joint line tenderness. Which of the following is the most likely diagnosis?

*pes anserine burisitis*

Oligoarticular juvenile rheumatoid arthritis has excellent prognosis when associated with

*positive antinuclear antibodies* - 4 or fewer joints affected - morning stiffness, joint pain, lethargy - infectious triggers = viruses, Borrelia, Mycoplasma

Manage patient presenting with ST-elevation MI using

*primary percutaneous coronary intervention (PCI)* - goal of therapy in patients with STEMI is to perform PCI within 90 minutes of presentation to a PCI-capable facility or within 120 minutes if patient requires transfer from non-PCI-capable hospital - patients may benefit from treatment up to 12 hours after onset of clinical symptoms & possibly even after this time

Pts who have acute migraine headaches more than three times per month should initiate prophylactic therapy. The agents with the highest level of evidence-based efficacy include

*propanolol*, timolol, valproate, amitriptyline - acute abortive treatments for migraine headaches = triptans, ergotamine, NSAIDs, antiemetics

Pancreatitis with new onset jaundice 4-6 wks later should raise suspicion for

*pseudocyst* - treatment conservative unless symptoms develop via mass effect

HIV-positive pt + low CD4+ count + ring-enhancing lesion on CT scan w/ contrast who has either cerebral toxoplasmosis or B-cell lymphoma + multiple lesions --> empiric therapy?

*pyrimethamine & sulfadiazine* - serology for toxoplasmosis should also be obtained - clinical improvement w/ this therapy in 10-14 days would confirm diagnosis of cerebral toxoplasmosis - if pt does not respond = diagnosis of lymphoma --> brain biopsy

Management of pt with acute pharyngitis

*rapid streptococcal antigen test* before initiation of antibiotic therapy - Centor criteria = temp > 100.5 F, tonsillar exudates, tender cervical lymphadenopathy, absence of cough = predicts likelihood of streptococcal pharyngitis - pts w/ 2-3 criteria = intermediate prob of having GABHS pharyngitis = recommendation of throat culture & others recommend rapid Ag detection test (RADT) with confirmation of negative results

Most important intervention in treating Central line-associated bloodstream infection (CLABSI)

*removal of central line*

Sickle cell dz is an AR condition that can lead to renal complications such as

*renal papillary necrosis* & renal medullary infarctions - presentation = hematuria, polyuria, nocturia

Pts who have strong clinical suspicion of Alport syndrome should first get a

*skin biopsy* - immunohistochemical analysis of skin done using monoclonal Ab against alpha-5 chain - if there is no expression of this protein on skin biopsy = diagnosis of Alport syndrome confirmed - X-linked disorder of hematuria, sensorineural deafness, lenticonus - defect in type IV collagen

Recognize *third-degree atrioventricular block*

- atria & ventricle depolarize independently = no relationship between the two - atrial rate usually 60-100 beats/min - ventricular rate depends on rate of ventricular escape beats that arise - ventricular escape beat rate slower than atrial rate = third-degree heart block = 20-40 beats/min - both atrial rhythm & ventricular rhythm are regular but independent = dissociated - no relationship between P & R waves - QRS narrow = high block relative to AV node - QRS wide implies low block relative to AV node

Time of apperance and most likely causes of postop fever: - day 1 = - day 3 = - day 5 = - day 7 = - day 10-15 =

- day 1 = atelectasis - day 3 = UTI - day 5 = venous thrombosis - day 7 = wound infection - day 10-15 = deep abscesses

PE of OA

- decreased passive ROM - crepitus - bony enlargement - altered alignment - effusion

ECG for hypokalemia

- depression of ST segment - decrease in T wave - increase in U wave amplitude that occurs at end of T wave

Diagnostic findings of children with bicuspid aortic valve

- ejection click (does not vary with respiration) followed by ejection murmur heard best at apex & upper right sternal border with suprasternal notch thrill - normal splitting of second heart sound - soft decrescendo diastolic murmur of aortic regurgitation

Most significant findings in necrotizing enterocolitis usually seen in premature infants:

- fever - feeding intolerance - distended bowels - change in bowel habits - bloody stools - pathognomonic intramural air in bowel loops

pain is hallmark of kidney stone - flank pain = - groin pain = - suprapubic pain =

- flank pain = ureteropelvic junction - groin pain = moves into ureter - suprapubic pain = near ureterovesical junction

Recognize *stable supraventricular tachycardia*

- heart rate > 150 bp - B/P within normal limits

Metabolic syndrome has some specific lab findings:

- high triglycerides & low HDL - hyperglycemia - high C-reactive protein - high fibrinogen

autoimmune hepatitis characterized by

- hypergammaglobulinemia - positive antinuclear Ab & anti-smooth muscle Ab - abnormal AST & ALT - enzyme immunoassay test for HCV Abs can give false-positive results in setting of hypergammaglobulinemia = should always be confirmed with recombinant immunoblot assay (RIBA) for HCV

Recognize *costophrenic septal lines* on chest x-ray, which are signs of pulmonary congestion & can be seen in patients with *cardiogenic shock caused by left ventricular dysfunction* Case: 70 yo man brought to ED after being found unresponsive at home. On arrival, his temp is 39.5 C (103 F), BP is 75/45 mmHg, pulse is 120/min, & respirations are 30/min. Bilateral rales heard on auscultation. Cardiac exam shows inaudible heart sounds. ECG shows sinus tachycardia. Urine outpute is 10 mL/h. X-ray film of chest shown. Right-sided cath shows pulmonary capillary wedge pressure of 20 mmHg, right atrial pressure of 6 mmHg, & cardiac output of 2.5 L/min. He is administered antibiotics. Cause of hypotension?

- hypotension - acute MI = most common cause

Management of torsades de pointes if: - unstable - stable - refractory to med treatment

- immediate unsynchronized cardioversion - IV magnesium sulfate - temporary pacemaker

Burn pts are at increased risk for prerenal azotemia (uremia). Clues to diagnosis of prerenal azotemia are:

- low urinary sodium (<20) - urine osmolarity (>500) - high BUN/creatinine ratio (>20:1) - high specific gravity (>1.035) = kidney still trying to save water by concentrating urine

Recognize *allergic bronchopulmonary aspergillosis* (ABPA) Case: 30 yo woman with ho asthma comes to doc bc of low-grade fever & cough productive of whitish sputum with brown-colored cords in phlegm for 2 weeks. She has completed 5-day course of azithromycin with no improvement. She has had no hemoptysis, weight loss, chest pain, or leg swelling. Current meds include inhaled salmeterol & fluticasone. She has no allergies. She has not had any recent travel. She smokes marijuana daily & does not use any other illicit drugs. Her temp is 37.3 C (99.1 F). Lungs are clear to auscultation. Lab studies show: Leukocyte count = 13,000 Segmented neutrophils = 44% Eosinophils = 20% Lymphocytes = 30% Monocytes = 6% Radiograph of chest shown.

- more common in ind.s with ho asthma or cystic fibrosis - brown cords = bronchial casts - marijuana smokers can be infected by aspergillus - causes asthma complications, fever, malaise, brownish mucus plugs in sputum, hemoptysis - radiograph = pulmonary infiltrates, signs of bronchiectasis / "tram line", "parallel lines", "gloved finger shadows" that extend from hilus - fungal culture of bronchoalveolar lavage sample indicated to confirm diagnosis - treated with oral glucocorticoids & itraconazole

Indications for Uric Acid Lowering Therapy

- more than 2 attacks in year - renal insufficiency related to hyperuricemia - recurrent nephrolithiasis (uric acid) - serum uric acid > 13 mg/dL in men, > 10 in women - urine uric acid excretion of > 1100 mg/day - chemo/radiotherapy prophylaxis for at risk malignancies - tophi-clinical/radiographic - clinical or radiographic signs of chronic gouty arthritis - frequent &/or disabling attacks allopurinol mostly used - can't be used with renal problems --> use feboxustat - can cause HS syndrome - long-term + gout flareup --> *leave them on!* = can cause another gout flare otherwise - should be on anti-inflammatories along with = colchicine + allopurinol for ex.

Recognize *junctional rhythm*

- no discernible P-waves - P-waves can be upside down before, after, or hidden in QRS wave - AV node fires b/t 40 & 60 bpm --> patient may experience signs & symptoms of bradycardia

Recognize *pulseless electrical activity*

- organized or semiorganized but lack palpable pulse Include: - idioventricular rhythms - ventricular escape rhythms - postdefibrillation idioventricular rhythms - sinus rhythm

Diagnostic criteria for multiple myeloma

- presence of M-protein in serum - presence of >10% of clonal plasma cells in bone marrow - presence of organ/tissue impairment (hypercalcemia, renal insufficiency, anemia, lytic bone lesions/bone pain)

Increased intracranial pressure caused by intracerebral hemorrhage evident from presence of Cushing triad: bradycardia, HT, & irregular respiratory patterns. It is diagnosed clinically, with CT scan or with direct measurement by intracranial pressure monitor insertion. Management encompasses various strategies to decrease intracranial pressure, including

- raising head of bed - sedation - mechanical ventilation - hyperventilation - administration of *mannitol* - surgical decompression with Burr hole or craniotomy

Recognize *sinus tachycardia*

- rate > 100 beats/min - no specific treatment - treat only causes of tachycardia - never countershock

Pseudohyponatremia

- really high glucose / HHS - multiple myeloma - lots of protein in blood

leriche syndrome

- represents atherosclerotic dz within aortoiliac system --> increases risk of distal embolization - peripheral arterial dz - buttock & hip claudication - diminished demoral pulses - erectile dysfunction - more aggressive approach = endovascular intervention or aortoiliac surgery

Recognize *second-degree atrioventricular block (Mobitz I Wenckebach)*

- site of pathology = AV node - progressive lengthening of PR interval until one P wave not followed by QRS complex (dropped beat) - common etiologies = AV nodal blocking agents (beta-blockers, CCBs, digoxin), conditions that stimulate parasympathetic system, acute coronary syndrome that involves right coronary artery - treat only when patient has significant signs/symptoms due to bradycardia

Benign-appearing adrenal nodules have the following features:

- size < 4 cm - smooth, rounded contours - are hypodense on CT scan Biopsy or resection not needed

Antibiotic prophylaxis to prevent bacterial endocarditis needed when what of 2 criteria are met?

- structural cyanotic cardiac disorder (would predispose to endocarditis if pt became bacteremic during procedure) - must be undergoing procedure that is likely to cause bacteremia

Key features of *autoimmune hemolysis*

- sudden onset of jaundice + predominately indirect (unconjugated) bilirubinemia - anemia - increased lactate dehydrogenase - presence of *spherocytes* on peripheral smear - hx of recent infeciton or drug exposure - positive Coombs test - Chlaymdyia & Mycoplasma pneumoniae = ppts for cold-agglutinin autoimmune hemolytic anemia - drugs = penicillin, cephalosporins, sulfa drugs, quinine, NSAIDs - treatment = supportive; splenectomy for unresponsive dz

Severe preeclampsia diagnosed when pt has any one of the following:

- sustained BP > 160/110 mmHg - proteinuria > 5 g/24 h - headache - visual disturbances - upper abdominal pain - oliguria - elevated serum creatinine - HELLP syndrome - obvious fetal growth restriction - pulmonary edema

Nephrotic syndrome by age

- teens/20s = minimal change - 40s/50s = membranous neph - middle age black male = FSGs

Good prognostic factors for breast cancer

- tumors < 2 cm - carcinoma in situ - *presence of estrogen and progesterone receptors on tumor cells* --> allows for treatment with tamoxifen = selective estrogen receptor modulator

Key features of criteria for concluding brain death:

- unresponsiveness = completely unresponsive to external visual, auditory, and tactile stimuli - absence of cerebral and brainstem function = absence of pupillary responses + inability to elicit eye movements by vestibulo-ocular reflex or by irrigating ears with cold water + flaccid limbs + primitive withdrawal movements in response to local painful stimuli mediated at spinal cord level can occur - apnea test = ascertains no respirations occur at PCO2 level of at least 60 mmHg; inability = medullary failure - body temp = must be above 32 C to rule out hypothermia - persistence of brain dysfuction = 6 hrs with confirmatory isoelectric EEG or electrocererbal silence; 12 hrs without confirmatory EEG; 24 hrs for anoxic brain injury without confirmatory isoelectric EEG

Inhaled steroids are treatment of choice in persistent asthma. It should thus be considered for pts who have any of the following:

- used inhaled beta-2 agonists 3x/week or more - symptomatic 3x or more - have 2 or more exacerbations within 6 mos, requiring oral corticosteroids

Equation for serum osmolality

2[Na+] + ([BUN]/2.8) + [glucose]/18

Risk of wound infection of clean-contaminated wound

3-5%

What is the usual post-cardiac arrest target range for PETCO2 when ventilating a patient who achieves ROSC?

35 to 40 mmHg

Average delivery time for twins

36 weeks' gestation

Teething occurs at what age?

6-8 mos - symptoms = local discomfort, bluish discoloration of overlying gums caused by hematoma or eruption cysts, drooling, irritability

considered high risk for breast cancer with breast cancer risk assessment tool (gail model)

>1.7% - consider chemoprevention

Demonstration of CD15 & CD30 on immunohistochemical staining required for confirmation of diagnosis. Most common presenting symptom is either palpable, non-tender neck mass or mediastinal lymphadenopathy seen on chest x-ray film

Burkitt dz

Immediate next step in trauma pt with concern for epidural or subdural hematoma

CT head

High sensitivity to detect cancer of head of pancreas

CT scan

Best initial test for identifying metastatic brain tumors

CT scan *with contrast*

Diagnostic gold standard of epidural hematomas

CT scan of head

Diagnose pancreatic injury using what imaging?

CT scan without contrast

Should be administered only to counteract life-threatening symptoms of magnesium toxicity (such as cardiorespiratory compromise)

Calcium gluconate

Cholinesterase inhibitors used for treatment of mild to moderate Alzheimer dementia. Which one may be best tolerated with fewer GI & peripheral side effects than other drugs?

Donepezil - tacrine not frequently used anymore bc of its hepatotoxicity

SSRI that has been approved for treatment of OCD.

Fluvoxamine OCD - low levels of serotonin in brain = associated with impulsivity - fluoxetine & fluvoxamine commonly used in treatment of OCD - of tricyclic antidepressant, clomipramine is the most serotonergic = used in OCD

Neurocognitive disorder due to HIV infection. Characterized by affective, cognitive, behavioral, & motor symptosm & signs.

HIV *dementia* - usually occurs after many years of HIV infection - symptoms controlled with low doses of neuroleptics

Most common cause of acute renal failure in young children

HUS - frequently follows episode of gastroenteritis via E coli - marked elevation of creatinine + hyperkalemia = initiate *peritoneal dialysis*

Pyelonephritis in diabetic pts best treated with

IV fluoroquinolones - unless gram stain reveals gram positive cocci = ampicillin/gentamicin

55 yo woman comes to ED bc of 3-day ho chills, spiking fever, & right-sided abdominal pain. Reports she underwent laparoscopic cholecystectomy for symptomatic gallstones at another hospital 3 months ago. She was told that operation had gone well & that intraoperative cholangiogram showed no stones elsewhere. But 10 days after surgery she became deeply jaundiced & required a second operation, an open laparotomy, but she does not know exactly what was found or done. Today, she is jaundiced, & the lab studies show: Total bilirubin = 8 mg/dL Indirect bilirubin = 1 mg/dL ALT = 56 mg/dL AST = 52 mg/dL Alkaline phosphatase = 1052 mg/dL Sonogram reveals extremely dilated intrahepatic ducts, but common duct could not be visualized. What is the most likely diagnosis at this time?

Iatrogenic *Stricture of common duct* - presents with biliary colic & obstructive jaundice = very high alkaline phosphatase, direct hyperbilirubinemia - CBD stricture got infected --> cholangitis - clinical presentation of cholangitis = Charcot triad = fever & chills, jaundice, RUQ abdominal pain

Viral infection characterized by maculopapular exanthem & tender lymphadenopathy of occipital, retroauricular, & cervical lymph nodes

Rubella (German measles)

Best test to distinguish most transudative effusion, especially due to cirrhosis & CHF, from exudative ascites

SAAG > 1.1 Transudative effusions = <1 WBC per 1000 mm^3 = normal glucose, LDH, protein concentrations

Treatment of intermittent explosive disorder

SSRIs anticonvulsants mood stabilizers psychotherapy focusing on anger management

A 77-year-old woman is admitted to the hospital for intermittent dizziness over the last few days. She reports no chest discomfort, dyspnea, palpitations, syncope, orthopnea, or edema. She underwent coronary artery bypass graft surgery 6 years ago after a myocardial infarction. She has hypertension and hyperlipidemia. Medications are hydrochlorothiazide, pravastatin, lisinopril, and aspirin. On physical examination, blood pressure is 137 /88 mm Hg and pulse rate is 52/min. The lungs are clear to auscultation. Cardiac auscultation shows bradycardia with regular S1 and S2 as well as an S4. A grade 2/6 early systolic murmur is heard at the left upper sternal border. Edema is not present. On telemetry, she has sinus bradycardia with rates between 40/min and SO/min, with two symptomatic sinus pauses of 3 to 5 seconds each. Which of the following is the most likely cause of this patient's dizziness?

Sinus Sick Syndrome (SSS) - episodes of sinus bradycardia correlated with dizziness - pathologic findings that result in bradycardia = sinus arrest, sinus exit block, sinus bradycardia - common in elderly - can be intermittent or nonspecific

5 mo old grl brought to office by her mom, who states that the girl had episode following feeding during which she began to breathe deeply, became blue, and then lost consciousness. Mom states that she picked her up and held her, and the infant regained her usual color & became alert. Physical exam reveals harsh systolic murmur. The remainder of the physical exam is unremarkable. Most likely diagnosis?

Tetralogy of Fallot - hypoxemic spell = hypercyanotic spells = Tet spells = 10-15 minutes = immediately after feeding or when child is crying vigorously = VSD + overriding aorta + RVH + pulmonic stenosis

Children exposed to lead usually have levels that peak when?

ages of 18 to 24 months - screening = between 1-2 years in high-risk individuals

Initial treatment for hypercalcemia

aggressive hydration with IV normal saline, plus loop diuretic *if needed* to treat fluid overload

MI via acute anemia best initially treated with

blood transfusion - to increase hematocrit & relieve cardiac ischemia

Cushing's reflex is

bradycardia, respiratory depression, & HT = Cushing's triad / Cushing's response - many believe that it relates to brainstem compression

side effects of trastuzumab

cardiotoxicity so monitor EF infusion rxns

OA affects what regions of spine?

cervical lumbar

For any single positive screening gFOBT result, what is indicated?

colonoscopy

Treatment of eosinophilic pneumonia

corticosteroids - to eliminate HS response - one month duration - goal = complete resolution of opacities on radiographs

Workup for sisters of male children who have fragile X syndrome?

cytogenetic testing

Predispose to dev't of acalculous cholecystitis

diabetes, long-term critical illness, total parenteral nutrition Diagnosis ... - new-onset RUQ pain + elevated WBC count + elevated LFTs (especially alk phosph) - IV broad-spectrum abx + eventual cholecystectomy = treatments

Factors associated with poor prognosis in schizophrenia

early age of onset single marital status negative symptoms poor inter-episode functioning

Expected trend in birth weight of infants by age of 12 months?

expected to triple their birth weight by age of 12 months - double their weight by 6 mos - quadruple birth weight by 24 mos - double their length by 4 years - don't triple their length until they are out of infancy & into puberty

How does CDC define anemia in pregnant women?

first & third trimesters = <11 g/dL second trimester = < 10.5 g/dL

first thing to do if calcium high

fluids

HIV associated nephropathy is due to

focal segmental glomerulosclerosis - diagnosed by biopsy - treatment = HAART drugs & ACEIs

When it is suspected that pt has trichotillomania, most appropriate initial step is to ...

identify presence of comborbid conditions

Diagnosis of steroid induced myopathy confirmed with

improvement in strength 3-4 wks after decreasing dose of steroid meds

Granulomatous dzes, such as sarcoidosis, causes hypercalcemia via

increased production of calcitriol / *1,25-dihydroxycholecalciferol* / active form of vit D - promotes calcium uptake from duodenum

Internal manual exam should NOT be performed by doc in cases of PROM bc of

increased risk of introducing infection into vaginal canal

Pregnancy is known to increase levothyroxine requirements in most pts receiving thyroid replacement therapy, & this expected increase should be anticipated by

increasing levothyroxine dose - typically increased in first (& sometime 2nd) trimester of pregnancy, with possible total increase of *30%* to 50% --> to maintain TSH level b/t appx 0.1-2.5 uU/mL = fewer maternal & fetal complications - fetus largely dependent on transplacental transfer or maternal thyroid hormones during first 12 wks of gestation - in pregnant women w/ hypothyroidism, thyroid function tests should be frequent = every 4 wks

Metabolic syndrome characterized by...

insulin resistance obesity increased abdominal circumference HT lipid abnormalities - serum triglycerides >150 mg/dL - serum HDL < 40 mg/dL in men & <50 mg/dL in women

Most common cause of blood nipple discharge in young women

intraductal papilloma

Best initial step in treating a pt who has suspected aortic dissection & elevated BP is to administer...

labetolol - controls heart rate - produces vasodilation - decreases shear stress in aorta to avoid complications - diagnostic studies = CT chest w/ IV contrast & TEE

Corresponding coronary artery: ST elevation in V1-V3

left anterior descending artery - anteroseptal wall

Osteoporosis is diagnosed by DEXA T-score of

less than -2.5 - or presence of fragility fractures - fragility fracture defines osteoporosis regardless of bone mineral density results

Pregnanct women with >2 episodes of documented UTI, >2 episodes of asymptomatic bacteriuria, or >1 episode of pyelonephritis should receive prophylactic abx for remainder of pregnancy. Drugs of choice include

low-dose nitrofurantoin or sulfisoxazole

Positive VDRL or RPR must be followed with a Treponema-specific test, such as the

microhemagglutination assay for antibodies to T pallidum (*MHA-TP*) or the fluorescent titer antibody absorption (FTA-ABS) - if these Treponema-specific tests are positive --> pts considered to have diagnosis of syphilis - negative? --> false-positive RPR or VDRL = can be caused by immune dz, infection (other than syphilis), etc

When the initial diagnosis of hemophilia is made by coagulation profile & factor VIII level, the next step is to differentiate congenital from acquired hemophilia (anti-factor VIII abs) is the

mixing study - hemophilia A: mixing study will normalize PTT bc normal serum has factor VIII - acquired anti-factor VIII ab pt: PTT will not normalize mixing

Beck's triad for *cardiac tamponade*

muffled heart sounds JVD hypotension

Magnesium sulfate contraindicated in women who have

myasthenia gravis - can ppt severe myasthenic crisis

Findings of lithium toxicity

neuromuscular excitability irregular coarse tremors motor agitation muscle weakness ataxia sluggishness delirium nausea vomting diarrhea leukocytosis sinus bradycardia hypotension - severe = seizures, stupor, coma, permanent neuro sequelae

Somogyi phenomenon due to

nocturnal hypoglycemia --> rebound morning hyperglycemia - decrease evening dose of insulin

Dawn phenomenon due to

nocturnal release of GH & cortisol - increase evening dose of insulin

Most common cause of Down syndrome

nondisjunction - risk increases with maternal age

synovial fluid of OA

noninflammatory or mild inflammatory (WBC less than 2000/mm^3)

First step in evaluation of hemoptysis or productive cough ...

obtain *chest radiograph* to rule in or rule out infectious, cancerous, or suspected immunologic dz - most common causes of hemoptysis = bronchitis, bronchogenic carcinoma, bronchiectasis

Epididymo-orchitis is treated with abx & supportive care. If there is no improvement or evidence of fluid collection (abscess), the preferred method is

surgical drainage - to avoid recurrence Epididymo-orchitis - pertitient findinings on ultrasound = increased blood flow to testicle (hyperemia) - abscess of testicle &/or scrotum should be treated with IV abx & surgical drainage of abscess fluid

Combination of hypokalemia, low blood pressure, metabolic alkalosis suggests

surreptitious chronic *vomiting* or chronic diuretic use - elevated serum bicarb --> high filtered bicarb load --> overwhelms reabsorptive capacity of proximal tubule & increase in amount of excreted sodium bicarb = volume depletion in combo with fluid loss from vomiting + hypovolemia-induced increase in aldosterone release = increased renal potassium secretion

Infant with gonococcal conjunctivities requires treatment with

systemic ceftriaxone - 30-50 mg/kg/day in divided doses IV or IM up to max of 125 mg/day - should have their eyes frequently irrigated with saline to eliminate discharge

Should be administered to pt with acute STEMI within 12 hrs of symptom onset, with no contraindications for thrombolysis, & who presents to facility without capability for PCI within 90 mins

tPA

Most common cause of early functional deterioration following liver transplantation

technical probz with biliary and vascular anastomoses

Erythema nodosum, associated with UC, presents as

tender, erythematous nodules on lower extremities

For V vulnificus w/ cellulitis & sepsis (w/ chronic renal or liver dz), treat the shock and use what abx?

tetracyclines or third-generation cephalosporins

Bleeding during first trimester + closed cervical os + viable intrauterine pregnancy defined as

threatened abortion - only supportive care indicated in first trimester - 50% of these pregnancies proceed to full abortion

Use of tamoxifen increases risks for

thromboembolic dz & *endometrial hyperplasia and cancer*

Primary goal of orchiopexy

to move testicle into scrotum so that *it can be easily palpated* & assessed for signs of developing testicular malignancy - done before 2 yo to allow proper monitoring for testicular cancer & fertility

Most effective modality to determine whether pt has valvular vegetation and to estimate degree of damage or destruction to mitral valve.

transesophageal echocardiogram (TEE)

All patients with breast mass should undergo

triple assessment: palpation, mammography with or without ultrasonography, *surgical evaluation for biopsy*

Only way to definitively diagnose pneumonia

visualizing infiltrate present on *chest radiograph* Indications of chest radiograph - abnormal vital signs (temp > 100.4), pulse >100/min, RR>24/min - rales or signs of consolidation on chest exam - epidemiological suspicion of pneumonia - suspicion on SARS