Fam Med NBME Form 2
56 yo - routine exam in October PMHx: T2DM - tx w/ metformin vitals stable she doesn't want to get the flu vaccine this yr bc she knows people who have "come down w/ the flu bc of the shot" most app physician response?
"Patients who are incubating the influenza virus when they receive the vaccine mistakenly attribute their symptoms to the vaccine. You should get the vaccine." you can also have a flu-like rxn to vaccines
42 yo - recent high BP readings past month: BP - 150/94 mmHg on 2 occasions at health fairs PMHx: migraines 2x/wk for last 6 months - tx ibuprofen 4-6x/wk BP: 152/92 mmHg pt should discontinue ibuprofen and take what app pharmacotherapy?
B-adrenergic blocking agent pt should stop taking ibuprofen bc the high BP might be what is causing her migraines BBs and ACEi - dec mortality and morbidity propranolol, timolol, nadolol, and metoprolol - can be used for migraine prevention as well
30 yo - fever, nonproductive cough, and L.chest pain for 5 days symptoms started during hiking trip in late August 1 friend has similar symptoms PE: mild diffuse crackles most likely causal organism?
Mycoplasma pneumoniae atypical PNA bugs: mycoplasma, legionella, chlamydia symptoms: gradual onset, dry cough, HAs, myalgias, sore throat, GI symptoms dx: symptoms + new infiltrate on CXR or CT tests for these bugs: > mycoplasma - serum cold agglutinins and serum mycoplasma antigen > legionella - urine legionella antigen test, sputum stained w/ DFA, cx > chlamydia - serologic testing, cx, PCR tx: macrolide, doxy
62 yo - 9 months of pain/swelling of finger joints pain inc w/ activity prog stiffness in fingers for last 2 yrs PMHx: mild HTN - tx w/ diet no meds BP: 138/90 mmHg PE: asymmetric distribution of enlarged bony PIP and DIP joints; some tender; passive ROM limited by pain; grip strength normal most app initial step in mgnt is administration of?
acetaminophen 1st line for acute dz: anti-inf meds (NSAIDs > acetaminophen tho) to reduce joint damage/disability - DMARDs added early (no later than 6 months from onset of symptoms) > methotrexate - 1st line > sulfasalazine or hydroxychloroquine - pts w/ milder forms of RA > others: gold salts, D-penicillamine, and azathioprine - corticosteroids - newer option: lefunomide (inhibits pyrimidine synthesis) - TNF receptor blockers
32 yo - painful blisters on penis for 2 days during past 2 yrs - similar blisters - occurred 4x/yr - lasted 10 days 6 months ago: viral cx of fluid from blister neg SHx: no smoking/alcohol; 6 lifetime female sex partners - no condoms; current sex partner - asymptomatic 100.6 F PE: BL inguinal LND; multiple 3 mm vesicular lesions on shalf most app pharmacotherapy?
acyclovir HERPES HURT has never gotten these treated before and he's had it for 2 yrs - will have this dz for life bug: HSV-1 (oral), HSV-2 (genital) 1-3 mm, regular, red, shadow ulcers symptoms: malaise, myalgias, and fever w/ vulvar burning and pruritus dx: Tzanch smear - multinucleated giant cells; HSV PCR; viral cx tx: acyclovir, famciclovir, or valacyclovir for primary infection
82 yo - 6 months of memory problems and strange behavior SHx: lives alone; high-school education daughter found pt wandering around apartment naked in middle of day; took his car/car keys away - pt repeatedly became lost while driving home from grocery store PMHx: head injury at 14 yo; hyperchol; HTN meds: simvastatin, diltiazem FHx: paternal grandma - AD vitals stable PE: slow but normal gait MSE: "okay" mood; mildly irritated for this appointment; 22/30 next step in pharmacotherapy?
add donepezil to the current regimen pt is showing early signs of AD higher risk of getting this w/ pos FHx common dx criteria: gradual onset; progression of cog dysfxn in > 1 area of mental functioning def dx: neuritic plaques and neurofibrillary tangles on autopsy memory is one of the 1st things to go in AD donepezil - cholinesterase inhibitor; use for mild-mod AD
67 yo - f/u PMHx: 10 yrs of T2DM, 3 yrs of HTN meds: glyburide, metoprolol, amlodipine, fluoxetine BP: 136/86 mmHg PE: BL lower ext - 2+ edema from mid calf to foot; sensitivity to pinprick and vibration dec over feet CMP: BUN, Cr - WNL UA: 1+ glucose; trace protein most likely cause of edema?
adverse effect of medication common SE of CCB (amlodipine) - swelling of the lower ext her T2DM is pretty well controlled - pt does have some neuropathy (BL feet) and mild renal damage
52 yo - 14 months of gen muscle pain and difficulty sleeping pain most severe during periods of stress exhausted after waking up - 8-9 hrs of sleep qNight vitals stable PE: 12 areas of muscle point tendnerness along w/ an aerobic exercise program, what is the most app tx for this pt?
antidepressant therapy homegirl prob has fibromyalgia widespread musculoskeletal pain along w/ fatigue, sleep, memory and mood issues "fibro fog" - problems w/ memory/thinking clearly tx: SSRIs; PT (trigger point release techniques; gentle stretching/exercises; myofascial release)
42 yo - 1 day of severe pain, swelling, and warmth in L.knee pain mod relieved w/ ibuprofen pain begun 1 day after aerobic kickboxing workout PE: upper aspect of L.knee erythematous/warm to touch w/ an effusion; ROM limited by pain next step in mgnt?
arthrocentesis aka joint aspiration red, hot, swollen joint? choose arthrocentesis just by looking at the PE - need to drain the fluid out of the knee normal joint - bunch of fluid degenerative dz (OA) - joint is just degraded inf joint - in between these; yellow/white fluid septic joint - pus; > 50,000 polys (neutrophils); pos cx gout - crystals
37 yo - 3 months of gen fatigue dec energy level - esp at end of day 3 yrs of abd bloating and int diarrhea (esp after eating pasta) no change in appetite/weight loss menses reg w/ light flow for 2 days BMI: 25 PE: mod pale oral mucosa; abd distended/tympanitic but no tenderness/organomegaly; rectal exam gucci stool for occult blood: neg labs: dec Hct, MCV; inc plt what test would confirm the underlying cause of her symptoms?
assay for anti-transglutaminase antibodies gluten hypersensitivity presents w/ chronic (fatty) diarrhea, FTT, anemia, and nutritional def can cause elevation of liver enzymes also associated w/ dermatitis herpetiformis (rash) and osteoporosis dx: serum tissue transglutaminase Ab and/or antiendomysial Ab; duodenal biopsy tx: gluten-free diet
16 yo - inc withdrawn last 5 months quit swim team; doesn't spend time w/ friends; grades dropped to Cs; sleeps 10-12 hrs qNight - nap after school states she's tired and stomach hurts 12 lb weight loss - dec appetite; not concerned; not intentionally dieting; nauseous after eating states she's not depressed or upset about anything; tearful when discussing physical symptoms - thinks she has mono bc always tired no fever, sore throat, cough, or diarrhea menses reg LMP: 1 wk ago SHx: drank alcohol once; no cigs; sex active w/ 1 male partner for past 6 months - condoms gen: tired BMI: 20 PE: no LND; abd gucci labs: Hct 39%, WBC 7000 next step in mgnt?
assessment for suicide risk
19 yo college student - 3 months of cough occurs in midafternoon and evening worse in cold weather - doesn't wake her up from sleep/prevent her from doing routine activities no PMHx/FHx of medical dz no hospitalizations PE and CXR: gucci most likely dx?
asthma pt so young w/ no risk factors/med dz - should think of asthma first remember also associated w/ Allergy and Atopy reactive obstructive airway dz IgE/mast cell mediated pts will complain of cough, wheezing, and dyspnea PE: wheezing; prolonged exp phase; hyperinflated/hyperresonant chest dx: PFT - dec FEV1/FVC; methacholine challenge test (to provoke bronchoconstriction) tx: progresses (you add on in the following order) - SABA > ICS > LABA > inc dosage of ICS > oral steroids
18 yo - pruritic facial rash for 2 days rash began around lips > cheeks SHx: sex active; OCP PMHx: asthma - tx w/ albuterol inhaler; chronic rash on ext for 13 yrs (photo shows red rash on ext surfaces) FHx: extrinsic asthma PE: uninvolved skin chronically dry/scaling; vesicular facial rash and eczematous lichenified plaques on cheeks, neck, and flexor surfaces of ext most likely dx?
atopic dermatitis with eczema herpeticum atopic dermatitis - scaly skin on extensor surfaces (infants/young kids) or flexor surfaces (old kids/adults) skin can be pruritic and become secondarily infected if severely excoriated causes: environmental exposure or food ingestion tx: emollients and moisturizers - baseline; topical steroids - exacerbations remember that Asthma, Allergy, Atopy like to appear together eczema herpeticum - arises from pre-existing skin disease, usually atopic dermatitis
16 yo - 1 yr of severe acne not responding to OTC topical meds no PMHx; no meds SHx: works in garage on wknds; track team at school; occasionally drinks coffee and sodas BMI: 20 photo of forehead shown (whiteheads + blackheads) Tanner stage 5 - genital and pubic hair give pt oral AB and topical retinoid therapy and recommend what?
avoidance of sun exposure sun exposure > sweating > inc oil production > clogs up pores and leads to acne retinoid therapy - need to dec sun exposure > makes skin more sensitive to the sun > inc risk for sunburn
82 yo - difficulty sleeping at night for 6 months watched TV or listens to talk radio at night - can't sleep daytime fatigue - freq naps husband died 3 yrs ago dog died 8 months ago 12 lb weight loss over 6 months BMI: 20 BP: 150/84 mmHg general: disheveled; cracked/chapped lips PE: gucci MSE: poor eye contact; answers questions w/ delayed, short responses; difficult finding right words; describes recent activities vaguely; takes 5 min on clock face test - had to be reminded of the time but still does it correctly; recalls 2/3 objects after 5 min next step in mgnt?
begin sertraline therapy grief is only "okay" for 12 months grief - normal rxn that doesn't impair normal functioning; hopeful; waxes and wanes depression - pervasive; hopeless recent weight loss is red flag gen appearance and neuro exam - pt doesn't look too good in these 1st line for depression - SSRI don't forget to screen for suicide
11 yo - brought in 1 hr after collapsing boys playing game - standing, breathing deeply and rapidly for 1 min, and then expiring against closed mouth collapsed and struck head on edge of bed didn't open his eyes/move for several minutes now alert and fully oriented PE: 1x1 cm ecchymosis on occipital scalp; pupils react to light; symmetric reflexes; gait/muscle strength normal most likely cause of LOC?
cerebral hypoperfusion breathing deeply and rapidly and expiring against closed mouth > messed up air exchange unable to get enough O2 to the brain
6 yo - 1 wk of itchy, nonpainful rash on arm began as small red spot > tripled in size since photo shown (tinea corporis) most app topical pharmacotherapy?
clotrimazole tx: vaginal yeast infections, oral thrush, diaper rash, pityriasis versicolor, and types of ringworm selenium sulfide - tx for tinea versicolor permethrin - tx for scabies and lice
27 yo - sadness, loss of appetite, and difficulty falling asleep since him and his wife separated 5 wks ago energy level dec no longer enjoys time w/ friends doesn't believe him and his wife will be able to work through their conflicts but wishes they could no PMHx FHx: sister - MDD (tx w/ sertraline) SHx: drinks 1-2 glasses of wine qNight; no drugs BMI: 33 PE: gucci MSE: sad mood; tearful; though process logical; no evidence of suicidal ideation/hallucinations most app tx?
cognitive behavioral therapy SIG E CAPS for dx of depression (5/9) for at least 2 wks 1st line for depression - CBT try to treat pt w/o meds - esp since this episode is provoked by a recent event
mom of 16 yo boy - request drug screening during his exam suspects he's been using bc grades have dropped and heard rumors that his friends use hasn't discussed this w/ her son asks physician to perform drug screening w/o her son's knowledge most app course of action?
do not agree to testing unless her son agrees to the drug testing damn right
27 yo - G2P1 - 26 wks gest vitals stable PE: ecchymoses in various stages of healing on forearms/lower abd; fundal height 27 cm; cervix long/closed; uterus nontender/firm fetal heart tones gucci labs: Hcb 12; plt 280,000; bleeding time 6 minutes most likely dx?
domestic abuse bruises in different stages of healing is a classic sign of physical abuse pregnant pt is also a typical victim check CBC and coag test to r/o medical causes of bruising HELLP: variant of preeclampsia (requires new onset HTN and proteinuria +/- alarm symptoms) w/ Hemolytic anemia, Elevated Liver enzymes, Low Platelets DIC: pt sick from something else > dec plts and bleeds; fibrin clots consume plts and factors; blood shears against these clots > hemolytic anemia and schistocytes; low fibrinogen, inc PT/PTT, and inc D-dimer; tx - plts + blood TTP: AI dz; hylaine clots form; vWF multimers persist and swallow plts; pentad (FAT RN) - Fever, Anemia, Thrombocytopenia, Renal Failure, Neurologic symptoms; tx - plasma exchange/transfusion ITP: AI dz; dx of exclusion; tx - steroids; IVIg to inc plts; splenectomy; rituximab vonW: plt type bleeding but normal plt count; vWF stabilizes factor VIII; messes w/ plt adherence; tx - desmopressin, if severe cryoprecipitate or factor VIII
57 yo - routine exam no PMHx; no meds SHx: smoked 1 pack qd for 20 yrs - stopped 10 yrs ago; drinks 1 glass of wine qd; no exercise; office assistant BMI: 23 BP: 140/90 mmHg lipids: chol 250, HDL 35, LDL 179, triG 180 next step in mgnt?
exercise program lipids are all out-of-whack also has stage 2 HTN recommended LSM and at least 2 anti-HTN meds - reassess in 1 month wouldn't recommend weight loss program since her BMI is WNL (18.5-24.9)
9 yo - mom noticed lump in L.breast 10 days ago FHx: mom - hx of breast cancer 70th perc - height 40th perc - weight Tanner stage: 2 - breast; 1 - pubic hair PE: no ax LND; 2x2.5 cm slightly raised mass beneath L.areola - tender and slightly granular, no erythema; R.nipple slightly tender next step in mgnt?
follow-up examination in 6 months mass shows benign characteristics: well-circumscribed, firm, mobile, tender, w/ no overlying skin changes pt is also 9 yo w/ stage 2 Tanner development - doesn't suggest malignancy most likely due to fibrocystic changes reassure mom and f/u to monitor the mass
47 yo - discuss weight loss PMHx: 5 yrs of HTN; T2DM (recent dx) meds: HCTZ, metformin overweight entire life; gained 20 lb after birth of each of her 3 kids tried OTC meds for weight loss and lost 40 lb on commercial diets - unable to keep the weight off SHx: walks 30 min 3x/wk - not on any diet; no cigs FHx: dad - died of MI at 52 yo BMI: 38 BP: 140/80 mmHg labs: glucose 140, total chol 225, HDL 50, LDL 120, triG 280 CBC, CMP, thyroid, LFTs: WNL most likely to be effective in achieving weight loss in this pt?
gastric bypass pts w/ BMI > 40 or > 35 + comorbid conditions - candidates for surgical tx of obesity 2 MC surgeries: gastric bypass and "lap banding" goal lipids: < 100 LDL, < 200 total chol, HDL > 60
27 yo - 1 wk of yellow eyes and dark urine SHx: prior IV drug use labs 6 months ago: pos HAV Ab assay, neg HBVs antigen assay, pos HBVs Ab assay PE: jaundice, hepatomegaly lab studies consistent w/ hepatitis most likely cause?
hepatitis C infection pos HAV Ab assay: > IgM - active infection > IgG - immunity neg HBVs antigen (HBsAg) assay: > pos - occurs early; means infection > neg - no infection pos HBVs Ab (HBsAb) assay: > IgM - infection > IgG - vaccination HBeAg - envelope for infectious labs suggest that pt has gotten HAV and HBV vaccines HCV - no vaccine > transmitted by blood - IVDA and blood transfusions > labs: look for Ab and HCV RNA - if both of these pos = chronic infection > screen for HCC w/ annual US and AFP > tx: genotype 1b - pegylated interferon w/ ribavirin; genotype 2/3 - direct acting antivirals
42 yo - 2 yrs of mild HTN tx w/ Na restriction and reduced-cal diet 4.4 lb weight loss FHx: dad - cerebral infarction at 55 yo SHx: no cigs; drinks 2 glasses of wine qNight; accountant; doesn't exercise regularly BMI: 39 BP: 160/98 mmHg lipids: total chol 228, HDL 45, LDL 148 strongest predisposing factor for cerebral infarction in this pt?
hypertension *HYPERTENSION IS THE SINGLE MOST IMPORTANT RISK FACTOR FOR STROKE* other risk factors: DM, male, older age, FHx, dyslipidemia, smoking
42 yo - persistent R.heel pain began 3 wks ago - took 5 mile walk tx w/ naproxen, heel cushion, and exercises - didn't relieve pain 4 days ago: foot swelling PMHx: T1DM and HTN meds: insulin and benazepril PE: 1+ edema BL to mid-calf most likely cause of edema?
impaired renal excretion of sodium even though her DM is well-controlled - she prob has some renal damage taking naproxen consistently for 3 wks leads to further renal damage
14 yo - routine exam sex active w/ boyfriend of 6 months - condoms, OCP SHx: smokes 1 pack of cigs weekly for 1 yr; drinks beer/wine occasionally PE: gucci next step in mgnt?
inquire about her attitudes toward smoking and health she's so young and already smoking + drinking starting so young > substance abuse/dependence at least she's been safe w/ sex
9 month - exam 2 wks ago: viral gastroenteritis; lasted 10 days; low-grade fever, vomiting, and diarrhea mom resumed cow milk-based formula - pt drinking this prior to illness infant's stools cont to be watery; pt very gassy immunizations up2date vitals stable PE: mild abd distention w/ inc bowel sounds; no palp masses/organomegaly explanation for pt's current GI symptoms?
lactose intolerance diarrhea, abd distention, and flatulence - common symptoms of lactose intolerance even though she was able to drink this prior to the illness - the virus may have messed up the baby's GI system cow milk allergy: > feeding intolerance, vomiting, FTT, bloody stool > cross-reactivity w/ soy > tx: avoid cow's milk protein until 2-3 yo
2 yo - hoarse cough and difficulty breathing began last night > worse during night immunization up2date appears tired - responds normally to stimuli 100.4 F P: 164/min RR: 40/min BP: 102/68 mmHg Pox: 86% PE: labored respirations; insp stridor (heard w/o stethoscope) most likely dx?
laryngotracheobronchitis (croup) bug: parainfluenza virus 3 months - 3 yo symptoms: viral prodrome; barking, seal-like cough (worse at night); insp stridor AP film: "steeple sign" tx: > mild - cool mist humification > mod - racemic Epi, steroids, O2 > severe - admit pt
62 yo - routine exam PMHx: T2DM, PVD meds: metformin, glyburide PE: dec dorsalis pedis and post tibial pulses BL lipids (1 yr ago to today): dec total chol (180), HDL (37), LDL (135), triG (140) most app recommendation?
lipid lowering therapy to decrease LDL-cholesterol concentration to less than 100 mg/dL to determine LDL goal of pt consider cig smoking, HTN, low HDL, age (>45 yo for men, >55 yo for women), FHx of premature CHD this pt falls under the first group since he has 2 CHD risk equivalents 1. pt w/ CHD or CHD risk equivalent (PAD, CV dz, AAA, T2DM, or multiple risk factors): LDL goal < 100 (>130 consider med) 2. pt w/ 2+ risk factors: LDL goal < 130 (consider med depending on 10 yr CV risk - if 10-20% risk >160; if < 10% risk >190) 3. pt w/ 0-1 risk factors: LDL goal < 160 (>190 consider med)
42 yo - PKD PMHx: HTN - tx w/ HCTZ BP: 156/94 mmHg on previous 2 visits; 160/96 mmHg today PE: lungs clear; cardiac gucci labs: serum Cr 1; UA - 2+ protein, 5-10 RBCs next step in mgnt?
lisinopril therapy homeboy's kidneys are clearly not working too good - proteinuria and RBCs present in urine sig microscopic hematuria if > 3 RBCs glomerular cause - sig proteinuria, RBC casts, and dysmorphic RBCs nonglomerular cause - 2/2 tubulointerstitial, renovascular and metabolic disorders; sig proteinuria but no RBC casts or dysmorphic RBCs ACEi - shown to improve kidney function along w/ lowering BP no change in BP after 3 visits - add another agent
4 yo - sore throat and temps to 101.8 F over last 24 hrs preschool - other students have similar symptoms gen: ill PE: erythema of tonsils w/ exudate rapid strep antigen test: neg throat cx: GAS what describes the rapid strep antigen test best regarding these results?
low sensitivity sens = proportion of actual positives that are correctly identified as such this test was unable to correctly identify that the pt has strep specificity = proportion of healthy patients known not to have the disease, who will test negative for it
66 yo - progressive SOB on exertion 2 wks: 2-pillow orthopnea and PND - not associated w/ neck, chest, or arm pain PMHx: untx borderline HTN BP: 150/94 mmHg PE: 3 cm JVD; BL insp crackles at BL lung bases; lat displaced PMI; S3 gallop w/o murmur; mild pitting edema BL next step in dx?
measurement of left ventricular ejection fraction homegirl most likely has CHF - just by looking at her current presentation also hasn't been tx for her HTN - no bueno sleeping patterns - L. HF due to pulmonary congestion JVD - R. HF heart is bigger - PMI is displaced S3 - large amount of blood striking LV > normal in young people and athletes > suggests CHF in elderly pitting edema - sign of L/R HF labs: BNP < 500 dx gold standard: echo tx: LMNOP - Laxis, morphine, nitrates, O2, position > everybody: dec salt < 2g/day and H2O <2L/day; ACEi/ARB; BB (don't start/inc this during exacerbation) > reduce preload: diuretics, nitrates, diet modifications > reduce after load: ACEi/ARB, hydralazine, spironolactone > EF < 35%: AICD (defibrillator) > ischemic: ASA and statin > class IV: inotropes, VAD bridge to transplant, transplant
32 yo - anemia noted on testing prior to blood donation recently - dec exercise tolerance reg periods stool for occult blood: neg labs: Hct 27%, MCV 73, WBC 5200 blood smear shown most app initial step in mgnt?
measurement of serum iron and ferritin concentrations gonna assume that bc the MCV is dec - need to check the MC cause of this which is Fe def blood smear shows RBCs that have an inc in central pallor and irregular shapes teardrop RBCs can be caused by Fe def
77 yo - 4 wks of mod severe aching/morning stiffness in shoulders/hips trouble getting out of bed in the morning and reaching over his head due to the pain admits low-grade fever and gen fatigue PE: dec ROM of shoulders/hips; no joint/muscle tenderness ESR: 70 next step in mgnt?
methotrexate therapy guess homeboy has RA classic: prolonged morning stiffness; symmetric arthritis involving 3+ joints (hands, feet, wrists - common); spares DIPs 1st line tx: methotrexate; NSAIDs to control symptoms + adjunctive therapy
22 yo - 3 days of malodorous vag discharge denies fever/chills/dysuria menses reg LMP: 2 wks ago meds: OCP BP: 130/76 mmHg 98.6F abd exam: bowel sounds normal pelvic exam: gray, thin, watery vaginal discharge UA and preg test: neg Gram stain of discharge shown (shows clue cells) results for chlamydia and gonorrhoea - pending next step in mgnt?
metronidazole therapy gram stain shows clue cells - dx for bacterial vaginosis pt complains of odor and inc discharge (grayish-white, fishy odor) wet mount (saline): "clue cells" (epi cells coated w/ bacteria) KOH prep: + whiff test BV vs trichomonas vs yeast infection (Candida) trichomonas: strawberry cervix; yellow-green, frothy discharge; motile trichomonads (flagellated) on wet mount; tx partners w/ metro as well Candida: thick, white, curdy discharge; hyphae on KOH prep; tx w/ azoles
82 yo - 2 yrs of painful tingling in his feet gabapentin and carbamazepine haven't help PMHx: T2DM (20 yrs) - tx w/ glyburide PE: normal muscle strength; sens to light touch dec to midcalves BL most app alternative pharmacotherapy?
nortriptyline homeboy has diabetic neuropathy the meds he was originally given are 1st line TCAs helpful as well - rarely used due to SE profile
52 yo - risk for developing thyroid cancer FHx: dad - dx w/ papillary CA no meds PE: gucci most app screening test?
palpation of the thyroid gland should palpate the thyroid before doing further testing on the pt screening for bladder, testicular, pancreatic, or thyroid cancer in asymptomatic adults - not recommended
32 yo - SOB, profuse sweating, and chest discomfort - while at concert 30 minutes ago similar episode 1 month ago at school play felt anxious since that time; concerned she's going crazy monitored pulse during past month - 70-80/min P: 110/min BP: 140/76 mmHg PE: opening systolic click over L. 4th ICS most likely cause of symptoms?
panic disorder episodes occur when pt is at a big social event she now feels anxious about another one occurring agoraphobia - fear and avoidance of public areas, crowds, public transport, or going outside alone r/o med conditions: acute coronary syndrome, hyperT, and asthma symptoms: STUDENTS PANIC - SOB, trembling, unsteadiness, depersonalization, excessive HR, n/t, sweating, palpitations, abd distress, nausea, intense fear of losing control/dying, chest pain tx: abort attack w/ benzos; long-term w/ SSRIs
82 yo - 6 months of frequent falls prior to each - feeling of imbalance when walking/turning denies LOC PMHx: stable CAD (5 yrs); OA of knees (10 yrs) meds: 81-mg ASA, lovastatin SHx: lives in ALF BP: 140/85 m mHg w/ no orthostatic changes PE: difficulty rising from her chair; gait w/ using cane - instability on turns; muscle strength 4/5 on BL lower ext next step in mgnt?
physical therapy instability when walking is common w/ inc age her long hx of OA doesn't help her either no orthostatic changes present - suggests her brain is still receiving ample O2 aka blood from the heart needs to just strengthen her muscles
37 yo - intermittent chest pain over past 2 days 4 days ago: sore throat, HA, malaise 2 days ago: fever and sharp stabbing pain in R.lat chest; pain resolved after 1 hr; recurred 6x since then; no pain w/ exertion vitals stable PE: lungs clear; cardiac gucci labs: Hct, plt - WNL; dec WBC 3700; inc serum CK 500 CXR and ECG: gucci most likely dx?
pleurodynia sudden occurrence of lancinating chest pain or abdpain attacks > commonly associated with fever, malaise, HAs common bug: Coxsackievirus B can occur at any age - more common in kids tx: supportive - NSAIDs; warm packs to areas of tenderness
16 yo - 2 days of urinary freq/urgency/pain w/urination past 2 months: 2 UTIs tx w/ TMP-SMX menses reg - uses tampons 3 months ago: sex active w/ 1 partner - depot medroxyprogesterone and condoms both neg for STDs PE: BL pelvic tenderness; no CVA after tx for current infection, most app recommendation to prevent future UTIs in this pt?
postcoital single-dose nitrofurantoin therapy this is her 3rd UTI w/in 2 months (and she just started having sex these past 3 months) - suggests that she needs some type of ppx all the other options don't make sense - should take this after sex to prevent infection
77 yo - 1 wk of heartburn and difficulty swallowing no weight loss PMHx: cerebral infarction 2 yrs ago; HTN; HLD meds: chlorthalidone, KCl, alendronate, ASA, lovastatin PE: residual R.sided weakness upper endoscopy: 2 shallow ulcers in distal esophagus most likely dx?
reflux esophagitis I'm assuming this is GERD pts w/ heartburn or acid regurg - more likely to have GERD use upper endoscopy if condition gets worse or malignancy is a possibility key symptoms: heartburn, regurg, pain in center of stomach, nausea, difficulty sleeping, use of meds tx: PPIs > H2 blockers
55 yo - routine exam no PMHx; no meds FHx: dad - HTN; mom - T2DM SHx: smokes 1.5 packs for 35 yrs; drinks 4 beers qd - considers his consumption normal/never caused him personal/work problems; high-fat diet; sedentary BMI: 34 BP: 136/88mmHg most app screening test?
serum lipid studies FHx of CAD and T2DM lipids out-of-whack and his SHx can all lead to both of these conditions since pt has high-fat diet and doesn't exercise - easily could have elevated lipids
55 yo - routine exam no PMHx; no meds FHx: dad - HTN; mom - T2DM SHx: smokes 1.5 packs for 35 yrs; drinks 4 beers qd - considers his consumption normal/never caused him personal/work problems; high-fat diet; sedentary BMI: 34 BP: 136/88mmHg lipids: WNL f/u 2 wks later - BP: 138/88mmHg what historical finding is the strongest mortality risk factor for this pt during the next 10 yrs?
smoking lipids good despite his awful SHx BP is stable between the 2 visits pt has a 52.5 pack yr hx bet high chol levels, DM, HTN, obesity, and smoking - smoking is #1 for CV mortality
67 yo - 1 month of diffuse abd cramps and worsening constipation last BM: 4 days ago; stool hard PMHx: constipation - 1 BM every other day; varies from 2 BMs qd to 1 BM weekly; stopped using laxative (bc diarrhea > fecal inconteince) colonoscopy (3 yrs ago): gucci PMHx: MDD w/ anxiety tx w/ sertraline and lorazepam 99F BP: 152/84 mmHg PE: and soft, nondistended, nontender; dec bowel sounds; rectal exam - no masses/stool stool for occult blood: neg next step in mgnt?
trial of fiber supplementation this should be 1st line for constipation homegirl prob has irritable bowel syndrome - comes in 3 forms (constipation, diarrhea, or both) dx: recurrent abd pain/discomfort >3x/month for past 3 months w/ 2+ of the following: > onset associated w/ change in freq of stool > onset associated w/ change in form > improvement w/ defecation tx: abd pain - antispasmodics (dicyclomine and hyoscyamine), TCAs, SSRIs (if dep or anxiety also present); constipation - inc fiber intake; diarrhea - loperamide
37 yo - 2 months of low-grade fever, fatigue, and cough productive of scanty white sputum that is occasionally blood-streaked no SOB SHx: prison guard; smokes 1 pack of cigs for 20 yrs; drinks 4 alc beverages qd BP: 95/68 mmHg PE: rhonchi that clear w/ coughing; no crackles labs: Hgb 9.5; BR 1.2, alk phos 80, AST 75, ALT 60 CXR: normal cardiac silhouette; RUL infiltrate; no pleural effusions most likely cause of cough?
tuberculosis pt's risk factors: alcoholism, crowded living conditions (prison) TB can affect almost any organ system - lungs, CNS, GU tract, bone, and GI tract presents w/ extended duration (> 3 wks) of symptoms presents w/ cough, hemoptysis, dyspnea, weight loss, fatigue, night sweats, fever, cachexia, hypoxia, tachycardia, LND, and abnormal lung exam dx active dz: mycobacterial cx of sputum (gold standard); acid-fast stain PPD test pos if: > 5 mm - "immunosuppressed" or close contacts of TB > 10 mm - "exposed"; incarcerated/homeless, health care provider, travel to endemic areas > 15 mm - shouldn't be screened tx: active - RIPE x 2 months, INH (+ vit B6) + rifampin x 4 months; latent - INH x 9 months
32 yo - 4 months of constant pain on outside of R.elbow at rest NSAIDs and wrist splint - not helpful recently begun building an addition to his house - lifting heavy supplies BMI: 24 PE: severe tenderness of bony R.distal humerus 1 cm prox to radial head; ext of R.wrist against resistance produces pain AP/lat x-rays of R.elbow: gucci next step in mgnt?
use of a forearm strap need to immobilize where the pain is works by dec tension of the muscles attached to the lat epicondyle homeboy probs has lateral epicondylitis - from recent, new, constant activity > pain reproducible when wrist is extended
23 - mod pain/swelling of R.ankle twisted it yesterday no PMHx; no meds vitals stable PE: mod edema of lat aspect of R.ankle, ecchymosis below lat malleolus, tenderness to ant aspect of lat malleolus; post aspects of lat/med malleoli - nontender; neurovascular fxn of ankle intact pt can bear weight as she walks across room - but has been using set of crutches along w/ recommending 2-day ice pack application to the injury, what is the next step in mgnt?
use of a soft protective brace and early range of motion exercises Ottawa rules ankle: get X-ray if pain in malleolar zone + bony tenderness > at post edge (6 cm) or tip of lat malleolus > at post edge (6 cm) or tip of med malleolus > inability to bear weight both immediately and in ER Ottawa rules foot: get X-ray if pain in midfoot zone + bony tenderness > base of 5th metatarsal > navicular > inability to bear weight both immediately and in ER
47 yo - 6 months of mild hand pain primarily over palmar surfaces pain associated w/ n/t esp over thumbs and index/middle fingers symptoms exacerbated by prolonged typing at work; sometimes wake her up no difficulty writing by longhand or grasping small objects PMHx: T2DM - tx w/ diet no meds vitals stable PE: tapping palmar aspect of wrist > pain/tingling in BL hands next step in mgnt?
use of wrist splints pt has not tried anything for this problem yet wrist splints: 1st line for carpal tunnel syndrome pos Tinel sign - tapping of wrist reproduces pain/tingling can also use Phalen test if symptoms don't improve - steroid injections; surgery for decompression of median nerve