UWorld General

Baby is born. What are the first things you do?

-Initial physical assessment (APGAR) -Removal or airway secretions -Dry and keep warm -Then gonococcal opthalmia prevention (drops?) -IM Vitamin K

What are the indications for acute hyperkalemia therapy? What could cause hyperkalemia without symptoms or changes?

1) ECG changes 2) Above 7.0 3) Rapidly rising This patient was at 6, but was asymptomatic and without ECG changes. Main cause: medications (BB, ACEi, K sparing diuretics, ARBs, NSAIDs)

How do you determine number needed to treat?

1/Absolute Risk Reduction Get that from % risk - % risk

What are the main characteristics of absence seizures?

<20 seconds Presence of automatisms (lip smacking, eye fluttering) Not improved by name calling Occurrance during all activities NB: not exacerbated by frightening events. That's apnoeic eposides

What is the gestational age at which tocolytics are a higher risk than allowing labor to go ahead? What if mother has had 2 previous deliveries and now this baby is breech presentation?

> or = 34 weeks 2 deliveries and breech: cesarean delivery

Mother has O+ blood and father has AB+ blood. Mom is concerned about autoimmune reaction. What should you tell her?

ABO incompatibility will can affect the baby, but it is usually a mild hemolytic reaction if symptomatic at all. Mom will already have anti A and B antibodies because things in food have A and B antibodies and can produce an anti A/B IgG immune response before pregnancy develops

Patient has hypothyroidism What metabolic abnormalities are they at risk of?

Abnormalities: -Hyperlipidemia ---High cholesterol bc decrease in LDL receptors ---Concurrent hypertriglyceridemia -Hyponatremia -Inc creatinine kinase -Inc serum transaminases

Mother gives birth prematurely because of IUGR. Baby has VSD, head circumference <5th centile. Exam: baby has closed fists with second digit overlaping the third and the fifth overlapping the fourth. What chromosomal abnormality does this baby have? What other finding would be present?

Abnormality: Trisomy 18 Other: micrognathia Low set ears

Patient has abdominal pain, nausea, vomiting, low grade fever, loss of appetite. He doesn't drink alcohol. He's being treated for seizures. CT is shown. What is the abnormality? What drugs can cause this?

Abnormality: pancreatitis--swelling of pancreas, peripancreatic fluid, fat stranding Drugs that can cause pancreatitis: -Valproic acid -Metronidiazole -Diuretics (furosemide, thiazides) -HIV meds (didanosine, pentamidine) -Immunosupressants (azathioprine, sulfasalazine, 5-ASA)

Patient punches a guy in the mouth. Now he has an infection in his hand. What antibiotics would you give? What bugs would it cover?

Abx: amoxacillin-clavulanate Bugs: gram pos, gram neg, beta-lactamase producing anaerobic eg: staph aureus, eikenella corrodens, hemophilus influenzae

Patient has a severe motor vehicle crash. He's in ICU. On examination, he has diminished bowel sounds, facial grimace on palpation of the right upper quadrant. NG tube aspiration shows retention of gastric contents. CT shows gaseous distension of the large and small bowels without air fluid levels. Gallbladder is distended with no gallstones and there is pericholecystic fluid. Diagnosis?

Acalculous cholecystitis Occurs in severely ill patients, due to cholestasis and gallbladder ischemia. Usually secondary to ascending infection Tx: antibiotics percutaneous cholesystostomy

Patient is 69 yo and comes into the department with left leg pain. He has clear intermittent claudication. Left leg appears pale and feels colder. Distal pulses are absent on the left and dimished on the right. Sensation to light touch is decreased on the left. Dorsiflexion is weaker on the left. Diagnosis? Next step in management?

Acute limb ischemia Next: thrombolysis with IV heparin infusion I thought ABI, but this is too acute of a presentation with risk of severe limb ischemia if you don't do something. Remember 6 P's pain, pallor, paresthesia, pulselessness, paralysis, perishing cold

2 yo boy has infection and fever that is not going away. He has enlarged cervical lymph nodes and splenomegaly. CBC shows: high WCC, low Hb, low platelets, 80% blast forms, 10% prolymphocytes, 10% lymphocytes. PAS staining is positive. No auer rods are seen. Diagnosis?

Acute lymphoblastic leukemia Auer rods are specific for AML, so obviously not. Prolymphocytes and lymphocytes are not blast cells (I guess that threw me off--so he has low mature lymphocytes, which you would expect if they're all blast cells) ALL has PAS positive staining

Patient has PE. How does this affect calcium in the blood? What could be manifestations?

Affect Ca: PE results in hyperventilation, which can result in respiratory alkalosis (high resp rate, blow off lots of CO2, resp alk) Resp alk causes H to become dissociated from serum albumin (to compensate for alkalosis) This leaves more room for free Ca to bind to albumin. This causes a decrease in free Ca This can lead to symptoms of hypocalcemia: -Tetany / carpopedal spasms -Paresthesias -Crampy abdominal pain

Patient has vehicle accident. 12 hrs after admission, he is agitated, hypervigilent, paranoid. He says he can hear people, but no one is actually around. He has a history of cocaine, marijuana, and alcohol abuse. He's tremulous and diaphoretic. Vitals are stable. Hallucinations resolve in a couple days and he's discharged. Diagnosis?

Alcoholic hallucinations Contrast: delirium tremens the vitals are not stable: confusion, fever, tachycardia, hypertension, diaphoresis, and hallucinations

Patient has respiratory acidosis. Cause?

Alveolar hypoventilation NB: atelectasis would cause resp alkalosis because it would increase resp rate and patient would breathe off more CO2

Patient starts with forgetfullness. Then she gets lost. Then she can't care for her finances. Then she depends on her daughter for everything. Then she thinks her granddaughter is stealing from her purse. Then she gets urinary incontinence. Then she has restricted range of motion and mild instability when walking. Diagnosis?

Alzheimer's disease Not lewy body because parkinsonianism isn't prominent. Lewy body dementia also has more fluctuation, visual hallucination, and REM sleep behavior disorder

Patient has bee sting and develops an anyphylactic reaction. She gets epinephrine. 10 minutes later, she has worsening hives, wheezing, and an additional episode of emesis. Resp rate is 18, and pulse ox is 97%. What is appropriate management?

Another dose of IM epinephrine

Patient has repair of descending thoracic aortic aneurism. The procedure was complicated and required blood transfusion. Now he has flaccid paraplegia and loss of pain and temperature sensation in the lower extremities. Vibration sensation is intact. What happened?

Anterior spinal cord syndrome. Common complication of descending thoracic aneurysm repair because the anterior spinal artery depends on the radicular arteries from the thoracic aorta for blood supply. Causes spinal shock initially (flaccid paralysis with loss of pain/temperature sensation--anterior cord), then progresses to spastic paralysis. Vibration and proprioception are preserved

Try to distinguish between different eye inflammation states: Anterior uveitis Episcleritis Bacterial conjunctivitis Viral conjunctivitis

Anterior uveitis: painful, loss of vision, redness photophobia; exam: white cells in anterior chamber (hypopyon) Episcleritis: redness, tearing but NOT painful and NO loss of vision Bacterial conjunctivitis: conjunctival edema, hyperemia, purulent discharge Viral: redness with watery or mucoid discharge

What is a side effect of electroconvulsive therapy?

Anterograde and retrograde amnesia

Patient has c. diff. What predisposes patient to this condition?

Antibiotic use PPI use (decreasing gastric acid production)

What is management of bacterial endocarditis with cardioembolic stroke?

Antibiotics And observation (don't give heparin or aspirin)

What is the most common complication of bronchiolitis?

Apnea

Mother brings 19 yo boy with intellectual disability in. The mother is encouraging him to answer questisons, but he's reluctant. What's the next step?

Ask mother to leave and question boy alone

How do you assess suicide risk? How do you respond to your assessment?

Assess: SAD PERSONS Sex Age Depression Previous attempt EtOH (or other substance use) Rational thought loss (psychosis) Social support lacking Organized plan No spouse or significant other Sickness or injury If high risk of suicide, you must admit--even against one's will

Patient has ADHD and mother doesn't want to give stimulants. What is an alternative?

Atomoxetine A selective norepinephrine reuptake inhibitor

Patient has adult ADHD and wants something to help. He's afraid of addiction as he has had addiction problems in the past. Best therapy?

Atomoxitine (norepinephrine reuptake inhibitor) Second: tryciclic (desiprimine) not first line bc of cardiotoxicity

What arrhythmia is specific for digitalis toxicity?

Atrial tachycardia with AV block -It increased atrial ectopy -It can also cause AV block So the combination of the two is specific for digitalis toxicity

Patient has hypertenison Next step in management?

Attempt lifestyle modification 1) weight loss (reduce to <25 bmi) 2) DASH diet (low sodium, high fruits, vegetables, legumes, low-fat dairy) 3) exercise 30 min a day 4) restrict salt 5) restrict alcohol

Group performs a prospective study. 50% from both groups are loss to follow up. What kind of bias is this?

Attrition bias--a type of selection bias.

17 yo patient has sickle cell and has leg pain in his left thigh for a year. First it was while running. Now it is all the time. He had an infection three weeks ago. Now all his vital signs are normal and he has no leukocytosis. There is pain on flexion, extension, and rotation of the hip with limited range of motion. Likely diagnosis?

Avascular necrosis and osteonecrosis of the hip Common in sickle cell disease because of microinfarctions resulting in decreased blood supply

HIV patient has CD4 count <50. He has fever, night sweats, fatigue, and skin lesions. They started as small reddish-purpule papules and have grown to large nodules. He has hepatomegaly. The lesions bleed easily. He has hopydense liver lesions that enhance with IV contrast. Diagnosis? Cause?

Bacillary angiomatosis Cause: bartonella henselae or quintana

Patient is on fluoxetine and lorazepam for depression and GAD. He stopped them 2 days ago because of fear from his boss. Today, he feels anxious, irritable, tremulous, he's having sleep difficulty and anxiety. Diagnosis/explanation?

Benzo withdrawal Mx: give long acting benzo (diazepam) and taper

Patient has pretty clear kidney stone history Best ways to diagnose?

Best: CT non contrast Then: US abd X-ray isn't as good because it can miss cystine stones. It also gives no info about obstruction of the ureter or kidney

What is the biggest modifiable risk factor for abdominal aortic aneurysm? What are other risks? What are indications for surgery?

Biggest: current smoking Other: large size (5.5 cm), high rate of increase in diameter, and current smoking Indications: size >5.5, inc rate >0.5/6 months or >1cm/year, any symptoms (back pain, abdominal pain, flank pain, limb ischemia)

Patient has jaundice, RUQ pain and a palpable mass. Conjugated bilirubin is up. Gallbladder is normal Diagnosis?

Biliary cyst

Farmer has skin lesions on right forearm and back of his neck. They are wartlike lesions. He has a dry cough, but no other symptoms. His hometown is southern wisconsin. Exam shows 4-5 cm warty, heaped up skin lesions with a violacious hue and sharply demarcated border. They are crusted. Skin scrapings show yeast. Diagnosis?

Blastomycosis

Patient is on warfarin. What things would make him more susceptible to bleeding? What would make him more susceptible to clotting?

Bleeding (inhibits CYP450): -Acetaminophen / NSAIDs -Antibiotics/antifungals (metronidiazole) -Amiodarone -Cimetidine -Cranberry juice, ginko alboa, Vitamin E -Omeprazole -Thyroid hormone -SSRIs (fluoxitine) Clotting risk (increases CYP450) -Vitamin K (spinach) -Carbamazapine, phenytoin -St john's wart -Oral contraceptives -Rifampin -Phenobarbital

5 year old girl has development of pubic hair and body odor. She doesn't have breast development yet. Next step in management?

Bone age If older than px age, then measure basal LH. If high, then you have central precocious puberty If low, then do GnRH suppression test. If still low, you have peripheral precocious puberty

What are screening recommendations for the following: Breast cancer? Colon cancer Cervical cancer? Hyperlipidemia? Osteoporosis? HIV? Hypertension?

Breast: mamogram every 2 years 50-75 (I missed this one because it's up to 75 years and the patient was 70) Colon cancer: FOBT every year or colonoscopy every 10 years Cervical: PAP smear every 3 years from 21-65 Hyperlipid: MEN over 35: lipid panel every 5 years Osteoporosis: DEXA for women over 65 HIV: one screen between 15-65 HTN: BP measurement every 2 years (18+)

Patient eats a lot, and then fasts and runs because she feels guilty. She's worried her boyfriend will leave her because of her disgusting body. She has a BMI of 20. Diagnosis?

Bulimia nervosa Mainly because of compensatory behavior and normal weight Not anorexia because BMI is not <18.5

Patient has failed multiple SSRIs. He has weight gain and hyper somnolence. What's the next antidepressant he should receive?

Buproprion Doesn't cause weight gain, and has a better side effect profile than tricyclics

What would be associated with the following? CAH Granulosa cell/estrogen-progesterone secreting tumor Testosterone secreting hepatoblastoma Central precocious puberty and causes McCune albright syndrome

CAH: salt wasting and virilization Gran cell: middle aged women with ovarian mass with menstrual abnormalities. Rare in kids, but if there, would be premature menstration and breast development Test: premature adrenarche in boys Central: -Advanced bone age -Elevated FSH and LH -Breast development Causes: -Hypothalamic glioma, pituitary harmartoma, idiopathic McCune albright: -Peripheral percocious puberty (low LH & FSH) -Cafe au lait macules -Fibrous dysplasia of bone -Premature vaginal bleeding and breast develop

Patient has hypertension and diabetes. They now have peripheral edema. What medication are they on?

CCB--amlodipine

COPD patient comes in with an exacerbation (productive cough, wheezing, dyspnoea). He gets steroids, bronchodilators, oxygen, and lorazepam for agitation. 30 min later, he's lethargic and confused, then he experiences a tonic clonic seizure. Explain what happened? So what contributed to these neurologic symptoms?

COPD got oxygen, probably wasn't monitored. O2 sat for COPD needs to be between 88-92/3%. If not, they go into CO2 retention -Normally, poorly ventilated, hypoxic areas of lung will vasoconstrict, preventing blood from going there. -If there's inspired oxygen, there's a loss of that vasoconstriction, which causes more perfusion to areas where there is poor exchange. -This leads to inc CO2 Also, COPD rely on hypoxia for resp drive. If there's excess CO2, that causes vasodilation in the brain, which can lead to seizure. Contributing factor: CO2 retention

Patient has blunt trauma from a fall from height. He has left upper quadrant pain, some guarding, some right shoulder pain, pain on deep inspiration. X ray is normal. There is no free fluid on FAST scan. Next step?

CT scan

Patient has gastric adenocarcinoma. Next step in management?

CT scan for staging I chose H. pylori testing, but no--need staging as it's more important at this stage. Erradication would improve outcomes, but you need to stage with CT

Patient has ACh receptor antibodies. What do you do next?

CT scan of the chest for thymoma

Patient is septic. She gets a central venous catheter placed and it's there--all good. Next step in management?

CXR to confirm positioning

Name three hyperpigmented lesions and their characteristics

Cafe au lait spots -Flat, hyperpigmented, multiple -Neurofibromatosis or McCune Albright Congenital dermal melanocytosis -Blue-grey patches -African amaericans and asians Congenital melanocytic nevus -Melanocyte proliferation -Increased hair follicles

26 yo patient has blood in the urine. He has colicky pain that radiates to groin. CT non contrast confirms stone. This has never happened before Likely comp of stone?

Calcium oxalate. Usually in association with some kind of malabsorption (of fat), resulting in more absorption of oxalate, leading to more Ca precipitating with oxalate

The association between OCP and breast cancer is 2 (for example). Then when stratified according to family history, it is: Pos: 3 Neg: 1.5 What is this called?

Called effect modifier. Not confounding bias because the association is still significant.

Patient is starting trastuzumab. What do you need to test before beginning treatment? Why?

Cardiac function (echocardiography) Why: bc it can cause cardiotoxicity, especially with doxorubicin. Stop if this happens because the damage is reversible

Patient has obvious hyperthyroidism. What are the effects of T3 on cardiac myocytes and blood vessels?

Cardiac myocytes -Increases contractility -Increases rate -Can cause arrythmia/atrial fibrillation -Results in increased pulse pressure -Results in systolic hypertension Blood vessels: -Actually causes a decrease in systemic vascular resistance. The hypertension is a result of the cardiac myocyte increase contractility -NB: hypothyroidism is hypertensive also because low thyroid causes vessel constriction

23 yo has MVA. BP is 80/40, pulse is 120, neck veins are distended, there are bruises on the aterior chest and upper abdomen, CXR shows small left sided pleural effusion and normal cardiac contours. What's the likely diagnosis?

Cardiac tamponade Why: -Can be quick onset so there's no inc in cardio-thoracic ratio on CXR ---Bleeding into stiff pericardium with no elasticity -Distended neck veins and hypotension

Patient has hypertension, diabetes, and end stage renal failure requiring dialysis. He has had line infections and has a carotid bruit. What is the most likely cause of death in this patient?

Cardiovascular disease Dialysis patients are at high risk for cardiovascular-related death, and this is the most common cause of death in these patients. -Higher risk of atherosclerosis -Kidney things affect vascular things and cause increased risk of cardiovascular disease

59 yo woman is hospitalized for GI bleed. She has COPD. Her Hb is stabilized. Urine output is low. On the fourth day, she becomes lethargic and difficult to rouse. Pulse Ox: 93% on 6 L O2 She has pH of 7.15 Pa CO2 60 mmHg She has normal anion gap What is the cause of her lethargy?

Cause: CO2 retention secondary to hypoventilation "CO2 narcosis" which occurs when PaCO2 > 60 mmhg. This is acute-on-chronic (not chronic) hypercarbia. You differentiate based on bicarb and associated acidosis (chronic CO2 hypercarbia would have normal pH and high bicarb; this px has low, acidic pH and low bicarb)

Patient had chemo and radiation for cervical cancer. Now she has dyspareunia and vaginal irritation that has worsened. She tried lubricants but they haven't worked. Vulvar skin shows shrinkage of clitoral tissue. Vaginal mucosa appears pale and thin. Cause of this? Contrast?

Cause: atrophic vaginitis Regressed vulvar tissue, reduced introitus diameter, dry vagina with decreased rugae Key: the inside of the vagina itself is pale and thin. Contrast: lichen sclerosis is sandpaper like skin of external structures (labia minora and majora) and it doesn't affect the vagina

Patient gets blood transfusions. Now has hypocalcemia Cause?

Cause: citrate used in the blood for anticoagulation during storage. The citrate can be there still The citrate can chelate calcium when transfused. So chelation by substance in transfused blood caused hypocalcemia

Woman with bipolar disorder is investigated for infertility. Periods have been irregular. She also has breast tenderness. Likely cause of infertility? Likely medication involved?

Cause: hyper prolactinemia Medication: 2nd gen antipsychotic: risperidone Not lithium because she has breast tenderness, which is more indicative of galactorrhea

70 yo patient is brought to doctor because of fatigue. He hasn't been to a doctor in 20 years. His Cr is high and his BUN is high. Ultrasound shows bilateral small kidneys and no evidence of hydronephrosis. Kidney biopsy shows intimal thickening, and luminal narrowing of renal arterioles. There is evidence of sclerosis. What is the most likely cause of these findings?

Cause: hypertension ("benign nephrosclerosis secondary to hypertension) Hypertension: -Damages the renal vasculature -More damage, more decrease in renal blood flow and GFR Damage: 1) Nephrosclerosis: hypertrophy and intimal medial fibrosis of renal arterioles 2) Glomerulosclerosis: loss of glomerular capillary surface area with glomerular peritubular fibrosis--eventually the kidneys shrink in size

17 yo boy is in a MCV. He breaks a lot of bones and gets rhabdo. Four weeks later, he's still recovering and can't move because of his injuries. Now his calcium is high, albumin is low, parathyroid is normal, 1,25 OH Vit D is normal. Cause of hypercalcemia?

Cause: immobilization NB: hypoalbuminemia would make Ca seem lower (bc Ca is normally bound to albumin) so that wouldn't make sense at all. NB: rhabdo causes hypOcalcemia because inc release of phosphate causes precipitation with Ca.

Patient has had longstanding hypertension that is not being well controlled on metoprolol. Amlodipine is added. On physical exam, she has +3 bilateral pitting edema in the lower limbs. No JVP, no ascites or hypoalbuminemia, and normal creatine. Cause of edema?

Cause: medication Amlodipine causes dilation of arterioles, which increases extravasation of fluid from vessels

Young patient has had a viral like illness which rhinorrhea and high temperature. His parents have been trying to manage with over the counter medications. Now their child is hallucinating. Cause?

Cause: medication side effect. Antihistamines (diphenhydramine) Alpha agonists (phenylephrine, pseudoephrine) Dextomethorphan (antitrussant)

Patient has HTN, general headaches, and general fatigue. He's on lisinopril and low dose thiazide. Labs: K: low, Cr: normal, Plasma renin activity: undetectable. Cause of lab abnormalities?

Cause: primary hyperaldosteronism (aldosterone secreting tumor or bilateral adrenal hyperplasia). I thought it was side effect of thiazide. It can cause hypoK, but there would be a compensatory increase in plasma renin activity. Plasma renin activity is low in PH because of feedback inhibition of renin by lots of aldosterone secretion

Patient has pre-eclampsia and is given magnesium sulfate for delivery. She has elevated serum creatinine and aminotransferases. She has 4+ proteinuria. Bloods: Ca: low, Glucose: high, Mg: high What is the cause of her hypermagnesemia?

Cause: renal insufficiency Mg is excreted by the kidney, so deficiency will put the px at greater risk of mg toxicity. I was thinking calcium, but hyperMg is the cause of hypoCa (bc high Mg has negative feedback inhibition on PTH, decreasing its release and causing hypocalcemia)

Patient has pulsus paradoxus. Causes? Pathophysiology?

Causes: -Cardiac tamponate / pericardial effusion -Asthma -COPD In asthma and COPD, it happens because when intrathoracic pressure decreases with inspiration, there is more pooling blood in pulmonary venous circulation. This decreases venous return and causes pulsus paradoxus

Patient had hysterectomy two months ago. Now she has a right leg that is red, erythematous. She has a high temp, high pulse, and raised white cell count. Diagnosis?

Cellulitis

Patient is going for cervical coinization. Risks of procedure?

Cervical stenosis Cervical insufficiency Preterm birth Preterm prlabour rupture of membranes Second trimerster preg loss

On physical exam, patient has subcutaneous emphesyma over the anterior chest. Next step?

Chest X-ray Subcutaneous emphesyma can be secondary to severe cough. Same mechanism as pneumothorax. Must get CXR to rule out pneumothorax

What do you use to compare two proportions, or categories of outcomes. (ex: number of people with high CRP on HRT in order to see if there is an association between HRT and CRP)

Chi-squared test. NB: two sample T test is to compare two means

What is the most common cause of pneumonia in children? What about in adults? What age does the switch occur?

Children: staph aureus Adults: psudomonas Switch: at age 20

Patient has decreased libido, gynecomastia, erectile dysfunction, fatigue, anorexia, weight loss, normal TSH, and low T3 T4 Likely diagnosis?

Chronic liver disease (gonadal injury, hypothalamic dysfunction, cirrhosis leading to inc estradiol. Liver also produces T binding proteins, so with liver function low, the overall T3 T4 will look low, but free will be normal, thus normal TSH

84 yo lady has progressive confusion. She has hx of dementia, but she's been getting progressively weaker and has fallen down on several occasions. She has been confused and sleepy, and has developed a headache. she's rousable but doesn't rec her care giver. There's weakness on the left, and upgoing plantars on the left. Diagnosis?

Chronic subdural hematoma Key: fall Internal capsule infarction would not present with the confusion

Woman has squamous cell carcinoma of the vagina. What is the greatest risk factor?

Cigarette smoking (tobacco use) HPV infection Cigarette smoking decreases the immune response, allowing HPV to run wild and cause carcinoma

Patient has recently had unpredictable mood swings. He's irritable and paranoid and at other times withdrawn. He got in a fight at work. He thinks his colleagues are hacking into his computer. He has fast speech, restless, tremulous, diaphoretic, and hypervigilant. He has pressured speech, thinks his business plan is genius, has hypertension and dilated pupils. What is the explanation for his behavior?

Cocaine abuse

24 yo girl wakes up and feels so depressed that she wants to die. She has no suicidal ideation but describes feeling depressed and unable to concentrate. For the last three nights, she was partying with "alcohol and other stuff" where she was talkative and in a good mood. She's had brief periods of depression over the last months lasting a few days with low energy, hypersomnolence, vivid dreams, and increased appetite. Diagnosis?

Cocaine withdrawal -Depression symptoms with thoughts of suicide -Hyperphagia -Dreams -Hypersomnolence

61 yo lady has headaches that occur 2-3 times a week. They are like "a band around her head that is constantly tightening." No visual disturbance, dizziness, vomiting, weakness, or other syx. She has poor sleep and loss of appetite. She moved in with her daughter 5 months ago bc of financial burden. She doesn't go out to meet her friends because of anxiety of driving. What are you concerned about? What's the next step?

Concerned: depression (tension headaches can be a manifestation of depression) Next: ask questions in hx about symptoms of depression

Mother has graves disease. 6 months before pregnancy, she had surgical resection. During the pregnancy, she became hypothyroid and needed more levothyroxine. Infant's weight is 4lb 9oz at birth, temp is 99, pulse is 190. Baby is irritable but consolable. and the infant has warm, flushed skin. What condition is the baby in? What is the cause of this?

Condition: hyperthyroid Cause: maternal TSH receptor antibodies crossing the placenta Levothyroxine can't cross the placenta in large amounts, neither can thyroid hormone. So basically without the presence of TSH receptor antibodies, baby would be self-dependent to produce TSH and T4

Week old boy has vomiting, poor feeding, hypotension, tachycardia, sunken eyes, depressed anterior fontanelle, dry mucus membranes, decreased skin turgor. Sodium: low, K: high, BUN: high Diagnosis? What would be high?

Congenital adrenal hyperplasia due to 21 hydroxylase deficiency, causing hypocortisolism High: 17-hydroxyprogesterone

What are contraindications to administering a vaccine? If someone has a fever after a vaccine, should they get acetaminophen before?

Contraindications: -Anaphylaxis -Uncontrolled epilepsy, infantile spasms -Encephalopathy within a week of previous vaccine dose Acetaminophen before? No. It doesn't prevent febrile seizures and it could dampen the immune response

Patient gets a cat bite. Treatment?

Copious irrigation *Antibiotic prophylaxis (amoxicillin clavulanate)* -Need to protect against pasturella Tetanus booster as indicated Don't close

Patient has vasovagal syncope. Best step in management?

Counterpressure maneuver education (cross legs, flex muscles to increase venous return and prevent syncope)

Patient has a big circular thing on his kidney. How do you differentiate a cyst from a mass? What do you do if it's a cyst?

Cyst: thin, smooth, regular wall, no septae, homogenous, no contrast. Malignant mass: irregular, thick, multiple septate, heterogeneous, contrast enhancement, possible symptoms. Cyst: reassurance--don't need to do anything

What is d-xylose? What is it used to test? Describe the test? What if px has fat malabsorption and low d-xylose in urine. They get rifaximin and their urine d-xylose is still low? Diagnosis?

D-xylose is a monosaccharide sugar that is absorbed in the proximal small intestine--doesn't need pancreatic or brush border enzymes for absorption. Therefore, if abosption is low, the amount in the urine will be low, and that indicates a problem at the proximal SI. Giving rifaximin first can out rule the possiblity of bacterial overgrowth at the SI fermenting the d-xylose and thus causing dec in absorption. So if no change after rifaximin, it's celiac disease (causing inflammation and malabsorption at the proximal SI). NB: chronic pancreatitis would have normal d-xylose test (high d-xylose in urine), as would crohn's disease because that often affects the terminal ilium more.

30 yo female has pain over the lateral side of her wrist for the last 4 days. It's bad when she lifts her newborn from the crib. There is tenderness on the radial side of the wrist. Passive stretching of the thumb tendons when the thumb is held in flexion aggrivates the pain. She has had no recent trauma Diagnosis?

De Quarvian tenosynovitis

Patient has ascites fuild in the abdomen. How would you determine the etiology? What is the biggest key? How many neutriphils would you expect?

Determine portal hypertension related or not: Serum albumin - ascities gradient (actually serum-ascieties albumin gradient) If > 1.1 then it's portal hypertension (serum minus ascities albumen is high, meaning that hydrostatic pressure is forcing fluid out) If < 1.1 then it's no portal hypertension, and the etiology is infection, TB, malignancy, pancreatitis, nephrotic syndrome

Patient is from mexico. He recently developed foamy sputum with a significant amount of blood (bright red). He hasn't had any coughing spells. There are expiratory wheezes on the right side. X-ray shows dense opacity in the right upper lobe Diagnosis? He coughs more blood (600 ml). Now has BP of 105/61 and pulse of 122. He is intubated and Fresh blood fills the trach tube Next step in management?

Diagnosis: TB Next: bronchoscopy because it's massive bleeding

Patient has a seizure. He was on valproic acid but stopped it because he didn't have a seizure for 9 years. BP is 105/68, pulse is 96, resp 18, pulse ox 99% Serum chemistry shows an anion gap metabolic acidosis Diagnosis? Next step in management?

Diagnosis: postictal lactic acidosis Observe and repeat lab tests after 2 hours Tonic clonic seizure can raise lactate significatly due to skeletal muscle hypoxia. The post ictal lactic acidosis is transient and resolves within 90 min.

Woman has failure to conceive at age 35. She still has cycles, but nothing else of note on hx or exam. Likely reason for not conceiving?

Diminished ovarian reserve They can still have periods (regular menstrual cycles) but decreased oocyte number and quality

Patient has an MI. Previously he was on lisinopril. On discharge his triglycerides are high (465). He doesn't exercise and drinks a lot of alcohol. In addition to high dose statin, what should he do?

Do: take statin (high dose) Stop alcohol Exercise, lose weight

Patient is in heart failure. She gets a drug that binds to Beta 1 receptors. What is the mech by which this med improves her condition?

Dobutamine Increases contractility (positive inotropy by increasing cAMP production in cardiac myocytes, leading to enhanced ca mediated binding of actin-myosin complex to troponin C It also increases heart rate The increased contractility *decreases end systolic volume*

Patient has pituitary adenoma causing hyperprolactinemia No visual field deficit. Management?

Dopamine agonists -Cabergoline -Bromocriptine This can lower prolactin levels and decrease tumor size. Then if still refractory of enlarging and causing mass effect, transphenoidal surgery

Male patient has primary syphillis. What treatment should he receive?

Doxycycline Don't do de-sensitization--only in pregnant women because doxycycline is contraindicated

Patient has post partum hemorrhage and needs blood transfusion. As it goes in, she gets flank pain, temperature, inc pulse, inc respirations. The transfusion is stopped and she gets bleeding from venipuncture site. Diagnosis? Cause?

Dx: ABO incompatibility reaction Cause: acute hemolytic reaction to ABO incompatibility

Patient has a diastolic murmur heard at the left sternal border. Diagnosis? What would be associated?

Dx: AR Associated: bounding pulse

6 yo girl has joint pain. A week ago, she had a sore throat that resolved on its own. Pain started a week ago. It was first in her knees. That has resolved. Now it's in her ankles and wrists. She has a non-puritic pink rash. She has elevated CRP and ESR. Likely diagnosis?

Dx: Acute rheumatic fever NOT juvenille idiopathic arthritis because that has to be going on for 6 weeks for diagnosis. Also it's less likely to be migratory

Patient has schizophrenia. He recently had his antipsychotic dosage increased. It decreased his voices, but he became more agitated. It was increased again, and his agitation didn't improve. He has started walking around the neighborhood excessively. Diagnosis? Next step?

Dx: Akanthisia--kind of restlessness (side effect of antipsychotic medication) Next: decrease antipsychotic and prescribe a dose of a beta blocker. Other alternatives to prescribe: -Benztropine (anticholinergic) -Benzodiazapine like lorazapam

Patient has hemolytic anemia. There are RBCs that are spherical with central pallor. Direct Coombs test is positive. Diagnosis?

Dx: Autoimmune hemolytic anemia Because Coombs test positive. I put hereditery spherocytosis--obviously not because Coombs test positive. HS would be Coombs negative

Patient has recurrent oral ulcers. Recently, she had blurred vision and was diagnosed with anterior uveitis. She has recurrent genital lesions. She has scattered, hyperpigmented skin lesions on her legs. Diagnosis?

Dx: Behcet's disease Recurrent amphmous ulcers Genital ulcers Anterior uveitis Erythema nodosum

Patient gets a technitium-99-labeled perfusion scan of the heart (I thought they were lungs) that shows a little bit of decreased tracer uptake. Likely diagnosis? Management?

Dx: CAD Mx: start on aspirin/anti platelet agent

52 hour old patient has vomiting and abdominal distension. She has not passed meiconium. She has billious emesis, abdomen is tense and distended. There is no stool in the rectal vault and there is normal tone. There are multiple loops of dilated bowel with paucity of air in the large intestine and rectum. There is free air above the liver on X-ray. Viscus meiconium is irrigated from the ileum and colon. The rest of the colon is diffusely narrow. Diagnosis? Complications in the future?

Dx: CF Complications: chronic rhinosinusitis

HIV patient has CD4 cound <50. He has intermittient bloody diarrhea, weight loss, 100 deg temperature. Diagnosis? What else would you check for?

Dx: CMV colitis (bloody = CMV; cryptosporidium is watery) Check for CMV retinitis

55 yo patient has 3 months of night sweats. 11 lb unintentional weight loss. Spleen tip is palpable. CBC with diff shows: High leukocytes, low-ish neutrophils, high basophils, high esinophils, high myelocytes. Diagnosis? Confirmation?

Dx: Chronic myelocytic leukemia Confirm: low leukocyte alkaline phosphatase score Contrast: leukamoid reaction has high leukocyte alkaline phosphatase score because the cells are active

Patient has weight gain, proximal muscle weakness, irregular periods, dark hair on lower abdomen, and elevated glucose. Diagnosis? Steps to confirm?

Dx: Cushing's syndrome Steps: Initial: -late night salivary cortisol -24 hour urine free cortisol -overnight low dose dexamethasone suppression test Next: -after hypercortisolism is confirmed -serum ATCH to see if it's primary (from adrenals) or secondary (from pituitary)

Patient is a gardener and was recently at a barbecue. Now he has an intensely pruitic lesion on his right foot. There is a vesicle and the surrounding streak-like erythema. Diagnosis? What happened to cause this?

Dx: Cutaneous larva migrans (hookwarm larvae from dog or cat) Happened: walking barefoot on contaminated sand or soil. The larvae get into skin, but can't penetrate, so just cause cutaneous symptoms. Can give antihelminths (ivermectin) to resolve faster

Baby has abnormal inguinal skin folds and apparent leg length discrepancy. Likely diagnosis? Management?

Dx: DDH Mx: US hips first X-ray after ossification after age 4 months

Patient has surgery and then later has unilateral calf swelling and erythema. It is painful and pain is worsened on dorsiflexion. Patient also has end stage renal disease Diagnosis? Treatment?

Dx: DVT Tx: UNfractionated heparin and bridge to warfarin Can't use LMWH in end stage renal disease Provoked DVT needs at least 3 months of anticoagulation. Warfarin is preferred long term anticoag, but need unfractionated heparin bridge in this case

Patient has cleft palate, flat nasal bridge, triphalangeal thumbs, and macrocytic anemia. Diagnosis? Etiology:

Dx: Diamond blackfan anemia (tri-diamond = diamond blackfan anemia) Congenital defect of erythroid progenitor cells, which causes apoptosis of RBCs and thus profound anemia They have other abnormalities, like short stature, cleft palate, webbed neck Presents with pallor and poor feeding due to anemia Heart rate (CO) increases to compensate for anemia NB: fanconi anemia is pancytopenia

4 yo boy has difficult walking after previously being fine Gower's sign positive Diagnosis? What is the best way to confirm?

Dx: Duchenne muscular dystrophy Confirm: genetic testing Biopsy can only support

Patient has fever, malaise, exudative pharyngitis, hepatosplenomegaly, generalized (bilateral) lymphadenopathy. There is leukopenia (white cells are low), elevated bilirubin, high reticulocytes, and low platelets Diagnosis?

Dx: EBV Yes, it can have leukoPENIA. It can cause cold IgM cold-agglutinin autoantibodies that can cause autoimmune hemolytic anemia. Also, abs can cross react with platelets.

18 month old boy has bad eczema. Now he has fever and facial rash for 2 days. He has numberous painful, clear vesicles over erythematous skin on both cheeks. He has a few scattered lesions with overlying dark red crusting. Lymphadenopathy is present. Diagnosis? Organism?

Dx: Eczema herpeticum Org: herpes simplex virus (1) Key: the hemorrhagic crusts (dark red crusting) Punched out erosions Painful Lymphadenopathy Fever

Patient gets an infection and receives trimethoprim sulfamethoxasole. He then develops dark urine. On blood lab, he has low Hb, high bilirubin (indirect), high LDH, decreased haptoglobin. Likely diagnosis? Seen on blood film? An enzyme is tested for activity in the blood and it is normal. Why?

Dx: G6PD def Blood film: bite cells Normal because the G6PD enzyme assay is not accurate in an acute episode. This is because acutely the deficient RBCs are lysed and the body produces more RBCs that do have the enzyme, so it's falsely normal. You have to wait 3 months before retesting

56 yo woman comes with asthma symptoms. She has nighttime cough and wheezing that has increased. She needs her inhaler right after meals. She has a sore throat recently and hoarseness in the morning that clears. She is obese. Diagnosis? Management?

Dx: GERD on top of asthma, exacerbating the asthma Mx: esomeprazole (PPI) -- will improve symptoms

33 yo patient has abd discomfort, nausea, 2 episodes of vomiting containing small amount of blood over the past couple hours. No prior medical problems. Last night, he had alcohol and cocaine, and woke up with a headache so he took aspirin. He has mild epigastric tenderness. Diagnosis?

Dx: Gastric Mucosal Erosion Cocaine can cause vasospasm/vasoconstriction which can decrease blood flow to mucosa. Then alcohol and aspirin can damage the mucosa. This can predispose to erosion and bleeding

Patient has weakness and tingling in his legs. Recently he had an upper respiratory tract illness. He also has tachycardia and orthostatic hypotension. He has absent knee and ankle reflexes. Diagnosis? What would CSF analysis show? Treatment?

Dx: Guillain-Barre syndrome CSF: high protein, normal WCC, normal glucose, normal RBC Treatment: IVIG or plasmapheresis

60 yo patient has recurrent infections, mildly raised lymphocyte count, splenomegaly, and smear shows cells with cytoplasmic projections. Diagnosis?

Dx: Hairy cell leukemia

Patient has a condition where she gets sent home one heparin. A week later, her platelets are low, but INR is the same. Diagnosis? Complication?

Dx: Heparin Induced Thrombocytopenia Comp: thrombocytopenia and Thrombosis (venous and arterial) NB: no consumption of clotting factors, so risk of hemarthrosis

Patient has hyperthyroid symptoms and a nodule. No opthalmopathy Diagnosis? What complications could this patient experience?

Dx: Hyperthyroidism -- toxic adenoma Complications: Increased thyroid hormone causes increased bone turnover. This can lead to osteoporosis and fractures It can also lead to hypercalcemia and hypercalciuria

Patient has a 2 week history of fever and generalized weakness. He's been hospitalized for pyelonephritis. He recently underwent cytoscopy for evaluation of persistient dysuria. He has a new holosystolic murmur at the apex. He has erythematous lesions at the fingertips. Diagnosis? Likely organism? Other organisms and their associations?

Dx: IE Org: enterococcus Enterococcus for bladder manipulation Viridans group strep for dental procedures Strep gallolyticus (bovis) for colon cancer or IBD Staph epi: prosthetic valves, intravascular catheters, implanted devices Staph aureus: prosthetic, intravascular catheters, implanted devices, IVDU

Patient had a URI 5 days ago. Now he has gross hematuria. There's no skin rash. There are RBC casts. There is normal level of C3 and C4. Diagnosis?

Dx: IgA nephropathy Contrast: Post strep glomerulonephritis occurs 10-14 days after infection. Also, it would have decreased complement

Patient has heavy smoking history. Now he has weakness of his extremities (3/5 in proximal muscles groups) violaceous papules involving the dorsum of his fingers. Reflexes are +2 bilaterally. X-ray shows a mass in the right lower lobe. Diagnosis? Pathophysiology?

Dx: Lung cancer with paraneoplastic syndrome: dermatomyositis Pathophys: immune mediated damage to muscle fibers

54 yo man is woken up in the middle of the night with substernal chest discomfort. He describes it as a burning sensation. He has left sided neck pain. He feels sweaty and short of breath. This has never happened before. He has T2DM, hypertension, and smoking history. Diagnosis? What physical finding might you associate with this condition?

Dx: MI (pain, radiating to neck, diaphoresis, SOB) Associate: S4--you can get it in the acute phase of an MI

Patient has mid sternal chest pain. Then he gets dizzy and becomes unresponsive. He gets resuscitated and regains consciousness In the ED, his ECG shows sinus rhythm, ventricular premature complexes, and ST segment elevation in V1-V3 Diagnosis? Mechanism responsible for syncopal episode?

Dx: MI (septal-anterior) Mech: ischemia leading to reentrant ventricular arrhythmias (eg ventricular fib, vent premature beats, ventricular tachy)

Patient has an acute MI. He has a II/VI holosystolic murmur at the apex. He has bilateral crackles in the lung bases. Diagnosis? What is likely to be elevated? What is not elevated?

Dx: MI with mitral valve prolapse Elevated: Left ventricular pressure Not: LA size, LV size, or compliance for either (that's because it takes more time for size and compliance to be affected)

Patient has trigeminal neuralgia. Later he gets spastic paralysis of the lower limbs. He also has decreased vibratory sensation and positional sensation in the left upper extremity. Likely diagnosis? What would lumbar puncture show?

Dx: MS LP: oligoclonal bands. Obviously not GBS because that would have ascending paralysis and decreased reflexes (not spastic)

Young boy has progressive muscle weakness, difficulty swallowing, ptosis, temporal wasting, thin cheeks, emaciated extremities, atrophy of thenar and hypothenar eminences. When stimulated, the muscles take a long time to relax. He also has small testes Diagnosis? Inheritance pattern?

Dx: Myotonic dystrophy type 1 Inheritance pattern: autosomal dominant

46 yo man comes to hx bc of tonic clonic seizure. No previous medical problems. Recently spent 3 months on a bolivian pig farm. MRI shows several intraparenchymal 5-10 mm cystic lesions with surrounding edema. There is no mass effect of midline shift. HIV test is negative. Diagnosis? Cause of condition?

Dx: Neurocysticercosis Cause: tapeworm eggs (tinea solium) in contaminated food or water

Patient has had a bad nose bleed one year ago and comes to the ED for another episode. He also has ruby colored papules on his lips that blanche. Digital clubbing is present. He has high hematocrit but normal everything else. Diagnosis? Cause of high hematocrit?

Dx: Osler-Weber-Rendu syndrome (many AV malformations, presents with bleeding often) Cause: AV malformations in the lung, resulting in decreased oxygen of blood, causing polycythemia

25 year old girl has hair loss and receding hairline. She has oligoovulation. She is obese. She has bad facial and back acne. Likely diagnosis? What further test should she receive?

Dx: PCOS Tests: oral glucose tolerance test (for diabetes) Fasting lipids US ovaries Risk of obstructive sleep apnoea Risk of nonalcoholic steatohepatitis Risk of endometrial hyperplasia/carcionma

Patient is agitated and combative, high temp, high BP, high pulse. He has ataxia, nystagmus, and muscle rigidity. Diagnosis? Management?

Dx: PCP intoxication Mx: Lorazepam Ineffective: haloperidol Ineffective: propofol

Patient has acute onset pleuritic chest pain and hemoptysis and tachycardia. She has HIV and CD4 count of 350. Recent PPD showed 2 mm induration. She recently had diarrhea. CT shows wedge shaped infarction. Diagnosis?

Dx: PE TB would not we wedge shaped. CD4 count that high would be less risky for TB. Also the 2mm induration is a negative test. Risk factors for PE: HIV and dehydration

Patient has operation for strangulated inguinal hernia. Post op day 3, he falls while getting out of bed. He's responsive but has slurred speech. BP is 89/50, pulse is 122, resp are 24/min. He has decreased bibasilar lung sounds and distended neck veins. ECG shows new onset RBB block with non specific ST and T wave changes. Fluids are unsuccessful. Pupils dilate, pulse drops to 45, and he becomes unresponsive. He dies. Diagnosis? Cause of death? Other way of management?

Dx: PE Cause: massive PE -Hypotension -Right heart strain -Syncope (massive PE) -JVD -New RBBB (sign of right heart stain) Because R heart can't get blood to get oxygenated, the L heart decreases its output, leading to ischemia of the brain and rest of the body, including the heart, leading to bradycardia and cardiogenic shock Other: thrombolysis is indicated in massive PE Surgery within preceeding 10 days is contraindication

Patient is found at home unconscious with weak pulse. he has hypertension, hyperlipidemia, T2DM, prostate cancer. BP is 80/40, Pulse is 120, patchy rales are present, 2/6 systolic murmur is heard at apex. Upper and lower extremities are cold and clammy. Nonhealing ulcer on foot. Right atrial pressure is 18 (UL 8) Pulm art pressure is elevated (43/21) Pulm cap wedge pressure is 9 (normal 6-12) Diagnosis?

Dx: PE There is severe build up on right side (intrinsic pulm artery problem) There is normal LV function (so LCA / MI problem) I guess ignore the other stuff

Patient has bone pain in the spine that does not improve, headaches, unilateral hearing loss, and femoral bowing. Diagnosis? Cause of the condition?

Dx: Paget's Disease of the Bone Cause: osteoclast dysfunction

13 yo boy has two weeks of rhinorrhea followed by dry cough. Cough is getting worse and he has vomited on 2 occasions. He completed his primary immunization series at age 4, but has received no vaccinations since. He has nasal congestion and subconjunctival hemorrhages. He has lymphocytosis. Diagnosis? How do you confirm?

Dx: Pertussis Confirm: Pertussis PCR testing NB: vaccination doesn't make you 100% immune. You also need a booster at age 11-18. The series is 5 of DTap and booster Tdap

Patient has abdominal pain and persistient vomiting. The pain is crampy and the vomit is green in color. Normal bowel movement was 3 days ago, and no diarrhea. He has hyperactive bowel sounds. Percussion reveals tympany. He is dehydrated. Diagnosis? What is likely in his history?

Dx: SBO History: surgery resulting in adhesions

African american patient has diffuse joint pain, rash, low-range proteinuria. Creatinine is 1.3. Renal biopsy shows focal peripheral glomerulonephritis She has pancytopenia. Diagnosis? Cause of pancytopenia?

Dx: SLE Cause: peripheral destruction

Patient has PE. She has a rash on her face that worsens in the sun. She has had 2 previous miscarriages. Diagnosis? What else is likely to be found on workup? Why?

Dx: SLE Else: prolonged APTT Why: because antiphospholipid syndrome has lupus anticoagulant which paradoxically prolongs APTT. NB: antibodies: antiphospholipid antibody: -Lupus anticoagulant -Anticardiolipan -Beta 2 glycoprotein 1 antibody

Patient has joint pain, rash that gets worse with sun exposure, occasional sharp chest pain. Likely diagnosis? Next investigation?

Dx: SLE Next: anti-nuclear antibodies These are more sensitive. Then you can proceed with anti-double stranded DNA antibodies or anti-smith antibodies

Patient we presume has sickle cell disease. Now he has HR 140, BP 80/60, and poorly localized abdominal pain. Diagnosis? What could prevent this?

Dx: Sepsis--infection with encapsulated org Prevent: vaccine with conjugate capsular polysaccharide

Patient is in swim camp. On her trunk, there are spots of hypopigmentation and hyperpigmentation. It's mildly itchy. Diagnosis? Management?

Dx: Tinea versicolor Mx: confirm: KOH prep showing "spaghetti and meatballs" Treat: topical ketokonazole, selenium sulfide, terbinafine

Patient is born with webbed neck, swelling of extremities, dysplastic nails, and she has a horseshoe kidney. Diagnosis? Cause of edema? What kind of pitting?

Dx: Turner's syndrome Cause of edema: lymphatic network dysgenesis (occurs in over half of TS patients). If severe, can result in cystic hygroma Edema is generally non-pitting due to the high protein content in the interstitial fluid

Patient just started sexual activity and has burning on urination. Culture grows E. coli. Diagnosis? Cause?

Dx: UTI cyctitis Cause: ascending infection (from vaginal introitus ascend the urethra into the bladder)

Patient had a recent viral infection 4 weeks ago. Now he has a 3 week history of a hacking, dry cough. He also has the sensation of liquid dripping into the back of the throat. He is healthy otherwise. Diagnosis? Management?

Dx: Upper Airway Cough Syndrome (UACS) aka post nasal drip Mx: emperic first generation antihistamine (H1 blocker--chlorpheniramine) If still not improving, consider other etiologies (GERD, asthma), and then order CXR

45 yo patient has shortness of breath, cough, and hemoptysis for 2 days. For 2 months, he's had fevers, malaise, and weight loss. He has GERD and chronic rhinosinusitis. He works with granite and marble. He has patchy rales bilaterally. He's anemic and has elevated creatinine Imaging shows multiple bilateral lung nodules with cavitation. Bronchoscopy shows tracheal narrowing with ulceration Diagnosis?

Dx: WeCKners granulomatosis with polyangitis BC of chronic rhinosinusitis, hemoptysis, bilateral pulmonary nodules with cavitation, tracheal narrowing, and kidney involvement I thought silicosis with TB, but that wouldn't cause tracheal narrowing or kidney dysfunction

Patient has has shanking and involuntary movements. The tremor gets worse on movement. There is also hepatomegaly and elevated liver enzymes. Diagnosis?

Dx: Wilson's disease

18 month old by has blood in stool, recurrent otitis media, herpes labalis, recurrent pneumonia, eczema, petichiae, low platelets. Diagnosis? Gene mutation? What is affected by this gene mutation? Treatment?

Dx: Wiskott-Aldrich syndrome Gene mutation: X-linked recessive WAS gene Affects: cytoskeleton of leukocytes and platelets "regulates cytoskeleton remodeling in response to cell signaling" Tx: hematopoetic stem cell transplantation

Patient has many small, acne-like bumps on her forehead. Diagnosis? Treatment?

Dx: acne vulgaris Mx: topical retinoids

Patient presents with acute onset right sided headache around her eye. She vomited once since the pain began. She's seeing halos around lights. This is the first time. She is on valsartan for hypertension and tolterodine for urinary incontinence. Her right pupil is dilated, non reactive to light, the eye is erythematous and there is excessive lacrimation. Visual acuity is decreased. Diagnosis?

Dx: acute angle closure glaucoma NB: the tolterodine is an anti-muscarinic that can cause the pupil dilation and precipitate the acute angle closure glaucoma

58 yo patient has headache, nausea, vomiting, blurred vision, halo changes in visual field. She's taking medication for parkinson disease. She has left eye corneal injection with a dilated, sluggish pupil. Visual acuity is decreased in the left eye. Diagnosis? What medication could cause it?

Dx: acute angle closure glaucoma Med: anticholinergic: trihexyphenidyl

Patient has pain and redness in his left eye. He has photophobia, headache, and severe nausea. No trauma. He recently took a decongestant. Exam: non-reactive, mid-dilated pupil with conjunctival flushing. Diagnosis? Management?

Dx: acute angle closure glaucoma (decongestants can precipitate increased intraoccular pressure) Mx: tonometry for increased IOP Gonioscopy to visualise the iridocorneal angle "Pressure lowering eyedrops" "Surgical iridotomy or iridectomy"

Patient has 10 days of purulent nasal discharge. She has pain over the sinuses. Diagnosis? Likely organism?

Dx: acute bacterial sinusitis Likely: strep pneumo, then moraxella NOT staph--that is more common in chroni, which would be over 12 weeks

38 yo woman comes to office with cough of blood-tinged sputum. She had sore throat, malaise, dry cough 10 days ago. Most sx improved, but the cough got worse and she started producing yellow sputum, for past 2 days, it's been blood-tinged. No chest pain, no smoking, vaccinations UTD, stable vitals. Wheezes and crackles are heard that clear with cough. CXR: clear lung fields Likely diagnosis? Next step in management?

Dx: acute bronchitis (viral infection leading to viral-induced production of sputum. blood can be produced from inflammation and epithelial damage. Not pneumonia because negative CXR) Next: symptomatic treatment only--it resolves on its own

Patient has fever, nausea, increased urination, and lower left abdominal pain. He has a history of chronic constipation and inguinal hernia repair. Tender palpation in LLQ, Bowel sounds present, no costovertebral angle tenderness Bloods: leukocytes high. Urinalysis: 1/hpf RBCs, 1-3/hpf WBCs, no leukocyte esterase, no nitrites. Diagnosis?

Dx: acute diverticulitis Mx: CT scan with contrast to diagnose Then NPO, antibiotics I can't believe I thought it was a renal stone. Let this be a lesson--that Q was so easy

EMS first responder encounters a traumatic scene two weeks ago. Now he has insomina, nightmares, and occasional flashbacks. He returns to work and is trying to brush it off. He appears visibly restless and tense, but cooperative. Diagnosis? Management? Course? Subsequent mangement?

Dx: acute stress disorder Mx: since he doesn't want to talk about it, provide *education* on the different responses to traumatic events--normalize the acute stress response and talk about symptoms. If they become a problem, he can come get help. First line management after education would be *trauma-focused cognitive behavioral therapy* (talk in detail, support from other first responders) Course: if it persists beyond 4 weeks, it can be diagnosed as post traumatic stress disorder Mx for PTSD: SSRI

73 yo lady has dry eyes, burning discomfort like sand in the eyes. Hx of hypothyroidism. She has dry oral mucosa with dental carries. Serum antinuclear antibody assay is negative. Diagnosis? Etiology?

Dx: age-related sicca syndrome Etiology: age-related exocrine gland atrophy Contrast: Sjogren's usually occurs in younger people, and antinuclear antibodies are more frequently present.

Patient has had trouble falling asleep (insomnia and fatigue). She takes a few glasses of wine before bed to help her fall asleep. She falls asleep, but regularly wakes up at 3 am and lies awake and worries about her children. She rarely experiences anxiety during the day. She has GERD, increase MCV, AST:ALT >2. Diagnosis?

Dx: alcohol use disorder NB: it helps her fall asleep, but after the alcohol is metabolized, she wakes up. Anxiety symptoms probably due to withdrawal

Patient has 3 months of breathlessness that is now present at rest. He is a heavy alcohol drinker. There is a third heart sound. Bloods show macrocytic anemia, low platelets, and elevated AST/ALT. There is no obstructive coronary artery disease. Diagnosis? Management to reverse his condition?

Dx: alcoholic cardiomyopathy (diagnosis of exclusion) Reverse: abstinence from alcohol

Patient has 3 weeks of red, itchy eyes. He has clear discharge. He rubs his eyes frequently. There is light crusting of both eyes when he wakes up. He has a history of asthma. His sister recently had a viral illness. There is edema of the eyelids. Diagnosis? Etiology?

Dx: allergic conjunctivitis Etiology: IgE mediated hypersensitivity I thought it was viral. Key distinguishing features: -Viral is not itchy (no ocular pruitis--he was rubbing eyes) -Viral usually doesn't last more than 3 weeks. NB: allergic can cause mild crusting

Patient has small blisters with oozing yellow fluid. He was cleaning out shrubery/bushes in his yard earlier. He has erythematous plaques with eroded vesicles and small bullae between fingers. Culture grows staph negative staph Dx?

Dx: allergic contact dermatitis (toxicodendron plants--poison oak/ivy/sumac) I guess the culture was just normal skin flora?

Patient (old) has deteriorating behavior. There is memory problems, word-finding difficulty, getting lost, urinating in a waste basket. Montreal cognitive assessment score is 15/30. Diagnosis? Findings on MRI?

Dx: alzheimer disease Findings: temporal parietal lobe atrophy

65 yo with known ischemic cardiomyopathy comes to clinic with shortness of breath and nonproductive cough. Increasing furosemide does not help. Six months ago, he was hospitalized for recurrent ICD shocks and was started on antiarrythmic therapy which he is still taking. Jugular veins are flat. There are bilateral inspiratory crackles, no murmurs, no peripheral edema. CXR shows bilateral lung infiltrates involving the middle lung fields. Diagnosis? Cause of symptoms?

Dx: amiodarone induced interstitial pneumonitis Cause: antiarrythmic toxicity

Patient is in bad shape after a car accident. He has a fractured femur. he gets IV lines, foley catheter. 30 min later, he has difficulty breathing, light headedness, BP 80/50, HR 120. There are rash and wheals over the chest and abomen. Diagnosis? Cause? Contrast?

Dx: anaphylactic shock Cause: latex allergy (foley catheter containing latex) Contrast: fat embolism: confusion, seizure, focal deficit (neuro impairment), petichial rash (not urticarial). Occurs 12-24 hours following injury

Patient has cold intolerance. She cycles 2-3 hours a day. She has dry skin, brittle hair, brittle nails, bradycardia, calluses on dorsum of right hand, low BMI. Low TSH Diagnosis? Management?

Dx: anorexia nervosa Mx: nutritional replacement and cognitive behavioral therapy

Patient has been vomiting in the bathroom. She says it's because she's nervous about a presentation. She is very thin (BMI 4th percentile) but wears baggy close "to hide her stomach." She has BP 106, pulse 62, she has parotid gland enlargement. Diagnosis?

Dx: anorexia nervosa--binge/purge type Bulimia basically maintains normal body weight. Binge eating: no compensation--they just binge eat without control and probably become overweight

33 yo woman has amenorrhea of 9 months. She had a tubal ligation. Her menses were skipping every 18 months and then stopped. She is obese. LH and FSH are normal Diagnosis?

Dx: anovulation secondary to obesity. Obesity--hormones are still being produced, but progesterone is not produced as much as estrogen. It causes lack of withdrawal bleed

Patient has been on SSRI for 3 years and wants to stop. She stops and 3 days later she feels her depression is coming back. She feels weak, tired, down, and her muscles hurt. Diagnosis? Management?

Dx: antidepressant discontinuation syndrome Mx: re-start previous SSRI, then wean/taper down gradually over a few weeks

Patient has recurrent abortions. Her VRDL is positive, but FTA-ABS is negative. Likely diagnosis? Management in further pregnancies?

Dx: antiphospholipid antibody syndrome Mx: LMWH to prevent thrombosis

Patient has a fall from a 3 story building. He is in pain and points to his chest. He gets an X-ray that shows mediastinal widening Diagnosis?

Dx: aortic injury

32 yo patient has a early diastolic murmur heard loudest at the left sternal border with the patient sitting up holding his breath in expiration Diagnosis? Underlying cause (most likely?)

Dx: aortic regurg Underlying: bicuspid aortic valve

18 yo girl presents a fractured wrist. She has ambiguous genitalia from birth, but normal internal female anatomy. She has never had a menstrual cycle She has no breast development and clitoromegaly. She has normal serum electrolytes. Estradiol and estrone are indetectible FSH, LH, testosterone, and androstenedione are high. Pelvic imaging shows multiple ovarian cysts. Diagnosis?

Dx: aromatase deficiency Aromatse converst testosterone and androstenedione into estriol and estrone respectively. Therefore, there's a lot of testosterone and thus virilization. Without estriol and estrone, there's no breast development or menses. There's also dec estrogen, so inc risk of bone fractures

Patient works restoring antique furniture. He has pins and needles in his hands and feet. He has hyper and hypo pigmentation on his neck. He has hyperkeratosis and scaling on his palms and soles. He has increased sensitivity to pinprick on his fingers and toes Plantarflexion and dorsiflexion are weak. There are weak deep tendon reflexes. Diagnosis? Treatment?

Dx: arsenic poisoning -Tingling and pins and needles -Skin changes are key--not seen in lead poisoning Treatment: dimercaprol or dimercaptosuccininc acid

Patient has recurrent nasal discharge and nasal congestion. Food tastes bland. She gets wheezy when taking aspirin. Diagnosis? What else would you expect her to have?

Dx: aspirin exacerbated respiratory disease Else: nasal polyp

Patient is post op (second post op night). He is tachypnoeic, smoker, decreased breath sounds at the right lung base. There is opacity at the right lung base. Diagnosis? ABG? How to prevent?

Dx: atelectasis ABG: low O2 (because lack of ventilation), low CO2 (bc tachypnoeic and blowing off CO2), so high pH. Prevent: deep breathing exercises

Patient has down syndrome. New she is dizzy, has urinary incontinence, is hypotonic, but hyperreflexic with a positive babinski reflex. Her gait is ataxic. What's the diagnosis?

Dx: atlanto-axial instability. -Hyperreflexia -Vertibrobasilar symptoms (vertigo, dizziness, diplopia) -Urinary incontinence

Patient presents to the ED with L sided weakness. She has fatigue, low grade fever, and occasional palpitations over the last 3 months. She has lost weight. She has S1 and S2 with mid diastolic rumble at the apex. Transthoracic echo show a mass in the left atrium Diagnosis?

Dx: atrial myxoma NB: it can cause low grade fever (systemic symptoms), raynoud's phenomenon If it were infective endocarditis, the symptoms would not go on for that long (3 months) without progression

Patient has early morning headaches. He has high blood pressure (180/105). His father died suddenly in his 50's. He has bilateral, non-tender abdominal masses palpated on examination. Hb is 15.2, creatinine is 0.8. Likely diagnosis? Next step in evaluation?

Dx: autosomal dominant polycystic kidney disease Next: abdominal ultrasound (visualize polycystic kidneys)

Patient has fever, chills, and drenching sweat, fatigue, malaise, and dark urine. He has had a splenectomy in the past. He drinks alcohol socially. He was recently in the New England woods and saw two tics on his leg. He has scleral icterus, palpable liver edge, anemia, thrombocytopenia, raised bilirubin, deranged LFTs, and raised LDH. Diagnosis? What will give you the diagnosis?

Dx: babesia causing babesiosis Confirm: blood smear -Intraerythrocytic rings (maltese cross)

Patient has sickle cell disease. She is febrile but has no pain anywhere. Diagnosis? Most likely organism? Contrast?

Dx: bacteriema (sepsis) Most likely: -1: strep pneumoniae (encapsulated) -2: hemophilus influenza -3: nisseria meningitidis Contrast: Osteomyelitis in sickle cells disease patients can be caused by salmonella or staph aureus. But that would present with bone pain, etc. So it's unlikely here.

26 yo gymnast comes with an egg sized, mobile, well circumscribed, soft mass at the labia majora. One year ago, she had a vulvar contusion. Diagnosis? Management?

Dx: bartholin duct cyst Her contusion was one year ago--duh Mx: observation--she's asymptomatic and they usually spontaneously drain

4 month old patient has macroglossia, and right upper and lower exremeties have a larger circumference than left. Diagnosis? What is the next step?

Dx: beckwith weidman syndrome Next: abdominal US because they are at higher risk of cancers in the abdomen -Wilms tumor (nephroblastoma) -Hepatoblastoma NB: they also have abdominal wall defects like omphalocele

27 yo patient had headache. She has nausea and vomiting but no visual complaints. She is obese. There are no meningeal signs. She has papilledema. MRI brain is normal. Diagnosis? Most severe/and likely complication?

Dx: benign intracranial hypertension (pseudotumor cerbri) Complication: blindness

76 yo man has disruptive behavior. At night, he was normal. Then took his before-bed meds, and returned an hour later agitated, irritated, and confused. He was beligerant. he's on terazosin and alprazolam. Everything else is normal. Likely diagnosis? Next step in management?

Dx: benzo intoxication As patients age, they are more susceptible to the adverse effects of benzos. -More prone to fall -More prone to confusion -More prone to paradoxical agitation (usually within an hour of administration) Next step: taper and discontinue alprazolam

Patient has target cells on blood smear and is asymptomatic. Diagnosis? Suspected iron studies? Management?

Dx: beta thalassemia minor Iron: Hb: normal-ish MCV: decreased Ferritin: high Iron supplementation: doesn't help Mx: reassurance with no specific therapy

Patient (36 yo female) has epigastric and right shoulder pain for 2 hours. Also has emesis. She had a similar episode last month but didn't get help because it resolved spontaneously after a few hours. She has hx of heartburn. Abdominal exam is normal. The pain comes and then is gone after 4 hours. Diagnosis? Cause?

Dx: biliary colic Cause: contraction of the gall bladder (hollow viscus) against a stone (outlet obstruction)

Patient is from Wisconsin. He has night sweats, fever, weight loss, lytic bone lesions, skin lesions, and upper lobe consolidations. Diagnosis? Treatment?

Dx: blastomycosis Tx: itraconazole or amphotericin B

Patient (5 yo boy) had rhinorrhea, congestion, and a cough 2 weeks ago. Now he is coughing so bad, that he vomits. It's worse at night and in the shower as well as with exercise. He has been late on vaccinations. He has bilateral subconjunctival hemorrhage and periorbital petichiae Diagnosis?

Dx: bordatella pertussis

Patient has an aortic aneurysm repair of the infrarenal aorta and receive IV prophylactic antibiotics. On day 1 post op, he has bloody diarrhea and abdominal pain. He also has fever and leukocytosis. There is pain in the left lower quadrant without rebound. Diagnosis?

Dx: bowel ischemia -Known complication of aortic aneurysm repair -Soon after operation--not enough time for c diff pseudomembranous colitis to develop

Patient has ongoing sinusitis that isn't resolving. Now he has seizures and headache. CT shows a single ring-enhancing lesion in the frontal lobe. Diagnosis? Organism?

Dx: brain abscess Org: staph aureus or viridans strep

65 yo patient has 3 week history of generalized rash and puritis. topical calamide lotion nor antihistamine creams have not provided any relief. Picture shows tense bullae. Biopsy shows linear IgG and C3 deposits at the dermal-epidermal junction. Diagnosis? Next step in management?

Dx: bullous pemphigoid Next step: high potentcy topical corticosteroid: *clobetasol*

Patient has diarrhea, abdominal cramps, dizziness, flushing, wheezing, and a feeling of warmth. He has a 2/6 ejection systolic murmur over the left lower sternal border that increases with inspiration. He has hepatomegaly. Hb is normal, liver enzymes are off. Diagnosis? What deficiency is this patient at risk of? Why?

Dx: carcinoid syndrome (tumor found in distal small intestine that can met to liver and then release histamine, serotonin, and vasoactive intestinal peptide into circulation. Inc serotonin production requires tryptophan. Depletion of tryptophan also causes depletion of niacin (bc niacin requires tryptophan for its production) Therefore, carcinoid syndrome puts a person at higher risk of niacin deficiency and its symptoms (pellagra: diarrhea, dermatitis, dementia)

5 yo boy falls while brushing his teeth and his toothbrush hits his throat. He says it hurts. 10 hours later, he has left hemiparesis and mild aphasia. Diagnosis? Confirm?

Dx: carotid artery dissection Confirm: CT or MR angiography

Patient has severe psychiatric illness. When you move him, he moves and then stays in that position. Diagnosis? Treatment?

Dx: catatonia (immobility, mutism, posturing) Tx: lorazepam and electoroconvulsive therapy

Patient has sharp, stabbing back pain that radiates to the back of the legs. He has difficulty urinating and pain in the saddle region with paresthesias. He has prostate cancer 1 year ago. He has lower extremity weakness and hyporeflexia. Diagnosis? Pathophysiology? Mangement?

Dx: cauda equina Pathophys: compression of nerve roots within the spinal canal Mx: -Imaging -IV glucocorticoids -Surgery

Patient has worsening headache. He has trouble sleeping because the headache is constant. He had an insect bite to his cheek two weeks ago, and now both his eyes are swollen. he has a temperature. He has erythema and swelling of the right cheek and bilateral eyelid edema. Bilateral extraocular movement is restricted. Forehead and mid face are tender to palpation. What is the most likely diagnosis?

Dx: cavernous sinus thrombosis Uncontrolled infection of the skin can spread to the cavernous sinus Inflammation of cavernous sinus can result in life threatening cavernous sinus thrombosis and intracranial hypertension It can result in periorbital edema, intracranial hypertension, papilledema CN III, IV, V, and VI go thru the cavernous sinus, so compression can lead to poor extraocular eye movement and paresthesia of the V1 and V2 distribution

Patient has decreased libido, erectile dysfunction, gynecomastia, decreased testosterone, and normal LH/FSH. Diagnosis? Why? Next step in management?

Dx: central secondary hypogonadism Because if testosterone is low, LH/FSH should be raised to compensate (release of feedback inhibition). Since it's normal, that shows something is wrong centrally. Next step: since something is wrong centrally, measure serum prolactin (possible prolactinoma) -Do it even though there were no abnormalities on visual field confrontation testing.

10 month old is not able to stand. He can commando crawl, but drags his legs. (should have diagnosis now) He is hypertonic in legs and hyperreflexive. He has equinovarus deformities. Diagnosis? Primary risk factor?

Dx: cerebral palsy Risk factor: prematurity

58 yo lady has difficulty walking, bilateral foot numbness and tingling. She's on chemo for hodgkin lymphoma, including vincristine. She also has diabetes. Exam: weakness on dorsiflexion, loss of pain and temp sensation affecting both toes. Present knee jerk, absent ankle jerk. Diagnosis?

Dx: chemo induced peripheral neuropathy Not diabetes. It would take longer. Motor weakness is a late sign

Patient has had asymptomatic gallstones, and now has right upper quadrant pain that radiates to the right scapula. She has temperature and RUQ pain on deep inspiration Bilirubin is basically normal, AST, ALT are normal. Alk phos is high normal, amylase is high normal Diagnosis? Initial event leading to symptoms?

Dx: cholecystitis Initial event: gallstone impaction in cystic duct Infection could be there, but the primary inciting event is the gallstone getting impacted

Patient has chronic abdominal pain and fatigue. Pain is epigastric, burning, and sometimes awakens her from sleep. There is duodoneal erythema and an ulcer on the anterior wall of the duodoneal bulb. She has an unusual appetite for paper and ice Diagnosis? Causing what?

Dx: chronic GI bleeding from an ulcer Causing: Fe def anemia

35 yo man has aching back pain for the past 3 months in the left lumbar paraspinal area. It's worse at the end of the day and relieved with overnight rest. There was no severe precipitating trauma. There are no red flag symptoms (fever, weight loss, nerve problems). He does lifting of 10-15 lb things at work. Diagnosis? Contrast? Recommendation?

Dx: chronic low back pain Contrast: -Acute: <4 weeks -Sub-acute: 4-12 weeks -Chronic: 12 weeks Recommendation -Acute: moderate activity, NSAIDs or acetaminophen. Possible other analgesics -Sub-acute: -Chronic: exercise (stretching, strengthening, aerobics), intermittent NSAIDs, condiser tricyclic antidepressants, duloxetine (opioids, benzos, muscle relaxants are not advised)

Patient has intermittent upper abdominal pain associated with nausea. He has dull epigastric pain. It lasts comes on 15-30 min after meals and lasts a few hours. Not relieved by antacids, but is relieved by sitting forward. He also has diarrhea and smokes. Diagnosis? What investigation to confirm?

Dx: chronic pancreatitis Investigation: abdominal CT (serum lipase can be low) Features: -Pain, relieved by leaning forward -Malabsorption (failed exocrine fn) -Diabetes mellitus Tx: -Pain management -Alcohol and smoking cessation -Frequent, small meals -Supplement pancreatic enzymes

Patient has urinary frequency, urgency and hesitancy. He has new onset back pain and perineal pain during ejaculation. He has no dysuria or hematuria. No other tenderness. Rectal exam shows slightly enlarged, smooth prostate. Urinalysis shows increased leukocytes, but nothing on culture. PSA is normal. Diagnosis? Cause of patient's condition?

Dx: chronic prostatitis / chronic pelvic pain syndrome Cause: non-infectious chronic prostate inflammation

2 week old has poor feeding and persistient vomiting. He has jerky movements. He is irritable, jaundiced. His liver and spleen are enlarged and cataracts are present. Diagnosis? Deficiency?

Dx: classic galactosemia Def: Galactose-1-phosphate uridyl transferase def

Patient has surgery for peptic ulcer perforation. Post op, he has fever and hypotension, treated with antibiotics and IV fluids for resus. Now he's day 7 and has watery diarrhea, nausea, abdominal pain, fever, tenderness in the LLQ. Leukocytes and neutrophils are up. Diagnosis? Confirmatory test? Treatment?

Dx: clostridium difficie colitis Test: stool toxin testing Tx: metronidazole or oral vancomycin

34 yo patient comes in with sudden excruciating L sided chest pain. He's anxious, agitated, sweating, pupils are dilated. He has ECG changes, but troponin and CKMB are normal. Likely diagnosis? Management? Important point?

Dx: cocaine intoxication (causing coronary artery vasoconstriction, inc HR, BP, cardiac O2 demand; it also enhances thrombus formation by promoting platelet activation and aggregation) Management: benzodiazapine (decreases agitation, decreases myocardial demand) NB: beta blockers are contraindicated because they could cause unopposed alpha adrenergic stimulation

36 yo patient has left leg weakness and numbness. Her left leg tingles, becomes numb, and goes limp, causing her to trip. Then it resolves spontaneously after a few hours. Fam hx: MS; she has also been stressed Exam: decreased pinprick sensation over the dorsum, weakness on toe extension, inability to walk on (left) heel. Diagnosis? Etiology?

Dx: common fibular nerve compression Etiology: Peripheral nerve compression (crossing legs, immobility, squatting)

Patient has right femoral artery embolectomy. Now he has a burning sensation in his posterior right leg. Right calf is swollen, erythematous, and very tender. Pain is worsened by passive extension of the knee. Dorsalis pedis pulses are palpable. Diagnosis? Etiology?

Dx: compartment syndrome Et: soft tissue swelling from reperfusion

3 day old girl has low birth weight. She has to be delivered because of IUGR mother is from India. At 20 weeks, serology showed: nonreactive rapid plasma reagin, negative HBV surface Ag, rubella and varicella IgG. Both lenses are cloudy, there is a continuous machine like murmur. Diagnosis? What management should have happened?

Dx: congenital rubella syndrome Before: vaccination before pregnancy

Patient has 2 weeks of increasing shortness of breath. He has a dry nighttime cough. No chest pain, palpitations, light headedness or syncope. BP is high. Likely diagnosis? Most sensitive for diagnosing?

Dx: congestive heart failure Most sensitive: elevated BNP

Patient has dyspnoea, fatigue, abdominal distension, previous farmer from china. He has pedal edema, elevated JVP that does not decrease on inspiration. There are decreased heart sounds and an accentuated sound after the second heart sound during diastole. There is a ring of calcification around the heart. Diagnosis? Etiology?

Dx: constrictive pericarditis Etiology: TB (endemic area--china)

Patient has insomnia, confusion, and memory loss over the past 3 weeks. He has muscle twitching, gait problems, and falls. No urinary problems. He's unkept and disoriented to date and time. He misses 3/3 delayed recall and can't draw a clock. He has nystagmus, hypokinesia, and positive extensor plantar response Head CT is normal. EEG shows periodic sharp waves. Diagnosis?

Dx: creutzfeldt jacob disease -Rapidly progressive dementia -Cerebellar (gait) or visual disturbance (nystagmus) -Hypokinesia -Myoclonus Confirm: spongiform changes on brain biopsy Genetic testing for prion protein (PRNP) Sharp wave complexes Elevated 14-3-3 regulatory proteins

Patient has HIV and oral thrush. She has fatigue, headache, and an episode of vomiting. Her roommate reports no personality changes, and she is awake and alert. Her neck is supple and she has no sensitivity to light. Exam: papilledema, but MRI is normal. Diagnosis? What would establish?

Dx: cryptococcal meningitis Establish: cryptococcal antigen testing of CSF

Patient has copious watery diarrhea. No fever, blood, or mucus. He returned 9 days ago from a 3 week trip to eastern europe. He went swimming in lakes and streams. Everything else is normal. No fecal leukocytes of blood. Diagnosis?

Dx: cryptosporidium parvum

Patient has BP os 220/120. He has bibasilar crackles and 4th heart sound. K is 5.0, and creatinine is 2.1. He's admitted and started on furosemide and IV nitroprusside. The next morning, he's confused, agitated, and has seizure. BP is 176/95. There is no focal muscle weakness. Diagnosis? What happened?

Dx: cyanide toxicity Happened: nitroprusside infusion (lots of it) can cause cyanide toxicity because its breakdown products include cyanide. Also, if renal function is poor (high Cr), then that puts him at more risk of cyanide toxicity Cyanide toxicity: altered mental status, lactic acidosis, seizure, coma

17 yo girl has a pelvic mass. It is 8 cm with calcifications and hyperechoic nodules. Diagnosis? 3 months later, she comes back with LLQ pain and nausea. LMP: 4 weeks ago. She has LLQ tenderness to deep palpation with voluntary guarding. What is causing her symptoms?

Dx: cystic teratoma Now: ovarian torsion causing ischemia and ischemic necrosis

Patient has fever, malaise, sore throat, and is very tired. He has no sig past medical history. He has sex with men. He has raised temp, pharyngeal edema, splenomegaly, morbilliform skin rash. No enlarged lymph nodes. Elevated leukocytes, especially lymphocytes, and smear shows large basophilic cells with vacuolated appearance. LFTs are a little raised. Monospot test is negative. Diagnosis?

Dx: cytomegalovirus infection (not EBV)

Patient in nursing home has a foot ulcer. It's located on bony prominences and looks red-ish. Likely diagnosis? Cause? Risk factors?

Dx: decubitus (pressure) ulcer Cause: pressure necrosis RF: poor mobility, poor nutrition, poor perfusion, poor sensation, dementia

Patient thinks that people are trying to poison her food. She won't eat anything unless it's prepackaged. She thinks a rash is due to someone trying to poison her and fears that it will progress into a fatal illness. She has no psychiatric history otherwise. Diagnosis?

Dx: delusional disorder

Patient has rash on buttox that is extremely itchy. She has had diarrhea and unintentional weight loss over the last months. Diagnosis? What would skin biopsy show? Treatment?

Dx: dermatitis herpetiformis Skin biopsy: microabscesses Immunoflourescence: anti-epidermal transglutaminase IgA deposits Tx: -Dapsone (immuonomodulatory--decrease symptoms) -Gluten free diet

65 yo diabetic complains of decreased vision in both eyes that is progressively worsening. Opthalmoscopy shows microaneurysms, dot and blot hemorrhages, hard exudates, and macular edema. Diagnosis? Contrast?

Dx: diabetic retinopathy Contrast: NOT central retinal vein occlusion Diff on history: CRVO is SUDDEN while DR is gradual onset Diff on opthalmoscopy: -CRVO has disc swelling, venous dilation, tortuosity and retinal hemorrhage and cotton wool spots -DR has microaneurysms, exudates, retinal edema, newly formed vessels, hemorrhages, cotton wool spots

Patient has road traffic accident trauma. Chest X-ray shows somewhat diffuse opacity in the left hemidiaphragm--not looking like a hemothorax or effusion. Likely diagnosis?

Dx: diaphragmatic hernia Impact raises intraabdominal pressure and causes herniation of bowel and abdominal contents into mediastinum. Needs surgical management

Baby is born, has decreased lung sounds on the left side and fair air entry on the right side. The abdomen is concave, and the heart sounds are louder on the right. Diagnosis? Management?

Dx: diaphragmatic hernia Mx: -Intubate immediately (no bag and mask because that would put air through the mouth, some could get into the esophagus and intestines and compress the lung volume further). -Insert nasogastric tube (decompress the bowel as much as possible to prevent further compression) -Umbilical artery catheterization (monitor ABG and BP) -Umbilical venous catheter (administration of fluids and medications)

Patient has retrosternal chest pain that radiates to the intrascapular region. They are precipitated by emotional stress or hot/cold foods. Cardiac workup shows no cardiac cause, but nitriglycerin does improve the pain. Upper GI endoscopy is normal. Diagnosis? Confirmation?

Dx: diffuse esophageal spasm Confirmation: esophageal motility studies (manometric recordings)

32 yo woman has shortness of breath and swelling of the feet. She had a recent cold 2 weeks ago. Now she has bilateral pulmonary crackles, JVD, pitting edema. Diagnosis? What would be shown on echo?

Dx: dilated cardiomyopathy secondary to viral myocarditis So on echo you would see dilated ventricles with diffuse hypokinesia

Patient is a sex worker. She has fever, chills, malaise, pain in multiple joints. She was just on her period. Her temp is over 100. She has pustules on her chest and extensor surfaces of her forearms. Palms and soles are unaffected. Diagnosis? Contrast?

Dx: disseminated gonococcal infection Contrast: staph toxic shock syndrome has a more diffuse rash and it involves the palms and soles. Also, there would be more hypotension

42 yo male is a farmer in Guatemala. He has upper abdominal discomfort and nausea, hepatomegaly. There is a 10 cm smooth, round cyst with daughter cysts inside. Diagnosis? What is most likely associated with this condition?

Dx: echinococcus granulosus (dog tapeworm causing large, smooth, hyatid cyst with internal septations) Associated: close contacts with dogs Confirm: IgG for E granulosus Treatment: albednazole or percutaneous surgery

Patient has skin bump on his lower back. He had a similar bump in the same location 6 months ago that resolved spontaneously. He has no trauma, puritis, pain, or other symptoms. It is firm, mobile, non-draining, does not change shape when pinched at the edges Diagnosis?

Dx: epidermal inclusion cyst. Epidermis becomes enlarged in the dermis because of trauma or comedomes Key: it went away and came back. Lipomas: are soft, rubbery, and irregular. They don't regress and return

63 yo man has 2 day history of scrotal pain worse with touch and movement. He has burning on urination and inc urinary frequency. He has a low grade fever. There is a mass in the left scrotum that is erythematous. No discharge is present. Diagnosis? Contrast?

Dx: epididimitis with e coli Contrast: patien <35, likely STI (gonorrhea, chlamydia) Patient >35, likely from bladder outlet obstruction (coliform bacterial like e. coli)

Patient had prostate cancer treated with radiation. Now he has severe back pain, difficulty walking and urinating, and point tenderness over T10 and T11. Diagnosis? Management (immediate)?

Dx: epidural spinal cord compression (likely secondary to mets) Mx: IV glucocorticoids (to decrease inflammation) Imaging to confirm

24 yo patient has 2 day hx of fever, sore throat, hoarseness, inability to swallow, temp. He is drooling, has muffled voice, and stridor. Phys exam shows pooled secretions in the oropharynx. Anterior neck is tender to palpation. Diagnosis? Highest risk factor for this? Contrast?

Dx: epiglotitis (likely Hem influ type B) Highest risk factor: not getting vaccinations for H flu type b. Contrast: ludwig angina due to cellulitis of submandibular space. This would have fever, drooling, muffled voice, stridor, dysphagia, but induration of submandibular area would be obvious and there would be elevation of the floor of the oropharynx

Patient has essential tremor that is worse on activity. Diagnosis? Treatment?

Dx: essential tremor Tx: beta blocker: propranolol

Patient has confusion and flank pain. He appears disheveled. BP is 110/70, pulse is 110, resp is 22, mild costovertebral angle tenderness is present. Catheter shows red urine with calcium oxalate crystals on micrsocopy. Labs: bicarb is 6, calcium is 6, lactate is mildy elevated, no ketones Diagnosis? Management?

Dx: ethylene glycol poisoning -It's metabolized into glycolic acid and oxalic acid. Glycolic acid causes AKI, and oxalic acid precipitates with calcium causing ---Hypocalcemia ---Calcium oxalate crystals -So flank pain, hematuria, oliguria, AKI are all consistient with ethylene glycol poisoning -Also, raised anion gap met acidosis Management: -Fomepizole (competitive inhibitor of alcohol dehydrogenase to prevent toxic metabolites) -Sodium bicarb may help -Dialysis if severe

Patient has an acute MI complicated by cardiogenic shock and is admitted to CCU. He gets renal failure. Thyroid gland physical exam is normal. TSH is normal, T4 is normal, T3 is low. Diagnosis?

Dx: euthyroid sick syndrome Thyroid hormone can decrease (T3 being the first) in the setting of acute illness. Thus thyroid function testing is not useful in acutely ill patients

19 yo girl has coughing and wheezing and breathlessness after her workout sessions. She doesn't have symptoms any other time. Diagnosis? Treatment?

Dx: exercise induced asthma Tx: albuterol inhaler 10 minutes before exercise. Second line would be antileukotriene 15-20 minutes is second line. Ipratroprium is better for COPD

24 yo patient is brought to ED after fainting during football practice on a hot day. He had dizziness and headache before collapsing. Temp: 41 C, 90/60 BP, 140 pulse, resp 22. Skin is dry and hot. Diagnosis? Managenent?

Dx: exertional heat stroke Mx: -Fluid resus -Correct eletrolytes -Ice water bath -Correct end organ damage NB: diagnosis: core temp >40, *CNS dysfunction* (ie why it's called stroke)

28 yo male has motor vehicle accident. He has pain in his right pelvis and lower abdomen, but no signs of peritonitis (rigidity/guarding or rebound tendeness). There's no blood at urethral meatus, a foley catheter is placed without trouble, and hematuria comes out. There is a pelvic fracture. Diagnosis?

Dx: extraperitoneal bladder injury

Patient was on haloperidol and developed spasms in the neck, restlessness, and difficulty sitting still. He has T2DM Diagnosis? What next?

Dx: extrapyramidal symptoms (acute dystonic reaction; akathisia) Next: start on second gen antipsychotic with low metabolic risk profile (ziprasidone or aripiprazole)

Patient is at 34 weeks. She feels uterine contractions. She had previous history of preterm labor in first pregnancy. Contractions are irregular and the cervix is closed. Diagnosis? Management?

Dx: false labor Mx: discharge home

Patient gets a blood transfusion. 6 hours later, he has chills malaise, fever. Diagnosis? Management? What could prevent this?

Dx: febrile nonhemolytic transfusion reaction Mx: -Stop transfusion -Give antypyretic (acetaminophen) -Exclude serious cause (do direct coombs test to rule out hemolytic reaction) Prevent: leukoreduction This is because RBCs and plasma are separated from WBCs, but some of the WBCs can remain and release cytokines during storage. When these cytokines get into the recipient's stream, they have a reaction. Leukoreduction is filtering out white blood cells before transfusion to prevent this.

Patient has 1 yr history of intermittent skin lesions. She has ulcerating lesions on the lower extremities associated with inguinal adenopathy. She has low grade fevers. She takes ibuprofen for joint pain. She has a palpable spleen tip on examination. She has low neutrophils and ANA is negative. Diagnosis? Cause of her condition?

Dx: felty syndrome Cause of condition: autoimmune disorder Splenomegaly, anemia, neutopenia, thrombocytopenia, arthritis (rheumatoid) Also: Vasculitis (mononeuritis multiplex, necrotizing lesions)

Patient has prolonged PR interval, but normal QRS duration. Diagnosis? Management? Contrast?

Dx: first degree heart block Mx: observation Contrast: if prolonged QRS, then the abnormality is likely below the AV node, and that requires further evaluation (electrophysiological studies)

4 yo girl patient has foul smelling vaginal discharge. There is also some spotting. Aside from the discharge, the girl is acting normally. Labia appear normal. There is a white foreign body in the introitus. Diagnosis? Management?

Dx: foreign body Mx: -Removal with Ca alginate swab -Irrigation with warm fluid after topical anesthetic -Sedation and general anesthesia if unsuccessful

15 yo boy has increasing ataxia. He also has dysarthria. He's developing scoliosis. He has absent deep tendon reflexes. He also have atrophy of the medulla and dorsal columns of the spinal cord. Diagnosis? Commonest cause of death?

Dx: friedreich ataxia Cause of death: hypertrophic cardiomyopathy

Woman gets an US after high alpha fetoprotein on second trimester quadruple screen. US shows thickened intestinal loops that are floating free in the amniotic sac. There is decreased fluid, suggestion oligohydramnios. Diagnosis?

Dx: gastrochisis Not omphalocele. This one has covered membrane, so alpha-fetoprotein wouldn't be that high in the first place. Also, gastrochisis exposes the intestines to the outside, which causes them to undergo chronic inflammation and edema. Also there can be nutrient losses, which cause the oligohydramnios

Patient has developed headaches, shoulder pain, and neck pain. She's had a lot of stress lately, and has difficulty sleeping, poor concentration, fatigue, and feeling overwhelmed. She's always been a "worrier" and started a new job 8 months ago. She's preoccupied about the safety of her children and makes lists of things she needs to do instead of focusing on her work. Diagnosis?

Dx: generalized anxiety disorder

29 yo patient has worsening right knee pain for 3 months. Ibuprofen doesn't really help. The right knee is swollen, tender, with decreased range of motion. X-ray shows eccentrically placed lytic areas in the epyphysis of the distal femur. Diagnosis?

Dx: giant cell tumor

56 yo woman is recently diagnosed with diabetes. She has weight loss. Her diabetes is well controlled with sitagliptin. she has occasional watery stools. She has a perioral rash and now a similar one affecting her left thigh. They are erythematous rashes with plaques and central clearing Labs: microcytic anemia. Likely diagnosis? What would you measure to confirm?

Dx: glucagonoma Measure: glucagon levels (<500)

Patient gets a bone marrow transplant from and HLA matched donor--a sibling. Two weeks later, he develops a maculopapular rash on his hands, face and feet. He had diarrhea and occult blood. LFTs are abnormal. Diagnosis? What is the pathologic mechanism for this?

Dx: graft versus host disease Mech: activation of donor T lymphocytes

Post menopausal woman has postmenopausal bleeding. It's similar to a period. She has an ovarian mass and endometrial biopsy shows complex hyperplasia without atypia. Diagnosis?

Dx: granulosa cell tumor Causes increased estrogen and inhibin Elevated estrogen causes postmenopausal bleeding

Picture of baby with well-demarcated red dot. Diagnosis? Treatment? Concern?

Dx: hemangioma (aka strawberry hemangioma) Tx: usually grow in first year, then regress later (ie no treatment necessary) Concern: if midline, there is risk that there could be some in the airway, which would be life-threatening

43 yo patient has right knee pain and diabetes. His father also had diabetes. Exam shows swollen, tender right knee with an effusion and mild hepatomegaly. X-ray reveals chondrocalcinosis and moderate effusion. Likely diagnosis? Confirmation?

Dx: hemochromatosis Confirm: serum iron studies NB: condrocalcinosis is calcium deposits in the cartilage, indicative of Ca pyrophosphate dihydrate crystal deposition (CPPD) Hemochromatosis can predispose to CPPD

43 yo man has erectyle dysfunction. He has fatigue, drinks 2-3 beers every day, 20 pack year hx, has brownish skin pigmentation on face and arms. Bloods are all normal except elevated blood glucose Diagnosis? What is this patient at higher risk of?

Dx: hemochromatosis (bronze diabetes) -Hepatic problems -Diabetes, hypogonadism, hypothyroidism -Restrictive or dilated cardiomyopathy, conduction abnormalities Higher risk of: hepatocellular carcinoma

Patient had an operation and is on heparin SQ injections. She develops red patches that progress to purple lesions. They are surrounded by erythema Diagnosis? Risk? Management?

Dx: heparin induced thrombocytopenia Cause: antibodies against a platelet component Risk: DVT (bc creates pro-coagulable state) Mx: stop all heparin products and start argatroban or fondaparinux

Patient has chronic liver disease. He gets a diuretic for ascites. He is now lethargic, confused, irritable, has low BP, and has flapping tremor. Lab abnormalities are low K and high bicarb. Diagnosis? Management?

Dx: hepatic encephalopathy Mx: replace K -Low K results in more H going into cells to maintain electroneutrality. This H going into cells causes more NH4+ to be NH3 which worsens HE Mx: give fluids -High bicarb also causes more conversion from NH4+ to NH3. NH3 then enters the CNS and causes HE Mx: consider lactulose (convert NH3 to NH4+)

Patient has liver alcoholic cirrhosis and esophageal varices. He has ascites. He has no dyspnea when lying down or on moving to an upright position. He has dullness to percussion and decreased breath sounds on the right. Left sided are normal. Diagnosis? Cause?

Dx: hepatic hydrothorax Cause: fluid passage thru diaphragmatic defects Ascites and transudative fluid excess can cross small defects in the diaphragm. It's more common on the right because the right hemidiaphragm is less muscular. Patients can have pleuritic chest pain, cough, hypoxemia, dyspnea. Diagnosis: thoracocentesis Treatment: diuretics and salt restriction; can try therapeutic thoracocentesis

Patient has liver cirrhosis from hep c. She then has an esophageal bleed. Her kidney function is bad (hypoNa, hyperK, creat 2.1, BUN 72). The next day, urine output decreases despite adequate fluid resuscitation. Her urine sodium is 5 mEq/L. Diagnosis? Underlying cause?

Dx: hepatorenal syndrome Underlying: renal hypoperfusion NB: hepatorenal syndrome, when bad, doesn't respond to fluids and the presentation is similar to that of pre-renal azotemia.

12 yo boy presents with left sided chest discomfort. 2 months ago, he was in a motor vehicle accident, but was okay and discharged home. Now he has decreased air entry on the left side, and X-ray shows opacity in the lower left zone and what looks like mediastinal shift to the right. Likely diagnosis? Next step?

Dx: herniation of bowel through weakened left hemidiaphragm secondary to MVA Next step: CT chest and abdomen to confirm

Patient has fever, throat pain, 1mm vesicles on the anterior tonsillar pillars, and there are greyish ulcerations in the posterior pharynx. There are no lesions on the lips or buccal mucosa. Diagnosis? Contrast?

Dx: herpangnia (coxsackie A virus) Contrast: Herpes Simplex Virus: vesicles on anterior oropharynx and lips/mouth (anterior!)--comes earlier in life and is more common, so anterior Coxsackie: posterior oropharynx and occurs later in life. Also seasonal (late summer, early fall)

34 yo HIV patient has CD4 count of 80. He recently moved to Missouri. Now he has fever, night sweats, cough, SOB, high temp, ulcers on the hard palate, and enhlarged lymph nodes. He has crackles on lung exam and hepatosplenomegaly. Lab shows pancytopenia and elevated aminotransferase levels. Diagnosis? Investigation to confirm? Treatment?

Dx: histoplasma Ix: urine histoplasma antigen Tx: -Amphotercin B (moderate-severe disease) -Itraconazole (mild disease/maintainence)

Young patient has history of developmental delay, eye problems for which she sees ophthalmologist, and now presents with sudden onset weakness, slurred speech, and loss of balance. She has marfanoid body habitus Diagnosis?

Dx: homocystinuria

Patient has osteoporosis and wants to prevent symptoms by taking more supplements. Now she has abdominal pain, urinary frequency, thirst, dry mucus membranes decreased bowel sounds. Diagnosis? Cause? Pathophys?

Dx: hypercalcemia Cause: milk-alkali syndrome Pathophys: basically too much Ca causing inactivation of Na-K-2Cl channels, leading to more diuresis, and resultant increase in bicarb resorption

Patient has painless proximal muscle weakness. She also has weight gain, back pain, demineralization of vertebral bones, and hirsutism. Diagnosis? Cause of her weakness?

Dx: hypercortisolism (cushing syndrome) Cause of weakness: muscle atrophy--increased glucocorticoids cause muscle atrophy

45 yo patient has fatigue, myalgias, and muscle weakness. She has difficulty getting up from a chair, decreased strength, and sluggish ankle jerks bilaterally. She has normal ESR and elevated CK. Likely diagnosis? Test?

Dx: hypothyroid myopathy Test: TSH and T4 Yes, hypothyroidism can present with myopathy with weakness, pain, and elevated CK. ESR is normal NB: polymyositis/dermatomyositis have less muscle pain. Also they'd have increased ESR.

Patient is on lithium. She has been urinating a lot, very thirsty, confused, lethargic. Her BP is 83/59, pulse is 122. He has high Na, high serum osmolality, and low urine osmolality. Diagnosis? Management?

Dx: hypovolemic hypernatremia Mx: correct hypovolemia first -Normal saline (0.9% saline) -Then, once stable, can go to hypotonic solution (5% dextrose is recommended) If there are very high levels of litium, maybe dialysis would be initiated, but that's not the first step here.

Patient is post op and has been on 0.45% saline with 5% dextrose. Now she has confusion, headache, nausea, and vomiting. Electrolytes show very low Na. Diagnosis? Management?

Dx: iatrogenic hyponatremia Mx: give hypertonic saline (3% saline) Giving normal saline is not good enough

16 yo girl had headache (worse in the morning), vision changes, nausea. She takes isotretinoin for severe acne. normal temp, BP 130/80, pulse 70, resp 15. Eye exam: papilledema and decreased visual acuity. No neck stiffness or other focal neuro deficit. LP: elevated pressure but nothing else. Diagnosis? Cause?

Dx: idiopathic intracranial hypertension Cause: medication side effect Examples: -Tetracyclines (doxy, minocycline) -Excessive Vit A (isoretinoin, all-trans retinoic acid)

6 yo boy has pinpoint "bruises" throughout his body. He has no bleeding or recent trauma. Three weeks ago, he had an URTI that resolved. Hb is normal, platelets are low, WCC is normal. Diagnosis? Management? What about adults?

Dx: immune thrombocytopenic purpura Mx: Children: -NO bleeding: observe--usually self-limited -Bleeding, then give IVIG and/or corticosteroids Adults: -Cutaneous manifestations (purpura) AND platelets <30,000, give IVIG and/or corticosteroids -Bleeding: IVIG and/or corticosteroids -Observe only if cutaneous manifestations and platelets >30,000

12 yo girl has poor grades, distractable mind at school, and misses important details. At home, she doesn't do her chores and forgets where she places things. In the office, she sits still but is distractable. Diagnosis? Treatment?

Dx: inattentive subtype of attention deficit hyperactivity disorder (commoner in girls) Tx: stimulants -Amphetamines -Methylphenidate

Patient is at 10 weeks gestation, has heavy vaginal bleeding, dilated cervix, US with fetus that has no heartbeat. Diagnosis? Management options? What determines management?

Dx: inevitable abortion Options: expectant and surgical (suction curettage) Determined by: -Hemodynamic instability (low BP, high HR) -Patient preference

Baby cries every evening for about 4 hours. Usually always in evening Diagnosis? Management

Dx: infantile colic (crying >3 hrs, >3 days for period of >3 weeks) Cause: overstimulation of infant or failed soothing methods Techniques: infant swing, swaddling, minimizing stimuli, dark room, rocking. Avoiding over or under-feeding Mx: advise parents regarding soothing techniques

Patient has burns over 20% of body. He now has confusion, dec urine output, temp of 35.5 C (96 F) BP 100/60, pulse 120, and resp 26. Some areas of partial thickness burns look to have developed into full thickness injury and necrosis. Platelets are 80,000, leuks are 16,000, glucose is 230. Diagnosis? Cause of patient's condition?

Dx: infection Cause: Gram-neg sepsis (confusion, oliguria, low temp, high WCC, thrombocytopenia, necrosis of wounds)

17 yo patient has 14 day history of neck lumps, sore throat, and malaise. She has fatigue, but no cough, abd pain, naus, or vomiting. She has difficulty swallowing due to throat pain. She is breathing loudly and tonsils are erythematous and enlarged bilaterally. There are multiple, tender cervical lymph nodes. Spleen is palpable 2 cm below the costal margin. Diagnosis? What is a complication?

Dx: infectious mononucleosis (secondary to EBV) Comp: acute airway obstruction

Patient has fevers and 5 mm mobile mass on the anterior leaflet of the mitral valve. There is moderate mitral regurg. Blood cultures grow eikenella corrodens. Diagnosis? What is the most likely predisposing thing?

Dx: infective endocarditis Predisposing: dental infection (periondontal because E corrodens is of the oral flora) Contrast: staph: IVDU/needles Strep gallolyticus: colorectal carcionoma Enterococci: nosocomal UTI

42 yo man has fatigue and weakness. He has joint pain, low grade fever, dark, cloudy urine, painful fingertips, shortness of breath. He has high ESR, positive rheumatoid factor, 2+ blood and 1+ protein on urine dipstick. Diagnosis? Why?

Dx: infective endocarditis Why: heart failure (SOB), osler's nodes (painful fingertips) IE can also cause immune complex deposition in the kidney, causing a nephritic-type syndrome

Px has low back pain and stiffness for 2 months. It's worse in the morning and improves with activity. He has intermittent abdominal pain and diarrhea for the past 3 months. Ibuprofen helped his back pain, but made his diarrhea worse. Exam: limited spine flexion and tenderness in the lower back. Labs: anemia and thrombocytosis. Stool cultures are negative. X-ray shows sacro-iliac joint inflammation. Diagnosis?

Dx: inflammatory bowel disease causing arthritis

Patient (4yo) has worsening ear pain. He tried antibiotics. Now he has headaches and vomiting in the morning. Temp is high, pain in ear, temple, and neck. Fundoscopy is normal. Leukocytes are high. Diagnosis? Management?

Dx: intracranial abscess Mx: Imaging first (CT or MRI--can't do XR because you need to see soft tissue also) Then possible needle aspiration, mastoidecomy, and antibiotics

Newborn boy is being evaluated. He has normal head circumference, but small weight and length. Diagnosis? He also has hepatosplenomegaly, jaundice, rhinorhea, macuopapular rash on the feet and buttox that desquamates. What congenital infection is this?

Dx: intrauterine growth restriction Congenital infection: syphilis -IUGR -Hepatosplenomegal -Rhinorrhea -Rash that desquamates

3 yo boy has abdominal pain. He brings his knees up and holds his belly. He has non-bloody, non bilious vomiting. Between episodes, he is pain free and playful. 3 weeks ago, he had gastroenteritis. He is tender in the right upper and lower quadrant. Fecal occult blood test is positive. Diagnosis? Investigation to confirm? Treatment?

Dx: intussusception Ix: US (100%: target sign) Treatment: air enema

Premature baby is exclusively breastfed. Looks pale. Mother eats balanced diet with vegetables and meat. Diagnosis? Mx?

Dx: iron def anemia (premature infants at higher risk Mx: iron and Vit D supplementation

63 yo man with easy fatiguability, osteoarthritis, and has been taking naproxen. HB is low, MCV is low. Likely diagnosis? Fe studies?

Dx: iron deficiency anemia--NSAID putting him at risk for blood loss Fe studies: low iron (would also be low in anemia of chronic disease anyways), high total iron binding capacity, low transferrin saturation

2 yo boy drinks a lot of milk and has conjunctival pallor. Hb low, MCV low Diagnosis? What else would you expect in iron studies?

Dx: iron deficiency anemia--common in milk over-consumption Else: increased red cell distribution width (because the body is trying to churn out more cells?)

Young boy takes pills from grandfather. Pills are unknown. He has nausea, abdominal pain, vomiting, and diarrhea.. BP is low. HR is high, resp rate is high. X-ray shows opacities in the stomach and duodenum Bicarb is low, pH is low, PaCO2 is low. Diagnosis? Treatment?

Dx: iron pill ingestion and poisoning (NB early nausea, vomiting, diarrhea, abdominal pain, and hypotension) Tx: -Whole bowel irrigation -Deferoxamine -Supportive care for airway, breathing, circulation

64 yo patient has coronary artery disease and peripheral vascular disease. He gets hypotensive. He then has abdominal pain and bloody diarrhea along with temperature. Diagnosis? What would CT scan show? In what area(s)?

Dx: ischemic colitis CT: fat stranding, surrounding colonic wall thickening Areas: splenic flexure (watershed of middle colic and left colic) rectosigmoid junction (watershed of sigmoid and superior rectal arteries)

10 yo girl has pain in multiple joints. It involves wrists, knees, and ankles. There is mild erythema and warmth. There have been no fevers, rashes, abdominal pain, or weight loss. Diagnosis? What would you expect on lab evaluation?

Dx: juvenille idiopathic arthritis Lab eval: inflammatory picture -Inc CRP and ESR -Inc ferritin (acute phase reactant) -Thrombocytosis -Hypergammaglobinemia -ANEMIA (think anemia of chronic disease)

Patient wears contacts and has trouble taking them out. She has globular yellow discharge at the medial corner of the eyelid. The cornea is edematous, hazy, ulcerated, and there is extensive scleral injection Diagnosis?

Dx: keratitis, specifically pseudomonal keratitis Keratitis because it involves the cornea It if only involved the conjunctiva, then it would be conjunctivitis

Patient has bloating, flatulence, abdominal cramps and explosive watery diarrhea after ingesting dairy products. Likely diagnosis? Confirmation?

Dx: lactose intolerance Confirmation: positive hydrogen breath test The lactose isn't broken down by the patient's enzymes. Thus the lactose gets to the bacteria in the gut. The bacteria break down the lactose and release H as a byproduct, which is measured. So positive hydrogen breath test

Patient has right arm weakness. Now he can't shake hands and walks with a mild limp. He has a headache, asymetry of the lower face, decreased muscle strength in the right arm, positive babinski on the right. Sensory exam is normal. CT shows no abnormalities. Diagnosis? Etiology?

Dx: lacunar infarct Etiology: microatheroma and lipohyalinosis

Patient has acute onset shortness of breath at restaurant. Flow volume loop looks like the peaks are cut off Diagnosis? Reason?

Dx: laryngeal edema (fixed upper airway obstruction) Reason: likely food allergy. The obstruction prevents complete inhalation or exhalation

Patient has HIV. CD4 count is 450. He's tested for TB with skin test, and the induration is 8mm. CXR is normal. Diagnosis Next step?

Dx: latent TB Next: start treatment with and isoniazid and pyridoxime for 9 months. HIV patient: >5mm is positive

Patient is brought to ED for near syncopal episode. She was dizzy and light headed. She has chronic diarrhea with 10-12 non bloody, watery bowel movements per day. It occasionally wakens her at night. She has hypokalemia and metabolic alkalosis and gets a colonoscopy which reveals dark brown mucosal pigmentation in the proximal colon. Diagnosis? What would also be expected?

Dx: laxative abuse Expect: positive stool laxative screen Non bloody, causes met alkalosis from hypo K, dark brown mucosal pigmentation is melanosis coli, a common finding in laxative abuse.

Patient had previous miscarriage. She has pelvic pain (currently like labor) and history of heavy menstrual bleeding and occasionally passes clots. She has an irregularly enlarged uterus. There is a 5 cm spherical mass visible thru the external os. It's firm, smooth, and blood surrounding. Diagnosis?

Dx: leiomyoma uteri (prolapsing) I think a threatened abortion wouldn't present with a mass coming out--the pregnancy would be too far advanced by then. Products of conception are soft. Aborting leiomyoma pulls on the uterus and pushes on the os, causing pain like labor

42 yo man has nonpainful skin lesion on the left upper arm. He has tingling and numbness around the fingers. There's hypopigmented patch on left upper arm with decreased sensation to pin prick. Ulnar nerve is thickened and tender at the left elbow. Touch and pain sensation are absent in the left ulnar nerve distribution. Diagnosis? Which test will confirm it? Tx?

Dx: leprosy Chronic, anesthic, hypopigmented skin lesions with raised, well-demarcated borders, loss of senasation. Diagnosis: full thickness biopsy Treatment: dapsone, rifampin, and if severe, clofazimine

Patient has 2 days of severe diarrhea and 6 hours of abdominal pain. He's confused and lethargic. He was recently treated for strep throat. His abdomen is mildly distended and he has pain in LLQ. Leukocytes are 44,000 with more neutrophils, bands, metmyelocytes. Next day leukocytes are 53,000 and leukocyte alkaline phosphatase score is high. Diagnosis?

Dx: leukamoid reaction LAP being high is the biggest thing Contrast: Chronic myeloid leukemia has less mature neutrophils (more metmyelocytes than myelocytes), and *leukocyte alkaline phosphatase score is low.* Absolute basophilia is present NB: metamyelocytes are the more mature ones. Think that early on, they are myelocytes. Then they grow and change and become meta-

3 yo patient has severe oral pain. She has had recurrent sinus infections and bouts of cellulitis. Skin cultures grow staph aureus and strep pyogenes. Exam shows ulceration and necrosis. Labs sho 55,000 leukocytes, with neutrophil predominance (90%) lymphocytes: 8% Diagnosis?

Dx: leukocyte adhesion deficiency Recurrent skin and mucosal bacterial infections No pus Leukocytosis with neutrophil predominance. Adenosine deaminase def would have less white cells

Patient has vulvar itching and burning. Over the counter lube provides no relief. She has thin, dry, white, plaque-like skin over the vulvar skin with the loss of the labia minora. There is clitoral hood retraction. There are excoriations bilaterally on the vulva. Diagnosis? Treatment?

Dx: lichen sclerosis Tx: topical corticosteroid

Patient has alzheimers. CT shows what looks like a bleed Diagnosis? Most common cause?

Dx: lobar hemorrhage Cause: cerebral amyloid angiopathy (beta amyloid deposition into the vessel walls. These amyloidogenic proteins are similar or the same as those in alzheimers

Patient has a 5 day history of back pain that started while he was moving boxes. The pain radiates down his leg to his foot. It is worsened by the straight leg raise test. There is no saddle anesthesia, incontinence, or lack of anal sphincter tone. Diagnosis? Management?

Dx: lumosacral radiculopathy (sciatica) secondary to a herniated disc. Mx: -These usually resolve on their own--no concerning or worsening features, so no need for more extensive investigation -Focus on symptom control ---NSAIDS ---Acetaminophen

Pregnant lady has tick bite and erythema migrans. Diagnosis? Management?

Dx: lyme disease (early localized) Mx: amoxicillin Not ceftriaxone because it requires IV or IM administration

38 yo has shortness of breath and easy fatiguability. He has been on isoniazid. He became vegan 4 months ago. He has conjunctival pallor and vitiligo. His tongue is shiny. He has low Hb, high MCV, low normal WBC, low normal platelets. Diagnosis? Likely cause?

Dx: macrocytic anemia Cause: pernicious anemia (eastern european, relatively young, vitiligo are biggest hints) Not myelodysplastic bc that would have more profound pancytopenia and does not present with vitiligo.

Patient has grandiose ideas and it is affecting his function at work. He thinks if he gets fired, he'll be a CEO of a new business. He's sleeping less and looks a big irritable. Diagnosis? Differentiate between two similar conditions?

Dx: manic episode Bipolar I Bipolar I: symptoms should be severe, lasting over 1 week, impairing function, DIGFASTER NB: NO depressive episode is necessary. Bipolar II: hypomanic (so not as severe) and depressive episode is necessary Cyclothymic disorder: >2 years of fluctuating, mild hypomanic and depressive symptoms that don't meet criteria for hypomanic or major depressive disorder

Chronic alcoholic comes in with epigastric pain, vomiting, blurred vision. Exam reveals disc hyperemia. He has a severe metabolic acidosis. Diagnosis?

Dx: methanol poisoning ME EYE! -- Causes eye changes Ethylene glycol causes kidney problems Ethyl is like a big kid

15 month old boy is brought to the hospital because he turned blue. He has has an upper resp tract infection for which his mother gave him aceteminophen and a "numbing cream." Pulse ox is 86% on room air. He is given oxygen and it doesn't improve. Diagnosis? Cause? What finding would be seen? Management?

Dx: methemoglobinemia Cause: topical anesthetic, dapson, nitrites) Finding: normal PaO2 (because it's just the O2 carrying capacity of O2 bound to hemoglobin that is affected. Ferric state is less affinity for oxygen. The remaining 3 ferrous sites have increased O2 affinity and don't release O2 to tissues Mx: give methylene blue

Patient has palpitations. Her apical impulse is displaced to the left. There is a third heart sound. There is a holosystolic murmur loudest at the apex and radiates to the axilla. Diagnosis? Cause of condition?

Dx: mitral regurg secondary to mitral valve prolapse (commonest cause of MR in the developed world) Cause: myxomatous degeneration of the mitral valve The LA dilation can lead to afib and palpitations

Patient 45 yo man has 2 month hx of painless, nonpuritic, painless, palpable purple lesions on his legs. He has fatigue, weakness, joint pain in knees and elbows. No fever, weight loss, abd pain. C3 and C4 are low, and there is blood and protein on urinalysis Diagnosis? What should you get to establish diagnosis?

Dx: mixed (type II or III) cryoglobinemia Establish: viral hepatitis serology Mixed can cause fatigue, joint pain, palpable purpura, and glomerulonephritis. It causes low C3 and C4. It is often caused by hep C infection, which is why you get the hep serology

46 yo man comes in because of several episodes of vomiting. The last one contained blood. History: -Alcohol abuse (raised AST/ALT ratio, hyperechoic liver) -Dyspepsia Had an US (hyperechoic liver) and endoscopy (esophagitis and gastritis) No melena Nasogastric suction shows normal stomach contents mixed with blood. Diagnosis?

Dx: mucosal tear at gastro-esophageal junction (ie mallory-weis tear) NB: not perforation from endoscopy: that would present with -Acute chest pain -Subcutaneous emphysema -Left sided pleural effusion I didn't see the beginning part where it said he was vomiting.

6 yo boy 2 day hx of facial swelling. It's bilateral. He has no acute ear infection. Not immunized Diagnosis? Complication risk?

Dx: mumps Comp: aseptic meningitis

34 yo patient has episode of difficulty swallowing food. She also has had dyspnoea and drowsiness. She has weakness trying to lift books. Her speech is nasal. She is using accessory muscles of respiration. She had a recent UTI treated with ciprofloxacin Diagnosis?

Dx: myesthenia crisis Bulbar symptoms are key Not ascending (like GB syndrome would be) UTI can set it off, ciprofloxacin can set it off

Patient has motor vehicle accident. They have low BP and normal PCWP. They get fluids, and that raises PCWP above normal. Diagnosis?

Dx: myocardial contusion

22 yo college student has sleep problems for 3 months. he's been stressed since his girlfriend broke up with him last month. He often falls asleep in class and is sleepy during the day. He hears voices and sees animals when he falls asleep. last week, he was talking to his girlfriend, and suddenly felt weak in his face and knees. Diagnosis? What is this associated with?

Dx: narcolepsy -Sleep hallucinations (hypnagogic--when falling asleep or hypnopompic--when wakening) -Intense emotion causing weakness (cataplexy) -Sleep paralysis (not present--inability to move when wakening) Associated with: low CSF levels of orexin-a / hyporetin 1

Patient is day 3 post op. He has T2DM, hypertension. He has pain around his wound. There is grey discharge and dusky, grey subcutaneous tissue. Sensation is decreased around the edges. Diagnosis? Management?

Dx: necrotizing surgical site infection Mx: parenternal abx and surgical debridement

Patient has ear pain with drainage for one weeks It is unrelenting and exacerbated by chewing. She has T2DM. She has raised temp and BP. Exam: external auditory canal is edematous with purulent discharge and granulation tissue on the floor. Diagnosis? Treatment?

Dx: necrotizing/malignant otitis externa -Distinguishing from regular otitis externa: extent of pain (severe and on chewing) Tx: IV ciprofloxacin

Baby was born with IUGR to mother who had poor prenatal care. The baby now has a high pitched cry, diaphoretic, sneezing and tachypneic. Diagnosis? What was baby likely exposed to?

Dx: neonatal abstinence syndrome Exposed to: heroine Other features of NAS: sleeping and feeding difficulties, vomiting and diarrhea, tremors, seizures, sweating and sneezing

What is the main aspect of diagnosis of paget's disease? What are the complications of it?

Dx: normal Ca and Phos, but elevated alk phos (bone turnover) Complications: Skull: headache, *hearing loss* Spine: spinal stenosis, radiculopathy Bones: bowing, fracture, arthritis Osteosarcoma

26 yo girl has blurry vision: a smudge in the center of her left field of vision 2 days ago. It has enlarged to include almost her entire L field. Color appears washed out. She has pain on movement and positive RAPD in left eye. Fundoscopic exam in unremarkable Diagnosis?

Dx: optic neuritis Esp bc shes a young woman, you're thinking beginnings of MS

Patient is a 34 yo farmer brought to hospital after attempting suicide. Clothes are soiled with voimtus. O2 sat is 86%, pulse is 50. His eyes are watering and pupils are 1 mm bilaterally. He has widespread ronchi with prolonged expiration. Increased bowel sounds and fasiculations are noted. Diagnosis? Next step?

Dx: organophosphate poisoning (inhibiting ACh-esterase and causing more ACh to be present) Next: -Atropine (reverse the condition by competing with ACh receptors) -Exposure removal

Patient has SLE and is on steroids. She has hip pain Diagnosis? Tests to confirm?

Dx: osteonecrosis of the femoral head Tests: X-ray--usually negative early MRI is next (not anything else--MRI) MRI shows necrosis X-ray, if late, shows subchondral translucency

Patient has pain in upper right arm. X-ray shows codman triangle and sunburst pattern (kind of looks like a bursting bone?). There were no systemic features or symptoms Diagnosis?

Dx: osteosarcoma

Patient 65 yo female has food falling out of her mouth. She also has had recent ear discharge. She has a history of T2DM. L ear canal shows granulation and there is L facial droop. Diagnosis? Causative organism? Treatment?

Dx: otitis externa causing progression, erosion, and osteomyelitis of the skull base and subsequent cranial nerve damage Organism: pseudomonas areugenosa Tx: abx, such as cipro (effective against pseudomonas)

Patient has chronic pancreatitis. Now she has an episode where she has pain and she has had recent weight loss. Liver function tests are normal and there is no jaundice. Diagnosis? Next step in management?

Dx: pancreatic adenocarcinoma Next step: abdominal CT scan

Patient has epigastric abdominal pain radiating to the back. She is a woman, in her 40s, with raised BMI. Bili is normal, Alk phos is high, ALT 172, AST 133, amylayse and lipase are both very high. Diagnosis? Next step in evaluating the underlying pathology?

Dx: pancreatitis (acute, gallstone) Next: US to assess for gallstones causing the pancreatitis ALT > 150 suggests gallstone pancreatitis I guess you don't have to have a raised bilirubin (?)

55 yo woman has one week history of pain in multiple joints (MCP and PIP). Pain is worse in morning for 10-15 minutes. She works in a daycare center and has normal vitals with normal ESR. Diagnosis?

Dx: parvovirus B19 "viral arthritis" Not RA: morning stiffness not long enough

Patient has achy pain in the anterior right knee. It's worse when running, sitting, and going up and down stairs. Sometimes she feels it's giving way. There is mild crepitus with full range of motion at the knee. Compressing the patella with the knee extended reproduces the pain. Diagnosis? Most appropriate next step?

Dx: patellofemoral pain syndreom Mx: -Reduce intensity of exercise -Activity modification -NSAIDs -Stretching and strengthening exercises

Patient has a continuous flow murmur at the right sternal border. Diagnosis?

Dx: patent ductus arteriosis

19 yo patient has sore throat, fever, and mild lower abdominal discomfort. She has a high temp. There is bilateral nontender cervical lymphadenopathy. Pharyngeal arches are erythematous without exudate. Abdomen is tender to deep palpation. Diagnosis? Etiology:

Dx: pelvic inflammatory disease Et: nisseria gonorrhea infection

7 yo boy has facial acne, growing taller, has coarse pubic hair. Bone age is 2 SD higher than chronological age. LH levels are low and GnRH stimulation test does not increase LH levels. Diagnosis? Cause?

Dx: peripheral precocious puberty Cause: likely nonclassic congenital adrenal hyperplasia. I picked "idiopathic precocious puberty" but this is equivalent to central precocious. So incorrect.

Patient has sudden onset retrosternal burning pain. It has never happened before. ECG is normal. Endoscopy shows a circumferential, deep ulceration with surrounding mucosa that looks normal. It's in the middle third of the esophagus. Diagnosis? Causes? Treatment?

Dx: pill esophagitis Causes: -NSAIDS (disrupts GI protection), -Tetracyclines (acidic medication) -Potassium chloride (osmotic tissue injury) Treatment: stop the medication

Patient has a tremor at rest. It goes away when he reaches for the remote. It become worse when engaged in mental tasks. Wine and coffee have no effect on the tremor. There are no other symptoms. Diagnosis? Where is the lesion?

Dx: pill-rolling tremor of parkinsons Lesion: basal ganglia Essential: worsen with movement that is goal-directed, bilateral, can involved chin, head, voice, trunk Physiological tremor: fine, worsened with stress and caffeine

Patient is young, obese, and lives sedentary lifestyle. He has pain over the intergluteal region. There is swelling and mucoid discharge. It is close to the level of the coccyx. Most likely diagnosis? Contrast?

Dx: pilonidal disease Contrast: folliculitis is many, pilonidal is one Abscess would have more systemic symptoms

Young patient has many white circular lesions on the plantar surface of her feet. She is sexually active with 2 people in the last year. Diagnosis? Etiology?

Dx: plantar wards Etiology: HPV infection

32 yo patient has 3 days of fever, malaise, cough productive of sputum (clear). He has no nasal congestion, rhinorrhea, sore throat, or chest pain. He has crackles at the lung bases and occasional expiratory wheeze. Likely diagnosis? Next step for diagnostic test?

Dx: pneumonia (no upper resp symptoms so less likely to be viral influenza) Next: CXR: that's diagnostic, then you can give abx

6 hour old baby has respiratory distress. He was born at 39 weeks gestation to a mother who had pre-eclampsia. Pulse ox is 96%, there is cyanosis at the lips, there is no cardiac murmur, X-ray is normal. What would be a likely diagnosis? What are the criteria? What are the complications? What is management?

Dx: polycythemia Criteria: hematocrit >65% Complications: neurologic (jittery, irritable, lethargy), respiratory (distress, cyanosis, apnoea), hypoglycemia, hyperbilirubinemia ruddy skin, abdominal distension Mx: fluids, glucose, partial exchange transfusion As a result of intrauterine hypoxia (IUGR, hypertension, smoking, placental insufficiency), delayed cord clamping, twin-twin transfusion, genetic causes (hypo/hyper thyroid, trisomies)

70 yo patient has pain in the neck, shoulders, and hips for last 3 months. It's worse in the morning. He has some weight loss. There's no headache, scalp tenderness, visual symptoms of jaw claudication. ESR is elevated. Diagnosis? Management?

Dx: polymyalgia rheumatica (pain, stiffness in morning <1 hr, elevated ESR) Mx: low dose steroids

50 yo lady has proximal muscle weakness, choking spells with water, and elevated CK. Diagnosis? Treatment?

Dx: polymyositis Tx: steroids--prednisone

33 yo lady has blisters on the back of both hands after gardening. She has had occasional blisters in the past. They're not too painful, but they do itch. She has hep C, and takes and OCP. Diagnosis? Underlying cause of skin lesions?

Dx: porphyria cutanea tarda Cause: porphyrin accumulation due to impaired metabolism

Mother is 4 weeks post partum. She is feeling down, fatigued, can't sleep, depressed. She has no thoughts of hurting herself or the baby. Diagnosis? Treatment?

Dx: post partum depression (after 2 weeks = depression; before 2 weeks: blues) Tx: SSRI

38 yo woman has depression and difficulty caring for their 3 week old son. She stares off and mumbles things slowly and softly. She has a history of bipolar disorder and is not taking medications. She says "I am a terrible mother. I can't save my baby from the devil." Dx: Mx:

Dx: postpartum psychosis (delusions about devil and mumbling to things not actually there) Postpartum psychosis is commonly seen with bipolar disorder Mx: medical emergency--risk of suicide and infantacide Women need hospitalization and antipsychotic medication

Patient (7 yo) has a painful, swollen eye. She has a high temp. Eye is tender, swollen, and erythematous, and there is an abraison below the eyelid. There is no pain on eye movement. There is no loss of visual acuity. Diagnosis?

Dx: preseptal cellulitis (There is a septal line between the orbit proper and the anterior orbit. If the infection is in the anterior portion, then it's called "preseptal." It's distinguised from orbital cellulitis by the absense of pain, visual changes, and lack of proptosis)

35 yo man patient has weakness, fatigue, weight loss, reduced appetitie, diarrhea. BP is 106/66. Serum Na: 130, K: 5.5 Likely diagnosis? Investigations?

Dx: primary adrenal insufficiency (PAI or addison's disease) Investigations: 8:00 am cortisol and ACTH assay But ACTH takes a long time, so to ACTH stimulation test (cosyntropin) If lack of response, suggests PAI

Patient 38 yo female has 3 week hx of weight loss, nausea, abdominal pain, and postural dizziness. She has been on oral steroids in the past for asthma. She has hypothyroidism. She has bilateral tonsilar enlargement, hyponatremia, hyperkalemia, hyperpigmentation and hypopigmentation in different areas of skin. Moderate eosinophilia. 8AM cortisol is decreased. Diagnosis? Cause?

Dx: primary adrenal insufficieny Cause: autoimmune adrenalitis (commonest cause of PAI) Not steroid withdrawal because steroids would cause supression of ACTH. This lady has hyperpigmentation/vitiligo, which is a sign of elevated ACTH, which is consistient with PAI. Also, steroids don't affect ADH, so you wouldn't get hypoNa and hyperK with steroid withdrawal

Patient 52 yo female has intense itching and fatigue. It's been a gradual onset. She also has hypothyroidism and carpal tunnel syndrome. She has no scleral icterus but does have excoriations and xanthelasma. Cholesterol is very high, alk phos is high. RUQ US shows no bile duct abnormalities. Likely diagnosis? Next step?

Dx: primary billiary cholangitis Next: anti-mitochondrial antibodies I got tricked because there was no jaundice. The cholesterol also threw me off--it can be elevated in PBC

Patient has hx of schophrenia. She stops taking her meds. She has a seizure. Eletrolytes show low Na, low K, low serum osmolality, low urine osmolality, low urine specific gravity. Diagnosis? Why?

Dx: primary polydipsia Bc: psych patients are more susceptible. If diabetes insipidus, the Na would be high (no ADH action to regulate that. If adrenal insufficiency, there would be hypotension and concentrated urine because ADH would still be working to hold on to water

Patient has hyperemisis, amenorrhea, beast fullness, and abdominal distension. She had a positive home pregnancy test. Two office pregnancy tests are negative. US shows a thin endometrial stripe. Diagnosis? Etiology? Management?

Dx: pseudocyesis (I just didn't read the last bit that said "two negative and thin endometrial stripe didn't register in my brain) Etiology: somatization of stress (d/t hx of infertility or previous pregnancy loss) Mx: psychiatric evaluation and treatment

34 yo patient has visual obscurations periodically. She goes blind for several seconds when standing up or changing head position suddenly. She has morning headaches. Likely diagnosis? What ocular features are most associated with this condition?

Dx: pseudotumor cerebri Features: papilledema (swelling of the optic nerve head) It is an emergency requiring immediate -Opthalmologic evaluation -Neuroimaging -Lumbar puncture with opening pressure Can lead to rapidly permanent vision loss

MS patient in a wheelchair has shortness of breath and left sided chest pain that started 2 days ago. They began suddenly. She has a normal leukocyte count Vitals: afebrile, normal BP, inc HR, 94% O2 sat Now she has reduced breath sounds and dullness to percussion at the left base "X-ray: small left pleural effusion with no infiltrate" Diagnosis?

Dx: pulmonary embolism

Patient has sudden onset weakness in right arm and leg. In the past month, he had episodes of weakness that resolved spontaneously. He has right sided hemiplegia and right lower facial paresis. He has normal ocular movement, normal speech, normal coordination, normal sensation. He names both right and left arms. Bedside visual testing is normal Diagnosis? Cause of symptoms?

Dx: pure motor hemiparesis Stroke in the posterior limb of left internal capsule Commonest cause: hypertension

Patient has right knee pain, right heel pain, and low back pain. He was recently treated for urethral discharge at an outside clinic. He is afebrile and vital signs are stable. Right knee is swollen, tender, and warm to touch. He has oral mouth ulcers. Synovial fluid analysis shows negative gram stain, but lots of polymorphonuclear leukocytes. Diagnosis? Treatment Contrast?

Dx: reactive arthritis Treatment: NSAIDs Contrast: not gonococcal septic arthritis because he's afebrile. Also, mouth ulcers and low back pain is more consistent with reactive arthritis Treat this with antibiotics

Child got adopted at age 2 after problems with birth mother and family. In her adopted family, she is distant, and she remains distant at school. She doesn't respond to comfort, plays quietly by herself, and cries for no reason. Diagnosis?

Dx: reactive attachment disorder

Patient has hematuria, fatigue, and fever. He has a 50 pack year smoking history. He has a left sided varicocele that doesn't empty when the patient is recumbant. Hb is 18, platelets are high too. Diagnosis? Test to confirm?

Dx: renal cell carcionma Test: abdominal CT Not bladder cancer because of the raised Hb and platelets (polycythemia) Also, the left varicocele that doesn't resolve

5 month old girl has failure to thrive (was at 50th centile at birth and is now at 5th). She has no diarrhea or vomiting. Newborn screening was normal. Family hx is significant for nephrolithiasis. Bloods show high Cl, low pH, low bicarb. Urinalysis shows high pH, normal K and normal Na. Diagnosis? Cause of failure to thrive?

Dx: renal tubular acidosis type 1 Cause: poor hydrogen secretion into the urine

Patient has stage 3 CKD and poor sleep. He feel spiders crawling on his legs at night. The sensation is relieved by walking around and massaging Diagnosis? Management?

Dx: restless leg syndrome (secondary causes: uremia (CKD), iron def anemia, parkinsons, medications (metochlopramide, antidepressants), pregnancy, diabetes) Mx: Supportive -Massage, heating pads, exercise -Avoid aggravation (sleep deprivation, meds) Medications to manage: -Pamiprexole (dopamine agonist) first line -Gabapentin

Patient has a recent cardiac catheterization procedure. 5 hours after the procedure, he has hypotension and tachycardia. He has weakness and back pain. He's diaphoretic, clammy, and neck veins are flat. He improves a little with IV fluids Diagnosis? Management?

Dx: retroperitoneal hematoma due to bleeding from the arterial access site and retroperitoneal extension. Confirm with CT abdomen and pelvis

Patient has fever and sore throat. Recently, she swallowed a fish bone. Past two days: difficulty swallowing and sore throat. Now she has neck stiffness, high temp, pooling of saliva in hypopharynx with a bulging posterior pharyngeal wall. Lateral radiograph shows increased thickness of prevertebral soft tissues with an air fluid level. Diagnosis? Complication risk?

Dx: retropharyngeal abscess Comp: acute necrotizing mediastinitis because it drains down with gravity

9 yo girl has sudden onset of writhing, jerking movements of the arms and hands, a sore throat that resolved spontaneously a month ago, pericardial friction rub, subcutaneous nodules over the hands, elevated ERS, PR depressions and diffuse ST elevation Diagnosis? Organism?

Dx: rheumatic fever (JONES criteria--O = <3 = pericarditis) Org: GAS; strep pyogenes

11 month old african american boy has failed closure of fontanelles, pliable skull bones with step-offs, bony prominences of costocondral joints bilaterally, genu varum. Diagnosis? Cause?

Dx: rickets Cause: vitamin D deficiency Features: -Failure to close fontanelles -Craniotabes (softening/thinning of skull bones) -Frontal bossing -Enlarged costocontral joints -Genu varum (bowed legs) -Metaphyseal cupping and fraying

Patient has fall on outstretched arm. His arm now hurts to abduct, extend, and externally rotate. It is painful to touch. Radial pulse is normal. There is no swelling, redness, or warmth of the joint. Likely diagnosis? How to confirm?

Dx: rotator cuff tear Confirm: MRI shoulder

Patient has a viral infection. Now he has confusion, dyspnoea, and cough. He has a high temp, resp rate, and pulse rate, bilateral crackles in the mid lung fields. 2/6 ejection murmur at upper sternal border. CXR shows alveolar infiltrates in mid lung fields bilaterally. Diagnosis?

Dx: secondary pneumonia with community associated methcillin resistant staph aureus

Patient has diarrhea ongoing. He has 5-6 nonbloody liquid bowel movements daily which sometimes awakens him at night. He has bloating. He had bowel surgery. Stool is brown and non bloody. Serum electrolytes are normal. The gap between measured and calculated stool osmolality is low. Diagnosis? Explain the measured and calculated stool osmolality gap?

Dx: secretory diarrhea Gap: measured is the same as the plasma osmolality. Calculated is sodium + potassium in stool x 2 (plasma osmolality) - (2 x (Na + K stool)) If it's a high gap, that means that there are umneasured ions in the stool, making it an osmotic diarreha. If it's a low gap, that means its secretory. Recent surgery can be cause of secretory diarrhea

6 yo boy just had dinner. He goes up to his room to sleep. He's asleep for 30 min and then is heard falling out of bed. His lips are blue, he is confused after. Diagnosis? Other features?

Dx: seizure Other: -Post ictal -Blue lips -During sleep -Tongue biting -Urinary incontinence

8 day old neonate has lethargy, hypothermia, poor feeding, full anterior fontanelle. Mother got prophylactic antibiotics for colonization with GBS before Cesarean section delivery. Likely diagnosis? Likely pathogen?

Dx: sepsis--meningitis Pathogen: GBS--most common

Patient is an IVDU. She has 3 day history of SOB, fevers, chills, pleuritic chest pain. She's HIV positive, has a temp, and crackles in both lung fields. CT shows nodular lesions with small cavities Diagnosis? Likely organism?

Dx: septic emboli from infective endocarditis (tricuspid bc IVDU) Org: staph aureus NB: TB would have more indolent course with fever, weight loss, etc. Septic emboli and IE can present without a murmur with IVDUs bc right side is less flow across the valve. They also often don't have the systemic manifestations

80 yo patient is lethargic and confused. She has been bed-bound from a stroke. She has a decubitus ulcer with purulent drainage and surrounding erythema. Temp is 36, BP is 74/48, pulse is 124, RR is 24. Pulm cap wedge pressure is 6 (norm 6-12) Venous O2 sat is 82% (norm 60-80) Diagnosis? Pathophysiology?

Dx: septic shock Pathophys: decreased afterload (peripheral vasodilation, distributive shock, decreased SVR, blood doesn't get O2 extracted from it well, so Venous O2 is high).

Patient recently finished 5th round of chemotherapy. On examination, light touching of the periumbilical area causes intense pain. Diagnosis? What will this patient likely develop?

Dx: shingles (varicella reactivation) Develop: vesicular rash in a dermatomal distribution

Newborn baby has crepitus at the clavicle, pain, and asymmetric Moro reflex. Diagnosis? Management?

Dx: shoulder dystocia and clavicular fracture Mx: reassurance (it will heal spontaneously), pinning arm to the torso, gentle handling

2 yo boy has a bad fever. He then has rhythmic convulsions for 3 minutes. He was sleepy and confused on arrival. Now he's alert and playful. Neck is supple with full range of motion. Diagnosis? Management?

Dx: simple febrile seizure (<15 minutes, rapid return to baseline) Mx: discharge home Advise: -No inc risk of epillepsy -Yes risk of having another febrile seizure -Antipyretics make child more comfortable, but do not decrease risk of future febrile seizures

Patient is anxious during meetings where he's presenting information, even though he's well prepared. He also doesn't want to go to the staff holiday party. He has turned down a promotion due to his stress. Diagnosis? First line treatment? Contrast?

Dx: social anxiety disorder First line: SSRI Contrast: if it's performance only (ie just when he's presenting) could consider propranolol. (beta blocker)

Patient is a gardener. He gets a papule on his right index finger that ulcerates and gives off an odorless discharge. He gets similar ones further up his arm. There are nontender subcutaneous nodules palpable on his right forearm. Diagnosis? What is the cause of this condition?

Dx: sporotrichosis Cause: dimorphic fungus from decaying vegetation

60 yo man has a sore on his lower lip. It's ulcerating. He is a farmer. There are no palpable lymph nodes. Likely diagnosis? What would biopsy reveal?

Dx: squamous cell carcinoma Biopsy: invasive cords of squamous cells with keratin pearls

Patient is a ballerina and is having shin pain on her right leg. She has a low BMI. There is point tenderness but no bony abnormalities. Diagnosis?

Dx: stress fracture Low BMI, potentially some hypogonadotrophic hypogonadism going on leading to low bone density. Not shin splints because that's more in runners and more diffuse, not point tenderness.

Patient is only shaves the right side of his face and only puts numbers on the right side of a clock. Diagnosis? Location of lesion?

Dx: stroke Location: right parietal lobe Spatial organization is on the right (non-dominant side). He is ignoring the left side, which makes sense when the fibers cross. Ignoring left side--lesion on right side. Only paying attention to right side, so ignoring left side, so lesion on right.

50 yo man has 2 day history of malaise, fever, fatigue, and pain in front of his neck. He recovered from a resp illness 1 week prior. He has a raised temp and his thyroid is diffusely enlarged. TSH is low, T4 is high, ESR is high. Diagnosis? Management?

Dx: subacute thyroiditis -Subacute because the infection 1 week ago probably set it off. -Presents with elevated ESR/CRP Mx: -Beta blockers for thyrotoxicosis -NSAIDs for pain NB: suppurative thyroiditis does not present with raised thyroid hormone--they're euthyroid.

Patient gets an injury to his left eye, leaving him blind. Now he's developing "floating spots" and blurred vision in his right eye. Inspection shows perilimbal flush. Diagnosis? Pathophysiology?

Dx: sympathetic ophthalmia Pathophys: damage to one eye causes breakdown of normal barriers of the eye in the damaged one. This leaves things (antigens) susceptible to sensitization. Antibodies can then develop against them and cause visual changes So "uncovering of 'hidden' antigens"

65 yo patient woke in morning with headache, and is progressively more incoherent over the course of the day. The day before, she had nausea and vomited. Three weeks ago, she was started on sertraline. BP is 110/70 without an orthostatic drop. No papilledema, mucus membranes are normal. Sodium is 119, everything else is normal Serum osmolality is low, urine osmolality is high, urine sodium is 56. Diagnosis? Cause of hyponatremia? Management?

Dx: syndrome of anappropriate ADH secretion (euvolemic, no orthostatic hypotension, hyponatremic, low serum osmolality, high urine osmolality with high sodium--means the body is holding on to water more than it should) Cause: start of SSRI Mx: fluid restriction Severe: ?salt tablets ?hypertonic saline

Patient has a painless genital lesion. It is raised with indurated margins and a smooth base. There is lympadenopathy. No other lesions are found. VRDL is negative and HIV is negative Likely diagnosis? Next step?

Dx: syphilis Fluorescent treponemal antibody absorption testing VRDL can have false negatives especially early.

Patient has schizoaffective disorder and has been on lithium and risperidone for 3 years. Recently, risperidone was increased. Now he has begun to make abnormal movements. He taps his foot repeatedly, protrudes his tongue, and smacks his lips Diagnosis? Next course of action?

Dx: tarditive dyskinesia Next: decrease risperidone and switch to clozapine NB: tarditive dystonia is prolonged contraction of a muscle, resulting in abnormal posture (torticollis is an example; the neck muscles contract, causing the head to twist to one side). Different from dyskinesia because dyskinesia is more like rolling, writhing movements and dystonia is prolonged contractions Tarditive dystonia can be managed with benztropine. NB: akanthisia is feeling of restlessness or inability to be still. It can look similar to dyskinesias. This can be managed with beta blocker

24 yo patient has chronic nonproductive cough. He also has back pain (dull). Imaging shows pulmonary nodules and retroperitoneal lymphadenopathy. Likely diagnosis? Confirmation?

Dx: testicular cancer (young male, metastatic presentation) Confirm: testicular US

Patient has surgery. Post op, she has tachycardia, nausea, vomiting, agitation, hypertension, fever, fine tremor, lid lag. She has no muscle rigidity and DTR are +2 Diagnosis? Next step in management?

Dx: thyroid storm (secondary to surgery) Management: Beta blocker, PTU, iodine solution, hydrocortisone (dec T4 - T3 conversion) Take thyroid hormone levels

32 yo patient has progressive weakness that began 18 hours earlier. It's in his lower extremities and worse in his left leg. There is no history of infection. He just returned from a hiking trip in Colorado. Cranial nerves and sensation are intact, but bilateral extremities are weak. Likely diagnosis? Confirm? Contrast?

Dx: tick-borne paralysis Confirm: meticulous search for a tick Tx: remove tick and resolution occurs Contrast: guillan barre syndrome This doesn't come on so fast (usually more like days to weeks--not hours) Sensation is usually abnormal CSF is abnormal (high protein with few cells--called albuminocytologic dissociation) Tx: IVIG or plasmapharesis

Patient gets medication and has a bad skin rash covering all of her back in the picture. Diagnosis? Contrast?

Dx: toxic epidermal necrolysis Contrast: less than 10%: steven-johnsons syndrome 10-30% is overlap of stevens-johnsons and TEN Treatment: wound care, similar to that for burns

Baby is born with macrocephaly and jaundice. The mother traveled to Zambia during pregnancy, and had an illness (fever, swollen glands, muscle aches). CT shows hydrocephalus, intracranial calcifications, elevated direct bilirubin. Diagnosis? Exposure to what made mom susceptible?

Dx: toxoplasmosis (calcification, ventriculomegaly. Jaundice and hepatomegaly are nonspecific) Exposure: undercooked meats or cats

Baby is born after having polyhydramnios. She gets respiratory distress when feeding. She has crackles of the right lower lung. X-ray shows a tube that stops. Diagnosis? Workup?

Dx: tracheo-esophageal fistula Workup: VACTERL (vertebral, anal atresia, cardiac, tracheo-esophageal, renal, limb abnormalities) If it were an isolated esophgeal atresia, then there wouldn't be resp distress with feeding. Also that is much more rare than T-E fistula

Patient has lower extremity swelling, feeling of pulsation in his neck when laying down. He had sick sinus syndrome 6 months ago and got a permanent pacemaker implanted. There is a 3/6 holosystolic murmur at the left sternal border. Lungs are clear to auscultation. Liver is enlarged. Diagnosis? Why?

Dx: tricuspid regurgitation (HOLOsystolic, not ejection systolic, so that's tricuspid regurg) Why: permanent pacemaker has leads that go in thru the tricuspid, making it more susceptible to regurg

34 yo patient has fatigue and easy bruising. He comes in with a bad nose bleed CBC shows: low Hb, low platelets, low leukocytes. PT and aPTT are prolonged Fibrinogen is low, LDH is high Diagnosis? Associated finding?

Dx: type of acute myeloid leukemia: Acute promyelocytic leukemia (presents with fatigue, coagulopathy, pancytopenia, elevated LDH) Associated finding: atypical promyelocytes in bone marrow (I got thrown off because the leuks were low. But turns out this can cause low leukocytes)

Patient has right adrenal mass, hypertension, hypokalemia, relatively normal Na, and aldosterone/renin ratio of 45. Diagnosis? He refuses surgery--treatment?

Dx: unilateral adrenal adenoma Tx: aldosterone antagonist -Spironolactone -Eplerenone

Patient is gravida 4 para 0 aborta 3 in constant lower abdominal pain. She had an abdominal myomectomy for removal of 15 leiomyomas for which the uterine cavity was entered. She is in labor. Fetal heart rate tracing shows variable decelerations. Diagnosis? Management?

Dx: uterine rupture (non-reassuring tracing and constant lower abdominal pain) Mx: Laparotomy and delivery NB: can't do vaginal delivery after a logitudinal or other procedure that enters the uterus. Only low transverse ceserean is a trial of labor warranted

Patient has episodes of nocturnal substernal chest pain that wakes her from sleep. There is sweating, nausea, palpitations, but no dyspnea. They last 10-15 minutes. She has no pain when walking up stairs. Extended ambulatory ECG shows transient ST elevation in leads I, VL, V4-V6 during episodes of pain. Diagnosis? Management?

Dx: vasospastic (Prinzmetal) angina Mx: calcium channel blocker (diltiazem)

Patient is a smoker 45 years old, and has nocturnal substernal chest pain that wakes her from sleep. Episodes last 10-15 minutes and resolve spontaneously. She has no other symptoms. ECG during a painful event shows ST-elevation in V4-V6. Diagnosis? What has a similar pathophysiologic mechanism?

Dx: vasospastic angina Similar mech: Raynoud's phenomenon Hyper-reactivity/vasospasm of smooth muscle. Both can be managed with CCB

Patient had an MI 2 months ago. Now for the past 2 weeks, he has progressive exertional dyspnea and fatigue. He has bilateral crackles. He has a faint systolic murmur over the apex. ECG shows normal sinus rhythm and deep Q waves with ST elevation. ECG is unchanged from 2 months ago. Diagnosis?

Dx: ventricular aneurysm 2 month time Persistient findings of Q waves and ST elevation is characteristic of ventricular aneurysm Aneurysm can then go on to cause valve problems

Patient has 2 days of back pain. He was moving boxes in his garage when the pain started. It is worse when coughing or straining and it is not relieved by lying down. Acetaminophen doesn't help either. Straight leg raise test is negative. He has tenderness at the fourth lumbar vertebrae. Diagnosis? Likely underlying condition?

Dx: vertebral compression fracture Underlying: osteoporosis--loss of bone mineral density

48 yo man has pain in right leg. He got a cut on the dock while sailing with a friend. Now he has throbbing foot pain, rigors, and is septic. He has edema, erythema of the wound with dark colored bullae and erythema going up the leg. He has hemochromatosis Diagnosis? Management?

Dx: vibrio vulnificus (ocean exposure and fast onset of necrotizing fasciitis) Mx: IV ceftriaxone and doxycycline

Patient has HIV. She has CD 4 count of 30. She has no thrush. She has very painful swallowing Diagnosis? Likely cause?

Dx: viral esophagitis (odynophagia--pain with swallowing; not dysphasia--difficulty swallowing) Cause: HSV (round ulcers) or CMV (linear)

22 yo girl patient has hypopigmented macules on her feet and hands and face. Some resolve, and some progress. Diagnosis? Association? Treatment?

Dx: vitiligo Association: autoimmune disease -Thyroid (Hashimoto's thyroiditis) -Lupus -Pernicious anemia -Addison's disease Treatment: Limited: topical steroids Extensive: oral steroids, or topical calcineurin inhibitors

Girl with anorexia nervosa is starting to get fed by total parenternal nutrition. She develops confusion, nystagmus, and difficulty walking. Diagnosis? Management?

Dx: wernikie's encephalopathy Mx: give B1 (thiamine) and then glucose. Feeding (glucose) before giving thiamine can worsen the condition

Patient has ileal resection. He says food does not taste the same. He has a skin rash with scaling and erythema around the mouth. No tenderness or JVD Diagnosis? Improve symptoms?

Dx: zinc deficiency Improve: zinc supplementation Syx: hypogonadism, impaired wound healing, impaired taste, immune dysfunction

14 yo girl has 8 days of fever, sore throat, malaise. No cough, nausea, or vomiting. Mom gave leftover amoxicillin and she got a rash over her body (px had taken amox perviously without a reaction). Exam: enlarged, erythematous tonsils bilaterally with thin white exudates. There is bilateral cervical lymphadenopathy. She has hepatosplenomagaly and an erythematous, polymorphous maculopapular rash Diagnosis?

EBV Amox causing a rash--seen in EBV It can cause exudate Hepatosplenomegaly

Patient has chronic kidney disease and low Hb. What might patient receive? What is a potential side effect?

EPO Side effect: hypertension

Patient is traveling to egypt. What vaccination is most important to receive? Contrast?

Egypt: hep A, B, and typhoid (North Africa) Contrast: yellow fever for sub-sarahan africa and equatorial south america

Patient has pelvic pain on and off for 8 months. Exercise makes it worse. She's been off oral contraceptives for 2 years and haven't concieved. Her uterus is normal sized, but there is a homogenous cystic appearing mass on the left ovary. Diagnosis?

Endometriosis (endometrioma--key is that it's homogenous and that she hasn't concieved off OCPs for two years)

Patient has GERD for 12 years. EGD shows barret's esophagus 6 months ago. He now has dysphagia to solid foods. Barium swallow shows and area of symmetric, circumferential narrowing at the distal esophagus. Explanation of this finding?

Esophageal stricture NOT adenocarcinoma. That develops after 20 years of GERD. Also, it would be asymmetric narrowing, not symmetric and circumferential

Male 43 yo patient has SLE. He feels burning chest pain at work when moving heavy things. Pain is relieved by rest. He has a history of GERD. Next step in investigation?

Exercise stress test. Likely atypical angina. SLE predisposes to atherosclerosis, so they can develop angina earlier. Resting echo would likely not show anything

Patient has fatigue, anxiety, difficulty sleeping. She has a history of menorrhagia, for which she takes OCPs. BMI is normal. Thyroid gland is normal. TSH is normal, and T4 is elevated. Explanation for laboratory findings?

Exp: OCPs increase thyroid binding protein, so that binds more T4. So serum T4 looks elevated, but actually free T4 is normal and she's euthyroid.

Parents come talking about their child who has restricted interests, specific routines that he doens't like to be interrupted, poor eye contact, and bullying in school because he's not able to play with them and enter into their conversations. What is the best response to the parents?

Explain the spectrum of developmental disorders and advise further investigation

Patient has abdominal pain, weakness, and is vomiting blood. She says she's too weak to walk. Neuro exam is 5/5 power in upper and lower extremities. When she's asked to walk, she is weak. She has another vomiting episode of blood, and the nurse finds her arm is cut. Diagnosis?

Factitious disorder

30 yo white male has a PE. He has swelling of his right leg Most likely predisposing factor or contributor?

Factor V leiden deficiency, which causes Activated protein C resistance So the factor V mutation makes it unable to respond to protein C. Protein C normally prevents clots by breaking down factor V, so if your factor V can't respond to protein C, then more factor V stays around and you get more clots

Patients are randomized into groups of receiving treatment with ramipril, amlodipine, or metoprolol. In addition, they are randomized into groups having different target BPs. What is the name of this kind of study design?

Factorial design study

Peds patient has HSP What are the features? What is the most common renal manifestation

Features: Lower extremity palpable purpura (non blanching) Arthralgias (pain on passive range of movement of hips) Abdominal pain/intususception Renal disease: hematuria is most common manifestation

Patient has altered mental status. He's agitated and disoriented. He was recently treated for a cold. He has a metabolic acidosis (raised anion gap) What features would you look for to determine the underlying cause? What is associated with envelope-shaped crystals?

Features: Methanol: osmolal gap and blindnes Uremic: renal failure and inc blood urea nitrogen DKA: ketones in urine and serum Propylene glycol: osmolal gap Isoniazid: drug ingestion/TB treatment Lactic acidosis: inc serum lactic acid Ethylene glycol: osmolal gap and ca ox crystals Salicylates: drug ingestion Envelope Ca Oxilate crystals: ethylene glycol poisoning

Patient has primary biliary cholangitis. Features? Complications?

Features: fatigue, puritis, xanthelasma, elevated alk phos, jaundice, cirrhosis, antimitochondrial antibodies Comp: malabsorption of fat soluble vitamins (resulting in osteoporosis or osteomalacia) Hepatocellular carcinoma

Patient has a solitary pulmonary nodule in the left upper lung field with 1 cm diameter. What is the process of working up this patient? (this patient had a previous X-ray that was normal)

First: compare to previous scans Next: (because there was no growth before) get a CT scan (if stable over 2-3 years, no further testing is required) Next: CT scan shows Benign --> serial CT scans to monitor Intermediate/suspicious --> biopsy or PET Highly suspicious --> surgical excision Things that increase suspicion: smoking history, patient's age, spiculated, size

Patient has bad MVC. He has resp distress and gets bilateral chest tubes. He has an x-ray that shows some rib fractures. Diagnosis?

Flail chest Mx: pain control, O2 supplemental, positive pressure ventilation or intubation

Patient has HIV and now has nephrotic syndrome. What is the most likely underlying disease?

Focal segmental glomerulosclerosis NB: memBranous nephropathy is associated with hep B (memB = hep B) HIV is the focus of many people concerned about infectious disease

8 yo patient has staring episodes. He turns his head to the right and does not respond to his name or to touch. It looks like he's chewing something. He is confused for 20 min after. Diagnosis?

Focal seizure that becomes generalized to cause loss of consciousness

What are these antidoes for? Fomepizole Methylene blue Sodium thiosulfate N-acetylcystine

Fom: alcohol intoxication (NB ethylene glycol) Meth blue: methemoglobinemia (dapsone or anesthetics causing cyanosis and resp depression) Sodium thiosulfate: cyanide poisoning (occupational exposure: mining or fire, causing severe lactic acidosis) N-acetylscystine: acetaminophen overdose

67 yo patient has difficulty performing his job at work. He's irritable, acts inappropriately, and gets into arguments with his boss for the first time in 20 years. Now he's distant, has cluttered, and wife says he's "not the man [she] married." He's not interested in his appearance, doesn't care about golf. 25/30 on montreal cognitive assessment. Diagnosis?

Frontotemporal dementia Not enough for depression. Acting inappropriately would have been the thing that tipped me off that I didn't see in the stem

5 yo boy is exposed to friends with chickenpox. His last well-child visit was age 3. He is asymptomatic. Next step?

Give varicella vaccine he's not completely immune. He had exposure, give vaccine. If immunocompromised, could give varicella immunoglobulin

54 yo man is having a routine visit. He has T2DM with hypertension. He needs vaccines. He got a booster Td 12 years ago. Which ones would you give? PPSV23, influenza, and Tdap

Give: -PPSV23 (NB) -Influenza -Tdap (it doesn't say he got Tdap, just booster, so he needs one Tdap before going back to boosters) NB: PPSV23 in the following patients <65 -Diabetes, chronic heart, chronic lung, chronic liver disease -Smokers and alcoholics If >65, should get the sequential PCV13 then PPSV23 If high risk and <65, should get sequential High risk: -CSF leaks, cochlear implants -Sickle cell disease, asplenia -Immunocompromised (HIV/malignancy) -Chronic kidney disease

28 weeks gestation woman is going into labor. What do you give her? What do you have to watch out for?

Give: -Steroids -Tocolytics -Magnesium sulfate (protects from CP) Watch out: in general, tocolytics include nifedipine (CCB) and indomethacin, but in <28 weeks, nifedipine with magnesium sulfate carries the risk of respiratory depression

Elderly lady with hx of dementia becomes delirious secondary to UTI. What do you give her to manage it?

Give: haloperidol

Patient has acute pain in left knee joint. She had wrist pain 4 days ago and left ankle pain 2 days ago. No recent resp illness, diarrhea, urinary symptoms or vaginal discharge. She has a temperature. There is tenderness, warmth, and erythema on palpation. Synovial fluid analysis shows 50,000 white cells with mainly neutrophils. Diagnosis/Cause?

Gonococcal septic arthritis Primary infection is usually asymptomatic Also, non-gonococcal arthritis usually isn't poly articular nor migratory

What is the best test for hep B infection?

HBsAg and anti-HBc IgM antibody HBsAg is the first marker to appear in the serum IgM anti-HBc appears shortly thereafter, and remains high between the window period of HBsAg disappearing and anti-Hbs appearing. So that's why it's good to test for both

22 yo man comes because his partner wants him to get screened for STIs. Which is the main STI he should be screened for? What test?

HIV P24 antigen and HIV antibody testing

HIV patient has changes in personality and bizzare behaior. He's alert and oriented to person, place, and time. He can't count backward from 100 by 7's or spell "world" backward. MRI shows diffuse increased intensity of white matter. Diagnosis? Contrast:

HIV associated neurocognitive dysfunction Contrast: progressive multifocal leukoencephalopathy presents with altered mental status, motor defects, ataxia, and vision abnormalities. MRI shows focal, asymmetric (not diffuse like this patient) lesions

Patient has unexplained thrombocytopenia. There are no clumping or malignant cells. What should you be looking for?

HIV infection Hep C infection

4 month old has PCP pneumonia. Also has candida. Lymphocytes are 18,000, Neutrophils are 50%, lymphocytes are 45%. Diagnosis?

HIV of infancy. I guess I was thinking you can't diagnose it that early, but it's just that they will have maternal antibodies, so you can't use that as your diagnostic test. They could still have HIV and suffer the consequences of opportunistic infections

Patient has has HIV for a long time. His mental status is decreasing. He is forgetful. He has subtle jerky movements when trying to walk. Diagnosis?

HIV-associated dementia

Patient has syncope and crescendo-decrescendo murmur at the left sternal border. Diagnosis?

HOCM

Patient needs oral hormone replacement therapy. She also has hypothyroidism and takes levothyroxine. How will HRT affect her thyroid status and levothyroxine dose?

HRT causes decreased clearance of thyroid binding globulin. This results in more thyroid binding globulin in circulation. Because there's more thyroid binding globulin in circulation, more levothyroxine will be bound by it. So end point: need more levothyroxine--increase the dose

19 yo college student has pain in his right hand for several days. He's been feverish and tired. he has a history of follicular abscesses requiring drainage. He is highly sexually active. He recently started gardening. Examination shows vesicular lesions. Diagnosis?

HSV herpetic whitlow Recurrent infections--could be immunocompromised. Exposure when heavy sexual activity

Patient has tourette's syndrome. Management?

Habit reversal therapy first Risperidone or other D2 receptor antagonists like haloperidol or pimozide Alpha 2 receptor blocker (clonidine)

Patient has parkinsons and is started on treatment. What are most likely side effects in early treatment?

Hallucinations, dizziness, headache, agitation Late side effects: involuntary movements

Patient has bipolar disorder. Recently, he's become confused, had vomiting, become tremulous, and had difficulty walking. He recently started atenolol and hydrochlorothiazide for coronary artery disease and HTN. He has been stable for many years on mood stabilizers and antipsychotics. What has likely happened? What is responsible? What are other potential side effects?

Happened: interaction between hydrochlorothiazide and lithium. Lithium is responsible Other side effects of lithium toxicity: Acute: -Nausea, vomiting, diarrhea -Neuro sequelae Chronic: -Confusion -Agitation -Ataxia -Tremors/fasiculations Mx: hemodialysis for severe

Patient had an MI 6 months ago. He now is having dyspnea, shortness of breath, and lower extremity swelling. He has jugular venous distension, crackles, and lower extremity pitting edema What has happened? What would ECG show?

Happened: left ventricular aneurysm ECG: persistient ST elevation and Q waves

Patient has periorbital edema and abdominal distension. Exam shows ascites and lower extremity edema. Protein excretion is >4g/day. The patient suddenly develops right sided abdominal pain, fever, and gross hematuria. What happened What is the diagnosis?

Happened: renal vein thrombosis -Acute -Presents with abdominal pain, fever, and hematuria Dx: membranous glomerulopathy (most common cause)

Patient has an MI. When discharged, his echo shows 50% ejection fraction. Two years later, the patient dies, and autopsy shows a dilated left ventricle with globular shape and thin walls along with a scar on the anterior wall. What has happened? What could have prevented this?

Happened: ventricular remodeling (resulting in thin wall, dilation, scaring) Prevent: ACE inhibitor I thought that a thrombus formed, but no, it's the remodeling they're asking about

Patient has systemic sclerosis and respiratory problems (shortness of breath on exertion). Her FEV1 is 95% predicted. Her FEV1/FVC is 84%. Doppler echocardiography shows pulmonary artery pressure of 65 mmHg (elevated) What is happening? What would lung biopsy show?

Happening: pulmonary artery hypertension, but not fibrosis because the FEV1 is normal. Biopsy show: pulmonary artery intimal hyperplasia

Patient has acute onset of vomiting, diarrhea, headache. She has a temperature (103), hypotension, and tachycardia. There is an erythematous, macular rash covering the entire body, including the palms and soles. Do you know what is happening? What is the likely microorganism causing this? Hint: she got off an international flight from southeast asia, she uses OCPs, and she is on the 3rd day of her menstrual period.

Happening: toxic shock syndrome Organism: staph aureus Associated with prolonged tampon placement. I thought syphilis, but that is secondary syphilis and would have a much longer, indolent course. This was acute.

Patient has pulmonary hypertension. She also has a reduced ejection fraction of 30%. She has peripheral edema and bibasilar crackles. What does she have? Secondary to what? Management?

Has: pulmonary hypertension Secondary to: LV failure Mx: diuretics and ACE inhibitors Endothelin receptor antagonists (bosentan) and phosphodiesterase 5 inhibitors (sildenafil) are for symptomatic idiopathic pulmonary hypertension

42 yo man has HIV. He's sexually active with men. His CD4 count is 670. What vaccinations can he get? He doesn't have immunity to Hep A, and he got Tdap 5 years ago following a motor vehicle accident. What vaccine should he get specifically?

He can get all vaccinations with CD4 > 200 Specifically: Hep A because he's at high risk (MSM) and he's at risk of liver failure. He doesn't need Td booster yet (?)

Patient comes in with malaise and palpitations on a background of T2DM and hypertension. BP is 170/90. ECG shows afib with fast ventricular response. Management?

Hemodynamically stable, so medical mx. -Beta blocker -CCB (diltiazem)

Patient's armpit has big nodules but don't look super infected. Diagnosis?

Hidradenitis supurativa In intertrigenous areas. D/t chronic infalmmatory occlusion of folliculosebacious units, which prevents keritnocytes from properly shedding

8 yo patient has sickle cell vaso-occlusive crisis. What would you expect to see on blood smear (besides sickled cells)?

Howell-Jolly bodies Why: because a functional spleen removes normal nuclear remnants of RBCs. If the spleen is not functional in a vaso-occlusive crisis, these howell-Jolly bodies will be present

Pregnant lady has hypertensive emergency. Management?

Hydralazine. She also had bradycardia, so labetolol wouldn't have been choice

Patient has proximal muscle weakness, tachycardia, weight loss, anxiety, irritability. Diagnosis?

Hyperthyroidism (thyroid disease)

Alcoholic patient is in for weakness, anxiety, and tremors. He appears disheveled and malnourished. He has low K. He gets fluids and supplemental K, but it's still low. Why?

Hypo Mg causing refractory hypo K. Alcoholics can often have hypoMg. With hypoMg, it causes increased renal losses of K, leading to refractory hypoK.

Patient has low calcium and is alcoholic. Cause of low calcium?

Hypomagnesemia It affects PTH release (hypoMg degreases PTH release) Hypophosphatemia itself doesn't cause hypocalcemia

Patient has fatigue and weakness. There is decrease in appetite, cold intolerance, dull headache, consipation, erectyle dysfunction, low libido. Glucose is low. Na is low-ish, K is normal. Diagnosis? Free T4? Serum cortisol? Serum aldosterone?

Hypopituitarism (low thyroid, low gonadotrophins, low ACTH and cortisol) T4: low Cortisol: low Aldosterone: normal (hence low Na and normal K--secreting it to hold on to fluid. If aldosterone were not functioning, then K would be elevated)

Patient has obvious RV MI. What is management?

IV fluids Increase preload volume in the RV, which helps cardiac output. Don't give nitrates--that decreases RV preload more, making things worse. Probably best to avoid beta blockers also.

Patient has WPW. Now he has afib. Management?

If unstable: electrical cardioversion If stable: give procainamide Don't give CCB like verapamil because that can worsen the conduction through the accessory pathway. and yes, AF can be a result of WPW accessory pathway. It has a high risk of progression to VF

Patient has a history of asthma, eczema, and multiple episodes of pneumonia. She gets a blood transfusion and has an anaphylactic reaction (requiring IM epi). Underlying condition?

IgA deficiency

Patient has bell's palsy. What is a manifestation of lesion of the involved nerve below (downstream of) the pons?

Inability to close the eye Loss of nasolabial fold Droop of the affected lip-side

Patient has obvious pneumonia on the left side. When lying on the right, O2 sats are 94. When lying on left, O2 sats are 85. Why the difference?

Increased R to L pulmonary shunting Gravity causes blood flow to consolidated lung, which decreases oxygenation (severe ventilation/perfusion mismatch) and causes a R to L pulmonary shunt

Patient has depression. How does this affect cortisol? How does this affect slow wave sleep and REM latency?

Increases (increases hypothalamic-pituitary-adrenal axis) Slow wave sleep: decreased REM latency: decreased

Patient has COPD and X-ray shows diaphragmatic flattening. How does this affect breathing?

Increases work of breathing because it can't contract and expand the chest as much. Diaphragm becomes flat because the alveoli lose their elasticity and don't expel air as well, making more air get trapped in the lungs

Patient is on tamoxifen. What is the indication? What are the side effects?

Indication: hormone receptor positive breast cancer (estrogen antagonist) SE: -Hot flashes (think ER antag, causing sx of menopause) -Venous thromboembolism -Endometrial hyperplasia and carcinoma

What are the indications for long term oxygen therapy in COPD patients? What is the result?

Indications: Without right heart failure, cor pulmonale, or hematocrit >55% -PaO2 <55mmHg -O2 saturation <88% WITH right heart failure, cor pulmonale, or hematocrit >55% -PaO2 <59 -O2 sat <89% Result: survival benefit

Patient has chorioamnionitis and is 2 cm dilated Management?

Induction of labor

Patient has hypotension, bradycardia, kussmal sign (inc of JVD with inspiration), ST elevation in II, III, aVF, and T ST depression in I and aVL. Diagnosis?

Inferior wall MI Right ventricular MI

Patient has HIV. What vaccinations should you ensure they have?

Influenza (always) HBV (unless they have immunity) Streptococcus 13 valent; then 23 valent 8 weeks later. Then again in 5 years and at age 65 Varicella

Patient is admitted for acute pancreatitis. He develops respiratory distress (ARDS) He's intubated and ventilated What would be the initial settings? Then his PaO2 is 105 (75-105), and his PaCO2 is 37 (low normal) What should be done next? Why?

Initial: -FiO2: 0.8 (80%) -RR: 14/min -PEEP: 7 cm H2O Next: since the FiO2 was high, decrease it to 0.6, and his PaO2 is high, so another reason to decrease Why: risk of oxygen toxicity (free radical formation and atelectasis)

Mother is worried about her potential for thallasemia. What is the initial test that should be done. What after that?

Initial: CBC Next: iron studies (Fe, TIBC, ferritin) -Normal in thallasemia -Abnormal in iron def anemia Then: electrophoresis

SLE patient is on medication Initial meds? Those don't work. What can be added? What are the main side effects of the added?

Initial: hydroxychloroquine and prednisone Added: cyclophosphamide Side effects: -Hemorrhagic cystitis -Bladder carcinoma -Sterility -Myelosuppression Avoid with MESNA and fluids

72 yo patient suddenly drops her fork, has slurred speech, right sided weakness. Later, she has vomiting, stupor, and decreased level of consciousness. She has a history of hypertension and diabetes and coronary artery disease. What happened? Why?

Intercerebral hemorrhage Why: acute focal neurological deficit, progressing to more general symptoms of increased ICP

Patient has pain in the right forefoot that's getting worse. She doesn't remember an inciting event. Everything else is normal. She has a clicking sensation when the third and fourth metatarsals are squeezed together. This reproduces her pain in the plantar surface. Diagnosis?

Interdigital (Morton) neuroma Mechanically induced neuopathic degeneration of the interdigital nerves that causes numbness, aching and burning

48 yo patient has "copper colored" fluid coming from her right nipple. She has no palpable masses. She is on an antipsychotic. What is the cause of her discharge?

Intraductal papilloma Unilateral, bloody = intraductal papilloma (most common) NB: antipsychotics would cause bilateral milky discharge. This is brown and bloody and unilateral.

Patient has confirmed infective endocarditis with strep mutans (viridans group strep). He is started on IV vancomycin. Later, it is confirmed susceptible to penicillin. What is the next best step in management?

Keep the abx IV: -IV penicillin G (every 4-6 hrs or continuous inf for 4 weeks) -IV ceftriaxone (once daily for 4 weeks) ---IV cef is preferred because it's just once daily dosing as opposed to pen G which is every 4-6 hours

Patient has periodic confusion. She has seen strangers in the backyard that no one else has seen. She has been walking more slowly. She has mild bilateral hand tremors and rigidity in the lower limbs. MRI shows cortical atrophy. Diagnosis?

Lewey body dementia

54 yo postmenopausal woman has increasing genital pruritis and burning. She scratched to the point that she bled. Labia majora are pale, excoriated, and thin. Labia minora are not visible. There is narrowing of the introitus. The perianal skin is pale white and appears crinkled. Diagnosis?

Lichen sclerosis *-Perianal skin like "cigarette paper" (ie crinkled)* -White, thinning skin -Lack of labia minoa -Narrowing of interoitus NB: vulvovaginal atrophy does NOT involve the perianal skin (so this should have been obvious)

7 yo patient has sore throat, poor appetite, and malaise for the last 2 days. Immunizations are up to date. Temp is raised, tonslis are swollen and covered with thin, white exudates. Anterior cervical lymph nodes are small and tender. Likely diagnosis? Next step?

Likely diagnosis: strep pharyngitis Next: rapid strep antigen test

Patient has abominal pain and cramps with bloody diarrhea, decreased appetite. Symptoms have been more severe. Temp raised, BP low, pulse high. Abdomen is distended, there is diffuse tenderness on palpation and decreased bowel sounds. No rebound. Mucus mixed with blood is in the rectal vault. Labs: mainly high leukocytes. What is the most appropriate next step in management?

Likely dx: UC, but this very severe presentation is most likely Toxic megacolon (fever, tachy, hypotension, bloody dia, marked colonic distension) So next: abdominal x-ray Then next mx: -NPO -NG suction/decompression (?) -Antibiotics -Corticosteroids (since IBD) -Surgery if unresponsive to mx

Patient has had bouts of ventricular tachy and has an ICD. He is now getting PFTs before starting another drug. What drug is most likely? Why?

Likely: amiodarone Why: it causes interstitial pneumonitis so it's good to have baseline function before starting to determine if the drug is causing this adverse effect

Patient has dysphasia to solids and liquids. He has weight loss and 20 pack year smoking history. CXR shows widened mediastinum. Barium shows dilated esophagus with smooth tapering of the distal esophagus. Likely diagnosis? Investigation?

Likely: pseudoachalasia due to tumor Ix: upper GI endoscopy

Patient has intracerebral hemorrhage. There is Right weakness, Right numbness, and left conjugate gaze palsy. Likely diagnosis?

Likely: putaminal hemorrhage

Young (7 yo) CF patient has pneumonia on background of influenza. Most likely organism? Empiric antibiotic?

Likely: staph aures Emperic: need to cover for MRSA bc of recurrent infections and likely colonization with MRSA. IV vanc Other option: 4th gen ceph--cefepime

Patient has schizoaffective disorder and is on lithium, risperidone, sertraline, and cephalosporin for infection. He's started on ibuprofen and acetominophen He becomes tremulous, uncoordinated. He develops diarrhea and vomiting and has fasiculations and a fine tremor bilaterally. An adverse effect of which medication is causing this?

Lithium Diarrhea, vomiting, fine tremor, ataxia

Patient is stabbed in the back. He has no motor activity on the right lower limb, but normal on the left. He has loss of light touch and proprioception below the right costal margin. Pinprick is absent on the left below the umbilicus. Where is the location of the injury?

Location: right T 8 Remember that pain and temp cross over early, but ascend a bit before.

Patient has been schizophrenic for a long time since birth. What might you see on neuroimaging?

Loss of cortical tissue volume Increased ventricular enlargement Decreased amygdala Decreased hippocampus

Patient has been on high dose steroid for a long time and has cushingoid appearance. He decides he doesn't like it and stops them abruptly. Now he has nausea, loss of appetite, fatigue, weakness. What would you expect him to be low or normal in? How would that affect electrolytes? Why?

Low in: ACTH and cortisol Normal in: aldosterone Why: because aldosterone is not controlled mainly by the hypothalamic pituitary axis. It's controlled mainly by the renin-angiotensin-aldosterone system, so it would be normal. Effect on electrolytes: Na normalish, K normalish Contrast to primary hypoadrenalism, which would cause Na hyponatremia and hyperkalemia

Guy is at a party, takes something, then becomes disoriented, flushed, and is sweating profusely. He has a seizure. He has a hx of depression and is on an SSRI. He is tachycardic, hypertensive, pyrexic, flushed, diaphoretic, has clonus and hyperreflexia. Na is 121. Urine tox screen is normal. Diagnosis?

MDMA aka ecstacy ingestion -Stimulant (synthetic amphetamine--tachy, hyper tensive, pyrexic) -Interacts with SSRI to cause serotonin syndrome (diaphoresis, clonus, seizure, hyponatremia)

Patient has medullary thyroid cancer. He also has marfanoid habitus. He has neuromas on his lips and tongue. Diagnosis?

MEN 2B

Patient has symptoms that sound like MS. She gets an MRI and it shows areas of demyelination. She currently has symptoms. Diagnosis? Next step?

MS Next: give high dose IV steroids (methylprednisolon) No need for LP and oligoclonal band analysis bc diagnosis is already clear

Patient has depression. Starts on 50 mg sertraline, then gets a higher dose to 100 mg. After the 100 mg does, he feels better. He asks when he can come off. Plan?

Maintain for 6 months at dose that was effective (continuation phase for single episode, unipolar major depression) Then taper If severe depression (which this patient wasn't) can continue for 1-3 years

Patient suffered the death of his wife. He has no energy or appetite for the last 3 months. He's lost weight. He has headaches and is convinced he has a brain tumor. He thinks he's being punished by God. He speaks slowly and doesn't enjoy work anymore. Diagnosis?

Major depressive disorder with psychotic features "punishment" and "tumor" are psychotic features

What defines malignant hypertension? What defines hypertensive encephalopathy? What are these both called? What is hypertensive urgency?

Malig: papilledema, retinal hemorrahges, exudates Encephalopathy: cerebral edema with non-localizing neurologic symptoms and signs Both called: hypertensive emergency Urgency: BP > 180/120 with no symptoms

Patient ingests Na-OH based drain cleaner as an attempted suicide. He has difficulty swallowing saliva and is drooling. Pulse is 110, but vitals are stable. There is oropharyngeal erythema and edema. Lungs are clear to auscultation. Tender abdomen, no X-ray abnormalities. Manage this patient?

Manage caustic ingestion: -Stable--no need for intubation -Remove exposures -Evaluate for perforation (X-ray, water-soluble contrast enema) -No perforation and stable: ---Upper GI endoscopy in 12-24 hours to assess for degree of damage (supportive measures, or if severe: tube feeds or surgery) NB: Don't give charcoal bc the mech of damage is immediate to the mucosa, so preventing absorption doesn't do anything. also charcoal will obstruct the view. Don't give neutralizing solution--can cause a reaction that could make things worse. Also the stomach has a lot of acid anyways Don't cause vomiting--that will re-expose the px to the chemicals

Patient has acute angle glaucoma. How do you manage? What do you avoid?

Manage: timolol (dec aqueous humor), manitol, acetazolamide, pilocarpine (constrict, gives more room for drainage). Avoid: atropine (dilates, that causes less space for drainage)

What are diseases that can have marfanoid appearance? What are features that distinguish them?

Marfan's syndrome -Ectopia lentis (anterior dislocation of eye???) -Aortic root dilation Ehler Danlos -Poor wound healing/wide scars -Easy bruising MEN 2B -Pheochromocytoma -Medullary thyroid carcinoma -Intestinal neuromas (leading to GI symptoms)

Patient is anxious, feels like he can't breathe, and like he's going to die. He has 3 mm pupils, conjunctival injection, dry oral mucosa, and healed scar on right thigh. Diagnosis?

Marijuana intoxication NB: conjunctival injection and dry oral mucosa with the anxiety

Patient has DKA. How do you monitor their response to treatment?

Measure serum anion gap and Direct assy of beta-hydroxybutyrate

By what mechanism does hyperventilation improve ICP?

Mech: causing cerebral vasoconstriction Hyperventilation causes decrease CO2 in circulation. Normally, if there is high CO2, the vessels vasodilate to get more flow to get more CO2 out. So this vasoconstricts, decreasing flow, decreasing the amount of blood there, and that decreases pressure

Patient has hx of PE and now has a DVT. It is found that she has elevated homocysteine. What are mechanisms of how homocysteine can be elevated? What can be done to prevent elevated homocysteine?

Mech: defect/deficiency in metabolic pathways -Homo --to-- methionine using methionine synthase and *VB12* as cofactors -Homo --to-- cysteine via cystathione beta synthase and *VB6* as a cofactor So to prevent elevated homocysteine: give VB6 (pyridoxine) with/without VB12.

Patient has a crush injury. Then succinylcholine is used for rapid sequence intubation. Mechanism of succinylcholine? Risk to health?

Mech: depolarization of post synaptic ACh receptors, causing influx of Na and efflux of K. This puts more K outside of cells. This could cause hyperkalemia, especially in the setting of a crush injury. And hyperkalemia could result in cardiac arrythmias

32 yo man has decreased libido and erectile dysfunction. He's on rispiridone, and schizophrenia is under control. He has weight gain and gynecomastia. Mechanism for decrease libido? Other pathways and their functions?

Mech: inhibition (decrease) of dopiminergic tuberoinfundibular pathway Other: Mesolimbic: responsible for the symptoms of schizophrenia--when agents block the dopamine receptors in this pathway, they're doing their job. So it causes euphoria, hallucinations Nigrostriatal: responsible for movement Tuberoinfundibular: responsible for sexual related things (libido, amenorrhea, galactorrhea, gynecomastia)

2 yo boy has painless maroon colored stool in diaper. He's been eating and drinking well, but has been more tired lately. Abdomen is soft, nontender, no palpable masses, no fissures or hemorrhoids. Labs are normal. Likely diagnosis? Test to confirm?

Meckel's diverticulum (due to incomplete obliteration of vitiline duct and heterotopic gastric tissue. gastric tissue secretes HCl and causes ulceration and bleeding) *Technetium 99m pertechnetate scan* -Detects ectopic gastric tissue

Patient has medium-large esophagral varices. Talk about management?

Medical: -Beta blockers (nonselective like nadolol or propanolol. They block the adrenergic vasodilatory response of the mesenteric arterioles. This results in unapposed alpha adrenergic tone, vasoconstriction, and reduced portal blood flow. The decreased portal flow decreases varices. -Endoscopic Variceal Ligation If these fail, then you could go to surgery: transjugular intrahepatic portosystemic shunt

Patient has SLE. What medication should she be started on? What needs to be monitored on this medication?

Medication: hydroxychloroquine Monitor: retinal toxicity; do periodic eye examination

Patient is going to India and needs malaria prophylaxis. What would you recommend?

Mefloquine >2 weeks before travel, continuation during stay, and continuation 4 weeks after return Chloroquine is one but there is a lot of resistance to it, so NO

37 yo has intense periumbilical pain with nausea and vomiting. He has had 2 bowel movements. He's an IVDU and has infective endocarditis. On palpation, there is mild, diffuse tenderness present. Diagnosis?

Mesenteric ischemia The pain is intense, but early in the disease, physical exam in unremarkable

Patient has weakness, tingling, numbness of her extremities. BP is low, HR 90, phys exam is unremarkable. Bloods: Na, K, Cl are low. Bicarb is high. pH is high Urine: Na is low, Cl is low Diagnosis?

Metabolic alkalosis. Because it's low Cl, it's due to vomiting. (I got confused because urine Na was low. Yes, urine Na would be low because you'd be trying to hold on to all the urine you could)

42 yo man is brought to the ED for assulting his wife. He hasn't slept or eaten for days. He has delusions, and feels like there are bugs under his skin. He was hospitalized 8 months ago for paranoid delusions and visual hallucinations. He's thin with poor grooming and dentition. He picks at his skin and has multiple sores on his face and body. He has elevated pulse, BP, temp, and dilated pupils. Diagnosis?

Methamphetamine abuse -Tactile hallucination -Agression -Scratching and sores with tooth decay -Sympathetic overactivity (BP, HR, temp, dilated pupils)

Patient is hyperthyroid and is started on methimazole. What is the greatest risk of this medication? What is a high risk of PTU?

Methimazole: agranulocytosis PTU: liver failure

Patient has a middle mediastinal tumor. Differential? What about anterior mediastinal tumor? What about posterior mediastinal tumor?

Middle: -Bronchogenic cyst -Tracheal tumors -Pericardial cysts -Lymphoma -LN enlargement -Aortic aneurysms of the arch Anterior: -Thymoma (NB myesthenia gravis) -Retrosternal thyroid -Teratoma -LN enlargement Posterior: -Neurogenic tumors (meningocele, enteric cysts, lymphomas, diaphragmatic hernias, aortic aneurisms) -Esophageal leiomyoma

What are the primary causes for nephrotic syndrome? In other words: What are the main differentials? What are each of their associations?

Minimal change disease, Membranous nephropathy, Membranoproliferative glomerulonephritis, Focal segmental glomerulonephritis, IgA Nephropathy Minimal change disease: NSAIDS, lymphoma Membranous nephropathy: adenocarcinoma (breast, lung), NSAIDs, Hep B, SLE Membranoproliferative glomerulonephritis: Hep B and C, lipodistrophy Focal segmental glomerlulosclerosis: African American, Hispanic, obesity, HIV, heroin IgA Nephropathy: upper respiratory tract infection NB: focal segmental glomerulosclerosis is the most common cause of nephrotic syndrome in adults

Patient has hodgkins lymphoma and now has nephrotic syndrome. Underlying cause?

Minimal change disease--associated with hodgkin's lymphoma

Patient takes in too much salcylates What will their ABG show?

Mixed metabolic acidosis and respiratory alkalosis, resulting in *near normal pH* Especially if the CO2 is down in the 20s

Patient has acidosis. Bicarb is low, and PaCO2 isn't as low as it should be to compensate. Diagnosis?

Mixed metabolic and resp acidosis

Elderly lady in nursing home has urinary incontinence. What are potentially reversible causes that you would need to investigate?

Mnemonic: DIAPPERS Delirium Infection (UTI) -- so do urine analysis Atrophic urethritis/vaginitis Pharmaceuticals (alpha blockers / diuretics) Psychological (depression) Excessive urine output (diabetes, CHF) Restricted mobility (post surgery) Stool impaction

CT scan shows obvious aortic dissection. Management?

Mx: -Analgesia -Decrease BP with IV beta blocker ---Propranolol, esmolol, nadolol ---This decreased BP and HR, which is what you want bc it decreases vascular wall stress and prevents propagation of dissection -Sodium nitroprusside if that doesn't work -Urgent surgery if ascending

Patient is delirious, especially at night. Management?

Mx: -Avoid polypharmacy and physical constraints -Maintain normal sleep/wake cycle (reduce night time disturbances) -Provide frequent reorientation -Treat underlying cause

Patient has an exacerbation of COPD. Management?

Mx: -O2 (if low O2 and all that) -Bronchodilators: salbutamol -Oral corticosteroids (methylprednisolone) -Antibiotics -Oseltamivir if influenza infection -CPAP is not sufficient -Intubation if still insufficient

Patient has acute lumbar muscle strain causing back pain. Management?

Mx: -Short corse of NSAID or acetaminophen -Maintain moderate activity -Consider muscle relaxant, spinal manipulation, brief course of opioids Chronic: consider exercise therapy along with intermittent NSAIDS. Also consider tricyclics or duloxetine

15 day old boy has green vomit. He passed meiconium on day 1. He has had normal daily stools. He has dry mucus membranes and his abdomen is distended Management? (in the question, it said abd x-ray shows gasless abdomen) Next step?

Mx: Initially: NPO, NG decompression, IV fluids Imaging: abdominal x-ray first -Free air? --> perforation --> go to surgery -Dilated loops of bowel? --> obstruction or meiconium ileus --> contrast enema -Double bubble? --> duodoneal atresia -Non-specific? --> malrotation or volvulus Next: upper GI series with contrast (barium swallow)

25 hour old boy has bilious vomiting. BP: 80/50, HR: 154, RR is 46. There is no stool in the rectal vault. X-ray of abdomen shows dilated loops of bowel with no rectal air and no free air. Management? Diagnosis? Next?

Mx: NPO and NG decompression Dx: likely meiconium ileus Next: contrast enema with imaging Should see microcolon (meiconium stuck at terminal ilieum so no stuff gets into the colon and it remains small

Patient has uric acid stones. Management?

Mx: alkalize the urine with potassium citrate That helps dissolve the stones

Patient is on antipsychotics and develops neuroleptic malignant syndrome. Management?

Mx: bromocriptine or amantadine It's a dopamine agonist, and dopamine antagonists are the things that cause NMS in the first place. Dantrolene can also be used

Patient is kind of depressed and reverts to negative thoughts about everything. Management?

Mx: cognitive behavioral therapy

Patient steps on a rusty nail. He had a 3 dose primary vaccination in childhood, but hasn't received anything since then. Management?

Mx: give single dose of Tdap vaccine I think it needs to be more dirty an incompletely immunized (he had the 3 doses as a child) in order to need the tetanus IG

38 yo homeless man is found unresponsive on the sidewalk. Temp is low, BP is 91/63, pulse is 96, RR is 5, O2 sat is 86%. He's disheveled and smells like alcohol. No JVD, lungs clear, bowel sounds decreased. Extremities are cool, pupils are 3mm. Management?

Mx: intubation, thiamine and glucose, *naloxone* because he has opiod overdose (bradypnea, decreased bowel sounds) External rewarming only if naloxone fails

Girl has sudden onset psychosis. Weeks earlier, she had sore knees and joints. She has low platelets, and on urinalysis, she has protein and blood. Management?

Mx: investigate for SLE Get antinuclear antibodies. NB: don't just treat psychosis right away--investigate for an underlying cause first.

Patient has amarosis fugax. He has similar episodes previously. Now it's bad. Management?

Mx: must be quick -Ocular massage (break up embolus and make it go more distal) -Oxygen

Patient has increasingly frequent loss of urine. She feels the urge to go, runs, and sometimes doesn't make it. She has a history of leakage when laughing, and got a mid-urethral sling for that. She has a bulge at the anterior vaginal wall. Management?

Mx: oxybutinin (after non-pharm like kegel exercises and bladder training to resist voiding longer) I got caught up with the anterior vaginal bulge. This is not the primary reason for her incontinence, so it was a trick

Patient has alcohol use disorder and wants to stop. Management?

Mx: psychosocial interventions Medical: -Naltrexone (first line--alters opioid reward receptors to decrease cravings) -Acamprosate (glutimate modulator) -Disulfaram (last resort--only used in patients who are already abstinent)

Patient is bitten by a dog (domesticated). The rabies status of the dog is unknown. Management?

Mx: quarantine dog -Observe for 10 days ---No symptoms: no need for post exposure prophyalxis ---Yes symptoms: yes PEP (It's expensive and painful, so avoid it if you can) Contrast: if wild, high risk animal, give PEP

15 yo girl has a self-palpated breast lump. She discovered it 2 days ago and it is tender to touch. She has no medical problems and takes no medications. There's no lymphadenopathy. Management? Likely diagnosis?

Mx: schedule follow up shortly after menses Likely: fibroadenoma. Can't reassure until after things settle after menses and the mass decreases

Patient has intrauterine fetal demise. Management?

Mx: tell them that induction of labor when they are ready is best. Spontaneous might not be best because retention of fetus for several weeks can result in coagulopathy (so don't wait more than 2-3 weeks)

What are the features of: -Neuroleptic Malignant Syndrome? -Serotonin syndomre?

NMS: -High fever (>40C) -Confusion *-Muscle rigidity* -Autonomic instablility (sweating) Serotonin syndrome -Fever not as high -Hyperreflexia/myoclonus (rather than rigidity)

Patient has daytime sleepiness. He once fell asleep while with a customer. He occasionaly hears voices while falling asleep and finds himself temporarily frozen sometimes. He is obese. Diagnosis? Management?

Narcolepsy Mx: sleep hygiene and modafinil (a wakefullness drug) NB: not OSA because of the features of the other features (hypnagogic hallucinations, sleep paralysis, cataplexy (loss of muscle tone))

Patient has a rhinoplasty a few months ago. Now she has a whistling noise during respiration. Diagnosis?

Nasal septal perforation. Rhinoplasties of the middle cartilinagenous septum often cause perforation because of the lack of regenerating capacity of the septum

What type of study would you need to determine if a town's location is related to leukemia incidence?

Need a cohort study. Since you're determining incidence, that's new cases, that needs to be followed over a period of time.

Patient is baby, have loss of motor milestones, hepatosplenomegaly, areflexia, and red spot on macula. Diagnosis? Deficiency?

Neimann Pick disease Sphingomyelinase deficiency Think: Neimann-Pick = Neimann-Marcus, which is a store that is mega over the top and mega expensive. Therefore, it has splenomegaly. Tay! Hey! You'd say that if you were hyperreflexive

6 day old baby is brought to the ED with spasms of the whole body. Baby hasn't been feeding well, has been given honey. Mother didn't have any vaccinations and baby was born at home. Baby has 101 fever, hypertonicity, neck stiffness, inspiratory stridor Diagnosis?

Neonatal tetanus Botulisim results in hypotonia, not hypertonia

Patient has dislocated shoulder. What nerve is at risk? What are its functions?

Nerve: axillary nerve Functions: -Sensory at shoulder -Motor: abduction

Patient just started rispiridone and citalopram. Now he has confusion, high fever, disorientation, muscle stiffness, but no myoclonus. Diagnosis?

Neuroleptic malignant syndrome

Patient gets a needle stick injury from an HIV patient. What do you do next?

Next: -Estabish baseline bloods in the injured. -Begin immediate Post Exposure Prophylaxis ---tenofivie-emtricitabine and raltegrair -Bloods in 6 weeks -Bloods in 3 months -Bloods in 6 months

Patient has no history or symptoms, but has a thyroid nodule. It's firm, nontender, and mobile. There's no lymphadenopathy. Next step(s) in diagnosis?

Next: -TSH level -Thyroid ultrasound Suspicion for malignancy? -FNA

Patient has syncope that's unexplained. Next step in management? His shows: Prolonged PR interval Prolonged QRS complex Normal QTc Prematur ventricular contractions 55% ejection fraction Likely cause of syncope?

Next: ECG Cause: bradyarrythmia Likely that this patient has conduction abnormalities that is causing bradyarrythmia. It doesn't have to be all the time--it can go in and out Prolonged PR and widened QRS complex is consistient with AV heart block causing brady

Patient has diabetes and symptoms of intermittent claudication. What should you do for them next in their management?

Next: ankle brachial index I thought since he had diabetes it would give a falsely high result, but apparently they weren't concerned about that.

3 yo boy has "inattentiveness." He has had 4 ear infections in the past year. Mom says that when asking him to do things, he sometimes ignores and continues doing what he's doing. He has become more withdrawn, but previously liked running around and playing. He speaks brief phrases of 2-3 words, similar to his presentation 6 months ago. Next step?

Next: check hearing--audiometry testing He may have hearing loss due to recurrent ear infections. It causes these symptoms, even withdrawal and lack of progression of speech and language.

Patient is 65 with 2 month history of fatigue and dyspnoea on exertion. BP is high, pulse is high, resp rate is high. She has a 2/6 systolic murmur in the left second intercostal space. She has guiac negative stool sample. Fe studies is obvious iron deficiency anemia. Next step in management?

Next: colonoscopy and endoscopy One negative FOBT does not rule out malignancy causing chronic bleed and iron def anemia. Still gotta do colonoscopy

Pregnant patient has never had an abnormal Pap smear. She has one now during her pregnancy. It's high grade squamous intraepithelial lesion Next step in management?

Next: colposcopy with biopsy if necessary I guess high grade needs immediate attention

Boy lives in a house that's old. He gets capillary blood test for lead which shows 12 ug/dL. Next step in management?

Next: confirm with venous blood sample (cap can be contaminated/not accurate) Then: If >45 ug/dL, give therapy ---succimer first (dimercaptosuccinic acid) ---Then dimercaprol + EDTA

Patient has a gun shot wound. Vitals: BP 85/43, RR: 21, HR: 126. It enters the left 6th intercostal space and leaves the 7th. CXR shows hazy opacities at the left lung base. FAST scan is negative. Next step in management?

Next: diagnostic laparotomy Indicated because diaphragm can go up to 4-5th intercostal space on expiration, so anything below that, you can't rule out abdominal organ injury. He's unstable, so he needs diagnostic laparotomy (stable could get CT, and other things that need diagnostic lap are signs of peritonitis, and evisceration of any organ)

Patient has diarrhea, nausea, decreased appetite. She has fatigue and palpitations. She has chronic afib and cardiomyopathy. She's on furosemide, metoprolol, digoxin, and warfarin. Pulse is 70 and irregularly irregular. She has scattered wheezes. Most appropriate initial test?

Next: digoxin levels (blood drug levels) Diarrhea, nausea, vomiting, confusion, weakness

38 yo patient has a period that lasts longer than normal. It began 11 days ago and she's changes lots of pads. Prior menstrual period was 3 months ago. BMI is 39. No nipple discharge. Pelvic exam: dark blood in vault with no active bleeding. Bloods are normal. Urine pregnancy test is negative. Vaginal US shows 3 mm endometrial stripe, no fibroids, no adnexal masses. Next step in management?

Next: endometrial biopsy I thought that bc stripe was 3 mm, biopsy was not needed, but in premenopausal women, a stripe of <4 mm is not a reliable indicator to rule out endometrial cancer. Especially this patient who has risk factors (unopposed estrogen with long periods between bleeding and obesity), biopsy would be indicated.

42 yo patient has no abnormal uterine bleeding or change in weight. Menses are regular. Last one was 3 weeks ago. Pelvic exam shows normal cervix with no visible lesions. Pap test shows atypical glandular cells. Next step in management? What are the indications for this step?

Next: endometrial biopsy Indications: -Atypical glandular cells in women >35 or women <35 with risk factors (obesity, anovulation) require evaluation for endometrial cancer. ---Atypical glandular cells can be due to EITHER cervical OR endometrial carcinoma Other indications for endometrial biopsy -Abnormal uterine bleeding >45 -Postmenopausal bleeding -Abnormal bleeding <45 plus ---Unopposed estrogen (obesity / anovulation) ---Failed medical management ---Lynch syndrome -Age <35 and atypical glandular cells on Pap

Patient gets a stab wound. He seems relatively stable. Exam: he has rebound tenderness and guarding. Imaging: US: no free fluid is detectable. Next step?

Next: explorative laparotomy. He has signs of peritonism (rebound and guarding) so he needs ex lap

30 yo patient comes to the ED: "something blew into my eye while I was drilling." He has foreign body sensation, lacrimation, photophobia. You look with a pen torch and see nothing. Next step?

Next: fluorescein examination Could have been high velocity injury and so you wouldn't be able to see it on initial exam. You need flourescein staining exam with slit lamp preferrably Fluorescein stain: orange dye used to detect foreign bodies or corneal damage

Patient had a DVT and is started on (heparin bridge) warfarin. His schedule makes him unable to attend clinic to get his levels checked. Now he has swelling in his right leg (pretibial edema) and INR is 1.3. There is a right popliteal vein thrombus that extends into the femoral vein on venous doppler US imaging. Next step in management?

Next: he needs anticoagulation immediately because it's extended into proximal veins Give: rivaroxaban/apixiban (direct Xa inhibitor) because they're as effective and don't increase risk of bleeding. They also have rapid onset and no need for monitoring Can't use them with impaired renal function

Patient has cirrhosis and history of variceal banding. Now he is vomiting lots of blood, including clots. Next step? Next step?

Next: intubate to protect airway Then: can do upper endoscopy (better to do while intubated so do that first)

36 yo woman has a 1 cm palpable breast mass with no lymph node involvement. Next step in management? Contrast?

Next: mamography first (then US if indicated) Contrast: if LESS than 30, US first (w or w/o mamogram)

Patient had Ca of 10.9 6 months ago. Today, it is 11.2. He is largely asymptomatic. What is the next step in management? Likely diagnosis?

Next: measure PTH (serum) Likely: primary hyperparathyroidism

Patient has chronic hep C. He has spider angioma, asciets, and esophageal varices that are medium sized and non-bleeding. Next step in management?

Next: prescribe beta-adrenergic receptor blocker Because they can decrease adrenergic tone in mesenteric arterioles, which causes unopposed alpha-mediated vasoconstriction and decreased portal flow. So first line: beta blockers Second line: variceal ligation (not scleropathy) If active bleeding: scleropathy

Patient has HCV infection but is asymptomatic. Other hepatitis panel shows +HBV surface antibody -HBV surface antigen -HAV antibody Next step in management?

Next: protect against further liver damage -HAV vaccine bc she's not immune -Avoid alcohol Consider sofosbuvir-velpatasvir

Patient has a bad trauma. He's on a backboard for stabilization of the spine. BP is 92/45, pulse high, resp 6, and O2 sat: 86% on 100% O2. He has superficial facial lacerations and a depressed temporal skull fracture. No periorbital or periauricular hematomas, no neck edema. Next step? Why?

Next: rapid sequence orotracheal intubation Why: because there is no significant facial trauma. You just need people stabilizing the C-spine

Patient has no risk factors for TB and has 12 mm induration. Next step?

Next: reassurance Not a positive test (positive is >15 mm in the US) If it were >15 mm, then you would get a CXR

18 month old patient drinks liquid oven cleaner and is brought to ED. He has blood-tinged oral secretions, difficulty swallowing, stable vital signs, crying and drooling. But no stridor and breathing appears normal. His shirt is covered in oven cleaner. Next step in management?

Next: remove clothing (reduce exposure of the substance to the skin as that can worsen the situation) NB: can do this because airway, breathing, and circulation is secure (no distress) but watch it carefully. Then remove clothing/exposure Then endoscopy within 24 hours

71 yo man has prostate cancer. He has confirmed bone mets. He is having pain that is limiting his activity and nocturnal pain that disrupts sleep. He has already received radiotherapy and leuprolide, and ibuprofen 3-4 times a day is not controlling his pain. Next step in management?

Next: short acting opioid (morphine or hydromorphone) After that would be long acting such as -Fentanyl patch or Oxycodone -Plus short acting for breakthrough pain

Pregnant woman (30 weeks) is in a motor vehicle accident. She has bleeding. Vitals are 95/65, 116/min, 22/min and 98% on RA. Hb is 7.6. Fetal heart monitoring shows contractions every 5 minutes, no accelerations, no decelerations. Next step in management?

Next: stabilize mom--give IV fluids (crystalloids) Need mom to be stabilized before you check out baby more

Patient has a thyroid nodule. There are not symptoms of thyroid disease. Histology has ground glass cytoplasm, pale nuclei, and inclusion bodies..."papillary thyroid cancer" Next step in management?

Next: surgical resection

Older man with wife and 2 kids has meningococcal meningitis. He wants antibiotics at home. Management?

No, he's too infectious and a risk to others. He needs hospitalization against his request and isolation

Is screening for bladder cancer recommended?

No--not in any patients, even heavy smokers

Pregnant mother has a 2/6 systolic ejection murmur. Does she need an echo?

No. Can be normal physiological

What is normal JVP? Patient has leg swelling normal JVP Diagnosis? What would help with her symptoms?

Normal: Less than 3 cm above sternal angle, which is also Less than 8 cm H2O (bc the LA adds 5 cm) Abnormal: Greater than 3 cm above sternal angle Greater than 8 cm H2O Dx: venous insufficiency Help: leg elevation; because she doesn't have raised JVP, diuretics would be too much

6 yo girl has imaginary friend. Parents are concerned. What should you tell them about this? Normal? Will it hurt other relationships?

Normal: yes It will actually improve other relationships

34 yo woman has chest pain ongoing for months. It's not in association with exercise, does not change with inspiration, unrelated with activity, increases with stress. No other symptoms, ECG is normal. Next step in management?

Nothing further Young, no risk factors for CAD, no further testing NB: intermediate risk: should have exercise testing (ECG if first ECG was normal and exercise imaging testing if ECG is abnormal) If high risk: start on CAD therapy and get expert evaluation

62 yo patient has definite iron deficiency anemia. Likely cause? Next step in management?

Occult blood loss (if no obvious blood loss on history and exam) Next: endoscopy (colonoscopy or esophageal-gastro-duodeneal) to look for malignancy or other. Especially over 50.

Patient has acute mania. Next step in management?

Olanzapine: faster onset of action and can be given IM Lithium takes several days and needs titration

18 yo african american has excessive urination. His mother died of a stroke at 32 due to sickle cell disease. Serum sodium is 138, urinalysis shows decreased specific gravity, but everything else is normal. What's going on? What is the cause of this patient's polyuria?

On: Px has sickle cell trait putting him at risk of hyposthenuria. This is when cells sickle in the vasa recta because the O2 is lower down there. It prevents normal functioning of reabsorption of water (countercurrent exchange), which is causing the low specific gravity. Serum sodium is still normal because the collecting duct is not affected (not supplied by the vasa recta) NB: if it were central diabetes insipidus, the Na would be elevated.

Patient has an obvious stroke. He doesn't get tPA because he was outside the time window. 48 hrs later, he's obtunded, temp is 101 bp is 154, and pulse is 64. He has dense right hemiplegia with deviation of head and eyes to the left. What's going on? Next step in management?

On: hemorrhagic transformation Next: emergent non-contrast CT, and then likely surgical decompression

Patient gets MMR vaccine 7 days ago on a background of eczema managed with emollients and steroid cream as needed. Today, he has a maculopapular rash starting and the head and spreading to the trunk with a temperature. What's going on? Management?

On: infection with vaccine-strain measles virus Management: -Reassurance (it's less virulent) -No need for airborne isolation (less virulent) -Should avoid contact with immunocompromised individuals

65 yo patient has shortness of breath and abdominal distension. He was treated with radiotherapy and chemotherapy for Hodgkin lymphoma 18 years ago. He has JVD 9 cm above the sternal angle. He has a positive fluid wave, liver edge is 5 cm below costal margin. There is lower extremity edema. What's going on? Cause?

On: right heart isn't pumping blood out, causing raised JVP and peripheral edema Cause: inelastic pericardium (constrictive pericarditis) secondary to radiotherapy

What is the policy on accepting gifts from pharmaceutical companies?

Only accept gifts that are of small monetary value and that directly benefit the patient

HIV patient has pain on swallowing. He has white plaques on the buccal mucosa that are easily removable. Next step(s) in treating "substernal chest pain?"

Oral fluconazole to treat candidal esophagitis Then, if it doesn't respond, investigate for other causes by doing endoscopy, biopsy, and cytology. I thought it wouldn't cause pain, but apparently it does cause pain

28 yo man has a hard mass in the left testicle. US is suggestive of a testicular tumor. Next step in management?

Orchidectomy (removal of testis and its associated cord) Don't biopsy bc risk of seeding

HIV positive male has deterioration of vision. He has eye pain and mild conjunctivitis with visual loss. Eye examination reveals keratitis. Fundoscopy shows widespread, pale peripheral retinal lesions and central necrosis of the retina. Likely organism?

Org: herpes simplex virus Herpes hurts me CMV retinitis is painless. It also shows fluffy, granular lesions near retinal vessels with associated hemorrhages (not conjunctivitis or keratitis)

19 yo has dry cough that disturbs sleep. He has sore throats, headache, and fatigue. Yesterday he had a rash on his legs and arms. He has paryngeal erythema. Macular rash is present on extremities. There are interstitial markings and small right sided pleural effusion What is the likely organism?

Org: mycoplasma pneumonia

Patient has had dizziness that causes her to need to lean against a wall or sit to resolve her problem. She is on amirtiptyline, acetaminophen, and polyethylene glycol What is this most consistient with? What drug can cause it?

Orthostatic hypotension Amitriptyline

Baby is born still birth There are multiple fractures, hypoplastic thoracic cavity, and short, bent extremities. Diagnosis?

Osteogenesis imperfecta type II

Patient has 2 month history of leg pain. It is worse at night, dull, aching, and is relieved by NSAIDs. He plays sports but his pain is not associated with activity. X ray shows a circle of radiolucency with sclerotic circle around. Diagnosis?

Osteoid osteoma

Patient is an IVDU. He has tenderness over the low back (L3/L4). Vitals are basically normal. Leuks are ok and platelets are high. Diagnosis?

Osteomyelitis Commonly presents without fever

Diabetic patient gets diabetic foot ulcer. Now they have bone pain and fever. Diagnosis? Multiple or single organism? Mode of spread? Treatment?

Osteomyelitis Multiple (gram pos: staph a, strep; and gram neg: pseudomonas) Mode: continguous Tx: piperacillin-tazobactam and vancomycin

Patient has clear RA. What bone condition are they at increased risk for?

Osteoporosis

Patient has nucleic acid amplification test from urine specimine that is positive for N gon. HIV testing is negative. What additional testing is warranted in this patient?

Other STIs Syphillis HIV Hep B (c is more blood bourne) Chlamydia (?) Counsel on safe sex practices

What are differentials of vision loss? (probably not exhaustive bc it was just in a UWorld Question) Painful? Painless?

Painful: -Optic neuritis (young female--MS) -Anterior uveitis Painless: -Open angle (peripheral vision loss) -Central Retinal Artery Occlusion (elderly) -Macular degeneration (patchy, elderly) -Retinal detachment (floaters, flashes, lose peripheral vision loss first)

Patient has symptoms of hyperthyroidism, but a painless thyroid gland that is mildly enlarged. They have high T3 T4 but low TSH. An uptake scan is done, and it shows little to no uptake. Diagnosis?

Painless thyroiditis If it shows high uptake, it would be graves. It it was painful, it would be subacute thyroiditis Struma ovarii is a rare ovarian tumor that can cause inc T3 T4 with normal thryoid

Patient has a uretral stone What can help pass the stone?

Pass: -Hydration -Analgesics -Alpha blockers ---Alpha blockers inhibit alpha receptors, which cause relaxation of smooth muscle in the ureter and bladder

Patient has right upper quadrant pain that worsens on inspiration. It started 5 days ago after returning from South Africa. She has fevers, chills, vomiting, but no change in stool color. She is sexually active and over the past 3 months, she has had occasional spotting. Temp is high, BP is 100/70, pulse is 104. The lower abdomen is diffusely tender without guarding. Urine pregnancy test is negative. Diagnosis?

Pelvic inflammatory disease Key distinguisher: Hugh-Fitz-Curtis syndrome Acute Viral Hep: would be jaundiced and likely changes in stool. Acute chole: NO because of the lower abdominal pain

Patient has partial pancreatectomy. He requires a blood transfusion. 12 hours later, he has decreased O2 sats, BP: 80/40, HR: 112, RR: 28. He has bilateral basal crackles. Cardiac index is 2 (2.2-4 is normal), and PCWP is 20 (normal is 6-15). Diagnosis?

Perioperative MI

Patient is getting conflicting adverse drug reactions. What could prevent this?

Pharmacist-directed interventions

Patient has prolactin of 35, low T4 and TSH, low Testosterone and low LH. Diagnosis?

Pituitary (non-functioning) adenoma The non-functioning kind cause a mild increase in prolactin. If it were functioning, it would be up in the 200's. The adenoma then can compress other pituitary structures and cause hypopituitarism

Mother is 40. She's having a baby and it's at 10 weeks--her first trimester visit. What test should be offered to her? If abnormal?

Plasma cell free DNA testing since she's over 35 and at high risk for aneuploidy. Abnormal: -1st trimester: chorionic villous sampling -2nd trimester: amniocentesis

52 yo patient has proximal muscle weakness. She has 4/5 strength in thigh muscles, and tenderness to palpation Likely diagnosis? Investigation to confirm?

Polymyositis Ix: muscle biopsy

Pneumococcal vaccines: What kind of response is illicited in the polysaccharide vaccine? What is in contrast to this? What does it cause?

Polysaccharide: 23 valent. It just reacts with the B cells and causes a weaker response without T cells and not as great of memory Contrast: 13 valent *conjugated* which reacts with T cells and increases the immune response

Patient is elderly, is waking up earlier, is losing interest in activities, and has lost weight. What is going on?

Possible major depressive disorder I thought normal sleep related changes with aging, but the anhedonia and weight loss makes it more severe

Patient is 5 and is having hair growth (pubic hair and under arms). No other symptoms. She is obese. Also facial acne is present. There is no breast bud development, and bone age is normal Diagnosis?

Premature adrenarche

What are the risk factors for neonatal respiratory distress syndrome?

Prematurity Gestational diabetes (high glucose --> high insulin; insulin inhibits cortisol, so if cortisol is down, the lungs wont mature well because cortisol helps mature lung) Perinatal asphyxia Cesarean delivery Male sex

Patient has 2 day history of knee pain and swelling. It interferes with walking. He was a concrete finisher. There is swelling anterior to the patella, faint erythema, and sharp tenderness. Passive range of motion is normal. Diagnosis?

Prepatellar bursitis

54 yo male has erectyle dysfunction. He has loss of libido and loss of early morning erections. He has hyperlipidemia and CAD. He has MI 7 months ago with stent placement. He recovered well. He's on metoprolol, atorvastatin, and aspirin and tecagrelor. Everything else (including no gynecomastia, testicular size, and testosterone blood levels) is normal. Next step in treating?

Prescribe sildenafil (PDE-5 inhibitor) Don't stop metoprolol because it's a crucial drug for his heart Contraindications for sildenafil (PDE-5 inhib) -Taking nitrates -Taking alpha blockers

Patient has diabetes. Exam shows decreased sensation, decreased vibration and proprioception, absent ankle jerk reflex, romber's sign positive. Which process is responsible for these symptoms? Contrast?

Process: axonopathy of LARGE nerve fibers Contrast: Axonopathy of large nerve fibers cause negative symptoms (loss of...so numbness, no proprioception, no vibration, no ankle reflex) Axonopathy of small nerve fibers causes positive symptoms (so inc feeling of pins and needles (paresthesias) pain out of proportion (allodynia) and pain in general)

Baby is born and has complication of shoulder dystocia. he has a waiter's tip posture. Prognosis? Treatment?

Prog: 80% resolve Treat: physical therapy to reduce contractures

Patient has malignancy-related cachexia. What should you prescribe them to help them gain weight?

Progesterone analogue

Patient has HIV with <50 CD4 count. He has left sided weakness and confusion with memory impairment. CT shows asymmetric, hypodense, nonenhancing white matter lesions with no edema Diagnosis?

Progressive multifocal leukoencephalopathy Secondary to JC virus activation. Present with confusion, memory impairment and paresis. Primary CNS lymphoma is single lesion and is enhancing

What medications can be given for migrane prophylaxis? What about acute treatment?

Prophylaxis: -Topiramate (think tope for you head) -Beta blocker -Tricyclic antidepressants and SNRIs Acute: -Triptans -NSAIDs -Acetaminophen -Ergots

Patient is started on niacin. What is a possible side effect? Management?

Prostaglandin-induced peripheral vasodilation, resulting in pruritis and flushing Mx: give low dose aspirin before

Patient is on warfarin. Then takes acetaminophen and phenylephrine. Now she has an obvious intracranial bleed. Management?

Prothrombin complex concentrate (contains Vit K dependent clotting factors II, VII, IX, and X) Also give vitamin K NB: protamine sulfate is to reverse heparin

Patient basically develops ARDS. What changes happen in ARDS to Pulmonary artery pressure? Fraction of PaO2 / Fi O2 Lung compliance?

Pulm artery pressure: increased (there's edema, there's hypoxia leading to pulm artery vasoconstriction, there's compression of structures) PaO2/FiO2 decreases (def <300 mmHg) Compliance: decreases

Patient has blunt trauma to the chest. He gets tachypnoea and tachycardia 2 hrs after admission. There are bruises and tenderness. CXR shows patchy, irregular alveolar infiltrate in the right middle and lower lobes. Diagnosis?

Pulmonary contusion, causing bleeding into the alveolar spaces. Not ARDS--that could develop but it would be bilateral and after 24 hours

Patient has afib. What is the most common anatomic site of origin for this arrythmia?

Pulmonary veins (they have atrial tissue that contract with the atria to prevent back flow)

18 yo patient is tired walking up a few flights of stairs. She has an extra high-pitched sound after S1. There is a 3/6 systolic crescendo-decrecendo murmur at the left upper sternal border. S2 is split and the splitting increases with inspiration. What is the mechanism of the murmur?

Pulmonic stenosis Key: "high pitched sound" is opening click Splitting increasing with inspiration proves that it's not ASD

Patient is fasting. Alanine gets converted to what in order to enter the krebs cycle?

Pyruvate

Patient has rheumatoid arthritis and nephrotic syndrome What would be pathological finding on kidney biopsy?

RA is most common cause of AA amyloidosis AA amyloid depositis in kidney cause nephrotic syndrome. Finding: glomerular deposits seen after staining with congo red and demonstrate apple-green birefringence under plain polarized light

Patient has a rash on the skin of her back and arms. She has SLE and has been treated with glucocorticoids. She previously had comedonal acne. Exam shows uniform appearing, 1-3 mm erythematous plaques across her back, shoulders, and upper arms. What rash is this? What is the most likely cause?

Rash: Drug induced acne -Glucocorticoids, androgens -Immunomodulators -Anticonvulsants (phenytoin, antipsychotics) -Anti-tuberculosis drugs *Monomorphic* papules/pustules (acne vulgaris has lesions of different phases) Cause: gulcocorticoids

Patient has been on combined OCP and is worried about weight gain. She had heavy periods with pain before. How should you advise this patient?

Reassure that weight gain is not due to OCPs Don't switch her to progesterone--those have higher chance of weight gain. No Cu IUD because those are worse for heavy bleeding

Patient has schizophrenia, is stabilized in the hospital, and discharged home on antipsychotics. What should be advised to improve outcomes?

Recommend family therapy / support

Patient (14) is brought to office dt tick bite that he got yesterday while camping in vermont. There is a small area of erythema. What is the next best step in management?

Remove tick with tweezers as close to the skin as possible Reassure that there's no need for prophylaxis because the tick has to be there for 48-72 hours in order for transmission of Lyme disease to take place. If it's been there less than 36 hrs, it's unlikely to cause disease If it were there 48-72 hrs, then you'd give one dose of doxy, but not if they are 8 or less, pregnant, or lactating

Patient has elevated BP. He has occasional headaches, but no CP, SOB, or syncope. He has CAD, T2DM, stroke. He is on a lot of hypertensive agents, but BP is still 184/120 in left and 170/112 in right. There is an upper abdominal systolic-diastolic bruit. Diagnosis?

Renal artery stenosis causing refractory hypertension RAS: bruit Change in BP is likely de to subclavian stenosis

Patient has HSV encephalitis. He gets acyclovir. 2 days later, his creatinine and BUN are elevated. Diagnosis? Etiology?

Renal tubular obstruction Acyclovir has low urine solubility and forms crystals that cause AKI

What is the requirement for hospice services?

Requires survival prognosis of <6 months

Patient has lower extremity edema, shortness of breath, distended jugular veins, no murmurs, breath sounds decreased at bases. Urine protein excretion is 1 g in 24 hours. There is LV concentric hypertrophy and atrial dilation on echo. EF is 70% Diagnosis?

Restrictive cardiomyopathy secondary to amyloidosis NB: proteinuria Also, hypertrophic cardiomyopathy is just the septum.

Patient has penile fracture. Next step in management?

Retrograde urethrogram because of risk of urethral injury

Patient has undescended testicle and orchidopexy. What are risks--changed and unchanged?

Risk of testicular cancer is decreased, but still higher than normal population Torison is decreased once the testis is descended Can have normal sperm production

What does being on an OCP put you at increased risk of? What is it protective of?

Risk: hypertension Thromboembolism Stroke and MI Protective: Ovarian cancer (prevents ovulation which decreases ovarian cancer) Endometrial cancer (contains progestins, which counteracts estrogen's proliferative effect on endometrial tissue)

Patient has HIV and has not been taking medications. He gets an infection of the lungs. (which is most likely?) He gets fluids in the hospital, and he becomes hyponatremic, but clinically he is not hypovolemic. Diagnosis? Cause of hyponatremia?

SIADH (SIADH is associated with lung pathology such as PCP) Cause: inappropriate antidiuretic hormone secretion

10 yo patient has fever, rash under his arms and in private areas. He's immunized and not toxic. The rash is papular and rough in texture. There is anterior cervical lymphadenopathy, erythematous tonsils with exudates. Two kids recently had this and now they have peeling of hands and feet. Diagnosis?

Scarlet fever I thought staph scalded skin syndrome, but that rash is bullous, not sand-paper like.

Patient has somatic symptom disorder. Management?

Schedule regular follow up appointments with the same doctor, build a rapport, and try to go from there.

Patient has psychotic symptoms and mood disorder (depression). Previously he had a similar episode. Then another time, he had hallucinations without mood disorder. Diagnosis?

Schizoaffective disorder Contrast: Schizophrenia: mood disorder is not prominent Schizophrenaform: shorter duration <6 months and mood disorder not prominent

Patient has manic symptoms. Then also has depressive episodes. Then he has times where he's mood stable and still hears voices. Diagnosis?

Schizoaffective disorder Persistence of hallucinations during mood stable times rules out bipolar 1

22 yo man is isolated. He doesn't seek out friends. He is an engineering major and does well in class. After class, he goes home, plays computer games, and reads comic books. When interviewed, he makes limited eye contact, gives brief responses, and looks anxious. When asked, he says that he would rather keep to himself. Diagnosis?

Schizoid personality disorder NB: avoidant personality disorder is when people are afraid of rejection and criticism Schizotypal is someone with fanciful thinking, odd thoughts, odd behavior

Patient has delusions and hallucinations for about 2 months. Diagnosis?

Schizophreniform disorder NB: brief psychotic: 1 day - 1 month Schizophreniform disorder: 1 month - 6 months Schizophrenia: >6 months

Patient is expressing psychotic symptoms and is cooperative. What should you give her?

Second gen antipsychotic: quetiapine

Young patient has a supracondylar fracture of the elbow after falling on it outstretched. What sign do you see on X-ray? What do you have to be concerned about? What sign indicates this?

See: anterior and posterior fat pad Concerned: neurovascular integrity AND compartment syndrome Indication: increasing pain despite pain meds

8 yo boy is playing in opposite room and mother hears a thud. She checks on him, and he is unresponsive on the floor. At the ED, he is unable to move his left arm or leg. What happened?

Seizure and todd's paresis Not homocystinuria because they would have intellectual disability and lens dislocation

Patient has intermittent dizziness (room spinning) nausea, and feeling unsteady. No factors bring it on. There is "mechanical humming" in right ear. No ear pain or discharge. Air conduction is greater than bone conduction in both ears. Webers test causes sound to be louder in the left ear. What kind of hearing loss does she have? What is the cause?

Sensorineural hearing loss Cause: meinere's disease -Intermittent vertigo -Tinnitus (mechanical humming) -Sensorineural hearing loss (due to poor drainage of endolymph, leading to distension of endolymphatic system and damage of vestibular and cochlear components of the ear)

Patient has CS for delivery. She gets antibiotics, but she still has a fever. She has no uterine fundus tenderness, but does have tender breasts and bilateral lower quadrant tenderness to deep palpation. Diagnosis?

Septic thrombophlebitis It's a diagnosis of exclusion -Fever unresponsive to abx -Nonspecific pain Tx: -Anticoagulation -Broad spectrum antibiotics

5 month old patient has fussiness for 2 days. He has had otitis media, oral candidiasis, and rotavirus. He's at 3rd centile for weight. Temp is 102, and he has bluging tympanic membrane with poor mobility on pneumatic otoscopy. No lymph nodes are palpable, and tonsils are not visualized. Leukocyts are low and so are lymphocytes. IgA, IgM, and IgG are all low; CD4 and CD 8 are low. Diagnosis? Treatment?

Severe combined immunodeficiency Bc: low T cells, which causes poor development of B cells and Ig Treatment: stem cell transplant ASAP Not bruton's agammaglobinemia because the T cells are low. In bruton's the T cells would be normal

Patient has pyelonephritis and is started on IV ceftriaxone. She starts to improve. Culture and sensitivity shows sensitivity to 2 oral abx. What should you do next?

She's improving So switch to oral antibiotics--trimethoprim sulfamethoxasole

How do you tell the difference between sinus tachy and AV re-entry / AV node re-entry tachy? Management for each?

Sinus: should see P waves AVRT/AVNRT: DO NOT see P waves--they're buried or look like spikes after the QRS. Mx sinus tachy: in this case, if bc of panic attack, then give benzo (alprazolam) Mx AVRT/AVNRT: valsalva, then adenosine

Patient has schizoaffective disorder. He has a 5 day history of malaise, loss of appetitie, nausea, and abdoiminal pain. He's on psychiatric medication. He has right upper quadrant tenderness and a bilateral hand tremor. He's a bit disoriented. LFTs are deranged. What medication is he likely on?

Sodium valproate Mood stabilizer most associated with liver toxicity

Patient has abdominal pain that is constant, unrelated to meals, along with nausea and bloating. She has had many investigations and they can find nothing wrong. She is distressed and distracted from work because of her symptoms. She also has headaches and obesity. Diagnosis?

Somatic symptom disorder Excessive anxiety and preocupation with >1 unexplained symptom (but they actually do experience the symptom) Illness anxiety: fear of having a serious illness despite few or no symptoms and consistiently negative evaluations (so they don't really have any symptoms or they're mild but they're still worried they have a serious disease) Conversion disorder: neurologic symptom that incompatable with any known neurological disease; often acute onset and associated with stress Facticious disorder: falsification of symptoms to assume the sick role Malingering: falsification of exaggeration of symptoms for external incentives (secondary gain such as avoiding jail, disability benefits, or narcotics)

Peds patient is brought in for evaluation of burns. They are on the back, buttox, and legs. What would raise suspicion for non accidental injury?

Sparing of the flexor surfaces Possible: splash or drip marks (I guess if baby is resisting)

Young patient has chronic back pain, neurologic dysfunction (eneurisis), and a palpable step off. Diagnosis?

Spondylolisthesis

Patient has a nonhealing ulcer on the left upper extremity. It has been itching and bleeding. Now he has local numbness, paresthesias, and burning pain. He recently had a kidney transplant for which he had immunosuppressive therapy. Diagnosis?

Squamous Cell Carcinoma

Patient has obvious PE What do you do next?

Stablize with O2 and fluids If high Wells score probability and no contraindications to thrombolysis, give LMWH right away before diagnosis. If there are contraindications or if well's score is low: get diagnosis first.

Patient has mild fever and left sided lymph node swelling. No trauma and no recent illness. There is a 2 cm anterior cervical chain mass only on the left side Likely diagnosis?

Staph aureus infection It's acute, and one sided If it were acute and bilateral: adenovirus If it were chronic and bilateral (with more systemic symptoms, esp fatigue) it would be EBV or CMV

Patient has hypovolemic hypernatremia Initial mangement?

Start IV infusion of normal saline It is hypotonic in comparison to the hypertonic blood, so it's ok. Correct at 1 mEq/L/hr

Patient is a middle aged woman presenting with vasomotor symptoms (night sweats, hot flushes, perspiration every night), insomina, difficulty concentrating. What is next step in workup?

Step: measure TSH bc hyperthyroid and menopause can present with similar symptoms

Patient has myesthenia gravis. He gets an infection and is hospitalized. He's on his normal dose of pyridostigmine. Then he develops respiratory distress (really bad) to the extent that he needs intubation and ventilation. Next step in management?

Stop pyridostigmine Plasma exchange/plasmapharesis or intravenous immunoglobulins (to clear antibodies) Also corticosteroids steroids

Patient is from an assisted living facility and has temp, inc resp, inc HR, crackles in lower lung field. CXR shows right lower lobe infiltrate Most likely pathogen?

Strep pneumo Health-care associated pneumonia isn't really a thing anymore. Only hospital acquired pneumonia (which develops >48 hours after admission to the hospital)

Patient has HIV. Her CD4 count is 300. She has pneumoia with a right sided effusion. She has a soft ejection systolic murmur at the left second intercostal space at the sternal border. Likely organism?

Strep pneumo. Still commonest cause of CAP, even in HIV px not staph because the murmur is just a flow murmur in response to hyperdynamic circulation from infection

38 yo woman at 33 weeks gestation has clear fluid leakage from the vagina. Occurs when she stands from sitting. No UTI. Cervix is slightly open and there is scant fluid in the posterior fornix. No fluid emerges when the patient coughs. The fluid does not turn nitrazine paper blue, nor is there ferning. Diagnosis?

Stress incontinence Secondary to the gravid uterus

Patient has weight loss, dry cough, and pain in his right arm. He has a 30 pack year smoking history. Imaging shows stuff in the left upper zone of the lung. Diagnosis?

Superior pulmonary sulcus tumor

Patient has measles. Treatment?

Supportive Vir A reduces complications

Patient is 65, has a cough, that resolves, then has X-ray that shows a 2 cm, peripheral, round lesion in right lower lung lobe surrounded by parenchyma. It's irregular and there are no calcifications. Suspicion for malignancy? Management?

Suspicion: high Mx: surgical resection

Patient has depression and has tried fluoxetine for 8 weeks. She's still depressed. Next step?

Switch to another first line SNRI like venlafaxine NB: adequate trial is 6 weeks, so she failed the adequate trial of fluoxetine

Patient is pregnant for the second time. She has exposure to cats. She is asymptomatic. What should she be screened for at 10 week visit?

Syphillis (rapid plasma reagin test, which is non treponemal, then FTA-ABS if positive, which is treponemal) Hep B HIV Chlamydia trachomatis Treatment of positive rapid plasma reagin/treponemal test: penicillin G Don't screen for toxo--only if symptomatic

What are the complications of oxytocin?

Tachysystole--more than 5 contractions in 10 minutes (such high contraction of the uterus that it can affect blood flow to the placenta and cause fetal hypoxia) Hypotension Hyponatremia

Patient has CCF and took an overdose of a medication. He has hypotension, bradycardia, first degree AV block, and bilateral wheezing. What did he take? Steps in management?

Take: beta blocker overdose Management -Airway -IV fluid bolus (for hypotension) -Atropine (inc HR) If still refractory *-Glucagon*

23 yo woman has hair loss. It came out while brushing her hair. She recently had 2 pregnancies. She then had depression. When he hair is pulled >20% of the fibers come out. Diagnosis?

Telogen effluvium Stress (pregnancy, depression) leading to hair loss

1 yo boy had anemia. He has a low MCV, normal Red Cell Distribution Width, and increased reticulocytes. Diagnosis?

Thalassemia minor MCV low should make you think basically between Fe def and Thal. Inc retic count is more consistient with thal.

What is the mechanism by which nitrates improve angina?

They cause systemic venodilation This decreases venous return to the heart and L ventricle *This decreases cardiac wall stress*, which decreases preload, which decreases work of the heart.

What's the latest age you should receive the HPV vaccine?

Thru age 26 for women Thru age 21 for men

Patient has diabetic nephropathy. What is the best management to prevent progression / alter course of the nephropathy?

Tight blood pressure management --Slows the decline in GFR Target should be about 130/80

Patient returned home from a gymnastics meed in Connecticut. Her friend got lyme disease earlier. The rash is a puritic patch with centrifugal spread. It is raised and scaly. It has a bit of clearing in the middle. Diagnosis? Treatment?

Tinea corporis (ringworm--gynmastics) Tx: topical clotrimazole

What drugs can cause ototoxicity? In a patient with CHF, what is the most likely cause?

Tox: loop diuretics, aspirin, aminoglycosides CHF: Diuretics (furosemide) aspirin dose needs to be high.

Patient ingests 20 tablets of 500 mg acetaminophen. Is this a toxic dose? What is the threshold? What would be the next step in management?

Toxic: yes Threshold: >7.5 g Next step: -If presenting within 4 hours of ingestion, do gastric decontamination with activated charcoal. -At the same time, get an acetaminophen blood level -If levels are above treatment line, give N-acetylcysteine NB: patients can be asymptomatic in the first 24 hours

Patient suffers from a house fire. What kind of toxicity is she at risk of? What is the treatment? How should they be given?

Toxicity: -Carbon monoxide -Hydrogen cyanide Treatment: CO: 100% oxygen HCN: hydroxocobalamin or sodium thiosulfate or nitrites to induce methemoglobinemia (which readily binds cyanide and prevents it from affecting electron transport chain) Symptoms of HCN poisoning: Early acute toxicity: headache, vertigo, dizziness, hyperventilation, tachycardia, nausea, vomiting. Progresses to neuro, resp, and cardio depression: coma seizure, bradycardia, hypotension, cardiorespiratory arrest

Patient has positive pregnancy test and presents with right adnexal tenderness. Transabdominal US is inconclusive. Next step?

TransVAGINAL ultrasound Then manage depending on stability -(I think: stable and not ruptured: methotrexate?) -Unstable and ruptured: laparoscopy -Unstable ruptured and bleeding: laparotomy

Patient is 16 weeks gestation and has a history of cold knife coinization. She's obese. What's the next step in evaluating the patient's risk for preterm labor? What can you give to prevent preterm labor?

Transvaginal ultrasound Vaginal progesterone

Mother is at 10 weeks gestation and has asymptomatic bacturia. Management?

Treat with abx Give: -Cephalosporin -Amoxicillin-clavulanate -Nitrofurantoin -Fosfomycin Trimethoprim sulfa is safe after 2nd trimester, contraindicated during 1st d/t interferece with folic acid metabolism. Should be avoided in 3rd due to risk of neonatal kernicterus

Patient has 2 episodes of needing his inhaler for asthma a week. He has no night time wakenings. What treatment should he have?

Treatment: as needed albuterol inhaler. Does not need inhaled corticosteroids--keep his treatment as is. </= 2 uses per week during day </= 2 night time wakenings per month Mild asthma that doesn't need additional therapy

Patient recently traveled to mexico. Now he has GI complaints, periorbital edema, double vision, pain in his neck and jaw, splinter hemorrhages, chemosis. Diagnosis? Treatment?

Trichinellosis Tx: albendazole or mebednazole

Patient has blurred vision in his right eye. There is no pain, ocular discharge, or gritty sensation. Fluorescein stain shows large geographic corneal staining defect Which nerve dysfunction is most likely responsible?

Trigeminal--innervation of the cornea

Patient has HIV. CD4 count is 40. They are asymptomatic. What should they receive?

Trimethoprim sulfamethoxasole (for PCP) Azithromycin (MAC) NO acyclovir--only if they have recurrence. NO fluconazole for candida--not recommended to give prophylaxis

What do you do with a help-rejecting patient?

Try to find some small goal you can both agree on

Patient is on loads of medications, including aspirin and naproxen. She has a BUN previously of 20 and a Cr of 1.5. Today both are higher. There are WBC casts. Diagnosis?

Tubulointerstitial nephritis NB: chronic glomerulonephritis has RBC casts

What statistical analysis do you use to compare two means? What about to categorical data? What if you employ variances in the calculation? What about comparing multiple (3 or more) means?

Two means: t-test Categorical: chi squared Employ variances: z-test 3 or more: ANOVA

7 yo boy has lyme disease. Treatment?

Tx: amoxicillin Not doxycycline under 8 yo because of risk of slowing bone growth and teeth discoloration

Patient is beraveing the death of his wife. It has been 7 months and he still has significant depression symptoms. Treatment? What is he has weight loss?

Tx: antidepressants with psychotherapy Loss: mirtazapine (stimulates appetite)

Patient has PCP pneumonia. What is the treatment? What are indications for an adjunctive treatment?

Tx: trimethoprim sulfamethoxasole Adjunctive: corticosteroids if: -PaO2 < 70 mmHg -Alveolar-arterial gradient is > 35 mmHg

What is the difference between second degree Mobitz type I and type II?

Type I: progressively longer PR interval More benign, predictive "group" beating Type II: episodic unpredictable absence of QRS after P Due to block in His-Purkinje system More indicative of starting a pacemaker

7 month old is fussy, febrile, and is making less wet diapers. The white cells are raised. Likely diagnosis/something you must rule out? Investigation?

UTI Ix: urethral catheterization, urine analysis, urine culture Needs to be catheterization because with patients who wear diapers, they will likely even have their clean catch urine contaminated

Patient (36 yo) has chronic cough productive of a little sputum. It didn't improve with cough syrup that had diphenhydramine. It's worse at night Differential? Most likely? Confirmation?

Upper airway cough syndrome (postnasal drip) GERD Asthma ACE inhibitors Malignancy, chronic bronchitis, bronchiectasis Abscess, interstitial lung disease Most likely: asthma Confirmation: PFTs

Patient has hypertension. What should be done for her workup?

Urinalysis (protein/creatinine ratio, hematuria) Lipid panel Chemistry panel ECG

Patient had severe right flank pain. He has decreased urination, but also episodes of high urine output and generalized weakness. He had total nephrectomy and hypokalemia. Diagnosis?

Urinary outflow obstruction Key: low urinary output and then sudden high output. Can lead to hypokalemia (will the diuresis) and weakness

Patient has hypercalcemia but is asymptomatic. Bloods are basically normal. Ca is high, PTH is high normal. What else do you want to look for to determine etiology?

Urine calcium / creatinine clearance ratio is (Ca urine/Ca serum)/(Cr urine/Cr serum) Two differentials: hypocalciuric hypercalcemia and primary hyperparathyroidism. In Hypocalciuric hypercalcemia, the body thinks it needs to hold on to more Ca, so there is a little Ca urine and a lot of Ca serum, making this ratio lower. In primary hyperparathyrodism, the body is trying to get rid of Ca because it knows there's too much, so there's high Ca urine, making this ratio higher. This presentation: low ratio, therefore, hypocalciuric hypercalcemia

Patient has a rash on her legs. They were acute in onset, worsened over 1-2 hours, improved by end of the day. They are puritic, well circumscribed, erythematous plaques with central pallor, along with intense pruritis Diagnosis?

Urticaria (acute)

Patient has a rash that is spreading. He is hungry all the time. Low weight and malnourished. Scaling and fissures are present at the mouth corners. They are cracked and inflamed. The tongue and oropharyngeal mucosa are swollen and hyperemic. There are erythematous, scaly patches on the eyebrows, cheeks, and nose, rash is on scrotal skin. He has low Hb, but normal MCV Diagnosis?

VB 2 def -Chelitis (fissures at corners of lips) -Glossitis (hyperemic tongue) -Stomatitis (edematous oropharyngeal mucosa) -Normocytic normochromic aneamia -Seborrhetic dermatitis Contrast: VB 6 causes more neurologic disturbances and it does not cause anemia

Patient is born premature, but stable. How should you manage baby's vaccines?

Vaccinate according to chronologic age, NOT gestational age.

7 yo caucasian boy had a splenectomy. What vaccination/prophylaxis should he get? Blood smear shows red blood cells with occasional round, blue inclusions on wright stain. What is the cause of this?

Vaccination: pneumococcal vaccination Prophylaxis: penicillin Cause: Howell-Jolly bodies, which are nuclear remnants within RBCs, that are *typically removed by the spleen.* So if you see these blue inclusion bodies, the patient either had a splenectomy or the spleen isn't working properly (functional hyposplenism due to splenic infarction)

85 yo patient has a rash on forehead, tip of nose, and left eye. He has pain and decreased vision. The rash is vesicular on the periorbital and lid margins. The L eye is red with chemosis. Dendridiform ulcers are on the cornea. Diagnosis?

Varicella zoster opthalmicus Not herpes: that is just dendritic ulcers on cornea with no dermatomal rash.

2 yo has fever and resp distress. A week ago he had rhinorrhea and nasal discharge. He still has fever and is progressively tired. He's tachycardic, with a temp, and has palpable cervical lymph nodes bilaterally. He has an S3 and new murmur at the mitral valve. He has respiratory distress and wheeze at the bases despite bronchodilator therapy and he has hepatomegaly. Diagnosis?

Viral myocarditis Especially new S3 and murmur with previous viral illness

A patient gets opioids for chronic back pain. What do you need to watch out for? What do you need to arrange?

Watch: risks of misuse -<45, psych disorder, personal or family use of substance disorder, legal history Arrange: -Prescription drug monitoring program -Random urine drug screening -Follow up visits every 3 months at least

45 yo man has recurrent sinusitis and otitis. There is yellow discharge mixed with blood. He has ulcerations in the right auditory canal. On urinalysis, he has blood, protein +2. Diagnosis?

Weckner's Granulomatosis with Polyangitis -Upper resp: sinusitis/otitis/saddle nose -Lower resp: (not here, but nodules/cavitation) -Kidney: (nephritic) -Skin: livedo reticularis and non-healing ulcers

What should happen to an infant's weight by 12 months? What about their height?

Weight: triple (double by 6 months) Height: inc by 50%

Patient has graves disease and opts for radioiodine therapy. What is the most likely outcome after this treatment?

Will not improve graves opthalmopathy Will cause gradual decrease in thyroid hormone production (slow necrosis of the thyroid follicular cells)

Patient description is obvious for acromegaly. What is the workup for diagnosis?

Workup: -Insulin growth factor 1 levels first -Oral glucose suppression test next (give glucose, should suppress GH) -MRI brain for pituitary mass (if pituitary is normal, ix for other cause, like ectopic GH or GHRH secreting tumors)

Patient has back pain that sounds like it's probably cancer. What imaging should be done?

X ray

Suspected pathology and proper imaging: X-ray MRI Radionucleotide bone scan or CT scan

X-ray: -Fracture -Malignancy (do XR first, then can go to MRI) -Ank spon MRI: -Sensory/motor deficit -Cauda equina syndrome (urinary retention, sadddle anesthesia) -Suspected epidural abscess/infection (fever, IVDU, infection, hemodialysis) Radionucleotide bone scan or CT -Indictions for MRI but can't have it

Should ladies get routine OGGT in pregnancy? When?

Yes after 2nd trimester (28 weeks)

Patient has HIV and is asking about getting the Varicella vaccine. Can you give it?

Yes, if CD4 count is >200

Is it normal to have little pink-ish spots on nappies after birth?

Yes. They are uric acid crystals and can be there up to the first week of life

Patient has epigastric pain, fatty stools, weight loss, two duodenal and one jejunal ulcer. What is the best explanation for this?

Zollinger ellison syndrome (multiple ulcers--some distal to duodoneum, diarrhea/malabsorption because there's excess acid secreted, and that inactivates pancreatic enzymes bc it's not an ideal pH) Pathophys: excess gastrin secretion, hyperplasia of parietal cells, excessive production of gastric acid)

Patient has mediastinal mass, elevated alpha-fetoprotein and beta-hCG. Diagnosis?

non-seminomatous germ cell tumor