Final IMP Test :)

Recovery community voices

Which alcoholic treatment group utilizes family support?

Risperidone

Which antipsychotic causes increased prolactin?

43 yo prescribed 6 weeks of IV ceftriaxone for cellulitis who develops net onset diarrhea on treatment day 7

Which of the following clinical scenarios would testing for C. Diff infection by PCR be appropriate?

Meckel diverticulum... rarely causes symptoms but infants by age 2 may present with painless passage of maroon0colored stools

1 year old boy is brought to ER because of passage of several maroon-colored stools per rectum. Abdominal examination reveals normal bowel sounds and no masses. What's the most likely diagnosis?

Reye syndrome. Often fatal sequela to certain viral illnesses. Encephalopathy and fatty infiltration and dysfunction of the liver. Salicylates are suspected of potentiating this syndrome in patients with viral illness. Mortality rate is 50%

13 year old adolescent, who has recently recovered from URTI presents to ER with lethargy, vomiting, and delirium. While transported to the ER, he has seizure. On physical, he's jaundiced and has hepatomegaly. He has no focal deficits on neurological exam but is comatose. What's the most likely diagnosis?

Osteosarcoma. Most common malignant of bone, most commonly involving distal femur, proximal tibia, and proximal humerus. Plain films reveal a moth-eaten destruction of bone with a sunburst appearance correlating to a spiculated periosteal reaction.

15 year old adolescent presents with complaints of pain in left distal thigh, close to knee. Pain present for 3 weeks and is increasing in severity; he recently noticed swelling. No history of trauma or previous hip or leg problems. A plain film of the area reveals a moth-eaten appearance of the distal femur with a spiculated periosteal reaction. What's the likely diagnosis?

Rupture of the medial collateral ligament

17 year old football player with his foot planted is tackled from the side, causing a forced valgus bending of the knee. On physical, there's tenderness over the medial femoral condyle. McMurray test is negative for any palpable clicks, but there is valgus laxity with the knee fully extended. Which of the following is the most likely diagnosis?

Lateral epicondyle tendinitis (tennis elbow), characterized by tenderness of common extensor muscles at their origin (lateral epicondyle)

20 year old woman presents complaining of proximal forearm pain exacerbated by extension of the wrist against resistance with the elbow extended. Denies trauma but is an avid racquetball player. What's the most likely diagnosis?

Start a potassium infusion

21-year-old woman presents to the emergency department with nausea and vomiting for the past two days. She has also had to Syria and abdominal pain for the past day. Medical history significant for type one diabetes. Medication's are insulin; however, she reports not having administered any insulin for the past two days because of poor appetite. Vital signs: normal temp, low blood pressure, High heart rate, normal respiratory rate, normal oxygen saturation on room air. Physical exam shows dry mucous membranes in right CVA tenderness but is otherwise unremarkable. Lab studies show glucose 305, sodium 131, potassium 3.2, chloride 98, bicarb 12, pH 7.23. In addition to administering isotonic fluids, which of the following is the most appropriate next step in management?

Surgical consultation to evaluate for possible debridement

27-year-old man brought to the ED with 10/10 pain in his left thigh for the past 12 hours as well as acute confusion for the past two hours. Past medical history significant for type one diabetes. Four days ago, he was involved in a car crash in which he suffered blunt trauma to his lower extremity. He was appropriately treated at that time and discharged home. Today, he appears ill and is sleepy but easily arousable unable to answer questions appropriately. Temperature is 102 blood pressure is low he is tachycardic and respiratory rate is normal, O2 sats 100% on room air. Physical shows diffuse swelling and tenderness to palpitation on his left anterior thigh with violaceous skin discoloration. The remainder of the physical exam is unremarkable. Lab studies show a white blood cell count of 26,000 with a left shift and Sam creatinine of 6.3. X-ray of the left lower extremity shows no evidence of fracture. The patient is given IV fluid bolus with improvement in his blood pressure. After collecting two sets of blood cultures and starting broad-spectrum antibiotic therapy, which of the following is the most appropriate next step in the management of this patient?

Order a thyroid stimulating immunoglobulin

25-year-old woman comes to the clinic with fatigue in a 20 pound weight loss for the past three months. She has also had heart palpitations and a sensation of feeling hot all day for the past two months. Vital signs show temperature of 98.9, heart rate of 120, normal blood pressure, and a BMI of 18. Physical shows swelling of the anterior neck with a bruit heard over the swelling as well as tachycardia but is otherwise normal. Labs showed low TSH and normal free T4. Which of the following is the most appropriate next step to establish the diagnosis of this patient?

Klebsiella species

25-year-old woman is admitted to the hospital with cough, dyspnea, and fever of 102 for three days. Medical history is non-contributory. No meds. Vital signs are a temperature of 101, blood pressure of 110/80, pulse of 80, respiratory rate of 22, and oxygen saturation at 90% on room air with improvement to 98% on 2 L of oxygen. Physical exam shows crackles bilaterally but is otherwise unremarkable. The show COVID-19 PCR negative, sputum and blood cultures negative. She has started on appropriate treatment for atypical pneumonia with improvement. Which of the following micro organisms is not considered an atypical cause of community acquired pneumonia?

Start HAART

26 year old woman comes to the clinic to establish care. CUrrently has no complaints. She diagnosed with HIV 1 month ago. No meds, vitals normal. Lab shows absolute CD4 count of 697 and vital load of 11,042. What's the next appropriate step in management of this patient?

Anabolic steroid use

A 19 year old collegiate football player is sent to your office by the teams coach because of occasional outbursts of anger and hostility. The patient is otherwise asymptomatic, has no past medical history and denies using tobacco, alcohol, or illicit drugs. Physical examination reveals a blood pressure of 140/90. The patient has gynecomastia and testicular atrophy. He states that his libido and sexual performance are adequate. His urine drug test is negative. Which of the following is the most likely diagnosis?

ALL. Comprises 80% of all childhood leukemias (peak incidence is between 2 and 6). Most patients present with fatigue, mucosal bleeding, low-grade fever, and lower extremity bone pain. Patients may present with an infection due to the severe neutropenia. Physical is often remarkable for pallor, petechiae, purpura, mucous membrane bleeding, bone pain, generalized lymphadenopathy, and hepatosplenomegaly

3 year old boy with a 4-day history of URTI presents to ER for evaluation of pallor and fatigue. Physical exam reveals a pale child with normal vital signs. He has scattered petechiae on the chest and extremities and a palpable spleen tip. Lab data reveals a leukocytosis. Low Hb and low platelet. Peripheral blood smear shows blasts. What's the diagnosis?

Carpal tunnel syndrome

30 year old woman, who works as a court reporter, presents with a three week history of hand tingling and numbness. It often awakens her from sleep. The symptoms resolve after she shakes her hands for a few minutes. In physical examination, there is no sensory or motor deficit of her hands but there is reproducibility of the tingling when tapped on the volar side of her wrist. Which of the following is the most likely diagnosis?

Intubation with mechanical ventilation

31 year old man brought by EMS to ED after police found him wandering on interstate. Uncooperative and has uncoordinated gait, abnormal arm movements and slurred speech. On arrival, vital signs are stable. During the physical examination, the patient becomes unresponsive and difficult to arouse with shallow respirations. Oxygen saturations are 88% on 4L. A stat CT head is obtained and is normal. Lab studies show alcohol level of 360. What's the next appropriate step in the management of the patient?

Nerve root impingement

33 year old graduate student complains of low back pain after carhrying heavy suitcase on recent Europe vacation. Neurologist in London recommended NSAIDs and bed rest. After 10 days, back pain resolved, but he comes to see yhou because of weakness in right anterior tibialis muscle. Rest of physical is normal. What's the most likely diagnosis?

Start daily TMP-SMX

A 19 year old man comes to the clinic for follow-up. He has no complaints. He is planning on attending college. Past medical history shows HIV. Vitals and physical is normal. Labs show an absolute CD4 count of 98 and viral load of 144,379. What's the most appropriate next step in management of this patient?

Application of ice and stretching exercises. First step heel pain is classic for plantar fasciitis, often seen in young, active adults due to repetitive micro trauma, as well as in obese patients, those who stand for a long time, or run frequently on hard surfaces, and in those with pes planus (excessive pronation of the foot) or pes cavus (high arch). Plantar fascia tightens the longitudinal arch and helps with the push-off phase of walking. Diagnosis can be made on history and with reproducibility of tenderness with palpation of the inferior heel at its attachment to the medial tuberosity of the calcaneus. Radiographic studies not needed

34-year-old female attorney presents to your office complaining of right heel pain. As the weather has recently improved, she has been running her usual daily 5 miles outside on the pavement and recently she has been involved in the trial which requires her to stand in court a lot during the day. She states that her pain is worst when she steps out of bed barefoot in the morning and after she has been sitting at her desk for a long time, though it seems to be better as she continues to walk around and heals during the day. She has no systemic symptoms or other joint involvement. On examination, she has tenderness upon palpation of the inferior heel near the medial tuberosity of the calcaneus. What is the most appropriate next step in management?

Calcium oxalate

34-year-old woman comes to the clinic with left flank pain for the past eight hours. She reports of this Pana woke her up from sleep and has been associated with nausea and vomiting. Medical history significant for Crohn's disease. Medication or adalimumab. Vitals show high blood pressure, tachycardia. Mild distress secondary to pain as she cannot lie still on the exam table but the remainder of the physical is normal. CT scan of abdomen and pelvis is obtained and shows 7 mm non-obstructing stone in the left ureter. Based on this patient's history, which of the following is the most likely composition of her left kidney stone?

Pregnancy

34-year-old woman comes to the clinic. She had a urinalysis and culture down as part of a work physical examination and is concerned about the results. Medical history is noncontributory. She currently has no complaints of dysuria, hematuria, or mellow dressing room. And review the results, they were your analysis is normal, but the culture of urine revealed more than 100,000 colony forming units of E. coli. And discussing these results with the patient, in which of the following clinical scenarios with the patients bacteriuria be treated?

L5 nerve root

37 year old man presents complaining of difficulty walking. ON physical, he is unable to walk on his heels.

Patients with T1DM and T2DM should have an annual urine microalbumin to screen for diabetic nephropathy

37-year-old woman comes to the clinic for follow up. Medical history significant for type one diabetes, diagnosed at age 18. Her diabetes is well-controlled now but was not always well controlled when she was younger. Medication's are an insulin pump and continuous glucose monitor, losartan, and a tour of a statin. Which of the following is true of the screening for patients with diabetes?

Graves' disease

37-year-old woman comes to the emergency department with a 100 pound weight loss over the past year as well as intermittent heart palpitations and hair loss over the past three months. She has also had 4 to 5 loose bowel movements per day and diffuse muscle weakness over the past two weeks. Medical history is non-contributory. Medication's are over-the-counter and thyroid supplement. Family history is non-contributory. Vital signs include temperature of 97.6, pulse of 130, and blood pressure of 145/75. Exam shows a diffuse thyroid enlargement with a bruit over the thyroid gland. The remainder of the physical examination is normal. Which of the following is the most likely diagnosis of this patient?

Lumbosacral strain. Since the patient has pain not radiating below the knee, paraspinous tenderness, and no neurologic compromise, the most likely diagnosis is lumbosacral back strain. Strain is common in people in their forties. Exacerbated by activities and improves with rest. Straight leg maneuver is positive for nerve compression from disk herniation, when radicular pain is produced down the leg to below the knee, at less than 70 of elevation. Crossover pain is also a strong indicator of nerve root compression, but only if pain is produced below the knee. Pain in hamstrings is not a positive straight-leg raise

41 year old construction worker complains of the sudden onset of severe back pain after lifting some heavy equipment. He describes the pain as being in his right lower back and radiating down the posterior aspect of his right butt to above the knee area. He has no bladder or bowel dysfunction. The pain has improved with bed rest. On physical, the patient has tenderness in his lumbar paraspinous area with palpation. The straight leg maneuver with the right leg increases the back pain at 80 degrees. Straight leg maneuver with the left leg causes posterior thigh pain. Sensation, strength, and reflexes are normal. Which of the following is the most likely diagnosis?

Fusobacterium

41 year old man is admitted to the hospital following an altercation. The patient reports he was assaulted and in the process of defending himself, he suffered a bite on his left hand from the assailant, who then ran away. Vital signs are stable. Physical examination shows swelling, erythema, and tenderness of the left hand on the owner side with puncture wounds consistent with teeth marks. Which of the following is the most likely cause in this patient's current findings?

Cervical musculoligamental sprain or strain (whiplash)

41 year old man was recently in a motor vehicle accident in which he was the driver. He states that he was wearing his seatbelt at the time of the accident. The day after the accident, he developed neck pain that is now continued for 10 days. He notices crunching on extension and lateral bending of the neck. Physical examination reveals no neurologic deficits. His neck has no areas of tenderness and there are no areas of spasm. He has normal lateral bend, extension, and flexion of the neck. Which of the following is the most likely diagnosis?

IV normal saline

41 year old woman comes to the ED with epigastric pain, nausea, vomiting, and altered mental status for the past 2 days. Past medical history is non-contributory. She does not take any medications. Vital signs are normal. Physical shows sleepy female that's responsive to painful stimuli, tacky mucous membranes, but otherwise unremarkable. Lab study shows very high serum calcium. What's the next most appropriate step in the management of this patient?

Compartment syndrome from elevated pressure in a confined space, compromising nerve, soft tissue, and muscle perfusion. 6 Ps of compartment syndrome: pallor, paralysis, paresthesias, poikilothermia, and pulselessness. Immediate fasciotomy and restoration of tissue perfusion is the treatment

42-year-old man presents with a crush injury to his left lower extremity. He complains of severe leg pain that seems out of proportion to the injury. He also complains of paresthesias of the injured extremity. Leg examination is significant for pallor and coldness. The dorsalis pedis and posterior tibialis pulses are not palpable. Which of the following is the most likely diagnosis?

Frozen shoulder due to partial rotator cuff injury. Passive ROM tests are performed by examiner if active ROM tests are unable to be performed by the patient. Loss of passive ROM indicates a stiffening shoulder (frozen shoulder or adhesive capsulitis). Most likely etiology would be impingement of rotator cuff, causing inflammation, degeneration, and possibly a partial tear. Rotator cuff, which is formed by the SITS tendons, stabilizes the glenohumeral joint and prevents upward movement of the head of the humerus. In a complete rotator cuff tear, the drop arm sign may be positive

45 year old swimmer presents with a right sore shoulder for nearly 2 months. He was taking NSAIDs throughout this period with minimal relief. Over the last several days, he has developed pain with elevation of his arm above the horizontal. On examination, he has some stiffness of passive motion in external rotation and with abduction and negative drop arm sign. The pain is relieved after you inject 2 mL of lidocaine into the subacromial space. What's the most likely diagnosis?

Acute interstitial nephritis

45-year-old man comes to clinic for follow up. He reports two days of leg swelling as well as blood in his urine. He denies chest pain, shortness of breath, abdominal pain, or dysuria. Medical history significant for hypertension. Medication's are lisinopril daily and ibuprofen three times a day five days a week when he's working. Vital signs are temperature 98.6, pulse 80 per minute and blood pressure 150/80. Physical shows 1+ bilateral ankle edema but is otherwise unremarkable. Labs show a creatinine of 2.8 in a urinalysis with RBC is 100 per HPF, WBC 10 to 20 per HPF, WBC casts, and trace protein. Renal ultrasound shows normal size kidneys and normal collecting system. Which of the following is the most likely diagnosis of this patient?

S. Pneumoniae

46-year-old man admitted to the hospital for fever and dyspnea for the past 18 hours. Medical history is non-contributory. Temperature is 102 blood pressure is normal pulse is normal respiration rate is normal and oxygen saturation is 88% on room air with improvement to 96% on 2 L of oxygen. Physical examination shows crackles in the left upper lobe. Chest x-ray shows a cavitation in the left upper lobe. Which of the following organisms is most likely the cause of this patient's current findings?

Nitrofurantoin orally

46-year-old woman comes to the clinic with dysuria and lower abdominal pain for the past two days. She also reports that her urine has appeared dark in color. She denies fevers, nausea, vomiting, or back pain. Vitals are normal. Physical shows mild suprapubic tenderness but is otherwise unremarkable. Which of the following is the most appropriate next step in the management of this patient?

Replace the Foley catheter in obtain a urinalysis from the new catheter with a reflux urine culture

46-year-old woman is admitted to the hospital with septic shock. Medical history significant for quadriplegia from a car crash at age 31 with a chronic indwelling Foley catheter. Vital signs are 102 temperature, blood pressure of 80/40, pulse of 110, respiratory rate of 18, and oxygen saturation of 98% on 2 L of oxygen. She appeared ill and is unresponsive to verbal stimuli. Physical examination shows quadriplegia, contractions of the bilateral upper and lower extremities, peg tube in place but is otherwise unremarkable. Appropriate therapy for septic shock is started. Which of the following is the most appropriate next step in order to obtain cultures from the Foley catheter?

Rosuvastatin

47-year-old man comes to the office for follow up. Medical history significant for T2DM that was diagnosed 3 months ago. Medications are metformin. He has also begun lifestyle modifications including a low carbohydrate diet. Vitals are temperature of 98.6, BP 130/86, pulse 72/minute, and RR of 12. Physical shows no diabetic retinopathy on fundoscopic examination and a normal foot examination. Lab study shows HbA1c of 6.9%, fasting glucose 93, creatinine 0.9, urine microalbumin 25, LDL 73, HDL 32, triglyceride 173. Which of the following medications is most appropriate to aid this patient's regiment at this time?

Metastatic breast cancer. Back pain that is not responding to NSAID and is made worse with lying down is a red flag for cancer. She's also lost weight recently

52 year old with history of low back pain for 2 months after she lifted a heavy patient at work. Nagging pain that worsens with bed rest. She has tried NSAIDs with no relief and has continued to work. Past medical history of breast cancer 8 years ago, and, except for a recent 10 lb weight loss, has been well since her lumpectomy. Tenderness over the lumbar vertebral bodies but her neurological examination and straight-leg raising test are normal. Rest of physical unremarkable. What's the most likely diagnosis?

High volume fluid resuscitation

52-year-old man is brought to the emergency department for evaluation of altered mental status by his wife. According to his wife he was recently treated for a UTI with an unknown anabiotic. She says that over the past few months he has been urinating more and drinking water constantly. Vitals show temp of 98.6, hypotension, increased heart rate, tachypnea. Oriented to person only, dry mucous membranes, and tachycardia with a regular rhythm. The remainder of the physical exam is unremarkable. Urinalysis negative for ketones. WBC is 4.5, Na 121, K 4.2, bicarb 24, glucose 1400. ICU is called for admission and a peripheral IV line is placed. What's the most appropriate next step in the management of this patient?

MRI of foot and antibiotics

55-year-old woman comes to clinic with a right foot ulcer for the past two weeks that has a foul smelling drainage for the past week. She otherwise has no complaints. She has type two diabetes. She takes Met Forman. Vital signs are normal. Physical exam shows one by one cm right plantar foot ulcer with yellow discharge and surrounding erythema but is otherwise normal. What is the most appropriate next step in the management of this patient?

Glargine 10 units nightly and aspart 3 units with meals plus sliding scale correction at meals

55-year-old woman is admitted to the hospital for community acquired pneumonia. She started on ceftriaxone azithromycin intravenously. Medical history significant for hypertension and type two diabetes. Medication's are metformin, dulaglutide, canagliflozin, and lisinopril. Vitals are 99.8 temp, 130/80 BP, pulse 80, RR 18, and O2 sats 98% on 2L O2. Physical shows crackles at the right base but is otherwise unremarkable. Lab studies shows HbA1c is 7.2%, glucose 203, creatinine 0.8. Which of the following is the most appropriate regiment for her diabetes while she's in the hospital?

Contrast induced nephropathy

58 year old woman admitted to the hospital with dry gangrene of left 4th and 5th toes. She has T2DM, HTN, and COPD. She takes metoprolol, lisinopril, and long acting insulin daily. She undergoes lower extremity angiography and angioplasty for severe peripheral vascular disease. On the day following her procedure, her creatinine is noted to be 3.5, admission creatinine was 1.5. Urinalysis shows no RBC, WBC, protein, or urine sodium hardly. Which of the following is the most likely cause of AKI in this patient?

Charcot joint

58 year old woman with a long-standing history of diabetes, complicated by neuropathy, retinopathy, and nephropathy comes for an initial visit. On physical exam of her feet, sensation is absent, and on the right foot she has an enlarged, boggy, painless midfoot

Remove CVC and treat with anti fungal agent

59-year-old woman is admitted to the ICU for sepsis from community acquired pneumonia. She is treated with vancomycin and piperacillin/tazobactam and placed on mechanical ventilation for four days. She has a right internal jugular central venous catheter placed for cardio pulmonary monitoring, blood draws, and antibiotics. On hospital day 8 she develops an uncomplicated central line associated bloodstream infection with blood cultures growing candida species. What's the most appropriate treatment for uncomplicated catheter-associated bloodstream infection from Candida?

Oral vancomycin

61-year-old man admitted to the hospital for postoperative intra-abdominal infection. Based on culture results, he has started on Lexofloxacin and clindamycin. On day 6, he has 6 episodes of non-bloody diarrhea. Labs show WBC of 8000, serum creatinine of 0.9 and C. Diff PCR toxin assay is positive. C. Diff infection is his first such episode. Which of the following is the most appropriate treatment for this patient at this time?

Exchange the Foley catheter

64 year old man hospitalized for Covid pneumonia. Medical history significant for quadriplegia. On admission, he is placed on 4L O21 and begun on dexamethasone and remdesivir. Blood cultures are obtained and urine cultures are obtained from a Foley. Patient shows clinical improvement within 48 hours. Blood cultures are negative and urine cultures are positive for Candida albicans with >100,000 cfu. Which of the following is the most appropriate next step in management of this patient?

Hypertrophic osteoarthropathy... nail clubbing accompanied by a symmetrical polyarthritis involving the large joints and occasionally the metacarpophalangeal joints. This condition may be seen secondary to malignancy, endocarditis, vasculitis, and other pulmonary and cardiac diseases

67 year old man with lung cancer presents with metacarpophalangeal joint pain. On physical, there's pain on moving his fingers and a spongy sensation when palpating the proximal aspects of the fingernails. Diagnosis?

L4 nerve root

71 year old woman has difficulty squatting or rising out of a chair

Trochanteric bursitis. Exacerbated by standing, external rotation, lying on it

73-year-old man presents complaining of right lateral hip pain that worsens when he lies on his right side or when he is standing. He has no other complaints. On physical examination, there is tenderness with palpation of the lateral aspect of the hip, but range of motion testing of the hip is normal. Which of the following is the most likely diagnosis?

Vancomycin and cefepime

74 year old man admitted to the hospital with community acquired pneumonia. Past medical history of OA, total right hip arthroplasty requiring 4 day hospital stay 2 months ago. He has been non-ambulatory since that time. 100.5 temp, normotensive, normal pulse, normal respiration, 92% on room air that improves to 100% when placed on 2L O2. Physical exam shows coarse breath sounds bilaterally with crackles in the LLL but is otherwise unremarkable. CXR shows a left lower lobe infiltrate. Which of the following is the most appropriate antibiotic regimen for this patient?

Varicella

8 year old child experiences a sudden onset of vesicles beginning first on the face and then spreading to the trunk and extremities. Some vesicles have evolved into pustules and crusts. The lesions are extremely Pruritic. 2 weeks ago, the child visited a nursing home on a school field trip

Urinary obstruction

91 year old man is admitted to the ICU for sepsis secondary to pyelonephritis. Medical history is significant for dementia, hypertension, and previous CVA with no residual deficits and benign prosthetic hyperplasia. He is placed on 2 L oxygen for hypoxemia, and the Foley catheter is placed. After three days of IV antibiotics with piperacillin/tazobactam, he improves and is transferred to the floor for seven more days of IV antibiotics. On hospital day six, his Foley catheter is removed. I'm hospital day eight, he is difficult to awaken, delirious, and often moaning. Which of the following is most likely the cause of this patient's current status?

Start levothyroxine supplementation

A 19-year-old man comes to the clinic for follow up with fatigue and a 10 pound weight gain over the past two months. He underwent transphenoidal resection of a pituitary tumor three months ago and subsequently developed polyuria which was consistent with diabetes insipidus. He received DDAVP for one week with subsequent resolution of the symptoms. Other medical history is central adrenal insufficiency. Medication's are hydrocortisone twice a day. Vital signs and physical examination or noncontributory. Labs show a very low TSH and a free T4 that is also low. Which of the following is the most appropriate next step in the management of this patient?

Monosodium urate crystal (needle shaped, negatively birefringent) deposition causing gout. Thiazide diuretics are known for hyperuricemia as potential adverse effect

A 49-year-old man presents with painful, recurrent episodes of swelling in his left great toe. He takes 25 mg of hydrochlorothiazide daily for blood pressure control but otherwise in good health. On physical examination, the patient is a febrile, but his great toe is warm, swollen, erythematous, and exquisitely tender to palpation. He has several subcutaneous nodules in his pinna. Which of the following is the most likely cause of his discomfort?

Radial nerve

A 12 year old boy is brought to your office two days after a fracture of the humerus in its distal third. The patient complains that he is unable to extend the wrist. On examination he has a wristdrop but his distal pulses in his arm are intact. Which of the following structures was most likely damaged?

Osgood-Schlatter disease is more common in males, occurs in adolescence, and is usually self-limited. It's due to patellar tendon stress, which causes pain, and often swelling, in the region of the tibial tuberosity. Tubercle is painful on palpation and when the patient extends knee against resistance.

A 12 year old boy presents with a 3 week history of pain of his anterior tibia, just below the patella. He plays baseball and soccer, but does not recall any history of trauma. On physical exam, he has swelling and tenderness to palpation over the tibial tubercle. Which of the following is the most likely diagnosis?

Slipped capital femoral epiphysis. Often obsess, but tall, males who present with thigh or knee pain. Disorder of unknown etiology that causes posterior and medial displacement of the femoral head, leading to a limp, reduced internal rotation of the hip, and leg weakness

A 13 year old adolescent presents with left knee pain. He does not play sports and does not recall any trauma. Physical examination, he is obese, but taller than normal for his age. When he walks to an examination table, you notice an antalgic gait. Upon exam, his hip strength is 4/5 and he has reduced ability to actively rotate the hip internally. Which of the following is the most likely diagnosis?

Normal puberty. Gynecomastia is seen in 50%-60% of adolescent boys and usually occurs during Tanner stages 2 or 3. Usually painful and may be unilateral or bilateral. Gradually appears and resolves spontaneously within 1 to 2 years of onset

A 13-year-old adolescent is worried that he is growing breasts and complains that the breasts are often painful, but he has no other complaints. He states that he has been growing taller this past year. On physical examination, you note some acne on the patient's face. His testes and phallus are appropriate for his age, and his scrotum is reddened, with some thinning of the skin. He has fine, sparse pubic hair. Which of the following is the most likely diagnosis?

Osteogenesis imperfecta, an AD trait

A 17 month old boy has a history of multiple fractures due to brittle bones. The child is short in stature and has a deformed skull. Physical examination is normal except for the findings of blue sclerae. Which of the following is the most likely diagnosis?

SLE

A 17 year old woman complaints of intermittent ankle pain and welling, and oral ulcers. On physical, she has a raised erythematous rash over her nose and cheeks, sparing her nasolabial folds. Diagnosis?

Serum hCG. Is she pregnant?

A 17 year old woman presents with amenorrhea for three months. She states that she has had irregular periods since her first period at the age of 12. She has no other symptoms or past medical history. Her physical examination is unremarkable, except breast examination reveals breast engorgement and tenderness. Which of the following should be the first test you order?

Lack of improvement after 72 hours on antibiotics. He has reactive arthritis (Reiter syndrome), which usually occurs in young men within a month following a GI or STI. Majority of symptoms resolve within weeks, but arthritis may persist. Synovial fluid will be culture-negative. Gonococcal arthritis may mimic Reiter, but is more commonly found in women and MSMs. Migratory polyarthralgias of the wrist, elbow, ankle, or knee. GC symptoms will markedly improve within 48 hours of antibiotics

A 19-year-old man was recently treated for chlamydia urethritis. He now complains of persistent dysuria, watery discharge of his eyes, and swelling of his right knee. On examination he has a low-grade fever, conjunctival injection and warmth of his right knee, with a ballotable patella. Which of the following features will best distinguish this arthritis from gonococcal arthritis?

IV ceftriaxone

A 19-year-old woman comes to the emergency department with a fever of 102, flank pain, nausea, and intermittent vomiting for the past two days. She has also had this year that is getting worse over the past day. She is not sexually active. Vital signs are temperature of 102.3, blood pressure 114/64, pulse of 112, respiratory rate of 18, and oxygen saturation 100% on room air. Physical exam shows sticky mucous membranes, bilateral CVA tenderness, as well as super pubic tenderness. The remainder of her physical examination is unremarkable. Lab showed negative urine pregnancy tests and urinalysis is positive for nitrate, bacteria, leukocyte esterase, and more than 100 white blood cells. Which of the following is the most appropriate initial antibiotic treatment for this patient?

Roseola

A 1year old has had a high fever for 4 days. Today the child is afebrile but developed a blanchable, maculopapular rash over the trunk and neck. The child appears remarkably well.

Anterior glenohumeral dislocation

A 20 year old college student develops left shoulder pain after jumping into a leg from a swinging rope. She presents to the emergency department holding her arm abducted beside her body and avoiding any shoulder movement. On examination, the rounded contour of the shoulder is lost and the head of the humerus is felt under the coracoid process. Which of the following is the most likely diagnosis?

HIV PCR quantitative

A 20-year-old man presents to the emergency department with fever, myalgia's, and a rash for the past two days. He recently returned from a trip to Florida two weeks ago where you had unprotected sex twice with two different female partners. Past medical history is not contributory. No medication's. Vitals are normal. Physical examination reveals mild bilateral cervical lymphadenopathy, diffuse erythematous maculopapular rash on his arms and trunk. He is concerned that he has contracted HIV. Which of the following is the most appropriate next step in the work about this patient?

Marfan syndrome... mitral valve prolapse, aortic regurgitation, and aortic dissections are associated with Marfan

A 21-year-old man presents to your office for a pre-employment physical exam. He is 6'3" tall and weighs 70 kg. Heart examination reveals a mid systolic click and systolic murmur that increases with Valsalva maneuver. The patient has an arm span that exceeds his height and has a long slender fingers. When he makes a fist with his thumb inside the thumb protrudes be on the owner margin of the hand. Which of the following is the most likely diagnosis?

Sounds like Grave's disease, the most common cause of hyperthyroidism. Serum TSH assay is the most sensitive test for primary hyper and hypothyroidism. TSH will be suppressed in Graves' disease, while serum T3, T4, and free thyroxine and thyroid are usually increased

A 21-year-old woman presents to the emergency room with palpitations. She also notes that she has been losing weight. Physical examination reveals an anxious and highly energetic patient. Her heart rate is 120. She has bilateral exophthalmos with lid retraction. Thyroid examination reveals a diffusely enlarged, non tender thyroid with an audible bruit. Fine tremors and hyperreflexia present. Most appropriate first step in the diagnosis?

Congenital adrenal hyperplasia due to 21 hydroxylase deficiency.

A 22 year old woman presents with the chief complaint of hirsutism. She has had irregular periods since menarche at the age of 13. She has a normal body weight and her facies is normal. Physical reveals excess back and chest hair. Pelvic exam is normal. The LH value is normal. Serum 17-OH progesterone concentrations are highly elevated. Which of the following is the most likely diagnosis?

Type IIA hyperlipoproteinemia. This patient is extremely young with a significant family history of hypercholesterolemia. The most common type of familial hyperlipoproteinemia is type IIA (elevated LDL). Heterozygous carriers present with a family history of coronary events and often have tendon xanthomas. Patients with type III dysbetalipoproteinemia (normal LDL with elevated IDL and VLDL) often present with palmar xanthomas and tuberous xanthomas. Hypothyroidism, DM, nephrotic syndrome, and liver disease are secondary causes of hyperlipidemia. Hyperlipidemia occurs in over half of patients with early nephrotic syndrome. Arcus senilis (gray band in the cornea) seen before the age of 40 is consistent with hyperlipidemia. Physicians should be able to calculate different cholesterol levels using the following formulas: 1. Total cholesterol = HDL + VLDL + LDL 2. VLDL = triglycerides / 5 3. LDL = total cholesterol - HDL - (triglycerides / 5)

A 24 year old man is referred to your practice for elevated cholesterol level. The patient has a father and two siblings with high cholesterol levels who are on medication's. His 31-year-old brother recently had a myocardial infarction. On physical examination, the patient has bilateral arcus Senilis. His extremities are remarkable for diffuse and nodular thickening of the Achilles tendon. Which of the following is the most likely diagnosis?

HCG mediated suppression of TSH

A 24 year old woman comes to clinic to establish care. She has no complaints and is currently 10 weeks pregnant with her first pregnancy. Meds are a daily prenatal vitamin. Vital signs and physical are non contributory. Lab studies show a TSH of 0.3 (0.5-4.5), with a free T4 of 1.2 (0.7-1.5). Which of the following is the most likely cause of the thyroid studies?

Limited systemic sclerosis (formerly CREST). Raynaud's usually the initial symptom. Limited has the sclerosis limited to the face and fingers. Rarely see organ dysfunction of kidneys, heart, or lung.

A 28 year old law student complains of blanching and cyanosis of her fingertips and cold-weather and in times of emotional stress. She complains that her fingers become numb and painful during these episodes. She has a six month history of dysphasia and arthralgias. She does not smoke or take any medication's. On physical examination the skin of her hands appears to be tout in a trophic, with a flexion deformity from the tight skin. Which of the following is the most likely diagnosis?

Ankylosing spondylitis. Most commonly affects spinal, sacroiliac, and hip joints in men beginning in their late teens and twenties. All have symptomatic sacroilitis, causing low back pain and stiffness that's worst in the morning. Uveitis, peripheral arthritis, aortic is with aortic insufficiency and limited chest expansion as a result of costovertebral joints. Strong association with HLA-B27 (found in half of black patients and 90% of white)

A 28-year-old man presents with morning back pain, stiffness with anterior flexion at the waist, and tenderness over the sacroiliac joints. The patient denies any previous history of eye or genitourinary problems. On physical examination, there is diminished chest expansion with breathing and a diastolic rumbling murmur. Which of the following is the most likely diagnosis?

Low calcium, low PTH, high phosphorus

A 30-year-old woman comes to the clinic for follow-up. She complains of tingling in her finger in around her mouth for the past three days. Medical history significant for Graves' disease for which she underwent a thyroidectomy five days ago. She does not take any medication's. Social history is negative for alcohol, tobacco, or less of drug use. Vital signs are temperature of 98.7, pulse of 90, blood pressure of 130/80. Physical exam reveals twitching of the right cheek when tapping on the right temporomandibular joint but is otherwise unremarkable. Which of the following lab findings would most likely be present in this patient?

X-ray series of the ankle. Ligament injuries of the ankle are common and occur when the foot twists as it lands on the ground. The lateral ligament is most commonly injured, often with inversion, and the medial ligament is typically injured with eversion. The lateral ligament is composed of 3 parts: the anterior talofibular ligament (most often injured), calcaneofibular ligament, and the posterior talofibular ligament. Injured ligament is usually tender, bruised, and swollen

A 31-year-old man has left ankle pain after stepping off a curb yesterday. He treated the injury with ice overnight, but today he cannot walk due to the pain. On examination of the ankle in the emergency department, he noticed that it is swollen and ecchymotic. There is tenderness to palpation in the anterior aspect of the ankle and over the lateral malleolus. Passive inversion of the foot is painful. The patient is unable to bear weight on his left foot. Which of the following is the next best step in management?

Polyarteritis nodosa, a life-threatening vasculitis of the medium-sized vessels. Often presents insidiously with systemic symptoms like malaise, fever, abdominal pain coupled with vasculitis neuropathy (known as mononeuritis multiplex, manifesting itself as wristdrop or footdrop). Skin findings of PAN include subcutaneous nodules and ulcers of lower extremities near malleoli. HBV associated with half of cases

A 31-year-old man with no past medical history presents with fever, nausea and vomiting, and arthralgias for 10 days. He complains of inability to move his left foot due to weakness. He also states he has had hematuria for several hours. On physical examination, the patient has a temperature of 101.2 and he is hypertensive. He has diffuse abdominal tenderness on palpation but has no rebound tenderness. He has subcutaneous nodules and shallow ulcerations near his medial malleolus on his left leg. Neurologic examination reveals a left foot drop. Which of the following is the most likely diagnosis?

You should have HIV testing because routine HIV screening is recommended for all persons between the ages of 15 and 64

A 34 year old woman comes to clinic for follow up. Medical history significant for diabetes type two. Medication includes metformin. She reports recent lung etting divorced about 6 months ago and has 2 teenage children. She has had unprotected sex with 2 male partners since the divorce. She's interested in being screened for HIV. Vitals and physicals are normal. What's the most appropriate statement by the physician in regards to HIV testing?

Subacute thyroiditis

A 34 year old woman comes to the clinic with generalized weakness and fatigue as well as a 10 pound weight loss over the past two weeks. She reports having rhinorrhea, nasal congestion, and a non-productive cough three weeks ago which was all, but then she developed a sore throat and difficulty swallowing. Vital signs are temperature of 98.3, pulse of 115, and blood pressure of 125/75. Physical shows tachycardia but is otherwise normal. Labs show low TSH and slightly elevated free T4. Which of the following is the most likely diagnosis of this patient?

Controlling the intestinal symptoms will likely eliminate the knee arthritis. Up to 1/3 of Chron's patients will develop extraintestinal symptoms. Up to 20% get asymmetric, polyarticular, migratory arthritis affecting large joints usually. Can be part of HLA-B27 PAIR (psoriasis, ankylosis spondylitis, IBD, Reiter) seronegative spondyloarthrpathies.

A 34 year old woman has a 15 year history of chron disease. She presents to your office with the acute onset of left knee pain. She recalls a worsening of her gastrointestinal symptoms a few days before the joint symptoms developed. Radiographs of the knee demonstrates soft tissue swelling and smaller effusions but no bone destruction. Which of the following statements best describes the patient situation?

Rhabdomyolysis

A 35-year-old man comes to the emergency department with diffuse bodyaches for the past week. He denies any medical problems or taking any prescription medication's. He has been taking Tylenol as needed for muscle aches. Social history is negative for illicit drug use. He's getting ready to compete in the triathlon and has recently started running 5 miles per day. Vitals show normal temperature normal pulse And slightly low blood pressure. Physical shows dry mucous membranes but is otherwise unremarkable. Labs show creatinine of 4.5, potassium a 5.2, and a phosphorus of 7.5. Urinalysis shows blood on dipstick with microscopy negative for red blood cells with the sediment showing muddy brown casts. Which of the following is the most likely diagnosis of this patient?

Addison disease symptoms, test with cosyntropin. After obtaining an AM cortisol level, cosyntropin is given and a repeat serum cortisol is obtained 1 hour later. Diagnosis is excluded if serum cortisol rises to at least 20. This with hypothyroidism is known as Schmidt syndrome, the result of polyglandular autoimmune destruction of the adrenals and thyroid gland, and may be accompanied by T1DM

A 37-year-old woman who recently was diagnosed a year ago with hypothyroidism presents with a chief complaint of weakness and a 20 pound weight loss. Her most recent TSH was within normal limits on supplemental thyroxine. On physical examination, the patient has increased skin pigmentation over even non-exposed skin, most prominently over her elbows, knees, and Palmer creases. She is afebrile. Her blood pressure is 90-60 supine and 70-50 standing. The rest of her physical examination is normal. Lab data reveals hyponatremia, hyperkalemia, and a metabolic acidosis. Which of the following is the best test to diagnose her condition?

Anti-CCP antibodies, which are the most specific for RA. Rheumatoid factor is present in up to 80% of those with RA, but can also occur with other autoimmune diseases, HCV, syphyllis, and TB

A 41 year old music teacher presents with a 10 month history of prolonged morning stiffness accompanied by swelling of her wrists and the proximal interphalangeal joints of both hands. Now she feels that her knees are also swollen and painful. Physical examination reveals synovial tenderness and swelling of her knees, wrists, and proximal interphalangeal joints. She has subcutaneous nodules in the extensor area of her right forearm. The right knee has a positive bulge sign consistent with an effusion. Which of the following is the best test to confirm your suspected diagnosis?

Dexamethasone suppression test... sounds like she has a pituitary tumor. Dexamethasone given at 11 PM and an AM cortisol is obtained in the next morning. Cortisol under 5 excludes Cushing syndrome. If abnormal test result, a 24-hour urine for free cortisol and creatinine will help confirm diagnosis. If hypercortisolism exists, a serum ACTH level should be drawn. MRI of the pituitary may be appropriate to rule out a lesion or a CT of abdomen might show adrenal abnormality. Cushing disease is tumor, Cushing syndrome is just the symptoms of excess glucocorticoids

A 41 year old woman with no previous medical problems presents with the chief complaint of generalized weakness. The patient states that she has been irritable lately and finds it difficult to concentrate at work. She has been amenorrheic for 12 months and feels her symptoms might be related to early menopause. On physical examination her blood pressure is 160/90. The patient has a moon face and a buffalo hump. She is hersuite. Physical examination reveals purple striae. Her extremities appear to be atrophied. Which of the following is the best first test to confirm the diagnosis?

MEN-1: 3 Ps: pancreatic endocrine tumor, parathyroid adenoma, pituitary adenoma

A 41-year-old woman presents with amenorrhea for nine months. She is found to have a prolactin secreting pituitary adenoma. Lab data reveal a serum calcium level of 12 and hypoglycemia. Which of the following is the most likely diagnosis?

Acromegaly

A 42-year-old man presents to your office for a check up. He has been an excellent health except for a recent diagnosis of mild hypertension and bilateral carpal tunnel syndrome. On physical examination, the patient is tall, with large and doughy hands. His facial features are coarse, and he has a prominent mandible with wide space teeth. His voice is deep, and he has macroglossia. Heart examination reveals the apical impulse to be displaced 2 cm laterally. His family history is unremarkable. Which of the following is the most likely diagnosis?

Surreptitious (secret) insulin injection, which is just as common as insulinoma. Facticious hypoglycemia should be suspected when hypoglycemic symptoms appear in health professions or in relatives of patients with DB. High insulin with low C-peptide

A 42-year-old nursing student presents to the emergency room with confusion, diaphoresis, and dizziness. She is tremulous and tachycardic. Serum glucose level is found to be 20, and she responds immediately to intravenous dextrose infusion. The patient states that she has been eating well. After the hypoglycemia is corrected, the physical examination is normal. Bloodwork reveals that insulin levels are high but C-peptide level is low. The rest of the laboratory data are normal. Which of the following is the most likely diagnosis?

Wegener's. Involves upper airways (sinusitis, otitis media, URTI) with necrotizing granulomas of the lungs, glomerulonephritis in 75% of patients and a migratory oligoarthritis. C-ANCA, which has high specificity. Differentiate from Churg-Strauss because Churg-Strauss has asthma followed by systemic vasculitis with peripheral eosinophilia (RAVE: rhinitis, asthma, vasculitis, and eosinophilia)

A 43 year old man presents with fever and arthritis. During the past two months he has been treated four times for a maxillary sinus infection. He also complains of the recent onset of hematuria. His complete blood count and differential is normal. Chest x-ray reveals nodules with no hilar lymphadenopathy. Which of the following is the most likely diagnosis?

Fasting plasma glucose of 130 (126 is cutoff). >200 randomly or 2-hour glucose on an oral glucose tolerance test of greater than or equal to 200 mg/dL on at least 2 occasions. A1c diagnosis is 6.5% or higher

A 43-year-old male construction worker is experiencing polyuria and polydipsia, as well as fatigue. He has a strong family history for diabetes. His physical examination is completely normal except for pre-hypertension and obesity. You note that serum chemistry done before the visit reveals a random plasma glucose of 220. Which of the following would confirm a diagnosis of diabetes?

Consult urology for placement of a percutaneous nephrostomy tube

A 43-year-old man come to the emergency department with right flank pain for the past six hours. He describes his pain is cramping and it is causing him not to be able to sit still. He reports no change in your output is no dysuria or hematuria. Medical history is non-contributory. Temperature is 98.6, blood pressure is normal, pulse is 112, and respiratory rate is 18. Physical exam is unremarkable. CT scan of the abdomen and pelvis is obtained and shows a 14 mm stone in his right ureter with associated right Hydro nephrosis. In addition to starting intravenous fluids, which of the following is the most appropriate next step in the management of this patient?

He has obvious DKA Mainstay of initial therapy is volume resuscitation and insulin therapy to clear the hyperglycemia and ketoacidosis. Aggressive volume expansion to restore normal perfusion should begin with 0.9% saline solution (normal saline) and should be changed to 0.45% saline (half-normal saline) when the serum sodium is greater than 150, and eventually to fluids containing 5% dextrose when the blood glucose falls below 250. Only regular (short-acting) insulin should be administered until the ketosis clears. Potassium should be higher because once insulin is administered, it will rapidly shift K+ into cells. Dont give bicarbonate unless pH is below 7.0 as it's potentially harmful

A 44 year old man with adult onset diabetes mellitus comes to the emergency room. He has been out of his insulin for a week. He is drowsy and reports abdominal pain, polyuria, and polydipsia. On physical examination he is hypotensive and tachycardic, but afebrile. His breath has a fruity smell to it. His examination is otherwise normal except mild diffuse abdominal tenderness to palpation without rebound or guarding. On serum chemistries, his sodium is 132, potassium is normal at four, and glucose is 450. His venous pH is 7.25, the urine dipstick reveals ketones. Which of the following is a proper management of his condition at this point?

Mucormycosis

A 44 year old woman with a 20 year history of poorly controlled diabetes mellitus presents with headache and unilateral proptosis. The patient is febrile and appears toxic. Her serum glucose level is 640. An urgent CT scan of the head reveals a retro orbital abscess and severe opacification of the frontal and ethmoid sinuses. Which of the following organisms is most likely responsible for this infection?

Fibromyalgia. History of chronic pain and fatigue with a physical revealing tender points make fibromyalgia the most likely diagnosis. Predominantly in females between 20-50 years old. Insomnia, lethargy, pain and stiffness. Diagnosis of exclusions, without objective evidence of inflammation

A 44-year-old woman presents with diffuse myalgias and excessive fatigue. She has morning stiffness and pain of all her joints, especially her wrists, elbows, shoulders, hips, knees, and neck. She does not sleep well at night. Her symptoms have been progressing for over four years. On physical examination, the patient has 13 tender points at the elbow, knees, shoulders, and hips. Which of the following is the most likely diagnosis?

He most likely has hypercalcemia of malignancy which should be treated initially with intensive IV hydration using IV saline to force renal excretion of calcium. Bisphosphonates would be the best treatment for hypercalcemia of malignancy; however, these agents take several days to work. Often calcitonin is used as bridge therapy until the bisphosphonates are at full strength. Dialysis may be used to treat emergency cases. Thiazide diuretics will actually increase serum calcium

A 46-year-old man with lung cancer is brought to the emergency room with confusion. He is lethargic and oriented to person but not to place or time. An electrocardiogram reveals a shortened QT interval. Which of the following should be the initial step in management?

Pheochromocytoma. Episodic symptoms of headache, sweating, palpitations, and sustained or paroxysmal HTN that should be evaluated for pheochromocytoma. May be associated with Von Reklinghouse syndrome, NF, and VHL disease, MEN-2A, and MEN-2B. Diagnose by elevated plasma-fractionated free metanephrines and confirmed by 24-hour urinate for total metanphrines and creatinine, with or without total catecholamines as well. 10% of pheochromocytomas are bilateral, and 10% are extra adrenal

A 46-year-old woman complains of headache, sweating, and diaphoresis that occur on a daily basis or sometimes twice a day while she is at work. She has gone to the company nurse during this episode and was told that her blood pressure was elevated. Aside from that, the nurse could not find any other problem. Physical examination is normal, including blood pressure, which is 130/80. Which of the following is the most likely diagnosis?

48-72 hours

A 47 year old man is brought by EMS to the ED after being called by neighbors for unusual behavior. He cannot provide a history, but a neighbor reports the patient has been intermittently agitated and responding to voices. The neighbor also reports that she has seen lots of empty beer cans in the backyard. Medical history unknown, unable to provide ROS. 100.1 fever, HTN, tachycardia, and slight tachypnea, O2 sats good. Unable to answer questions clearly, often responds to auditory hallucinations and quickly falls asleep if not stimulated. Remainder of physical is normal. Labs are pending. May be experiencing alcohol withdrawal. Based on symptoms, when is the most likely time he last consumed alcohol

Scaphoid fracture

A 47-year-old man fell on his outstretched right hand while rollerblading. Several days later, he develops a right wrist pain below his spine that is constant and progressive. Pain is primarily in the area of the anatomical snuffbox and as worse with wrist flexion, extension, and ulnar deviation. On examination, the anatomical snuffbox is tender to palpation with mild swelling. The Finkelstein test is negative. Which of the following is the most likely diagnosis?

Primary hyperparathyroidism. Most common cause of hypercalcemia in the outpatient setting and it results in elevated excretion of calcium and phosphate by the kidneys. Seen more frequently in women and usually due to one parathyroid adenoma (usually in the inferior lobe). Patients often have a history of hypophosphatemia, fatigue, hypertension, depression, bone pain, kidney stones.

A 47-year-old woman presents to your office complaining of fatigue and bone pain. She has a past medical history significant for kidney stones and hypertension treated with a beta blocker. Routine laboratory studies reveal an elevated serum calcium and hypophosphatemia. Which of the following is the most likely diagnosis?

Osteoporosis. Corticosteroids can stimulate osteoclasts and inhibit osteoblasts

A 49-year-old man presents with a compression fracture of his sixth thoracic vertebra. He is a tobacco and alcohol user and has taken oral corticosteroids on and off since childhood for asthma and now for COPD. Which of the following is the most likely diagnosis?

Charcot joint. Diabetics with peripheral neuropathy are susceptible to this. The insensitivity of the feet predisposes the patient to multiple silent fractures, causing a deformed foot

A 49-year-old man with a 25 year history of diabetes presents with a painful right foot. He denies a history of trauma. On physical examination, the patient has loss of pain and vibration in both feet. His Achilles deep tendon reflexes are absent bilaterally. Peripheral pulses are palpable, and there are no skin lesions. The right foot is erythematous with some edema. The patient's gait reveals a limp due to foot pain. Radiograph of the ankle reveals osteopenia and multiple fractures of the tarsal bones. Which of the following is the most likely diagnosis?

Hypocalcemia

A 51 year old woman is seen in your office several weeks after a parathyroidectomy for a parathyroid adenoma. She is complaining of paresthesias. Physical examination reveals contraction of the right facial muscles when you tap lightly over the right side of the patient's face. Which of the following is the most likely diagnosis?

Sjogren syndrome

A 52 year old woman is unable to wear her contact lenses because of burning and itching of her eyes. On physical, she has caries at the gum line. Her Schiller test is abnormal. Diagnosis?

Necrobiosis lipoidica diabeticorum. Location and description of rash gives it away

A 52 year old woman with a 20 year history of insulin-dependent diabetes mellitus presents complaining of a rash that has developed on her legs and ankles. Physical examination reveals several oval shaped plaques with demarcated borders and a glistening yellow surface located on the anterior surface of the lower legs and dorsum of the ankles. Which of the following is the most likely diagnosis?

Amiodorane induced hypothyroidism. Amiodorane has high iodine content and causes hypothyroidism in 8% of patients. Check serum TSH

A 52-year-old woman presents to her physician with the chief complaint of hoarseness. She sings in the church choir, and her friends have noticed a voice change. Her past medical history significant for heart arrhythmias, which have been well-controlled for three years with amiodarone. Physical examination reveals a woman with coarse hair and skin. Her fingernails are thick and her eyes appear puffy. The thyroid gland is normal and nontender. Her muscle strength is excellent, but the relaxation phase of her ankle reflects is prolonged. Which of the following is the most likely diagnosis?

Neuropathic impotence

A 53 year old diabetic man with a history of gastroparesis and peripheral neuropathy presents with erectile dysfunction. What's the likely mechanism causing the symptoms?

Dermatomyositis

A 53-year-old woman presents with a two month history of difficulty climbing stairs and arising from the seated position. On physical examination, she has a purpleish discoloration of the skin over the forehead, eyelids, and cheeks. She has tenderness on palpation of the quadriceps muscles. Diagnosis?

Begin chlordiazepoxide

A 54 year old man is admitted to the hospital with spontaneous bacterial peritonitis and acute encephalopathy. Medical history is significant for alcoholic cirrhosis. Medications are none. Social history is 6-8 beers/day for 20 years. Following paracentesis on the day of admission, he is placed on antibiotics and show signs of improvement in his mental status. On hospital day 4, he comes acutely confused. Vital signs are 100 temp, HTN, tachycardic. Physical shows a confused man unable to follow commands or respond to questions. Which of the following is the most appropriate next step in the management of this patient?

Central diabetes insipidus

A 60 year old man is involved in a head-on motor vehicle accident and sustained significant head trauma. He is awake and oriented to person, place, and time but complains of dizziness. Physical examination reveals normal vital signs, no orthostasis, and no neurologic findings. Heart and lung examinations are normal. Overnight in the surgical intensive care unit, the patient develops excessive thirst, polydipsia, and polyuria. He develops orthostatic changes on physical examination. His serum sodium rises to 160, and his serum glucose is normal. Which of the following is the most likely diagnosis?

Osteoarthritis, which most often affects weight bearing joints like the knee. No systemic manifestations, worse with exertion, better with rest (after which the joint may become stiff, which is called "gelling"). Crepitus. Could also see Heberden nodes (DIPs) and Bouchard nodes (PIPs)

A 60 year old mildly obese woman presents complaining of bilateral medial right knee pain that occurs with prolonged standing. The pain does not occur with sitting or climbing stairs but seems to be worse with other activities and at the end of the day. The patient does not have morning stiffness but her knees are stiff after sitting for a long time. Examination of the knees reveals no deformity, but there are small effusions. Some mild pain and crepitus are produced with palpation of the medial aspect of the knees. Which of the following is the most likely diagnosis?

Baker cyst, which occurs in the midline of the popliteal fossa and is often a complication of RA or OA. Cyst represents a diverticulum of the synovial sac that protrudes through the joint capsule of the knee. The knee has 12 different bursae. Anserine bursitis occurs with inflammation of the bursa on the medial side of the proximal tibia. Prepatellar bursitis (housemaid's knee) is characterized by inflammation of the bursa anterior to the patella. Inflammation of the infrapaterallar bursa is called clergyman's or carpet-layer's knee

A 61 year old woman with a 10 year history of rheumatoid arthritis presents with painful swelling at the back of the knee that is visible on physical examination only when the patient is standing with the knee extended. Which of the following is the most likely diagnosis?

Sciatica

A 61-year-old woman has recurrent back pain in her lumbar area that radiates to her right buttock and laterally down her right leg to her knee. Both sitting and walking aggravate the pain. She does not report bladder or bowel dysfunction. On physical exam, the patient has normal sensation and reflexes of the right lower limb. Straight leg raise and cross leg raising tests are positive for reproduction of the right lower limb symptoms. The patient has no spinal deformities. Which of the following is the most likely diagnosis?

Superior vena cava syndrome. Simple goiter, if sufficiently large, may be accompanied by tracheal compression, dysphagia, odynophagia, mediastinal obstruction, and superior vena cava syndrome. Retrosternal goiter may cause mediastinal obstruction and SVS (swelling of face, neck, and upper extremities with engorged veins in the neck and chest). Pemberton sign (elevate arms above head obstructs the thoracic inlet and prevents venous return) leads to facial plethora and dizziness

A 63 year old woman has a large retroclavicular goiter. Whenever she elevates her arms over her head, she experiences facial plethora and dizziness. Which of the following is the most likely diagnosis?

Fasting glucose of 131 on two occasions

A 65 year old man comes to the office for a wellness visit. He has no known medical problems and takes no meds. He has no complaints on today's visit. He would like to be screened for diabetes as he has a strong family history of diabetes. Which of the following diagnostic studies is most likely to be seen in a patient with diabetes?

Perform an arthrocentesis of the right knee effusion. He has septic arthritis of his knee, typically presenting as acute inflammation of a large weight-bearing joint, usually the knee. Patients at risk for this are usually immunocompromised, have damaged or prosthetic joints, or have a source of bacteremia. This patient's knee replacement, end-stage renal disease, and likely infected dialysis catheter site make this the leading diagnosis, and he should be hospitalized

A 65-year-old man with end-stage renal disease on hemodialysis and a history of a right knee replacement three years ago presents with acute onset of right knee swelling and pain. On examination he has a low-grade fever, but is hemodynamically stable. His cardiac and lung examinations are normal. The right knee is warm to the touch, with a positive bulge sign, and his patella is ballotable. What is the next best step in management of this patient?

Lumbar spinal stenosis. Usually in people over age 60 and results from spinal osteopaths, hypertrophy of the ligamentum flavum, or bulging of intervertebral discs. Usually complain of gradual onset of aching and numbness starting in the lower back and radiating into the thigh and sometimes as far as below the knee. The pain is often bilateral, exacerbated by prolonged standing or walking, and relieved by lumbar flexion or setting. Slight proximal muscle weakness, but few have positive straight leg raise or diminished DTRs. Best confirmed with spinal MRI. Normal distal pulses rule out claudication and lack of shoulder and neck weakness rules out poly myalgia rheumatic a. Lumbar disc herniation and sciatica cause neuropathic pain radiating from but down to leg below the knee. Straight leg raise will be positive for these patients, though

A 70 year old man complains of aching lower back pain that radiates to his butt and upper thighs over the past few months. He does not recall any trauma and has no past medical history except for allergic rhinitis. He notes that the pain worsens with walking, especially downhill, and gets better with sitting or leaning forward. On physical exam, bilateral straight leg raise test is negative and his deep tendon reflexes are normal in his lower extremities. He has slight proximal thigh weakness with flexion at the hip but his upper extremity strength is 5/5 and all muscle groups bilaterally. His dorsalis pedis and posterior tibial pulses are 2+ in both legs. What's the most likely diagnosis?

Strictly use soap and water and enforce contact precautions with gowns and gloves.

A 70 year old man is admitted to the hospital with CAP and osteomyelitis of the right foot. Medical history is significant for T2DM, COPD, and osteoarthritis. He was started on IV vancomycin and piperacillin/tazobactam at admission which have been continued for the past 2 weeks. 1 week in to his course, he developed diarrhea and was diagnosed with C. Diff colitis. He was started on oral vancomycin which he has been tolerating well. One of his family members asks what can be done to prevent C. Diff infection. In addition to limited unnecessary antibiotic exposure, which of the following is the most important statement by the physician in regards to the prevention of C. Diff infection?

DEXA T-score <-2.5. She suffered a hip fracture with minimal trauma, indicative of osteoporosis. Fair-skinned, indicating she avoids the sun and likely has low serum 25-hydroxyvitamin D levels. Serum calcium, phosphorus, and PTH will usually be normal, though.

A 72-year-old fair skinned Caucasian woman with a history of hypertension presents to the emergency room complaining of left hip and groin pain. She remembers that she stumbled on a curb a few days before but did not fall. The pain has become so difficult that she has been unable to bear weight on her left leg. On physical examination her left leg is externally rotated. A hip radiograph confirms a fracture of the left femoral neck. What would you expect to find on further testing?

Polymyalgia rheumatica from giant cell temporal arteritis

A 75-year-old woman presents with malaise and myalgias for the last several months. She is chronically tired and has one hour morning stiffness and pain in the cervical, shoulder, and hip areas. She also has developed headache and jaw pain with chewing. Neurologic examination reveals normal sensation, strength, and reflexes. Diagnosis?

Henoch-Schonlein Purpura, a small vessel vasculitis that affects mostly male children. IgA deposition in postcapillary venules. Remember AGAR: abdominal symptoms, glomerulonephritis, arthralgia, and rash (usually on lower extremities).

A 9 year old boy with no past medical history presents with the acute onset of fever, arthrlagias, abdominal pain, hematochezia, and hematuria, but no cough or hemoptysis. Physical examination reveals palpable purpura discolorations that do not blanch on the patient's lower extremities bilaterally. Which of the following is the most likely diagnosis?

Has no predictive value regarding long term outcome, but tells you a great deal about the newborns' respiratory efforts and does predict survival in the neonatal period

A newborn has an APGAR score of 0 at 1 minute and 10 at 5 minutes. What's true regarding the apgar score?

Primary hyperparathyroidism

A five year old woman comes to the clinic to establish care. She currently does not have any complaints. Medical history significant for hypertension. Medication's are amlodipine and lisinopril. Vital signs and physical exam are unremarkable. Lab studies Ravel serum calcium of 11 (slightly high). Serum phosphorus of 2.5 (slightly low), intact PTH that is high. Which of the following is the most likely diagnosis?

March fracture... metatarsal stress fractures caused by repetitive stress

A long-distance runner develops foot pain with exercise. Diagnosis?

Felty syndrome

A patient with a 15 year history of RA develops splenomegaly and neutropenia. Diagnosis?

Bunion... the metatarsal is what does the valgus, but the big toe itself is pushed in the opposite, lateral direction.

A patient with hallux valgus develops a lateral displacement of the extensor and flexor hallucis longus tendons. Diagnosis?

Psychogenic impotence

A previously healthy 42 year old man presents with impotence. He takes no meds and does not smoke, drink, or use drugs. He attains nocturnal erections but is impotent with his sexual partner. What's the most likely mechanism causing his symptoms?

Subacute thyroiditis

Acute, painful, glandular enlargement with dysphagia. Gland is woody, hard, tender Tx: ASA and NSAIDs, beta blockers. Recent velar infection, palpitations, and thyroid tender to palpation

Lachman test (patient supine with knee flexed at 15 degrees; positive if examiner is able to move the tibia anteriorly) and anterior drawer test (foot is immobilized while hip and knee are flexed to 90, then tibia is moved anterior to the femur)

An 18 year old gymnast heard a popping sound in her left knee while practicing for the Olympics. Her knee immediately became swollen and painful. On physical exam, it's obvious that the left knee has an effusion. Which of the following tests is best to confirm an ACL tear?

Minimal change disease. Nephrotic syndrome is a clinical complex consisting of more than 3.0 g proteinuria in 24 hours, hypoalbuminemia, edema, hyperlipidema, lipiduria, and hypercoagulability. MInimal change disease is 80% of nephrotic syndromes in children under 16 and 20% of nephrotic syndromes in adults

An 8 year old girl presents with the acute onset of swelling of her hands, feet, legs, and face. Her past medical history is significant for URTI. Physical exam reveals normal vital signs. The patient has clear lungs but has pitting edema up to her sacrum. Heart exam is normal, urinalysis shows 4+ proteinuria. What's the diagnosis?

Post obstructive renal failure

An 85-year-old man who is a resident of a nursing home is brought to the emergency department via ambulance with diffuse abdominal pain for the past day. He was recently treated for upper respiratory infection with over-the-counter cough and allergy meds. Medical history significant for type two diabetes, hypertension, and coronary artery disease. Vitals are normal. Physical reveals abdominal fullness in the supra pubic region without tenderness as well as a diffusely in large prostate on digital rectal exam but is otherwise unremarkable. Lab studies show creatinine of five as well as urinalysis that is negative for bacteria RBCWBC and proteins. Urine sodium is 35 and urea is 49. Which of the following is the most likely diagnosis in this patient?

Approximately 80% of children develop symptoms before 5 years of age. May be misdiagnosed in infants and toddlers. Few flare ups before diagnosed with asthma. Coughing may be the sole presenting symptom. Single most common external risk factor for the development and progression of asthma symptoms in children is tobacco smoke. History is key to diagnosis. Decreased FEV1 and decreased FEV1/FVC since this is an obstructive disorder. >12% reversibility in FEV1 after inhaled B2 agonist. If no improvement with classic drugs, consider IV MgSO4 or SQ/IM epinephrine or terbutaline

Asthma info?

Lower respiratory tract infection, obviously. Edema, excessive mucous production, and sloughed epithelial cells lead to airway obstruction and atelectasis. Main cause is RSV. Under 2 years of age, seen in fall and winter. #1 leading cause of hospitalization in infants and young children. Initially low grade fever + URT involvement for 1-3 days (rhinorrhea and nasal congestion). Later (3-5 days in), lower respiratory tract involvement with cough, respiratory distress, diffuse crackles and/or wheezing. Viral testing and CXR not indicated. Supportive care is all. No antibiotics, bronchodilators, or steroids indicated.

Bronchiolitis info?

neisseria

Child with a fever, poor oral intake, and a rash on trunk and extremities

Brief and discontinuous. Fluid in small bronchi, bronchioles, and alveoli. More common during inspiration, but may be heard during both. Flag whipping in wind sound. Fine crackles = rales

Crackles info?

3 months to 3 years, uncommon in children older than 6. Parainfluenza main cause. Onset with fever, rhinorrhea, and congestion with slow progression of symptoms over 12-48 hours. Virus typically infects the nasal and pharyngeal mucosal epithelia initially and then spread locally along respiratory epithelium to larynx and trachea. Stridor and seal-like cough. Steeple sign, showing subglottic narrowing. Mild croup treated with 1 dose of dexamaethasone. Moderate to severe treated with racemic epinephrine + dexamethasone. May repeat epinephrine q15 prn

Croup info?

Esophageal bodies orient in the coronal plane, whereas tracheal foreign bodies orient in the sagittal plain

Differences in radiographs for foreign body ingestion?

Bromocriptine and cabergoline

Dopamine agonists used as treatment for hyperprolactinemia due to prolactinoma

3rd generation cephalosporin + anti-staphylococcus + MSSA

Drug therapy for epiglottitis?

Associated with Down's, polyhydramnios. Symptoms develop within first 24 hours of life. Double bubble sign; treat with NPO/IVFs. NG/OG tube insertion for gastric decompression (air the stomach outward so that it doesn't collapse on surgical instruments and adhere to it), then duodenoduodenostomy (sew the separate duodenal parts together and canalize it)

Duodenal atresia info?

2-5 days after the non-specific symptoms appear, slapped cheek rash appears, followed by lace-like rash on trunk and extremities. Transient aplastic crisis in people with sickle cell. Benign and self-limited, supportive care

Erythema infectiosum info?

Administer a series of 5 abdominal thrusts. Conscious child should be left alone if he or she is able to cough, but bystanders should intervene once stridor or respiratory distresses increase or the child becomes unconscious. At this point the airway should be opened with a head tilt/chin lift maneuver and ventilation should be attempted. If this fails, it should be attempted again. If there is no chest rise, attempt to remove the foreign body. If over age of 1 and still conscious, Heinrich maneuver. Examine airway after and remove with finger sweep if object is seen. If not, ventilate and repeat the Heimlich maneuver. For babies under 1 year, combination of back blows and chest thrusts should be given with the baby positioned on your forearm and lap with head downward.

Family friend's home when the friend screams that her 18 month old daughter is unable to breathe. Child's brother said she aspirated a Lego. Attempt to ventilate doesn't result in chest rise. What's the appropriate next step?

Subscapularis

Gerber's lift off test tests what muscle?

Constitutional growth delay... normal length and weight at birth and normal growth for the first year. Through childhood, their height is sustained at a lower percentile, paralleling the norm, and their pubertal growth spurt is delayed. Careful family history often reveals hat their parents or other relatives had short statures in childhood, with delayed puberty and eventually normal height

Healthy 12 year old boy brought to office by parents concerned for his height. 50th percentile for height and weight at birth and for first year. A student at school and plays several sports well. Upon discussion with parents, you find out they had late growth spurts. What's the most likely cause of his growth problem?

Osteoporosis

Hey 55-year-old man comes to the clinic for follow-up. He currently has no complaints. Medical history significant for hypertension and atrial fibrillation which was diagnosed three months ago. He takes Coumadin and amlodipine daily. During the workup for his atrial fibrillation, he was found to have a TSH that was really low with a free T4 that was normal. Vitals Showed temperature of 98.5, pulse of 88 and a regular, and blood pressure of 130/80. Physical shows no abnormalities. Upon a work up of the thyroid studies, a thyroid uptake scan to obtain and shows a toxic adenoma. Which of the following is this patient at most at increased risk for in the future based on these thyroid findings?

Dexmedetomidine

Hey 65-year-old man is admitted to the hospital for right knee replacement. Medical history significant for history of a DVT, osteoarthritis, and anxiety. Her medication's are warfarin daily and diazepam as needed. Social history is a fifth of whiskey three nights per week. On admission he is placed on alcohol withdrawal protocol and requires lorazepam intravenously every 2 to 3 hours following surgery due to tremors, hallucinations, and tachycardia. He requires transferred to the ICU for closer monitoring. Which of the following pharmacological agents is most appropriate for this patient in the ICU to treat his current conditions with minimal sedative effects?

Obtain a TPO antibody

Hey 67-year-old woman comes to clinic for follow up. She has had a 5 pound weight gain over the past two weeks but she attributes to recent vacation. She has also had fatigue for the past two months. Medical history is significant for hypertension dyslipidemia and coronary artery disease. She takes metoprolol, aspirin, atorvastatin, and lisinopril daily. Vitals are normal, BMI is 33. Physical is unremarkable. Lab show a really high TSH with a free T4 in normal range. What's the next step?

Foul smelling urine

Hey 71-year-old woman is admitted to the hospital for an elective hip replacement. On postoperative day two, she expresses concern that she might have a urinary tract infection. Which of the following is not an appropriate indication for forming the urine culture to diagnose urinary tract infection?

Legal guardian (if applicable) > spouse > adult children > parents of patient > siblings of patients > others relative or friend

Hierarchy of surrogacy if a patient cannot consent?

Failure of NCCs (future enteric ganglion cells) to migrate completely during intestinal development. The aganglionic segment fails to relax, causing a functional obstruction. 80% of cases involve the rectosigmoid colon. Associated with Down's. Majority of patients present during the neonatal period, and there's a delay in meconium passage of more than 48 hours. Contrast enema shows a transition zone, where it transitions from constricted/aganglionic segment to dilated/ganglionic segment. Gold standard is rectal suction biopsy showing absence of ganglion cells. Treat with surgical resection of the abnormal part

Hisrschprung disease info?

Mediastinum shifts away from the lung field containing the foreign body

How does mediastinum shift in response to foreign body?

Disease is from ACTH pituitary adenoma

How is Cushing disease similar from Cushing syndrome?

With brain death, not even the brain stem is alive. There are no autonomic neurological circuits that will function on their own

How is brain death different from persistent vegetative state?

2-4 years

How old are kids with epiglottitis typically?

Stones, bones, groans, thrones, psychiatric overtones. Kidney stones, bone changes, abdominal pain, nausea, vomiting, polyuria (nephrogenic diabetes insipidus due to nephrocalcinosis), psychiatric overtones (depression, anxiety, etc.). Also band keratopathy

Hypercalcemia symptom?

First-born male effect, presenting at 3-6 weeks of age. Very forceful vomiting, olive-like mass at RUQ. Labs are what you would expect, and you diagnose with ultrasound. Rehydration and surgery (divide it down into submucosa)

Hypertrophic pyloric stenosis info?

Occurs during 10th week of gestation due to incomplete rotation of the midgut. Associated with other defects and abnormalities. 40% are diagnosed within the first week of life, 50-60% by 1 month, and 90% by 1 year. Fear of volvulus (midgut twists around SMA): pain, distension, bilious vomiting, hematochezia due to bowel ischemia, and hemodynamic instability. Ligament of Treitz (duodenum to diaphragm) on right side and corkscrew appearance of duodenum.

Intestinal malrotation info?

CRASH and burn: conjunctivitis, rash, adenopathy, strawberry tongue, and hands and feet. Fever that is minimally responsive to antipyretics. Self-limited if untreated, but should be treated due to cardiovascular complications. IVIG dramatically decreases frequency of coronary artery aneurysm morbidity and mortality. Aspirin, too. 30% have coronary artery dilation at diagnosis, but aneurysms are typically not present. Aneurysm can lead to occlusion and ischemia, though.

Kawasaki info?

Measles virus. Fever, malaise, anorexia Prodrome. 3Cs: conjunctivitis, coryza, and cough. 2-4 days in duration. See Koplik spots on buccal mucosa, appearing 48 hours prior to onset of the rash and coalesce and resolves as the rash appears. The rash is erythematous, blanching, and maculopapular. Palms and soles rarely involved. After 3-4 days, the rash darkens brown and begins to fade with complete resolution in around 7 days. Diagnose with IgM serology and treat with supportive care and Vitamin A

Measles info?

From Neisseria. 3 syndromes: meningococcemia without clinical evidence of meningitis; meningococcemia + meningitis; meningitis alone. Non-specific initial symptoms. Rapid progression to severe illness. Vital signs concerning for sepsis: fever, tachycardia with normal BP (compensated shock), tachycardia with hypotension (uncompensated shock). Meningitis signs include nuchal rigidity, photophobia, Brudzinksi's sign (passive flexion of neck causes flexion of both legs and thighs), Kernig's sign (supine patient with hip flexed to 90, can't fully extend knee). Remember, absence of meningitis does not exclude the diagnosis of systemic meningococcal infection. Petechia rash develops in hours, present on trunk and lower extremities, correlating with degree of thrombocytopenia and clinically important for potential for bleeding complications secondary to DIC. Diagnose with isolation of Neisseria from sterile body fluid and lumbar puncture studies. Do NOT delay antibiotics: mortality rate is 10-15% despite antibiotics. Empiric therapy with 3rd generation cephalosporin such as cefotaxime or ceftriaxone (plus vancomycin). Treat for 10-14 days.

Meningococemia info?

Incubation period of 7-10 days; range 6-20 days. Catarrhal stage: 1-2 weeks, similar to a viral URTI with coryza and cough. Fever uncommon. Transmission risk greatest here; Paroxysmal stage: 2-8 weeks, paroxysmal cough (coughing until you throw up really), whoop noise from inspiration because you're so winded; Convalescent stage: cough slowly resolves over weeks to months Pertussis PCR and culture of nasopharyngeal specimens for diagnosis. Macrolides are antibiotics of choice. Treat exposed contacts with the same medicine

Pertussis info?

long term, high dose use of glucocorticoids

Most common cause of Cushing syndrome?

Wilms tumor... the most common renal tumor in children usually age 2-5. Abdominal mass which may or may not be painful, hematuria, weight loss, nausea, and vomiting. Fever, HTN, and abdominal mass

Mother brings her 3 year old child to the ER after finding an abdominal mass while bathing her. The mother states that the child has been losing weight and has been complaining of nausea and vomiting. Vital signs reveal a blood pressure of 135/85 and a temperature of 102. Palpation of the abdomen reveals a mass that extends to the left flank. CT scan of the abdomen reveals a non calcified tumor. What's the most likely diagnosis?

Tay-Sachs disease

Mother of 11 month old infant is concerned because her child is easily startled by slight noise and can't sit alone without assistance. Child does not respond to visual cues and is extremely hypotonic. Fundoscopy shows cherry-red spot. What's the most likely diagnosis?

Acute encephalopathy

Nursing home patient. Seemingly normal. Then, the patient can only say "yes" or "no" and is unsteady on her feet.

Administer naloxone 0.4 mg IV

Oh 82-year-old woman has made it to the hospital with a right femoral neck fracture. Medical history significant for osteoporosis. Current medication swelling the hospital are low molecular weight heparin, acetaminophen, oxycodone, and docusate. On hospital day one, she undergoes repair of the fracture without complications. Hospital day three, the physical therapist notes the patient to be difficult to arouse. Vital signs showed temperature of 96.9 slightly low blood pressure bradycardia and bradypnea. Physical exam shows the patient to be unable to follow commands, somnolent but arousal to sternal rub, and minimal serous drainage from the surgical site without erythema. REmainder of physical unremarkable. What's the next step?

Infection of peritonsillar space, and it's polymicrobial (GAS, Staph Aureus, respiratory anaerobes), seen in older child/adolescent. Most common deep neck infection. Very swollen with uvula pushed to other side. If drain abscess, send it for culture. Drug treatment: ampicillin/sulbactam, amoxicillin/clavulanate for 10-14 days OR clindamycin for 10-14 days

Peritonsillar abscess info?

Viral is most common cause of pneumonia in pediatrics. Bacterial tends to be more focal. Also bacterial pneumonia is ill-appearing, whereas atypical bacterial and viral look non ill appearing. Can diagnose without CXR. Drug treatment: amoxicillin/clavulanate, ampicillin, cephalosporins for bacterial. Azithromycin for atypical bacterial

Pneumonia info?

Get an X-ray

Question involved lady in her early or mid thirties who had tripped over dishwasher and fell on her knee. Upon examining it, the clinician notes that her knee is tender to palpation and without effusion. She is unable to bend her knee past 60 degrees but could walk on the leg, albeit with a limp. What would next step be?

Infection of retropharyngeal space, also polymicrobial (GAS, Staph Aureus, respiratory anaerobes). 2-4 years of age. Soft tissue lateral neck X-ray. Prevertebral space is increased in depth compared to the anteroposterior measurement of the adjacent vertebral body. Thickening of the retropharyngeal space. Drug treatment: ampicillin/sulbactam, amoxicillin/clavulanate for 10-14 days OR clindamycin for 10-14 days

Retropharyngeal abscess info?

2-3 weeks following strep pharyngitis, occurring in children 5-15 years of age. Evidence of preceding GAS infection + 2 major criteria OR 1 major and 1 minor criteria. JONES criteria is major: joint involvement, myocarditis, nodules, erythema marginatum, Sydenham chorea. Minor criteria are inflammatory signs, fever, etc. Arthritis may be first symptom to develop. Treatment includes symptomatic relief, like NSAIDs for arthralgia. You need to eradicate GAS, so long-acting IM penicillin G benzathine and prophylaxis against future GAS infection to prevent progression of cardiac disease (long-acting IM penicillin G benzathine every 21-28 days until 21years of age

Rheumatic fever info?

Sounds like water in pipes. Low pitch wheeze. Caused by secretion or fluid in the lower airway: COPD, pneumonia, chronic bronchitis, CF.

Rhonchi info?

HHV6 (6th disease). 3-5 days of HIGH fever followed by defervescence and development of rash (erythematous, blanching, and macular to maculopapular that begins on neck/trunk and spreads to face and extremities. Resolves within 1-2 days). Benign and self-limited. Supportive care.

Roseola info?

Rubella virus, causing asymptomatic to mild symptoms. Low-grade fever and rash. Posterior cervical, posterior auricular, and sub occipital lymphadenopathy. Pin-point pink maculopapules and begins on the face and spreads to the trunk. Rash resolves in around 3 days. Benign and self-limited, just need supportive care.

Rubella info?

Sciatica/impingement, piriformis outlet

Straight leg test differentials

Loud, high-pitched monophonic sound heard due to turbulence in the large portions of the airway. Choking like sound. Croup should be on the differential if acute. Think of respiratory tract in extrathoracic and intrathoracic regions: inspiratory happens in extrathoracic regions and expiratory stridor happens with intrathoracic obstruction. If you hear inspiratory stridor, you can think of things like adenoid hypertrophy, tonsillar hypertrophy, macroglossia, even some malignancies. You can also think of anaphylaxis because this causes edema of the tongue near the vocal cords and can compress the airway. Chronic stridor should make you think of laryngomalacia, which is due to intrinsic deficits in maturation of laryngeal structures. Inspiration causes prolapse of flaccid structures (worse in supine, when crying, when agitated). Omega sign during inspiration. Chronic can also be laryngeal web and vocal cord paralysis simply because they both narrow the airway. Even though croup gets both intra and extrathoracic parts, it's mainly inspiratory (parainfluenza viruses). Biphasic stridor indicates narrowing of the subglottis, the cartilage right below the vocal cords

Stridor info?

rheumatoid arthritis... so should spongey knuckles

Synovitis should make you think of this disease

Hawkins test (flex elbow to 90 degrees, abduct the arm to 90, internally rotate humerus)

Test for Rotator Cuff tear?

Forward bending test... presence of a hump or asymmetry when the child bends forward is the hallmark of scoliosis deformity

Test for scoliosis?

Finklestein... tests DeQuervain's

Test run for radial wrist pain?

Acute hypoxic respiratory failure secondary to pulmonary edema in an anuric patient

The ED resident calls you with an admission for AKI. He reports that they have not given the patient any therapies, but the serum creatinine is 4.0 (no previous baseline available). You as the night resident are concerned that the patient may need dialysis and want to notify the nephrology fellow as soon as possible before the fellow goes home for the night. In reviewing the patient with the ED resident so that you can notify the fellow if needed for dialysis, which of the following are indications for dialysis in the setting of AKI?

Hyperglycemia hyperosmolar state, seen in patients with non-insulin dependent diabetes, usually precipitated by an illness. The low blood pressure indicates hypo volumia due to excessive diuresis. The residual insulin prevents lipolysis and ketosis.

The family members of a 70 year old woman with a 20 year history of diet control diabetes bring her to the emergency room because she has been confused. They stated that the patient recently had a hip fracture and has been recuperating at home where she lives alone. The blood pressure is 90/60 and the pulse is 120. The patient is lethargic but follows commands. Pupils are 3 mm bilaterally and reactive to light and accommodation. Neurologic exam reveals no focal deficits. Glucose is higher than 800, and arterial blood gas reveals a pH of 7.36. Which of the following is the most likely diagnosis?

Usually begins 6-24 hours after the last drink. It can last for up to one week. 6-12 hours: minor withdrawal (shivers, headache, anxiety, sweating, nausea, vomiting, high HR, fever, tachypnea) 12-24 hours: alcoholic hallucinosis, confusion... less severe symptoms may persist. Seizures can start at 12 hours 24-48: seizures (seizures and other mild symptoms)... still earlier symptoms 48+ hours: usually begin to improve after 48 hours, but sometimes can advance; delirium tremens (characterized by hallucinations that are indistinguishable from reality, severe confusions, seizure, HTN, and fever that can persist from 4-12 days

Timeline of alcohol withdrawal syndrome?

60% in right lung: 52% main bronchus, 6% lower lobe bronchus

Tracheobronchial foreign body aspiration most common lodged location

Hydrocele

Transilluminates with light in the scrotum

Rigid bronchoscopy... CXR negative but suspicion remains high

Used to remove foreign objects form lung.

Most commonly the ilium going into iliocecal valve (90%) of cases. Typically presents between 6 months and 3 years: 60% before 1 year, 80-90% before age 2. The most common abdominal emergency in children under 2. A pathological lead point is only identified in 25% of cases, and the most common one identified is Meckel diverticulum. Severe pain, vomiting, currant jelly stool (mixture of blood and mucus). See target sign on abdominal ultrasound. Air/contrast enemies is both diagnostic and therapeutic. Surgery when acutely ill patients, suspected perforation, and in those where non-operative procedures did not work

What is intussusception?

Partial arousal, but not true awareness. It's like a step up from coma, which is lack of not only awareness but also wakefulness. Eyes can open and there can be some sleep/wake circadian behavior, but no cognitive function

What is persistent vegetative state?

Autism screening, Hgb screening, few others

What's not included in the normal 12 month checkup

Have patient prone, knee flexed to 90 degrees. Grab their heel and ankle to stabilize, and push down on their sole of the foot to press knee into table. Rotate foot and assess pain. Tests both medial and lateral menisci

What is Apley test?

Have patient extend arm out in front of them. Stabilize their elbow, and have them push their ulnar side of the hand laterally against resistance. Pain is positive. Indicates lateral epicondylitis (Tennis elbow)

What is Cozen test?

Name the emotion, understand (empathize), respect, support, and explore... how to respond to strong emotions

What is NURSE?

Delivering bad news: setup (getting started), perception (what does the patient know?), invitation (how much does the patient want to know?), knowledge (sharing the information?), emotion (responding to patient, family feelings), summary (planning and follow-up)

What is SPIKES?

In association with GAS pharyngitis, caused by erythrogenic toxin-producing strain. Begins 12-24 hours after onset of pharyngitis, diffuse erythematous rash that begins in the axilla and groin and spreads to the trunk and extremities. Numerous small popular elevations, giving sandpaper rash. Blanches with pressure, spares palms and soles, accompanied by circumoral pallor and strawberry tongue. Treat with penicillin IM, PO amoxicillin. Risk of development of rheumatic fever.

What is Scarlet fever?

21-hydroxlase deficiency is the most common cause, accounting for more than 90%. 3 phenotypes: classic salt-losing, virilizing form (75%); classic non-salt-losing, virilizing (25%); non-class / late-onset. Salt-losing is due to lack of aldosterone, so presents with adrenal crisis early on. Screen with high serum 17-hydroxyprogesterone concentrations, which is a component of the newborn screen. Confirm with high dose ACTH stimulation test

What is congenital adrenal hyperplasia?

Arms out in front of you, giving two thumbs down. Have patient resist you pushing their arms down. Tests supraspinatus

What is empty can test?

Continuous with musical quality (SpongeHenge), produced by turbulent airflow through a narrowed (partially obstructed) airway in the lungs.

Wheezing info?

Bitemporal hemianopsia

You suspect that a 26-year-old woman presenting with galactorrhea and infertility has a large pituitary tumor. If your hunch is correct, which of the following is the most likely visual field defect you will find on physical examination?

Hawkins Kennedy Test

compression of the supraspinatus tendon against the coracoacromial ligament to assess the possibility of impingement of the subacromial bursa

18

legal age in MS

Phalen test (reverse prayer position, with back of hands touching)

test for carpal tunnel syndrome?