NBME CK

MSMT of plts count -Pt presents w/ preeclampsia ( HTN & Proteinuria) & she is at increased risk for developing HELLP → We would check: --H → Hemolysis --EL → Elevated liver enzymes --LP → Low plts US pelvis -Only If we suspected fetal adverse effects [But Fetal HR is normal]

A 21F, primigravida, at 37-wks has had mild epigastric pain & a moderate headache for 24-hrs. The pregnancy has been otherwise uncomplicated. Temp is 98.6F, & BP is 150/89. The fundus is non-tender, & fundal Ht is 36-cm. Fetal HR is 130/min. Deep tendon reflexes are 3+ bilaterally. Urine protein is 3+. What is the most appropriate next step in MGMT? (MSMT of plts count OR US of pelvis)

Brief psychotic disorder -Characterized by: --1) ≥1 positive symptoms of schizo (Delusion/hallucinations) --2) Last ≥1 week-to- <1 month------w/ full return to pre-morbid level of functioning --3) Stressful events are common precipitants Schizoaffective disorder -Psychosis w/ associated intermittent mood disorders (mania/depression) - PT most have symptoms for ≥1 month -----[pt has had symptoms for 1 WEEK]

A 23M, presents b/c of auditory hallucinations & confusion since his wife was killed in a MVC 1-wk ago. His mother reports that he was unable to make any decisions regarding his wife's funeral & has been confused & disorganized since her death. PE shows no abnormalities. He is oriented to person, place, & time. MSE shows a sad affect. He appears pre-occupied & has difficulty concentrating. He states that he hears his brother's voice telling him that everything will be okay; his mother reports that her other sone lives in another state. Which of the following is the most likely Dx? (Brief psychotic disorder OR Schizoaffective disorder)

Serum TSH -Common AE of lithium include: --1) Hypothyroidism (Cause for wt gain in this pt) --2) CKD --3) Nephrogenic DI --4) Hyper-PTH & Hyper-Ca+ Fasting serum glucose -Lithium is not associated w/ increased fasting glucose levels (which can also cause Wt gain in this pt)

A 30F, presents for a follow-up exam 4 months after starting TMT w/ lithium carbonate; during this period she has had a 7-lbs wt gain. Her med was prescribed soon after the birth of her son to treat racing thoughts, increased speeding, & over-talkativeness; she has had difficulty sleeping for more than 2 hours nightly. Her symptoms decreased after 2 weeks of lithium carbonate. She continues to take lithium (300mg 3x's/day). Temp is 98.6F, BP is 120/80, pulse 70/min. Exam shows normal findings. The most appropriate next step is measurement of which of the following? (Serum TSH conc OR Fasting serum glucose conc)

DA -Pt most likely was given an antipsychotic (affects DA) → and now presents w/ neuroleptic malignant syndrome → symptoms include: --1) Signs/symptoms ----Severe hyperthermia ----ANS instability ----Lead pipe rigidity ----Altered sensorium --2) Labs ----a) Elevated CK levels ----b) Elevated WBC's Serotonin -Pts would have serotonin syndrome → presents similarly to NMS, however pt would have Hx of increased SSRI use ----[SSRI's are not used to treat psychotic symptoms (hallucinations)] -Other key difference → Hyper-reflexia & myoclonus would be present

A 32M, present to the ED by a friend b/c of a sudden onset of confusion & agitation. He has a long-standing Hx of schizoaffective disorder, depressed type. Five days ago, a new med was added to his regimen b/c of auditory hallucinations, but he is not sure what it is. He rarely drinks & does not use drugs. He is confused & does not know why he is at the ED. Temp is 103.1F, pulse is 110/min, RR are 160/100. Neuro exam shows muscle rigidity. Leukocyte Ct is 15K, & serum Cr 950. Which of the following neurotransmitters is most likely responsible for this pts condition? (DA OR Serotonin)

CT scan of the head -Pt most likely presents w/ malignant otitis externa → symptoms include: --1) Sever ear pain (OOP to PE findings, ± displacement of ear) --2) Drainage of ear --3) Granulation w/ otoscopy --4) Cranial involvement (advanced cases) Diagnostic --1) Otoscopy --2) CT (showing boney erosions) → to rule out abscess --3) Biopsy --4) Bacterial culture TMT 1- IV cipro 2- Surgery Tympanocentesis -This the TMT for Acute otitis media → indications include: --1) Recurrent AOM --2) Persistent AOM ≥ 4 months w/ complications

A 3B, presents for a follow-up exam. He just completed a 10-day course of Amox that has not resolved his right ear pain. He appears irritable. Temp is 102F. Exam shows downward & lateral displacement of the right auricle w/ tenderness to palpation on the posterior auricle area; his neck is supple. Which of the following is the most appropriate next step in the Dx? (CT scan of the head OR Tympanocentesis)

No intervention is necessary -Newborn babies have conferred resistance to Chickenpox via their mothers for up to 6 months after birth (IgG)

A 4B, develops chickenpox 8-hours after visiting his newborn sister in the nursery. 6 other full-term newborns were also exposed; all o the mothers have a Hx of chickenpox prior to pregnancy. Which of the following is the most appropriate recommendation to prevent chickenpox in the newborns? (Administration of varicella vaccine to all exposed OR No intervention is necessary)

Pt controlled IV morphine -Pt has had a MAJOR surgery → IV morphine is the Med of choice for major surgeries Oral aspirin & codeine -Can be used in minor surgeries

A 64F, has moderately severe post-operative pain 1 day after a TAH-BSO. What is the most appropriate analgesic med? (Oral aspirin & codeine OR Pt controlled IV morphine)

V-tach - Pt most likely has a ventricular arrhythmia → Common up to 6 months after an MI - ECG findings: ---Wide QRS complexes A-fib -Usually not associated w/ an MI -ECG findings ---Narrow QRS complexes

A 70F, presents to the ED 3 hours after the onset of substernal chest pain, weakness, & dyspnea. She sustained an acute MI 6-months & has recurrent chest pain on exertion treated w/ nitroglycerin. On arrival, temp is 98,8F, RR are 22/min, BP is 60/40. Exam shows no other abnormalities. An ECG is shown. What is the most likely Dx of this pts chest pain? (V-tach OR A-fib)

Pyschogenic polydipsia -Supporting characteristics include: --1) Seen in pts w/ mental illness (Schizophrenia) --2) Pt is drinking in excess w/out being thirsty SIADH - Also causes hyponatremia - However, key differences include: ---1) PRESENTS AS EUVOLEMIC hyponatremia -------[pt has signs of dehydration which eliminates SIADH as possible answer choice] ---2) RF's for SIADH include ------a) CNS diseases → Head trauma, meningitis, encephalitis, stroke ------b) Acute psychosis ------c) Tumors → SCLC ------d) Other pulmonary diseases → Pneumonia, acute respiratory failure ------e) Meds → Vincristine, SSRI's, Chlorporpamide, Oxytocin, Opiates, Desmopressin, Carbamazepine, Oxcarbazepine, Cyclophosphamide, Ifosfamide, NSAID's, MDMA --------------[pt has no RF's]

A 72M, presents for a follow-up exam 4-wks after beginning a 10-day course of quinolone therapy for a UTI. His pain w/ urination has decreased & increased frequency have resolved, & his urine has been clear. He says that he has been drinking 12-15 glasses of water daily to prevent another infection. He has a 30-yrs Hx of schizoaffective disorder. Current meds include risperidone. He is oriented to person but not to place or time. Pulse is 80/min, BP is 128/60 w/ no orthostatic changes. Exam shows dry oral mucosa & no JVD. The lungs are clear to auscultation. Abd exam shows no abnormalities. There is no peripheral edema. Muscle strength is 5/5, & sensation is intact. Reflexes are 1+ bilaterally. Labs show: -HCT-----------------------40% -Serum- -Na+------------------------122 -K+--------------------------4 -Cl--------------------------94 -HCO3-----------------------22 -BUN------------------------16 -Cr--------------------------1.1 -Urine- -Blood-----------------------N/A -Glucose---------------------N/A -Protein----------------------N/A -Na+------------------------20 -Osmolality-------------------200 Which of the following is the most likely cause of this pts hyponatremia? (Psychogenic polydipsia OR SIADH)

The result are not adjusted for co-morbidities -Although the researchers accounted for confounding bias they did not account for the effect of co-morbidities on recovery time (which is a major factor in recovery time)

A health status survey compares the clinical outcomes of pts treated for hip fracture at two hospitals. A total of 560 subjects are studied for a year after sustaining a hip fracture. After adjustment for age & gender, the level of physical functioning following TMT is found to be significantly lower among pts treated in one hospital (p=.02). Researchers conclude that TMT at this hospital was suboptimal. Which of the following raises the most concern about this conclusion? (The results are not adjusted for co-morbidities OR The surgery instrument does not include clinical measures)

Fluid restriction - Pt has Signs & RFs concerning for SIADH -A) MGMT ----a) Dx tests -------1) Electrolyte tests ----b) TMT → BASED ON EMERGENT SITUATIONS VS NON-EMERGENT SITUATIONS --------b.1) Emergent situations include neurological deficiencies, abnormal vitals --AA) NON-EMERGENCY ------1) Fluid restriction ------2) ± Vasopressin (V2) receptor antagonists --BB) EMERGENT SITUATIONS ------1) 3% hypertonic solution (saline) ------2) Furosemide ---------a) In conjunction w/ hypertonic saline

A previously healthy 52M, presents to the ED b/c of hiccups for 1 week. He has smoked two packs of ciggs daily for 30 years. He does not drink alcohol. He is alert * oriented. Temp is 98.6F, BP 150/95, pulse is 70/min, & RR 12/min. PE & neuro exam shows no abnormalities. His serum Na+ conc is 120. A CXR shows a right hilar mass. Which of the following is the best next step? (Fluid restriction OR 3% saline therapy)

Selective IgA deficiency -Pt had a RXN to blood transfusions CVID -Pt would present w/ increased respiratory & GI infections -Later, would have skin manifestations including: --Alopecia --Necrotizing granulomas --Cutaneous vasculitis

An asymptomatic 32M, presents for a routine health exam. He has a 10-py smoking Hx of frequent sinus & pulmonary infections. He has an anaphylactic RXN to a blood transfusion following a MVC 3 years ago. Temp is 98.6F. Exam shows mild erythema in the posterior pharynx. The lungs are clear to auscultation. A CBC & serum protein electrophoresis are normal. Which of the following is the most likely cause of the frequent infections? (CVID OR Selective IgA deficiency)

CXR -Pt Most likely has pneumonia → Supporting signs include: --1) Fever --2) Increased leukocytes --3) Decreased breath sounds at left lung base --4) Splenectomy → which increases her risk of infection w/ strep pneumo MGMT for pneumonia includes -1) CXR to confirm -2) Antibiotics → (Confirm first then treat) Angiography -Used if we suspected PE → However, Pts does not present w/ any signs for PE, including → pleuritic chest pain, dyspnea & tachypnea, Rales & cough, Tachycardia, Hemoptysis

5 days after undergoing an open splenectomy for ITP, a 57F, has the onset of SOB. During the operation, dissection of the splenic hilum was difficult. Her only med is morphine. Temp is 99.2F, pulse is 80/min, RR are 20/min, & BP is 120/80. The surgical wound appears normal. Breath sounds are decreased at the left lung base. Leukocyte Ct is 15,6K, plts 112K, & serum amylase is 90. Which of the following is the most appropriate next step in MGMT? (CXR OR IV antibiotics OR Angiography)

Surgical exploration of mediastinum - Pt presents w/ signs concerning for Aortic dissection -Presentation includes -1) Etiology ---a) Associated w/ CABG ---b) HTN (most common) ---c) Connective tissue diseases ---d) Inflammatory diseases → (Takayasu, RA, GCA, Tertiary syphilis) -2) Vitals sign abnormalities ----a) Abrupt decrease in BP ----b) Abrupt decrease in cardiac output w/ concomitant increase in pulmonary artery diastolic pressure -3) CXR ---a) Mediastinal widening Administration of epinephrine -Would be correct if this pt had cardiogenic shock -Presentation includes: -1) PE findings ---a) JVD ---b) Crackles over the lung bases bilaterally (in pts w/ pulmonary edema) ---c) Altered mentation ---d) Cool, clammy skin ---e) Weak, thready pulse -2) Echo ---a) Severe systolic dysfunction or mechanical abnormality [XR would not show widened mediastinum]

6 hours after CABG, a 62M has a decrease in systolic BP from 120/80 - 100/85. Urine output decreases from 60mL/h to 10mL/h, & cardiac output decreases from 6L/min to 3L/min. Pulmonary artery diastolic pressure has increased. A CXR shows a widened mediastinum. Which of the following is the most appropriate next step in MGMT? (Administration of epinephrine OR Surgical exploration of the mediastinum)

XR of the hip -The pt most likely has Slipped capital epiphysis -Presentation includes: --1) RF's -----Obesity is number one --2) Thigh & groin Pain -----That can sometime present as knee pain --3) PE findings ------Trendelenburg gait ------External rotation during passive hip flexion (limited hip flexion) ------Limited hip internal rotation & abduction MGMT 1) XR of hip MRI of the knee -We would use this if we suspected tendon damage (MCL, ACL) tear

A 14B, w/ sickle cell trait presents to the ED b/c of a 1-day Hx of severe pain in his left thigh & knee. He has been unable to bear wt on his left leg since the pain began. He has not had swelling, locking, or "catching" of his knee. 6 days ago, he was evaluated in the ED after he twisted the knee during a B-ball game. An XR of the knee is shown. He was instructed to take an NSAID & apply ice packs to the knee. He was also given crutches & told to bear wt as tolerable. His symptoms improved during the next 3-days, & he discontinued use of crutches & all meds at that time. On arrival, he is walking w/ assistance of the crutches. He is 5-ft, 8-in & weighs 210-lbs; BMI is 32. Temp is 98.6F, & BP is 110/70. Exam of the LLE shows joint line tenderness of the knee; there is no effusion. ROM of the left hip is limited by pain. The remainder of the exam is normal. Leukocyte Ct is 8K, & ESR is 10. Which of the following is the most appropriate next step in MGMT? (XR of the left hip OR MRI of the left knee)

Catecholamine producing tumor -Pt presents w/ NF 1 → complications of NF 1 include: --1) Pheochromocytoma --2) Malignant CNS tumors --3) Developmental delays --4) Intellectual disability --5) Peripheral neuropathy --6) Vision abnormalities --7) Bone abnormalities Essential HTN -Seen in middle aged pts d/t atherosclerosis - Pt would NOT HAVE any other symptoms besides HTN ----[pt has many more symptoms then just HTN]

A 16B, w/ NF 1, presents for a follow-up. His uncle also has NF 1. He has a 1-year Hx of headaches during which his parents say he appears pale. Six months ago, he underwent operative TMT for an optic nerve glioma. BP is 164/105, pulse is 102/min, & RR are 14/min. The thyroid glands are not enlarged. No murmurs are heard, & radial pulses are equal. Abd exam shows no abnormalities. Which of the following is the most likely cause of this pts HTN? (Catecholamine producing tumor OR Essential HTN)

Family therapy -All of the family must be involved in therapy b/c all of the family is contributing to this pts behavior Psychodynamic psychotherapy of the pt -Would be correct if the pt was Dx'd w/ MDD

A 16F, presents by her mother who requests contraception for her daughter. The mother asks to speak to the physician alone & explains that she persuaded her daughter to come b/c the girl has begun to stay out late, receive many calls from several boys, & wear tight clothing & excessive makeup. She says her daughter confides many details of her date to her. She adds that the girl's father is furious & berates her about this behavior even tho he does not know about most of what is going on. To protect her daughter, she does not want to tell him about all the daughter's activities. On individual interview, the girls says she does not understand why she does these things, but she would like to understand. PE shows no abnormalities. Which of the following is the most appropriate next step in MGMT? (Psychodynamic psychotherapy of the pt OR Family therapy)

Aortic incompetence -Pt most likely has Ehlers-Danlos → presentation includes --1) Heart valve abnormalities -----MVP -----Aortic root dilation -----Weak vessels -this pt has a DIASTOLIC murmur, indicating Aortic regurgitation Mitral incompetence -This Describes Mitral regurg - Mitral regurg is a SYSTOLIC murmur

A 16f, present w/ episodes of palpitations over the past 6 months. The episodes occur when she runs or plays basketball. She is otherwise asymptomatic. BP is 124/46, pulse is 78/min, RR are 18/min. She weighs 121-lbs & is 71-in tall. Her arm span is 74-in & the upper segment to lower segment ratio is 0.85. Her fingers appear long & are hyper-extensible. A grade 4/6, early diastolic murmur is heard along the upper & middle left sternal border w/ radiation to the apex. Peripheral pulses are bounding. Which of the following is the most likely cause of these findings? (Aortic incompetence OR Mitral incompetence)

PCP -Presentation includes --1) Nystagmus (Rotary or simultaneous horizontal & vertical) → highly indicative --2) Violence/psychomotor agitation (psychosis) --3) HTN & Tachycardia --4) Lethargy/stupor --5) Constricted pupils --6) Hypertonia --7) Analgesia (Decreased pinprick sensation) --8) Delirium & seizures MGMT -1) Benzos (first line) -2) Antipsychotics (haloperidol, droperidol) → adjuncts to benzos Hallucinogen (LSD) -Presentation includes --1) Perceptual distortion (visual, auditory) --2) Depersonalization --3) Anxiety --4) Paranoia --5) Psychosis --6) Possible flashbacks

A 19M, present to the ED by police for eval after he was found standing in his neighbors living room during the middle of the night. He is conscious but remains mute during questioning. Temp is 98.6F, pulse is 98/min, RR are 18/min, BP is 160/95. PE shows bilateral nystagmus, constricted pupils, hypertonia, & decreased sensation to pinprick. Which of the following is the most likely substance taken? (Hallucinogen OR PCP)

Psychogenic polydipsia -Labs --1) LOWSerum Osm (<2800) --2) LOW Urine Osm (usually < 100) ----(B/c everything is working normally → so the more water you drink, the more water you pee out → Making your urine MORE DILUTE) --2) RF -----a) PT has a 6 months Hx of INCREASED thirst & INCREASED urination SIADH - Also a cause of EUVOLEMIC hyponatremia & LOW serum Osmolarity (<280) - However, key differences include ----1) HIGH URINE OSMOLARITY → >100 -------[pt has a LOW urine osmolarity] ----2) MISSING RFs for SIADH

A 19M, presents to the ED b/c of generalized tonic-clonic seizures that began 45-mins ago & lasted 20-mins. She says that her son had had excessive thirst & urination for the past 6-months. Otherwise, he has no Hx of serious illness & takes no meds. He appears lethargic. Temp is 38C (100.4F), pulse is 80/min, RR are 14/min, BP is 120/80. Physical & Neuro exam show no abnormalities. Labs show: -Na+-------------------------121 -Serum Osm-------------------250 -Urine Osm--------------------50 Which of the following is the most likely Dx? (SIADH OR Psychogenic polydipsia)

Language: Normal Psychosocial: Normal At 2 months -Motor --Eyes follow to midline --Lefts head to 45⁰ -Language- --Coos & makes gurgling noises --Turns head toward sounds -Social- --Begins to smile --Tries to look at parent -Cognitive --Pays attention to face --Begins to follow w/ eyes --Begins top act bored (Crying/Fussiness) Red flag: Rolling over earlier than 3 months may indicate hypertonia At one month: -Motor --Reacts to pain --Can make tight fist --Can hold head up --Turns head while supine -Language --Ability to cry (make throaty noises) -Social --Establishes eye contact Red Flag: Failure to alert to environmental stimuli

A 2-month-old boy presents for a well-child exam. He smiles spontaneously & vocalizes w/out crying, but he does not appear to laugh or squeal. He will not work for a toy that is out of reach. Which of the following is the most appropriate assessment of language & psychosocial development? (Language: Delayed/Normal Psychosocial: Delayed/Normal

IV penicillin G -The stem does not tell you if she has a positive culture or not → however, the question directly asks what you must give to prevent GBS transmission in newborns

A 24F, primigravida, at 38 weeks is admitted in labor. She had spontaneous ROM 2-hours ago. Contractions are moderate & occur every 5-6 mins. At 20-weeks, she was treated w/ ampicillin for a GBS UTI. She has no other sig PMHx & takes no meds. Temp is 98.6F, pulse is 82/min, RR are 18/min, BP is 122/74. The cervix is 2-cm dilated & 80% effaced; the vertex is at -1 station. Administration of which of the following is the most appropriate to prevent GBS in this pts newborn? (IV penicillin G OR No prophylaxis indicated)

Fat embolism -Presentation includes --1) ABG findings ----Hypoxemia on ABG ----Respiratory alkalosis ----Increased A-a gradient --2) PE findings ----Petechial rash & hemorrhages ----Neuro impairment --3) CXR findings ----Bilateral Hyper-intense (fluffy) infiltrates → (main differentiating factor between fat embolism & ARDS) ARDS -Presentation includes: --1) PE findings ----Dyspnea ----Tachypnea ----Tachycardia ----Diffuse crackles --2) CXR ----Bilateral (patchy/ground glass) diffuse infiltrates → (main differentiating factor between fat embolism & ARDS)--3) No ABG findings

A 24M, has SOB 2-days after open reduction & internal fixation of a mid shaft right femoral fracture sustained when he was struck by a car. On exam in the ED, abrasions were noted over the left anterior chest wall. A CXR at that time showed no abnormalities. Pulse is 96/min, RR are 24/min, BP is 130/74. Exam shows petechial hemorrhages of the conjunctivae & petechiae over the chest & UE's. ABG shows: -pH-------------------7.48 -PCO2-----------------30 -PO2------------------56 -HCO3-----------------23 A CXR shows fluffy infiltrates in both lung fields. Which of the following is the most likely Dx? (ARDS OR Fat embolism)

IM administration of betamethasone -Pt is in preterm labor & has active GBS infection - However, pre-term labor MGMT takes precedence -MGMT includes: --1) Expectant MGMT (even w/ PROM) --2) Hospitalization, hydration, & activity restriction --3) Tocolytic therapy ----Indomethacin → 24-32 weeks ----Nifedipine → 32-34 weeks --4) Glucocorticoids (betamethasone/dexamethasone) --5) Empiric penicillin (IV penicillin G- not oral) → If delivery is imminent Oral Amox -This is a TMT for GBS infection - However, Preferred meds include: ---1) IV → Penicillin, Cefazolin, Clindamycin, Vancomycin -------[NOT ORAL Amoxicillin]

A 25F, at 27-weeks presents to the ED b/c of severe contractions for 6 hours. She says the contractions have not resolved despite changing positions & increasing her fluid intake. She also noted a small amount of vaginal spotting the last time she voided. External fetal monitoring shows contractions every 2-3 mins & a fetal HR of 130/min w/ no decelerations. The cervix is 1-cm dilated & 10% effaced. The fetal presenting part is high. During the next hour, she receives oral hydration. Temp is 99F, pulse is 110/min, RR are 16/min, & BP is 110/70. The lungs are clear to auscultation. The fundal Ht is 27-cm. The cervix is now 1-2-cm dilated & 70% effaced; the vertex is -2 station. Vaginal culture for GBS is positive. Which of the following is the most appropriate next step in MGMT? (IM administration of betamethasone OR Oral amox prophylaxis)

Aspirin -Pt presents w/ an MI → unless CI, MGMT of all pts w/ an MI includes: --1) Supplemental O2 (if hypoxic) --2) Nitroglycerin (± morphine) --3) B-blocker (metoprolol) --4) Statin (atorvastatin) --5) Anticoagulant (heparin) --6) Dual antiplatelet therapy (Clopidogrel + Aspirin) -----Aspirin is first line In pts w/ ST elevation despite medical therapy --1) CT angio + Percutaneous coronary intervention (PCI) Nitroprusside -Not used in TMT for acute coronary syndromes -Short acting drug used in hypertensive emergencies - Also, would not be used in conjunction w/ nitroglycerin

A 25M, presents to the ED 1-hr after the onset of severe non-radiating substernal chest pain. He smoked crack cocaine 30-mins prior to the onset of of pain. He has not had any other symptoms or previous episodes of pain. There is no personal or FMHx of serious illness. He takes no meds. He has smoked 1-pack of ciggs daily for 10-years. He does not drink. He has a 3-yrs Hx of routine crack use. He exercises for 30-mins 6days/wk & has had no associated chest pain or SOB. On arrival, he is in moderate distress. He is 6-ft & weighs (175-lbs); BMI is 24. Temp is 99F, pulse is 95/min & regular, RR are 16/min, & BP is 145/85 in both arms. JV pulsations are present 3-cm above the sternal angle & decrease by 2-cm w/ inspiration. Cardiopulmonary exam shows no abnormalities. CXR shows no abnormalities. An ECG shows tachycardia & 4-mm ST-elevation in leads V1-V4. In addition to nitroglycerin therapy, which of the following is the most appropriate initial pharmacotherapy? (Aspirin OR Nitroprusside)

ACTH stimulation test -The diagnostic approach to Addisons disease is: ---1) Cortisol ---2) ACTH (Cosyntropin & Metyrapone test) Dexamethasone suppression test -Used for suspected Cushings

A 26F, presents to the ED b/c of marked confusion for 2 hours; she also has had a flu-like illness for 3 days. Over the past 6 weeks, she has had increased fatigue, weakness, & nausea. She recently started thyroid replacement therapy for autoimmune thyroiditis; 1 week ago, her serum TSH was 3. Temp is 100.4F, BP is 80/40, & pulse is 140/min. She appears confused & lethargic. Exam shows cool, mottled skin. There is generalized hyperpigmentation, especially involving the palmar creases. The lungs are clear to auscultation. Abd exam shows diffuse mild tenderness & no rebound. Labs show: -Hb------------------------10 -Leukos-------------------9K --Neutros-----------------55% --Eosinos------------------20% --Lymphos----------------25% -Na+-----------------------124 -Cl-------------------------92 -K+-------------------------6.4 -HCO3--------------------16 A CXR & urinalysis are normal. An ECG shows sinus tachycardia w/ peaked T-waves. Which of the following is most likely to confirm the primary cause of this pts condition? (ACTH stimulation test OR Dexamethasone suppression)

Small bowel obstruction -Presentation includes: -A) Etiology ----a) Post-op adhesions ----b) Neoplasms ----c) Hernias ----d) Crohns ----e) Other -------1) Congenital stricture, Appendicitis, diverticulitis, intra-abdominal abscess, Intussusception, volvulus, congenital strictures, Traumatic intramural hematoma, gallstone -B) Signs & symptoms ----1) Nausea, vomiting, obstipation -------a) Pain exacerbated by eating & relieved by vomiting ----2) Atypical abd pain --------a) localized, continuing, worsening ----3) Fever, tachycardia -C) Labs ----1) WBC's > 10K -D) PE findings ----1) Peritoneal signs (rigidity, guarding, rebound tenderness) ----2) High pitched tinkling sounds (tympanitic) ----3) Hypoactive/absent bowel sounds Gastric outlet obstruction -Can present w/ vomiting of undigested food -However, key differences include ---1) PRESENTATION ------a) GOO DOES NOT present w/ bile in vomitus --------[pt had clear-green liquid initially (bile)] -----b) GOO DOES present w/ succussion splash --------[pt DOES NOT have succussion splash] ---2) OCCURS IN SPECIFIC SETTING ------a) GI CACNER ------a) Pyloric stenosis ------b) PUD ------c) Cancer ------d) Pancreatic pseudocyst ---------[pt has none of these]

A 27F, presents b/c of a 5-day Hx of headache, severe, diffuse abd pain, & nausea & vomiting. The pain is exacerbated by eating & relieved by vomiting. The vomitus initially consisted of a large amount of semi-solid material mixed w/ a clear green liquid but now consists of clear yellow liquid only. She has not had any other symptoms. She has Crohns treated w/ prednisone; she was instructed to taper her dosage 2 weeks ago. Additional meds include mesalamine & Azathioprine. Her last menstrual period was 7-wks ago. She is sexually active w. one male partner, & they use condoms inconsistently. She appears ill & is in moderate distress. Temp is 101.2F, pulse is 120/min, RR are 12/min, & BP is 90/50. Exam shows dry oral mucosa & pale conjunctivae. The abd is distended, diffusely tender, & tympanitic. Bowel sounds are decreased. Pelvic exam shows no abnormalities. Labs show: -Hct--------------------31% -Leuko Ct--------------15K -Amylase---------------300 (N 25-125) -Lipase-----------------9 (N 14-280) Which of the following is the most likely Dx? (Gastric outlet obstruction OR Small bowel obstruction)

Transfusion of O- packed RBC's -Pt has been administered crystalloid but is still was hypotension → the next step would be a transfusion w/ packed RBC's Administration of hetastarch -Used to PREVENT hypovolemia in procedures

A 27M, presents to the ED by paramedics 30-mins after being involved in a high-speed MVC in which he was an unrestrained driver. He was unconscious at the scene, & he was extracted from his vehicle. On arrival, his Glascow score is 10. Temp is 98.6F, pulse is 130/min, RR are 36/min, & BP is 90/60. Breath sounds are decreased on the right; there is crepitus to palpation over the right hemithorax. A CXR shows a right hemopneumothorax. FAST shows no abnormalities. An XR shows an unstable pelvic fracture. Placement of a right thoracostomy tube yields 300mL of blood. After rapid infusion of 3L of crystalloid, the pt remind tachycardic & hypotensive. Which of the following is the most appropriate next step in MGMT? (Administration of hetastarch OR Transfusion of O- packed RBC's)

Mitral stenosis -Presentation includes: --1) Loud S1 --2) Low-pitch diastolic murmur following an opening snap --3) Symptoms are exacerbated by increased cardiac demand (i.e., pregnancy) --4) Cardiac apex is not palpable Aortic regurg -Presentation includes: --1) Most common etiologies of ACUTE ----Traumatic aortic root enlargement (Ehlers-Danlos) ----Endocarditis --2) Presentation ----Rapid onset of severe CHF ----CV collapse ----Cardiogenic shock ----Normal/Reduced pulse pressure ----Thready pulse

A 28F, at 28 wks reports excessive fatigability & dyspnea. BP is 118/74, pulse is 110/min & regular, lungs are clear to auscultation. The cardiac apex is not palpable. S1 is loud, & there is a sharp sound after S2. A low-frequency diastolic murmur is heard at the apex that increases in intensity before S1. Which of the following is the most likely Dx? (Aortic regurg OR Mitral stenosis)

Amoxicillin -Pt presents w/ Lyme disease → MGMT is based on the stage of disease presentation: -Early localized Lyme disease- --1) Doxycycline → First line for early localized disease ------CI in pregnancy & kids --2) Amoxicillin → preferred in pregnancy --3) Cefuroxime → preferred in pregnancy -Early disseminated or Late lyme disease- -(pts w/ heart block/meningitis) --1) IV ceftriaxone (First line) --2) Cefotaxime --3) Penicillin G Prednisone -Not a TMT for lyme disease

A 32F, presents b/c of fever, headache, joint pain, & fatigue for 2-weeks. 3 weeks ago, she had a bright red rash on her calf for 7 days. She has no Hx of serious illness & takes no meds. Temp is 99.9F. PE shows normal findings except for mild pain on hyperextension of the knees. Neuro exam shows no abnormalities. An IgM antibody assay to Borrelia is positive. Administration of which of the following is the most appropriate next step in MGMT to prevent ling-term complications of this disease? (Amoxicillin OR Prednisone)

Appendicitis -Presents w/: --1) Migratory RLQ pain w/ rebound (can be right adnexal tenderness) --2) Nausea, --3) Fever & leukocytosis --4) US shows no mass Tuboovarian abscess -Typically presents on US as a complex, multi-cystic/multi-locular adnexal mass w/ enhancing rims ----(pt has NO adnexal mass) -Pt would have fever & leukocytosis → usually presents in the setting of PID; w/ discharge

A 32F, presents to the ED b/c of a 2-day Hx of vomiting, diarrhea, & right-sided pelvic pain. Her last menstrual period was 3-wks ago. Temp is 102.2F, RR are 20/min, pulse is 100/min, & BP is 120/70. Abd exam shows RLQ tenderness w/ rebound. Bowel sounds are decreased. Pelvic exam shows right adnexal tenderness. A serum pregnancy test is negative. Labs studies show: -Hb------------------12 -Leukos---------------15K --Neutros-------------80% --Bands---------------10% --Lymphos------------5% --Monocytes-----------5% US shows no adnexal mass. Which of the following is the most likely Dx? (Tubo-ovarian abscess OR Appendicitis)

Triglycerides -Pt most likely has acute pancreatitis --The most common etiologies for acute pancreatitis are: ---1) Alcohol ---2) Gallstones ---3) Triglycerides LDL-cholesterol -Triglycerides are associated w/ acute pancreatitis [not Cholesterol]

A 32F, presents to the ED b/c of abd pain & nausea & vomiting for 6-hours. She underwent a cholecystectomy 2-yrs ago. Menses occur at regular 28-day intervals; her last menstrual period was 2-wks ago. She does not smoke or drink. She appears acutely ill. Temp is 99.3F, & RR are 14/min. Pulse is 110/min & BP is 130/70 supine; pulse is 135/min & BP is 90/60 while standing. Abd exam shows guarding w/ rebound over the epigastrium; bowel sounds are decreased. The remainder of the exam shows no abnormalities. Serum studies show: -Na+-------------------146 -K+---------------------3.3 -Ca+-------------------8.9 -Total Bili----------------1 -ALP--------------------120 -AST--------------------64 -Amylase----------------1022 The most appropriate next step in determining the underlying cause is measurement of which of the following serum concentrations? (LDL-cholesterol OR Triglycerides)

Influenza -Pt has NORMAL CD4+ Counts Hep A -Only if pt was traveling or if CD4+ Ct was below 500

A 32F, who is HIV+ has a CD4+ Ct of 800 (N ≥500). Her health maintenance regimen should include immunization against which of the following pathogens? (Influenza OR Hep A)

Propranolol - This pt presents with a migraine headache → presents w/: --1) Severe, throbbing headaches → often unilateral --2) Nausea, vomiting --3) Photophobia --4) Phonophobia (sensitivity to sound) --5) Flushing, terming, rhinorrhea --6) Can last anywhere from 4-72 hours Migraine w/ aura --1) Can also appear w/ dark spots on eyes (scotomas) -B) MGMT -----a) TMT → ABORTIVE Vs PROPHYLAXIS --aa) ABORTIVE ------1) First line ----------a) Sumatriptan (OR) ------------Metoclopramide (OR) ------------Prochlorperazine ----------b) Diphenhydramine --------------b.1) Used as adjunct to metoclopramide/prochlorperazine to prevent acute dystonia --bb) PROPHYLAXIS ------1) TCA's (amitriptyline) ------2) Beta-blockers (propranolol) ------3) Ca+ channel blockers (nifedipine, verapamil) ------4) Anticonvulsants (valproate, Topiramate) ------5) Calcitonin gene-related peptide antagonists ----------a) used for prophylaxis in pts refractory to other tmts -----------b) Erenumab -----------c) Galcanezumab -----------d) Frmanezumab

A 32M, presents b/c of severe throbbing headaches that have been increasing on frequency over the past 3 months. He has a 10-yrs of similar headaches that typically last 6-12 hours & are associated w/nausea, vomiting, & photophobia. The headaches used to occur approximately every 6 months but now occur twice weekly. He is unable to identify any precipitating factors. OTC meds have been ineffective. He is otherwise healthy & active. Temp is 37C (98.6F), pulse is 72/min, BP is 120/75. Exam shows no abnormalities. Which of the following is the most appropriate prophylaxis for his headaches? (Propranolol OR Sumatriptan)

ARDS -1) Etiology "AAAARDDDSSS" ---AAAAA → Aspiration, Acute pancreatitis, Air/Amniotic embolism ---R → Radiation ---DDD → Drug OD, DIC, Drowning ---SSS → Shock, sepsis (most common etiology), Smoke inhalation -2) CXR findings ---Bilateral (patch/ground glass) diffuse infiltrates Interstitial lung disease -This can describe any RESTRICTIVE type of lung disease → However I was thinking of Idiopathic pulmonary fibrosis -This pt presents in an ACUTE setting → & idiopathic pulmonary fibrosis presents chronically -Also, CT findings include ---1) Honeycomb pattern ---2) Reticular opacities

A 37F, w/ alcoholism is admitted to the ICU for TMT of severe alcoholic pancreatitis. She had several episodes of vomiting 2-hours before admission. During the first 12 hours, her vitals have been in the following ranges: pulse 100-130/min; RR 28-36 min; Systolic BP 90-110. Fourteen liters of crystalloid solution have been infused to maintain a urine output of 30 mL/h. B/c her arterial O2 sat has fallen into the 80%-89% range on 100% O2 by face mask, she is intubated & being mechanically ventilated. One hour after intubation, her pulse is 110/min, BP is 90/60. The lungs are clear to auscultation. Pulmonary artery cath shows: -Cardiac index--------------4.2L (N 2.5-4.2) -CVP------------------------11 (N 5-8) -PCWP----------------------10 (N 5-16) ABG on an FiO2 of 60% & PEEP of 10-cm H2O shows: -pH---------------------------7.32 -PCO2-------------------------38 -PO2--------------------------78 A CXR shows bilateral, diffuse, hazy infiltrates w/ cephalization of the pulmonary vasculature & perihilar fullness. Which of the following is the most likely Dx? (ARDS OR Interstitial lung disease)

Autonomous production of aldosterone -Pt has only HTN as her main symptom -She has decreased K+ levels which would be affected by increased aldosterone levels Catecholamine producing tumor -This describes a pheochromocytoma → However, pt would have other symptoms besides her increased BP -Additionally, pheochromocytoma is not associated w/ electrolyte abnormalities (↓ K+ levels)

A 42F, presents for evaluation of persistently increase BP. At her last two office visits during the past 3 months, her BP has ranged between 150-170/105-115. During this period, she has had occasional headaches. In addition, she has had an increased urine output over the past 6 weeks that she attributes to a diet high in sodium. She is otherwise healthy & takes no meds. BP today is 168/115, pulse is 68/min, & RR are 14/min. Funduscopic exam shows mild AV nicking. The point of maximal impulse is not displaced. There is no edema, abd bruits, or masses. Serum studies show: -Na+--------------------144 -K+---------------------2.9 -Cl----------------------90 -HCO3-------------------32 -BUN--------------------20 -Cr, serum---------------1.2 Which of the following is the most likely underlying cause of this pts HTN? (Autonomous production of aldosterone OR Catecholamine-producing tumor)

H.influenza -Small Gm(-) rod -MOST DIFFERENTIATING FACTOR → H.flu Most often causes CAP pneumonia → Seen on CXR as Consolidation in lung -1) RF's ----a) COPD & smoking ----b) Alcoholism ----c) DM ----d) Sickle cells ----e) Immunocompromised Pseudomonas -Can cause pneumonia → However, usually causes pneumonia in CF & intubated pts (Immunocompromised) -MOST DIFFERENTIATING FACTOR → Pseudomonas Most often causes ATYPICAL pneumonia → Seen on CXR as diffuse infiltrates -1) RF's include: ---a) Severe structural lung disease → bronchiectasis, CF, severe COPD ---b) Hospitalized pts/nursing home residents ---c) Ventilator-assisted pts ---d) Pts who have received broad-spectrum antibiotics or high-dose steroids therapy E.coli - NOT A COMMON cause of pneumonia - Commonly causes meningitis in newborns

A 43M, presents b/c of a 3-day Hx of temps 101.1F, left-sided chest pain, malaise, loss of appetite, & a cough productive of yellow phlegm & a 36-hours Hx of increasing SOB. He has smoked 2 packs of ciggs daily for 25 years. He appears ill. Temp is 101.8F, pulse is 112/min, RR are 22/min, BP is 118/72. Crackles & wheezes are heard at the left base; breath sounds are decreased. There is increased left tactile fremitus & dullness to percussion at the left base. Exam shows no other abnormalities. CXR are shown. Gram stain of sputum shows small Gm(-) bacilli & leukocytes. The most likely Dx is pneumonia cased by which of the following organisms? (H.influenzae OR Pseudomonas OR E.coli)

CT scan of the head -The pt presents w/ meningitis → the diagnostic approach for meningitis includes & is in order --1) Two sets of blood cultures before antimicrobial TMT is initiated --2) Lumbar puncture + CSF analysis --3) CT ***HOWEVER → CT is indicated first if pt has signs of ICP, including: --1) Papilledema (optic fundi not visualized) --2) Altered mental status --3) Focal neurological deficits --4) Immunocompromised state --5) New onset seizure (w/in 1 week) --6) Hx of CNS disease or head trauma

A 47F, presents b/c of fever, nausea, vomiting, & severe headache for 24 hours. Temp is 102.2F. Exam shows weakness of the RUE & nystagmus; optic fundi cannot be visualized. Kernig sign is present. Which of the following is the most appropriate next step in Dx? (CT scan of the head OR Lumbar puncture)

Hypovolemia -The pt presents w/ signs of shock → most likely caused by hypovolemia from 3 days of vomiting including: --1) Hypotension --2) Cold & clammy skin --3) Confusion --4) Tachycardia Esophageal rupture -The pt would present w/a Hx large volume hematemesis → he does not say he had hematemesis -Signs include: --1) Imaging -----Widened mediastinum on CXR (or pneumomediastinum, pneumothorax, plural effusion) ----- CT → esophageal wall thickening, mediastinal fluid collection --2) Signs/symptoms ----Chest/back/epigastric pain + systemic signs ----Pleural effusion w/ atypical green fluid ----Crepitus, Hamman sign (Crunching sound on auscultation) --3) Setting ----Instrumentation (endoscopy) → trauma ----Effort rupture (Boerhave) ----Esophagitis

A 47M, presents to the ED b/c of a 3-day Hx of nausea & vomiting & burning non-radiating epigastric pain. He notes that the vomitus was initially yellowish, but the last two episodes were darker. He consumed 1 pint of whiskey 4-days ago. He takes no meds. On arrival, he is awake & confused. Temp is 99.3F, pulse is 128/min, BP is 90/50. The skin is cold & clammy. Cardiopulmonary exam shows no abnormalities. Abd exam shows diffuse tenderness w/out rebound. Neuro exam shows no focal or sensorimotor abnormalities. Test for stool occult blood is neg. A CXR shows no abnormalities. An ECG shows sinus tachycardia. Which of the following is the most likely cause of this pt's abnormal vital signs? (Hypovolemia OR Esophageal rupture)

Pulmonary contusion -Presentation includes: --1) Most commonly caused by trauma --2) Hypoxia → d/t fluid accumulation --3) Dyspnea → ± grunting/retractions --4) Tachypnea & Tachycardia --5) CXR → UNILATERAL diffuse lung infiltrates ARDS -Diagnosis requires all of the following criteria --1) Acute onset respiratory distress (<1 wk) --2) Bilateral (patchy/ground glass) Diffuse infiltrates [pt has diffuse infiltrates only on one side] --3) Cardiogenic pulm edema --4) PaO2/FiO2 ≤300 mg w/ PEEP/CPAP ≥5

A 4B, presents to the ED 20-mins after being involved in a MVC. He was unrestrained. On arrival, his BP is 110/70, pulse is 100/min, & RR are 32/min w/ grunting & retractions. Exam shows multiple bruises over the chest. ABG while on 40% O2 shows: -pH----------------7.38 -PCO2-------------34 -PO2---------------66 An CXR 4 hours later shows diffuse infiltrates on the right side. Which of the following is the most likely Dx? (Pulmonary Contusion OR ARDS)

Pericardial window -The pt presents w/a cardiac tamponade d/t pleural effusion → Effusion is most likely caused by malignancy -A) MGMT ----b) TMT --------1) Pericardiocentesis/pericardial window Administration of increased dose of furosemide - Although the pt presents w/ signs of fluid overload (Bilateral lung crackles), the presence of: ----1) Distant heart sounds ----2) Hypotension ----3) Alternating QRS amplitude on ECG ----4) Cardiomegaly on CXR -Indicate cardiac tamponade - Cardiac tamponade is quickly fatal & must take priority

A 50F, w/a 5-year Hx of metastatic breast cancer has had SOB for 8 hours. Pulse is 116/min, RR are 32/min, & BP is 90/60. End-inspiratory crackles are heard at the base of both lung fields. Exam shows JVD. Distant heart sounds are heard. ABG shows: -pH------------------7.50 -PCO2---------------28 -PO2-----------------78 A CXR shows cardiomegaly. An ECG shows alternating amplitude of QRS patterns. Echo shows paradoxical motion of the IV septum & pericardial effusion. Which of the following is the most appropriate next step? (Pericardial window OR Administration of increased dose of furosemide)

Decreased androgens -Testosterone is the most influential hormone for sexual desire in men & women -Pathophysio → Pt is taking conjugated estrogen → this increases the amount of SHB which then binds testosterone & DHT Decreased LH -LH would be increased d/t neg feedback from the decreased testosterone

A 52F, presents b/c decreased libido; this symptom began 8 months ago, after she underwent a TAO-BSO for leiomyomata uteri & menorrhagia. She has been taking hormone replacement therapy w/ conjugate estrogen since the operation. Exam shows a moist, rugated vagina. Which of the following is the most likely cause of these findings? (Decreased androgens OR Decreased LH)

Biolar disorder -Bipolar I criteria includes: --1) At least 1 manic episode --2) ± depressive episode -There is no time criteria SIDE NOTE - Bipolar II criteria --1) ≥1 episode of hypomania --2) ≥1 episode of MDD --3) No Hx of mania Schizophreniform -Criteria Must include: ---1) ≥2 following (1-5 below) ---2) Symptoms Must be present for ≥1 month [pt does not meet the time criteria] ---3) At least 1 must be from 1-3 ---4) Must include social/occupational dysfunction --1) Delusions --2) Hallucinations --3) Disorganized speech (loose associations) --4) Disorganized/catatonic behavior --5) Negative symptoms

A 52F, presents b/c of a personality change since the death of a close friend 2-wks ago. He reports that she has been irritable, requires little sleep, & speaks rapidly, jumping from topic to topic. He says that she has never had these symptoms before, but she has had episodes of excessive sleeping, decreased energy, & loss of interest in her usual activities. He never thought these episodes were severe enough to seek medical attention. MSE shows loud, rapid speech & flight of ideas. She is difficult to interview & is distracted by irrelevant stimuli. She paces in the exam room. She says that she is not sad, but uplifted by her friends voice. She hears her friends voice & communicates w/her. What is the most likely Dx? (Bipolar OR Schizophreniform)

Add lisinopril -ACEI's/ARB's are protective in pts w/ nephropathy Switch metformin to glyburide -Glyburide is used in pts that have not achieved good blood glucose control w/ metformin -Criteria is usually HbA1c > 7.0%

A 52F, w/ a Hx of DM II presents for a follow-up. Her only med is metformin. FBG concentrations typically range from 100-140. She has 1-2 symptomatic hypoglycemic epodes weekly that are relieved w/ ingestion of OJ. BP has ranged between 120-135/65-68 over the past 2 years; BP today is 128/75. Exam shows no abnormalities. HbA1c is 6.9%, & urine albumin:Cr is 60 (N <30). Which of the following is the most appropriate next step to prevent the progression of nephropathy on this pt? (Add lisinopril OR Switch from metformin to glyburide therapy)

Exercise stress test -Pt present w/ two RF's for CAD → should be investigated via an exercise stress test -RF's include ---1) 20 year smoking Hx ---2) BP of 140/90 Spirometry -Would be correct if pt complained of asthma like symptoms

A 52M, present for a routine health exam. He has smoked 1 pack of ciggs daily for 20 years & does not drink alcohol. He has a sedentary lifestyle & requests advice about beginning a regular exercise program. His father died of an MI at the age of 62. His 77-year-old mother & 51-year-old sister are healthy. He is 5-ft 10-in tall & weighs 176; BMI is 25. Pulse is 80/min, RR are 12/min, & BP is 140/90. Exam shows no other abnormalities. In addition to msmt of serum cholesterol, which of the following is the most appropriate next step prior to this pt starting an exercise program? (Spirometry OR Exercise stress test)

Indomethacin -A) MGMT → DEPENDENT ON ACUTE Vs CHRONIC ---aa) ACUTE gout -------1) NSAID's (Naproxen, indomethacin) → First line TMT -------2) Colchicine -------3) Glucocorticoids ---bb) CHRONIC gout -------1) Allopurinol/Feboxustat ----------a) Xanthine oxidase inhibitors ----------b) Used in pts that excrete >800 mg uric acid/day --------2) Probenecid, sulfinpyrazone -----------a) Uricosuric agents -----------b) used in pts that excrete <800mg uric acid/day --------3) Pegloticase, rasburicase ------------a) Recombinant uricases Celecoxib -Can be used in Gout → however it primarily used as an off-label tmt -Even if celecoxib Is used → the pt can still be switched to the first-line TMT NSAID's

A 52M, presents b/c of excruciating pain & swelling of his great right toe since undergoing appendectomy 10 days ago. The pain is so severe that he cannot tolerate his bedsheets touching his toe. TMT w/ Celecoxib has provided no relief. Temp is 99.6F. Exam shows swelling, erythema, & marked tenderness of the metatarsophalangeal joint. Which of the following is the most appropriate next step in pharmacotherapy? (Allopurinol OR Indomethacin)

Zinc deficiency -1) Signs/symptoms ---Alopecia ---Pustular skin rash (peri-oral & extremities) ---Hypogonadism ---Impaired wound healing ---Impaired taste ---Immune dysfunction -2) Associated w/: ---Malabsorption syndromes ---Bowel resection ---Gastic bypass ---Poor nutrition Selenium -Can lead to thyroid dysfunction & cardiomyopathy [pt none of these signs]

A 56F, w/ short bowl syndrome caused by mesenteric infarction has had a diffuse maculopapular rash & hair loss since a 2-wks hospital stay for TPN. The pharmacy had inadvertently excluded the trace elemental supplement to her TPN. A deficiency of which of the following trace elements if most likely responsible for the clinical findings? (Zinc OR Selenium)

PDA -Characteristics include: --1) Wide pulse pressure --2) Best heard in the 2nd left intercostal space --3) Continuous murmur ("To-and-Fro") --4) Loud S2 & bounding peripheral pulses Coarctation of aorta -Most common as part of Turners -Differential Cyanosis -Differential BP -Inter-scapular systolic murmur

A 6-month-old girl presents b/c of poor feeding & labored breathing for 2-months. She has had recurrent respiratory tract infections since birth. Exam shows a to-and-fro murmur in the second left intercostal space, a loud S2, bounding peripheral pulses, & a widened pulse pressure. Which of the following is the most likely Dx? (Coarctation of aorta OR PDA)

Obstruction of CSF -Pt presents w/ myelomeningocele → this causes the brain to herniate lower on the spinal cord causing an OBSTRUCTION of normal CSF flow Decreased absorption of CSF -Seen in interventricular hemorrhage Overproduction of CSF -Usually seen in infections (meningitis, congenital)

A 6-month-old presents for a routine health maintenance exam. She was born w/ a lumbosacral myelomeningocele which was repaired at 2 days of age. The anterior fontanelle is 6x8-cm & bulging, & the posterior fontanelle is 3x4-cm & bulging. She has severe motor & sensory deficients involving both LE's. A head growth chart shows: -----Age------------------Head circumference -----Birth------------------------34.2 -----1 month---------------------36.6 -----2 months--------------------38 -----4 months--------------------44 -----6 months--------------------47 Which of the following is the most likely cause of increased intracranial pressure? (Decreased absorption of CSF OR Obstruction of CSF flow OR Overproduction of CSF)

Renal US -The diagnostic approach to renal failure includes: --1) US → to determine kidney size/hydronephrosis, hydroureter --2) CT → if nephrolithiasis is suspected --3) Renal arteriography → renal artery occlusion --4) Renal biopsy → Glomerulonephritis/AIN is suspected [pt has no signs of intra-renal injury]

A 62F, is admitted to the hospital for surgical resection of an ovarian tumor. She has had an 25-lbs wt loss over the past 2-months. Exam shows an adnexal mass; no other abnormalities are noted. Pre-op labs show: -Serum- --BUN-----------------80 --Cr-------------------5.7 -Urine- --Glucose---------------N/A --Protein----------------trace --WBC's-----------------0-2 --RBC's-----------------0-2 --Casts-----------------N/A --Crystals---------------N/A --Bacteria---------------N/A Which of the following is the most appropriate next step to determine the cause of renal failure in this pt? (Renal US OR Renal biopsy)

Radiation therapy -Usually given after mastectomy & indicated for cancers that have metastasized to the spine Chemotherapy -Usually given before surgery and before radiation

A 62F, presents to the ED b/c of a 4-day Hx of increasingly severe upper back pain, progressive weakness of both legs, & tingling in her legs & feet. She has had episodes of urinary incontinence during this period. 6-months ago, she underwent mastectomy for TMT of breast cancer, which was LN positive. Exam shows normal cranial nerves & normal strength in the UE's. Muscle strength in the LE's is 3/5 bilaterally w/ increased tone. Sensation to pinprick is mildly decreased over the mid-trunk, & sensation to vibration is decreased in the LE's. Deep tendon reflexes are normal in the UE & brisk in the LE. Babinski is present bilaterally. Which of the following is the most appropriate next step in MGMT? (Chemotherapy OR Radiation therapy)

Nitroprusside -Pt presents w/ Malignant HTN → this is a subset of hypertensive emergency (Presence of end-organ damage → pt has neurological end-organ damage) -Criteria for Malignant HTN include: --1) BP (systolic > 180, Diastolic > 120) --2) Presence of papilledema MGMT for malignant HTN 1) Nitroprusside (Most common) 2) Fenoldopam (for CKD pts) 3) Labetalol (pregnancy) Nitroglycerin -Would be correct if pt presented w/ end organ damage that is heart related (MI symptoms, presence of murmurs)

A 64F, presents b/c of a 2-day Hx of fatigue & a 1-hrs Hx of headache & confusion. She has not had fever, nausea, or vomiting. She has a 6-yrs Hx of HTN treated w/ hydrochlorothiazide & lisinopril. Temp is 97F, pulse is 90/min, RR are 22/min, BP is 250/135. Funduscopic exam shows bilateral papilledema. The lungs are clear to auscultation. Cardiac exam shows an S4 & no murmurs. An ECG shows LV hypertrophy w/ a strain pattern. Which of the following is the most appropriate initial pharmacotherapy? (Nitroprusside OR Nitroglycerin)

Ween from ventilator -Pt presents w/ COPD → this means that she NORMALLY has increased PCO2 w/ decreased PO2 → she is probably normal at the current levels → so we must ween her from ventilator to prevent any ventilation associated complications Increasing FiO2/Increasing RR -The pt is most likely at her normal PCO2 & PO2 levels at this time d/t her COPD Hx → so there is no need to increase her FiO2 or RR -Additionally, she is in no respiratory distress & has normal vitals

A 67F, has been intubated for 1-week after undergoing a left lobectomy for lung cancer. She has COPD. Her pre-operative FVC was 40% of predicted. She is awake & alert. BP is 130/75, & pulse 72/min. The ventilator settings are a synchronized intermittent mandatory ventilation of 8/min, FiO2 of 40%, & PEEP of 5 cm H2O. ABG shows: -pH--------------------7.42 -PCO2-----------------47 -PO2-------------------90 -O2 Sat----------------96% Which of the following is the most appropriate next step in MGMT? (Increased FiO2 OR Increase respiratory rate OR Ween from ventilator)

Intramural hematoma of the proximal small bowel -Presentation includes: --1) Spontaneous intestinal intramural hematoma is a rare complication of anticoagulant therapy --2) Decreased Hb levels --3) Distended & moderately tender ± voluntary guarding --4) Absence of other causes → (No masses, no organomegaly, no hernias) Intestinal ischemia from a cardiac embolus -This would present as acute mesenteric ischemia - Also presents w/ acute abd pain in pts w/ RF for embolus (A-fib) - However, key differences include: ---1) MISSING KEY SYMPTOMS ------a) PE findings → PERITONEAL SIGNS ----------[Pt DOES NOT have peritoneal signs] ------b) CURRENT JELLY STOOLS (BLOOD IN STOOL) ----------[pt's rectal exam reveals NO BLOOD] Malrotation of small bowel -Would be seen d/t a surgical procedure d/t adhesions or infection -Signs include → abd pain, constipation, hematochezia -------[Pt has No Hx of recent procedures/surgery & has no Hx of constipation/hematochezia]

A 67F, is hospitalized b/c of abd pain & persistent copious vomiting for 24 hours. Two weeks ago, she was hospitalized for TMT of A-fib; after CV to a normal sinus rhythm, she began TMT w/ warfarin. Yesterday at a flood-up visit, her INR was 6, & warfarin was discontinued. She takes no other meds. Temp is 98.6F, BP is 110/78, pulse is 120/min & regular, RR are 20/min. The abd is distended & moderately tender; there is voluntary guarding in the epigastrium. There are no masses, organomegaly, or obvious hernias. Rectal exam shows no abnormalities. Test for stool occult blood is neg. Hb has decreased from 13 yesterday to 7.8 today. An ECG shows normal sinus rhythm. Which of the following is the most likely explanation for this pts abd symptoms? (Intestinal ischemia from a cardiac embolus OR Intramural hematoma of the proximal small bowel OR Malrotation of small bowel)

Strep pneumo -A) MGMT ----a) Dx tests -------1) BM biopsy ----------a) ≥10% Clonal Plasma cells & either: --------------1) End organ damage -----------------a) hypercalcemia, renal failure, anemia, bone lesions, proteinuria, immunosuppression ---------------2) Focal biomarkers of malignancy ----b) TMT -------1) Stem cell transplant -------2) Chemo -------3) Activity encouraged → to ↑ Bone density -------4) Vaccinations -----------a) Strep pneumo -----------b) Hib -----------c) Annual flu -------5) Radiation for: -----------a) Plasmacytomas -----------b) Bony lesions that cause pain/compress spinal cord -------b) Proteasomal inhibitors ----------b.1) Bortezomib, carfilzomib, and ixazomib ----------b.2) Bortezomib can cause peripheral neuropathy M.Tb -Not associated w/ increased risk in pts w/ MM

A 67M, presents b/c of easy fatigability & generalized weakness for 3-months & left chest pain for 1-month. The chest pain is worse on deep inspiration. He appears slightly pale. There is tenderness over the left 8th & 9th ribs laterally. Exam shows no other abnormalities. HCT is 28%. Serum & urine protein electrophoresis shows a monoclonal spike. A biopsy of BM shows greater than 50% plasma cells. A CXR shows a 1-to-1.5-cm area of radiolucency in both ribs corresponding to the sites of tenderness. This pts condition makes him most susceptible to infection w/ which of the following organisms? (M.Tb OR Strep pneumo)

Randomized, controlled clinical trial -The main advantages of a randomized clinical trial: --1) Establish the cause & effect of a new drug, a treatment, or procedure --2) Control for possible confounding factors Case-controlled observational study -Best used to establish how & if a particular exposure leads to development of a disease Case reports -Best used to study rare diseases

A 67M, presents d/t a 1-mnths Hx of rectal bleeding. He says he passes bright red blood w/ BM's. He has not had any other symptoms. He has HTN & OA. Current meds include losartan, metoprolol, amlodipine, & naproxen. His father received the Dx of colon cancer at the age of 70-yrs, & died at the age 74-yrs. His 89-y/o mother received the Dx of breast cancer 20 years go & has survived. He is 6-ft & weighs 200-lbs; BMI is 27. Vital signs are within normal limits. A mass is palpated in the rectum. The remainder of exam shows no abnormalities. Colonoscopy shows a large ulcerating rectal mass. A biopsy specimen of the mass shows rectal cancer. Review of which of the following types of clinical studies is likely to be most useful in developing a TMT strategy for this pt? (Case-controlled observational studies OR Case reports OR Randomized, controlled clinical trail)

Right Vertebral -Causes lateral medullary syndrome (AKA Wallenberg) -Can also be caused by PICA -Symptoms include: --1) Contralateral sensory of body --2) Ipsilateral sensory of face --3) Ipsilateral cranial nerves (Vagus & glossopharyngeal) ---Dysphagia ---Nystagmus ---Weakness palate ---Dysarthria --4) Ataxia Anterior spinal artery -Affects the: --1) Lateral Corticospinal tract → Contralateral hemiparesis in UE & LE --2) Medal lemniscus → Decreased contralateral proprioception --3) Hypoglossal nerve → ipsilateral paralysis of tongue Posterior spinal artery -Supplies dorsal columns of the Spinal cord → lead to sensory less

A 67M, presents to the ED 1 hour after the onset of vertigo, nausea, & imbalance. He has a 20-yrs Hx of HTN. His pulse is 70/min, RR 20/min, & BP is 210/115. Exam shows a small right pupil, mild right ptosis, & nystagmus. Neuro exam shows weakness of the right palate. Sensation to pinprick is decreased over the right side of the face & left extremities. There is incoordination on finger-nose testing & heel-knee-shin testing on right. Which of the following arteries is most likely to be occluded? (Right Vertebral OR Anterior spinal)

Brain abscess -Pt presents w/ a recent URI → the most common complications of URI are BRAIN ABSCESS -Brain abscess are most commonly caused by: --1) Strep → secondary to sinusitis --2) Staph → secondary to truma --3) Anaerobes → secondary to chronic otitis media Venous thrombus sinus -This describes a cavernous sinus thrombus → Presentation includes: Headache, eye dysfunction, peri-orbital edema, Hypo- or Hyper- esthesia in the V1 & V2 dermatomes -Etiology includes: ---1) Sellar mass (pituitary adenoma) ---2) Carotid cavernous fistula ---3) Infection of sinus, skin, orbit [this pt has an URI → not any of the above infections]

A 67M, presents to the ED b/c of a 3-day Hx of fever & headache. Five years ago, he underwent placement of a mechanical aortic valve for TMT of sequelae of rheumatic fever. He appears ill. Temp is 104F, BP is 110/65, pulse is 110/min, RR are 22/min. A grade 3/6, systolic ejection murmur is heard. Neuro exam shows mild hemiparesis. Babinski sign is present on the left. There is no nuchal rigidity. This pt is at greatest risk for which of the following complications? (Brain abscess OR Venus thrombus sinus)

Ruptured aortic aneurysm -Presentation includes: --1) Pt would present w/ acute onset of severe pain that radiates to the back --2) Hypotension --3) Tachycardia Spinal stenosis -Pt would not present w/ CHRONIC pain ± radiation -Stenosis is not associated w/hypotension or tachycardia

A 67M, presents to the ER 4 hours after the onset of severe mid-lumbar back pain. He is anxious, pale, & diaphoretic. Temp is 98.8F, BP is 105/65, & pulse is 120/min. Exam shows no other abnormalities. X-rays of the lumbar spine show degenerative disc disease w/ calcifications anterior to the vertebral bodies. Which of the following is the most likely Dx? (Ruptured aortic aneurysm OR Spinal stenosis)

Protein-----------------2.5 ---This is LOW in transudative effusions Segmented neutrophils----60 ---Would be normal (b/c not d/t infection) Monocytes--------------40 ---Would be Normal (b/c not d/t to infection)

A 67M, w/ long-standing signs & symptoms of CHF is admitted to the hospital b/c of SOB. Exam shows no other abnormalities. A CXR shows cardiomegaly, cephalization of blood vessels, & right-sided pleural effusion. Which of the following set of pleural findings is most likely in this pt? (Protein -----------------2.5/4.5 Glucose-----------------90 Leukocyte Ct------------2000 Segmented neutros----60/50 Monocytes--------------40/50

An excess of very long chain FA's -Pt most likely presents w/ adrenoleukodystrophy → characteristics include: --1) X-linked --2) Dysfunctional peroxisomes leading to build-up of VLCFA's --3) Symptoms include: -----Primary adrenal insufficiency -----Hypogonadism -----Demyelination & neurological (White matter) Vit E deficiency -Associated w/ Down syndrome

A 6B, presents d/t progressive visual loss over the past year. Over the past 2 years, he has had deterioration of his hearing, speech, writing, & intellectual performance. His maternal uncle had similar symptoms. Visual acuity is 20/200 bilaterally. Funduscopic exam shows optic atrophy. His hearing is markedly impaired. There is weakness & spasticity of all extremities. Deep tendon reflexes are extremely hyperactive. Babinski's sign is present bilaterally. On MSE, he is not oriented to place, year, month, or the names of his siblings. An MRI shows marked symmetric white matter disease involving all lobes. Diagnostic studies are most likely to show which of the following? (An excess of very long chain FA's OR Vit E deficiency)

Gram stain of abd fluid -Pt most likely presents w/a spontaneous bacterial peritoneal abscess -Presentation includes --1) Fever --2) Increased leukocyte counts --3) Toxic appearing --4) Peritoneal signs on PE -MGMT includes: --1) Paracentesis → (Gram stain of abd fluid) (both therapeutic & diagnostic --2) Third-Gen cephalosporins (Ceftriaxone, Cefotaxime) CT scan of the abd & pelvis -Would be used to look for blood in the setting of Abd/pelvic trauma

A 70F, has had increasing abd pain over the past 2 days. She has had renal failure & has been receiving peritoneal dialysis for 18-months; her last TMT was 2 hours ago. She appears toxic. Temp is 102.2F, BP is 140/90. Her abd is distended & diffusely tender to deep palpation w/ rebound tenderness. Leuko Ct is 18K. Which of the following is the most appropriate next step? (Gram stain of the abd fluid OR CT scan of the abd & pelvis)

SIADH -Presentation includes: --1) Etiologies ----CNS disorders/trauma (stroke, hemorrhage, infection, trauma) ----Pulmonary disease (pneumonia) ----Ectopic production (SCLC) ----Surgery (Transphenoidal pituitary surgery) ----Drugs (Cyclophosphamide, carbamazepine, SSRIS's) Key lab results --1) Serum Hyponatremia ------Normal K+ ------Normal HCO3 --2) Serum Osmol → Hypoosmolality (N=280, but > 100) --3) Urine osmol (>100, submaximally dilute) --4) Urine Na+ (Normal/high, ~20 is normal) MGMT 1) 3% hypertonic solution → Emergency situations (Coma, neurological symptoms) 2) Non-emergent ---a) Fluid restriction ---b) V2 vasopressin antagonists ---c) Furosemide (can be used in conjunction w/ infusion of hypertonic solution) ---d) Demeclocycline (no longer used) DI -Etiology -This is a cause of HYPER-natremia --1) Central ----Idiopathic, head trauma, tumors, anorexia --2) Nephrogenic ----Hypokalemia ----Hypercalcemia ----Hereditary renal disease ----Drugs (Lithium, demeclocycline, cidofovir, foscarnet, amphotericin) Key lab findings (Applies to both Central & nephrogenic DI) --1) Inappropriately dilute urine → Urine osmol < serum osmol ----Urine Osmol < 200, Serum Osmol >290 [pts = Urine osmol 358, serum osmol 255]

A 72F, has hyponatremia 3 days after admission to the hospital following a cerebral infarction. She has been receiving 5% dextrose in 0.45% saline (100 mL/h) since admission. Current meds are phenytoin & atenolol. She has expressive aphasia. Pulse is 86/min, RR are 16/min, & BP is 130/86. Exam shows right dense hemiparesis. Labs show: -Serum - --Na+------------------120 --Osmol---------------255 -Urine- --Na+-------------------50 --Osmol---------------358 Which of the following is the most likely cause of this pts hyponatremia? (DI OR SIADH)

Ex-Lap -The pt most likely presents w/ METS from a cancer - We know this b/c the mass is SOLID & non-tender ----(A cyst would be tender) Therapeutic paracentesis - Therapeutic paracentesis is NOT THE TMT OF CHOICE for aspiration → it is mainly used in SBP or ascites - Aspiration is generally AVOIDED in Cysts d/t complications - Cul-de-sac masses are almost always excised

A 72F, presents b/c of an increase in abd girth over the past 2-months. She has had an 8-lbs wt gain during this period despite being unable to to finish any meal. She has one martini daily after her 3-mile walk. She underwent lumpectomy & radiation therapy for stage I BC 4-years ago & has been treated w/ tamoxifen since. Abd exam shows a fluid wave. Pelvic exam shows an 8-cm fixed, non-tender mass in the cul-de-sac. Labs show normal findings. Which of the following is the most appropriate next step in MGMT? (Therapeutic paracentesis OR Ex-Lap)

Cor pulmonale -A) Etiology ----1) LHF →Most common cause ----2) COPD/Interstitial lung disease --------a) (Chronically elevated Pulmonary BP) → COR Pulmonale ----3) Cirrhosis -------a) Pt has ascites -B) Signs/Symptoms ----1) Peripheral edema ----2) JVD ----3) Ascites ----4) Hepatosplenomegaly Ischemic heart disease -Pt would have Hx of CHF or MI - However, pt only has Hx of DM I & angina - Pt has no Hx indicating CHF/MI

A 72M, is hospitalized b/c of dyspnea for 6-wks. He has a Hx of DM I & angina. Meds include insulin, & warfarin. During the past 4-months, he was hospitalized once for DVT & another time for PE. Exam shows JVD, ascites, & pitting pre-tibial edema of both LE's. A CXR shows mild cardiomegaly & no evidence of pulmonary edema. Which of the following is the most likely cause of this pts worsening condition? (Cor pulmonale OR Ischemic heart disease)

Heat stroke -Characteristics include: --1) Temp >104F --2) CNS dysfunction → altered mental status, confusion, seizures --3) Hypotension --4) Hot, dry skin Labs --1) Hemoconcentration --2) Electrolyte disturbance --3) Elevated transaminases --4) Rhabdomyolysis --5) Increased PT, PTT, & Bleeding time → DIC --6) Metabolic acidosis Anticholinergic poisoning -Presents w/ anti-muscarinic properties including --1) Blind as a bat → Mydriasis --3) Hot as hades → Hyperthermia --4) Red as a beet → Flush --5) Dry as a bone → Dry skin & mucous membranes --6) Mad as a hatter → altered mental status --7) Tachycardia --8) Urinary retention --9) Gallstone ileus --10) Seizures

A 75M, presents to the ED b/c of confusion & lethargy for 2 days. He was gardening on a 100F day before the onset of symptoms. He has a 15-yrs Hx of DM II treated w/ glyburide & a 25-yrs Hx of HTN treated w/ hydrochlorothiazide. He underwent a laparoscopic cholecystectomy 6-wks ago. He smokes 1-pk of ciggs daily & drinks two martinis every night. He traveled to Hawaii 2-months ago. Temp is 106.7, pulse is 120/min, BP is 90/60. The skin is dry & hot but not erythematous. Muscle tone is decreased. Serum Cr is 8000, & serum AST is 400. Which of the following is the most likely cause of this pts condition? (Anticholinergic poisoning OR Heat stroke)

Memory loss -Memory loss is associated w/ dementia & Alzheimer's → which is why this the most concerning symptom in this elderly pt Decreased deep tendon reflexes at the ankles & Decreased sensation to vibration over the toes -These are normal declines associated w/ age

A 77F, presents by her son for a routine exam. She says that she feels well. Her son reports that 1-month ago, she got lost while driving home from the local supermarket. Two weeks ago, she forgot to turn off the stove after cooking dinner. She has been wearing bilateral hearing aids since audiometry 2 years ago showed bilateral high-frequency hearing loss. Her visual acuity corrected w/ glasses is 20/25 in both eyes. Neuro exam shows mild fine tremors of the hands when the arms are outstretched; the tremor is not present at rest. Muscle strength is 5/5 in all extremities. Deep tendon reflexes are decreased at the ankles & 2+ elsewhere. Her gait is normal. Sensation to vibration is mildly decreased over the toes. On MSE, she is awake, alert, & conversant. Her language function is normal. She is oriented to person, place, & time & recalls 1/3 objects after 10-mins. Which of the following findings in this pt warrants further eval? (Decreased Deep tendon reflexes at the ankles OR Decreased sensation to vibration over the toes OR Memory loss)

Destruction & dilation of distal airways -Pt most likely has bronchiectasis → Signs include: --1) Long Hx of productive cough & recurrent pneumonia --2) Exam → bronchophony --3) CXR → ----Thin-walled cysts ----± air fluid levels --4) Pathology -----Destruction & dilation of distal airways Laryngeal penetration by food & liquids -Pt would have aspiration pneumonia -He would have a Hx of disorder that effects swallowing, gingival disease -Pt would have foul smelling sputum, fever, night sweats, wt loss -CXR would have air-fluid levels But NO walled-cysts

A 77M, presents to the ED 15 mins after the onset of cough productive of large amounts of blood-tinged sputum. He has a life-long Hx of chronic productive cough & recurrent episodes of pneumonia in the right lower lobe of the lung. 15 mins after arriving, the bleeding stops spontaneously. Temp is 98.6F, pulse 110/min, RR are 24/min, BP is 110/70. Exam shows bronchophony in the right lateral lung. A CXR shows thin-walled cystic spaces in the right lower lobe w/ some air-fluid levels. Which of the following is the most likely explanation for these findings? (Destruction & dilation of distal airways OR Laryngeal penetration by food & liquids)

Decreased RBF - Pts Furosemide was recently increased - Furosemide + Lisinopril causes decreased renal blood flow - Decreased renal blood flow would show as: ---1) Increase BUN & Cr ---2) NO other abnormalities Renal tubular necrosis -ATN presents w/ brown-muddy, hyaline, or pigmented casts on urinalysis -----(Pts urinalysis shows no abnormalities)

A 82M, w/ CHF presents for a follow-up. One month ago, he had worsening dyspnea while lying in bed at night & walking up the stairs, & his dose of furosemide was increased. His only other med is lisinopril. He was Dx'd w/ CHF 5 years ago after he sustained an MI; he underwent coronary angiography & stent placement at that time. He has not had chest pain since then. He also has a 10-Yrs Hx of well-controlled CKD; serum Cr concentrations have ranged from 1.3-1.5, & urinalysis have shown no protein. Today, pulse is 90/min, RR are 14/min, & BP is 130/86. Cardiopulmonary exam shows no abnormalities. There is trace edema of the ankles, which has decreased since exam 1-month ago. Serum studies show: -------------1 month ago----------------Today -Na+----------138-----------------------140 -K+-----------4.0------------------------4.2 -Cl------------101-----------------------103 -HCO3---------26------------------------28 -BUN----------15-------------------------24 -Cr------------1.8------------------------2.3 Urinalysis shows no abnormalities. Which of the following is the most likely explanation for the change is his labs during the past month? (Decreased Renal blood flow OR Renal tubular necrosis)

Avoidance of wooded are -Even without looking at the picture, the pts Hx suggest a reaction to something in the woods, including: --1) Did not appear until 24-48 hrs after woods --2) Is pruritic --3) Presents w/a clear demarcation of rash --4) Posion Ivy description ---Itchy, red, with bumps & blisters (Bullous lesions w/ discharge)

A previously healthy 10B, presents b/c of a 2 day Hx or a pruritic rash on his arms & legs. He says he first noticed the rash 24 hours after he played in a wooded area in his neighborhood & that the rash has been spreading. He has not had fever. There is a pet cat at home. The pt is alert & is scratching his arms & legs. Temp is 98.6F. Exam of the UE & LE shows severe erythema & bullous lesions w/ discharge; there is a sharp line of demarcation between the rash & the unaffected skin. A photo is attached. Which of the following is the most appropriate recommendation to prevent recurrence of this type of rash? (Avoidance of the wooded area OR Prophylaxis w/ an antibacterial agent)

TB -Presentation for Tb (in this pt) Include: --1) Visited endemic country --2) Fever --3) Cough w/ unilateral chest pain PE findings --1) Shallow respirations --2) Decreased breath sounds --3) Exudative effusion (unilateral) -----Effusions associated w/ Tb Pulmonary aspergillosis -This is an allergic type RXN seen in pts w/ asthma or CF

A previously healthy 16B, presents d/t a fever & cough w/ right-sided Chest pain for 2 weeks. Six months ago, he visited his grandparents in Albania for 2 weeks. He weighs 120-lbs & is 68-in tall. He appears thin & pale. Temp is 100.8F, pulse is 76/min, & RR are 36/min. Exam shows shallow respirations w/ decreased breath sounds at the right lung base. A CXR shows a right pleural effusion & hilar adenopathy. What is the most likely Dx? (Pulmonary TB OR Pulmonary aspergillosis)

TTP -Presentation includes: -1) Signs/symptoms --a) Microangiopathic hemolytic anemia ----(pt has Schistocytes) --b) Thrombocytopenia ----(pt has 52K plts ct) --c) Acute kidney injury -----(pts Cr is 3.5) --d) Neuro abnormalities -----(pt is waxing & waning) --e) Fever → typically low; may be absent -2) Occurs in the setting of: ---a) Bloody diarrhea (Food poisoning) ---b) Pregnancy ---c) Cyclosporine ---d) Gemcitabine (anti-cancer meds) -3) Marker ---a) Decreased ADAMTS13 activity level ITP -Presentation includes: -1) Antibodies ---GPIIb/IIIa -2) Frequently associated w/ → HIV, HCV, CLL, SLE ----(pt has none of these) -3) Most common manifestations: ---a) Mild mucocutaneous bleeding (epistaxis) ---b) Petechiae, purpura ---c) Fatigue -----(pt has none of these, only presents w/ neurological symptoms) -4) Isolated thrombocytopenia w/out anemia/leukopenia ----(pt has anemia (Hb 11%)

A previously healthy 32F, at 16 weeks present to the ED b/c of a 6-hour Hx of fever & waxing & waning consciousness. Her only med is a multivitamin w/ iron. Temp is 101F. Neuro exam shows no abnormalities except for a fluctuating level of consciousness. HCT is 11%, Plts 52K, Cr 3.5. A PBS shows schistocytes. Which of the following is the most likely Dx? (ITP OR TTP)

Ulnar nerve at the elbow -Pt has paresthesias w/ compression of the cubital tunnel (this is the elbow)

A previously healthy 37M, presents b/c of a 2-month Hx of pain in the forearm & little finger of his dominant hand; he has been working as a receptionist for 6-months. He describes numbness in his little finger & weakness of his grip. There is decreased sensation to light touch at the tip of the little finger. Paresthesias are elicited w/ compression of the cubital tunnel. Where is the most likely site of nerve injury? (Ulnar nerve at the elbow OR Ulnar nerve at the wrist)

Stress incontinence -Presentation includes: --1) Pt presents w/ stress incontinence symptoms --2) RF's -----Cysturethroceles are associated w/ multiparrity Urethra diverticulum -Would present as a pocket or bulge next to the urethra -Associated w/ abscess -Pt would have additional symptoms including pain, frequent UTI's, hematuria, & incontinence

A previously healthy 44F, G4P4, presents b/c a 9-months Hx of progressive loss of small amounts of urine while running; she now has to wear an absorbent pad. Exam shows a second-degree cysturothrocele. Which of the following is the most likely cause of the urinary incontinence? (Stress incontinence OR Urethra diverticulum)

Fibrillation potentials in multiple muscles of multiple extremities -Expected findings in ALS Short duration, low amplitude motor unit potentials -Characteristic in myopathies

A previously healthy 47M, presents b/c of a 6-month Hx of progressive weakness that began in his right leg & has gradually spread to his other extremities. During this period, he has had mild difficulty swallowing solids & liquids. Exam shows atrophy of the right quads & both deltoids & fasciculations in both quads. Babinski reflex is present bilaterally. Electromyography & nerve conduction studies are most likely to show which of the following? (Fibrillation potentials in multiple muscles of multiple extremities OR Short duration, low amplitude motor unit potentials)

URTI -More likely in a young Pt presents w/Hx of URTI -Presentation includes: --1) S3/S4 heart sounds (If pt has ventricular dysfunction) --2) Tricuspid/Mitral regurg (if severely dilated) --3) Pericardial friction rub (If pt has concomitant pericarditis) --4) HF signs/symptoms --5) PMI displacement --6) Palpitations & arrhythmias (Atrial tachycardia) VSD -Pt would have a holosystolic murmur heard along the left sternal border SINCE BIRTH ---[pts Hx DOES NOT INCLUDE murmur] ---[VSDs is not typically associated w/ palpitations & arrhythmias]

A previously healthy 4B, presents b/c a 3-day Hx of fever, cough, & runny nose. He has not had wheezing, vomiting, or diarrhea. He is at the 75th percentile for Ht & Wt. Temp is 99.5F. The skin is warm & pink. Capillary refill time is 2 seconds. Exam shows clear rhinorrhea. Breath sounds are normal. Cardiac exam shows palpations & arrhythmia. Which of the following is the most likely Dx? (URTI OR VSD)

Insulin -Pt has insulin resistance (b/c of obesity & high blood sugar) → Insulin is elevated in this pt Ketones -Uncommon in DM II (Only seen in pts w/ DM I & only when they are in emergency situations →aka DKA)

A previously healthy 52M, presents b/c a 3-months Hx of increased urinary volume & increased urinary frequency at night. He has had a 15-lbs wt loss during this period despite no change in appetite. His father has HTN, & his mother has HTN & DM II, He currently weighs 210-lbs & is 70-in tall. His BP is 160/85 in both arms. Exam shows no other abnormalities. His non-fasting serum glucose is 280. Which of the following serum conc is most likely to be elevated in this pt? (Ketones OR Insulin)

IV labetalol -Pt presents w/ aortic dissection → presentation includes: --1) Abrupt-onset chest, back, abd pain → (described as sharp, tearing, ripping) --2) Pulse/BP variations between the RUE & LUE --3) Mediastinal widening MGMT --1) β-blockers (esmolol/labetalol) -----Alternative to β-blockers → Non-dihydropyridine Ca+ blockers (Diltiazem, verapamil) --2) ± vasodilators (nitroprusside/nicardipine) Sublingual nitroglycerine -Not used in aortic dissection

A previously healthy 62M, presents to the ED 30-mins after the sudden onset of severe chest pain. He reports a tearing sensation in his midcoast that radiates to his back. Pulse is 104/min, RR are 24/min, & BP is 200/120 in the RUE & 180/100 in the LUE. Exam shows a decreased left brachial pulse. A grade 2/6 diastolic decrescendo murmur is best heard at the right sternal border. A CXR shows a widened mediastinum. Administration of which of the following is the most appropriate initial step in pharmacotherapy? (Sublingual nitroglycerine OR IV labetalol)

CT scan of abdomen -Pt presents w/ signs concerning for diverticulitis -A) Signs/Symptoms → (CLASSIC TRIAD - 1st THREE) ----1) LLQ pain ----2) Low-grade fever ----3) Leukocytosis ----4) Nausea, vomiting ----5) Altered bowel habits -------a) Constipation > diarrhea - but can present w/ either ------b) Urinary frequency, urgency, dysuria -B) PE findings ---1) Rectal exam findings ------a) NO BLOOD ---------a.1) Blood is more commonly associated w/ DIVERTICULOSIS ------b) Painful rectal mass -C) MGMT ----a) Diagnostic Tests -------1) CT of abd & pelvis w/oral & IV contrast → Findings include: -----------a) Segmental bowel wall thickening -----------b) Disproportionate pericolic fat stranding -----------c) Presence of colonic diverticula ***SIDE NOTE → Colonoscopy & Barium enema are CI b/c can cause bowel perforation*** ----b) TMT --------1) Clear liquid diet/NPO x 2-3 days --------2) Antibiotics for 7-14 days -----------a) Metro PLUS --------------a.1) Cipro OR Levo OR TMP-SMX -----------b) Amoxicillin-clavulanic acid/Moxifloxacin --------3) Pain control --------4) IV fluids --------5) FOR COMPLICATED/SEVERE PRESENTATION -----------a) Piperacillin-Tazobactam/Carbapenem --------6) Surgery (Emergent colectomy w/ end colostomy (HARTMANNS) -----------a) PTs refractory to meds -----------b) PTs w/ diverticulitis complicated by colonic perforation/diffuse peritonitis Barium enema -Barium enema & Colonoscopy are CI in acute diverticulitis b/c they can easily perforate the inflamed bowel wall

A previously healthy 62M, presents to the ED b/c of abd pain for 48 hours. Temp is 101.5F, BP is 130/80, pules is 110/min, RR are 15/min. Abd exam shows diffuse LLQ tenderness w/no peritoneal signs. Rectal exam shows no abnormalities; test for occult blood is neg. Leukocyte Ct is 14,7K. Which of the following is the most appropriate next step in Dx? (CT scan of abdomen OR Barium enema)

Brisk rotary nystagmus on the left -Brisk rotary nystagmus is NOT A TYPICAL part of parkinsons presentation - However, it is concerning for A STROKE - Additional, the nystagmus is FOCAL → which further supports the stoke Dx Decreased upward gaze -Upward (& downward) gaze impairment is associated w/ older age ---Upward gaze impairment → 70's ---Downward gaze impairment → 60's

A previously healthy 82F, presents b/c she is concerned has parkinsons. Over the past 6-months, she has had occasional difficulty finding the word that she wants to use, & her ability to distinguish smells has decreased. She reports that her reaction time to shifts in posture seems slow, & she needs to use a handrail to steady herself while walking on the stairs. She lives alone & is able to manage her own finances. The pupils are 3-mm. There is mild reduction of upward gaze & brisk rotatory nystagmus on left lateral gaze. Audiometry shows mild high-frequency hearing loss. There are no tremors or rigidity. Her gait is normal. Her MSE is 29/30. Which of the following warrants further eval? (Brisk rotary nystagmus on the left OR Decreased upward gaze)

Ankylosing spondylitis -Characteristics include: --1) Etiology ----Most common presents in ages 20-40 → but can present in younger pts --2) Symptoms ----a) Inflammatory lower back pain → w/: -------Onset <40 y/o -------Gradual onset -------Relieved w/ exercise -------No improvement w/ rest -------Night pain relieved upon rising ----b) Neck & upper thoracic pain ----c) Pain down the posterior LE ----d) SOB ----e) Enthesitis --3) XR ----Bamboo spine Juvenile RA -Presents w/ ---Systemic symptoms → Daily spiking fevers, Salmon-colored rash, Arthritis involving multiple joints, lymphadenopathy, Uveitis ------[pt has none of these]

A previously healthy 9-y/o boy presents b/c of low back pain for 4 months. The pain is present throughout the day but is most severe when he awakens in the AM & after physical activities. He describes the pain as a dull ache w/ stiffness in the morning & after prolonged inactivity. He walks w/ a stooped gait but appears well. Exam shows tenderness of the right sacroiliac joint, paravertebral muscle spasms, & decreased flexion at the waist. Exam of the skin shows no abnormalities. His CK is normal & ESR is increased. A spine XR is shown. What is the most likely Dx? (Ankylosing spondylitis OR Juvenile RA)

Confounding variables -This is a case-control study comparing Lorazepam (a known TMT) to a Midazolam (A new TMT) --Control group → Lorazepam --Cases → Midazolam The Disadvantages of case-control studies include: --1) Selection bias --2) Presence of Confounding variables --3) Results of study do not estimate risk of developing a disease (not applicable in this study)

A study is conducted to compare the effectiveness of lorazepam & midazolam in providing sedation for children who require mechanical ventilation. 100 children from the ages of 2-12 who require mechanical ventilation are randomly assigned to receive a continuous infusion of lorazepam or midazolam. Paralytic agents are administered to 26/50 children in the lorazepam group & to 2/50 in the midazolam group to allow more synchronized mechanical ventilation. A sedation score of 1-5 is used to assess the amount of mvmt for each child over the course of 3 days (w/ 1 indicating no mvmt & 5 indicating thrashing mvmts). Results show a sedation score of 1 for 92% of the lorazepam group & 12% of the midazolam group. The authors concluded that lorazepam was significantly more effective than midazolam in providing complete sedation. Which of the following features of the study raises the most concern regarding the validity of this conclusion? (Confounding variables OR Lack of control group)

Splenectomy -Pt has HS -MGMT includes: --1) Splenectomy (usually deferred until age >6) → eliminates hemolysis & anemia; both of which are these pts symptoms --2) Supplemental folate --3) EPO --4) Blood transfusions

An 18F, presents w/a 3-day Hx of fatigue & yellow eyes. She has a Hx of mild anemia but is otherwise healthy. Her 16 y/o bro also has mild anemia. Temp is 98F, pulse is 82/min, RR are 14/min, BP is 105/60. There is scleral icterus. Exam shows multiple, 1-cm, cervical LN's that are mildly tender. The spleen tip is palpated 3-cm below the left costal margin. Labs show: -Hb-------------------8.6 -MCHC----------------38% (N 31-36%) -Reticulocytes-----------8% (N 0.5-1.5%) A direct Coombs test is negative. A PBS is shown. Which of the following is most likely to have prevented this pts current symptoms? (Splenectomy OR No preventive measures are efficacious)

Amniotomy & vaginal delivery -Although pt has a Hx of recurrent herpes outbreaks → she is not currently in an outbreak; so vaginal delivery is fine CS delivery -Only indicated during a current outbreak

An 18F, primigravida, at 37-wks is admitted in labor. Regular uterine contractions occur every 3-mins. Pregnancy has been complicated by several episode of genital herpes; the most recent episode was 6-wks ago. She says that she has had no lesions or prodromal symptoms since the last episode. Exam shows no lesions over the external genitalia, perineum, vagina, or cervix. Membranes are intact. Fetal mvmt has been appropriate. The cervix is 100% effaced & 5-cm dilated; the vertex is at -1 station. Which of the following is the most appropriate next step in MGMT? (CS delivery OR Amniotomy & vaginal delivery )

Operative TMT -This pt presents w/ Coarctation of aorta (most likely w/ accompanying aortic valve) → presentation includes: 1) Decreased pulses in LE's Vs UE's 2) UE's appear more muscular than LE's 3) Systolic murmur (aortic stenosis) 4) LV hypertrophy (aortic stenosis) MGMT -Based on pt's presentation → However, the only MGMT is surgery, --1) Asymptomatic → No action needed --2) Symptomatic → Surgery Pharmacological MGMT -There is not Pharmacological TMT for Coarctation of Aorta -If pt had Hypertrophic cardiomyopathy → pt would present w/ fainting or loss of consciousness during sports -Pt would not have a differing BP values between the UE & LE

An 18M, presents 1 week after he had a BP of 140/110 during a routine pre-college exam. Temp is 98.7F, pulse is 92/min, & RR 12/min. The UE's appear to be more muscular than the LE's. Radial pulses are normal; femoral, posterior tibial, & dorsalis pedis pulses are decreased. A grade 2/6 systolic murmur is heard over the precordium, anterior chest, & back. An ECG shows LV hypertrophy. Which of the following is the most appropriate next step in MGMT? (Pharmacological MGMT OR Operative TMT)

CRVO -Presentation includes: --1) Key Funduscopic findings ----a) Cotton wool spots (white exudate) ----b) Dilated retinal blood vessels ----c) Hemorrhages ----d) Edema --2) Etiology ----a) Increased age ----b) HTN ----c) DM ----d) Obesity ----e) Smoking --5) Signs ----Blurred vision, graying vision, painless monocular vision loss CRAO -Presentation includes: --1) Key Funduscopic findings ----a) Whitening of the fundus ----b) Cherry red spot ----c) Decreased blood vessel sizes --2) Etiology ---->65 y/0 ----HTN ----DM ----Smokers --3) Setting of ----Carotid artery atherosclerosis, cardiogenic embolization, inflammatory diseases, hematologic diseases --4) Signs ----Painless, Acute onset, mono-ocular

An 82F, presents to the ED b/c of visual loss in the left eye since awakening this morning. She has HTN treated w/ lisinopril. She also takes a daily aspirin. The pupils are 2-mm bilaterally & reactive to light. Visual acuity is 20/30 on the right & 20/400 on the left. Funduscopic exam of the left eye shows dilated retinal veins & widespread retinal hemorrhages intermixed w/ patches of white exudate. The right optic fundus is normal. Ocular mvmts are full. Which of the following is the most likely Dx? (CRAO OR CRVO)

ETEC -Most common cause of travelers diarrhea -Pt would be afebrile Listeria -Most common cause of febrile gastro → muscle aches, fever, flu-like symptoms, nausea & diarrhea -Mostly affects pregnant women & immunocompromised

An afebrile 32F, presents b/c of cramping abd pain & watery stools for 4 days. Exam shows no abnormalities. Hb is 12.5, leukocyte Ct is 8,5K. Exam of the stool shows no neutrophils. Which of the following is the most likely causal organism? (ETEC OR Listeria)

Pneumococcal -HIV pts w/ Normal/near-normal CD4+ counts are advised to get: --1) Pneumococcal --2) Influenza --3) Tdap --4) Meningococcal conjugate --5) Hep B --6) HPV --7) MMR varicella CD4+ Counts <200 --all except HPV & MMR/varicella Hep A -Only if pts is at increased risk for Hep A

An asymptomatic 27F, HIV+, presents requesting advice concerning immunizations. All her childhood immunizations are up to date. She received MMR when she was a graduate student 4 years ago. Her last tetanus was 6 years ago. A test for HBsAb was positive 3-wks ago. CD4+ is 450 (Normal 500) 3 weeks ago. Exam today shows no abnormalities. Which of the following immunizations is most appropriate to administer to this pt? (Hep A OR Pneumococcal)

Serum lipid studies while fasting -Pt presents w/ elevated cholesterol → the next step would be a measurement of fasting lipid studies Step 2 American heart association cardiac diet -Used as part of the DASH diet for HTN

An asymptomatic 47M, presents for a pre-employment exam. He has never been hospitalized. He is a computer programmer, & he plays handball once weekly. His maternal grandmother had DM II, & a paternal uncle had heart disease. The pts BP is 126/80. Exam shows no abnormalities. Total serum cholesterol is 225. Which of the following is the next best step in MGMT? (Step 2 American heart association cardiac diet OR Serum lipid studies while fasting)

Spondylolisthesis -Presentation includes: --1) Signs & symptoms ----Progressive low back pain → particularly w/ lumbar extension ----Radiating pain, numbness, weakness, --2) CXR findings ----Step-off pattern in lumbar vertebra Intervertebral disc space infection -This would be a spinal abscess -However, pt has no Hx of drug use & has no fever signs of infection -Localized back pain & tenderness

An otherwise healthy 37M, presents b/c of a 3-month Hx of low back pain. Use of NSAID's has provided minimal relief. Forward flexion of the spine is normal & does not produce pain; hyperextension of the spine increases the pain. Muscle strength in the LE's is 5/5; sensation & reflexes are normal. A lateral XR of the lumbar spine is shown. Which of the following is the most likely Dx? (Intervertebral disc space infection OR Spondylolisthesis)

Pagets disease of the breast -Presentation includes --1) DCIS that has extended up the ducts to involve the skin of the nipple → presents as an eczematoid lesion of the nipple or areola ---Eczematoid → (red, peeling, scaling, crusting) Eczema -Usually occurs as relapsing & remitting red, scaly, crusting lesions on the cheeks, face, flexural creases & extensor surfaces -[it is unlikely to occur on the nipple → when it does it is Pagets disease of breast]

An otherwise healthy 70F, presents b/c of peeling, scaling, & cracking of the right nipple for 2 months. Breast exam shows no masses, & mammography shows no masses or calcifications. What is the most likely Dx? (Pagets disease of the breast OR Eczema)

Migraines present w/: --1) Severe, throbbing headaches → often unilateral --2) Nausea, vomiting --3) Photophobia --4) Phonophobia (sensitivity to sound) --5) Flushing, tearing, rhinorrhea Migraine w/ aura --1) Can also appear w/ dark spots on eyes (scotomas) Cluster headaches -A) Signs/symptoms -----1) Occur at the same time each day -----2) Occur for days-to-weeks at a Time -----3) CLASSICALLY awaken pt from sleep & last 15-to-180 mins & resolve w/out TMT -----4) Ipsilateral autonomic symptoms ---------a) Ptosis, Miosis ---------b) Lacrimation ---------c) Rhinorrhea ---------d) Conjunctival injection ------5) Unilateral periorbital pain → described as drilling ------6) More common in males -B) MGMT TMT → ABORTIVE Vs PROPHYLAXIS --AA) ABORTIVE ------1) 100% O2/Sub-Q sumatriptan (FIRST LINE) ------2) Alternatives ---------a) Prednisone -------------a.1) Especially in pts w/ active cluster headache periods <2 months ---------b) ergotamine/lithium/topiramate --BB) PROPHYLAXIS ------1) Verapamil ---------a) FIRST LINE PROPHYLAXIS

Compare Contrast Cluster headaches Vs Migraine headaches (Signs/symptoms, TMT)

Pericarditis -A) Etiology ----1) Serous (effusive) -------a) Autoimmune (SLE, RA) -------b) Viral infection -------c) Uremia ----2) Fibrinous -------a) Uremia -------b) MI -------c) Acute RF -------d) Radiation ----3) Purulent -------a) Bacterial infection ----4) Hemorrhagic -------a) Malignancy -------b) Tb -B) MGMT ----a) Dx tests -------1) PE & Hx -------2) ECHO → ALWAYS NECESSARY -------3) ECG (BEST TO CONFIRM DX) ----b) TMT - BASED ON CAUSE -aa) Pericarditis d/t viral, auto-immune, post-cardiac injury, idiopathic ----1) Colchicine + NSAIDs -------a) Colchicine reduces rate of recurrent pericarditis -------b) Aspirin preferred NSAID following MI ----2) Colchicine + Glucocorticoids --------a) For REFRACTORY to NSAIDs --------b) Pericarditis secondary to connective tissue disease/Autoimmune --------c) REFRACTORY to DIALYSIS -----3) IV antibiotics + drainage via subxiphoid pericardial windowing/pericardectomy -----4) Dialysis (initiation/intensification) --------a) Pts w/ advanced CKD/renal failure Tamponade -A) Etiology → Mnemonic PUNAs -----P → Post-Viral -----U → Uremia -----N → Neoplastic -----A → Acute hemoperricardium (Trauma) -B) MGMT ----a) Dx tests -------1) ECG ----------a) Electrical alternans ----b) TMT -------1) Pericardiocentesis/pericardial window

Compare the Diagnostic tests, TMTs, & etiology of Pericarditis Vs Tamponade?

PCOS -↑ LH:FSH Ratio ----However, individuals levels may be normal - Normal TSH - Normal Free Testosterone & DHEAS ---(However, ↑ DHEA → causing virilization) Premature ovarian failure - Decreased estrogen

Differentiate between the hormone level abnormalities in PCOS Vs Premature ovarian failure (LH:FSH ratio, TSH, Free testosterone & DHEAS, DHEA, Estrogen)

Central venous catheter -The most common cause of infections -The pt shows no signs of infections in wound Operative wound -The wound would look infected if this was the source on infection ----[Exam of colostomy bag shows no abnormalities]

Four days after undergoing resection of an obstructing sigmoid colon cancer & colostomy, a 47M has a temp of 102.8F. During the procedure, a central venous catheter was inserted into the left subclavian vein. Pulse is 94/min, RR 20/min, BP is 128/70. The abd is soft & nontender. Exam of the colostomy shows no abnormalities. Blood cultures grow Staph. Which of the following is the most likely source of the bacteria? (Central venous catheter OR Operative wound)

DI -Pt most likely has central DI → --1) Etiology includes -----Idiopathic (destruction of ADH-secreting cells by brain tumor (meningioma) -----Trauma -----Tumors -----Anorexia --2) ---Sudden onset of symptoms → points more to Central DI -[nephrogenic is more gradual] Key labs --1) Urine Osmol → inappropriately dilute urine → Urine Osmol < Serum Osmol ----Urine Osmol <200 ----Serum Osmol > 290 --2) Urine specific gravity <1.006 (N=1.002- 1.030) Primary hyperaldosteronism -Presentation includes --1) Key labs ----↑ Na+ & ↓ K+ [Pt has normal K+] ---Usually Occurs in the setting of hypertension & chronic setting --1) Etiology ----Bilateral sporadic hyperplasia of the adrenal glands ----Aldosterone-producing adenoma (Conns)

One day after removal of a large meningioma, a 42F, is comatose. She remains intubated & mechanically ventilated. She groans & moves her extremities to painful stimuli. Temp is 99F, pulse is 96/min, RR are 14/min, BP is 110/72. Neuro exam shows no focal findings. Labs show: -Na+---------------------155 -Cl-----------------------120 -K+-----------------------3.6 HCO3-------------------24 -BUN--------------------16 -Cr-----------------------0.8 -Urine specific gravity--1.004 Over the past 24 hours, she has received 2L of IV 0.9% saline & has had a urine output of 6L. Which of the following is the most likely explanation for the hypernatremia? (DI OR Primary hyperaldosteronism)

Increased dosage of corticosteroids -MGMT for acute rejection includes: --1) IV corticosteroids (Methylprednisone) Transplant nephrectomy -This would be the TMT for HYPER-acute rejection (occurs immediately <24 hours of transplant -However, this rarely occurs d/t cross-matching & Blood typing

One month after undergoing an uneventful renal transplant for chronic renal failure secondary to glomerulonephritis, a 38F, is hospitalized b/c of increased serum BUN & Cr. Prior to transplant, she had been receiving dialysis for 3 years. Current meds include cyclosporine & prednisone. Exam shows no abnormalities. Over the past 48 hours, urine output has remained stable. Both renal biopsy & a radionuclide scan confirm the Dx of acute rejection. Which of the following is the most effective TMT? (Increased dosage of corticosteroids OR Transplant nephrectomy)

Abstinence from alcohol -Pt has several RF's that support alcohol induced ataxia including: --1) Drinks 3 vodka drinks every night --2) Wide-based gait --3) Cannot walk heel-to-toe & tends to reel from one side to another TMT w/ IM benzathine penicillin G -This describes the TMT for tertiary syphilis → Presenting signs do include: --1) CNS symptoms → Broad-based ataxia → However, many more symptoms would present in this pt including Argyll Robertson pupil, Romberg sign (swaying when standing w/ eyes closed), Charcot joints, Stroke w/out HTN --2) Gummatous symptoms --3) CV symptoms

Over the past 2-years, a 67M has had gradually progressive difficulty walking. The pt has been in excellent health & takes no meds. He has smoked 1&1/2 packs of ciggs daily for 50 years & drinks three vodka cocktails w/ dinner almost every night. He has a wide-based gait & tends to reel from one side to the other. He cannot walk more than three steps heel-to-toe in a straight line. No other abnormalities are noted. Which of the following is most likely to have prevented this pts condition? (Abstinence from alcohol OR TMT w/ IM benzathine penicillin G)

Haloperidol -Pt presents w/ delirium → MGMT includes --1) Haloperidol → preferred in pts w/ actue delirium + agitation/psychotic symptoms --2) Quetiapine → Used in pts w/ underlying Parkinsonism Alprazolam -Should be avoided in pts w/ delirium b/c they can exacerbate symptoms

Two days after beginning ACTH therapy for MS, a hospitalized 47F, begins to exhibit bizarre behavior. She is easily angered & thinks the nurses are terrorists. The nursing staff reports that she has pulled our her IV catheter & has been wandering the halls at night w/her walker. Muscle strength in the LE's is 2/5. On MSE, she is fidgety, has labile effect, & is easily distracted. She is oriented to person, but not to place/time. Which of the following is the most appropriate pharmacotherapy for this pts symptoms? (Alprazolam OR Haloperidol)

Decreased K+ -Signs of hypokalemia include: -Caused by Digoxin use -Less severe hypokalemia- --1) Fatigue, myalgias --2) Muscular weakness --3) Cramps --4) Constipation Severe hypokalemia --1) Cardiac abnormalities → Flat T-waves, U waves, QT prolongation, ventricular arrhythmias, & cardiac arrest --2) Paralysis --3) Hypoventilation --4) Rhabdomyolysis Increased K+ -Cardiac muscle excitability including → palpitations, syncope, & SCD -Digoxin use causes hypokalemia not hyperkalemia

Two hours after emergency repair of a perforated gastric ulcer, a 75F has multifocal premature ventricular contractions. She has a Hx of heart failure treated w/ digoxin & diuretics. What is the most likely abnormal serum conc. ? (Decreased K+ OR Increased K+)