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48 Cards in this Set
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A 5 yo boy complains of problems hearing for the past week.
He has a history of recurrent otitis media and recently finished a trial of amoxicillin. PE reveals fluid and bubbles behind the left tympanic membrane. The lateralization test reveals louder vibrations on the left compared to the right. Which of the following is the next best step? Follow-up in two weeks Schedule a more formal hearing evaluation CT and refer to ENT specialist Prescribe amoxicillin with clavulanate Prescribe amoxicillin |
Follow-up in two weeks
The child has a recovering serous otitis media. The best treatment at this time is time. If the fluid persists for more than a month after treatment with amoxicillin, then an alternative should be sought |
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A 55 yo M complains of abdominal cramps, bloating and loose stools for the past 3 months.
His PMH is unremarkable. He admits to double vision that is worse at night and joint pain that is worse in the morning. CBC shows anemia. Which of the following is the most likely diagnosis? Lactose intolerance Pernicious anemia Zollinger-ellison syndrome Whipple disease Celiac sprue |
Whipple disease
Whipple disease is a MALABSORPTION caused by TROPHERYMA WHIPPELII, a PAS POSITIVE Gram Positive bug This pt has double vision worse at night, a sign of Vit A deficience, which is due to malabsorption Whipple's also causes joint pain and cardiac problems Celiac sprue does NOT cause joint pain and would have presented at a much younger age with a RASH (dermaitits herpitiformis) and ANTI-GLIADIN/TISSUE TRANSGLUTAMINASE ANTIBODIES Zollinger-ellison may present with malabsorption due to excess gastrin secretion, but would not cause a rash Pernicious anemia causes a malabsorption of Vit B12, leading to a megaloblastic anemia Lactose intolerance will cause profuse diarrhea |
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A 48 yo M with a known Hx of HIV is in need of a mitral valve replacement surgery secondary to bacterial endocarditis.
Following referral to a cardiothoracic surgeon at your hospital, you receive a phone call from the surgeon stating his refusal to operate on the pt, based on his HIV status. Instead, the surgeon recommends "conservative" care with medication only. Based on this scenario, the most appropriate course of action to take at this time is to: Contact your department chairman regarding the situation Report the surgeon to the Chief Medical Officer (CMO) of the hospital Consult an infectious disease specialist regarding the pt's risk for transmission Refer the pt to a different cardiothoracis surgeon for operative evaluation Initiate treatment with furosemid to reduce preload and the left ventricular volume |
Refer the pt to a different cardiothoracic surgeon for operative evaluation
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A 17 yo F presents to the ED because she thinks she may have been sexually assualted.
She attended a party last night and drank alcohol for the first time. She only remembers parts of the night, but woke up in a M friend's bed with only her shirt on. The most useful method for detecting semen is: Wood lamp Gram stain Nitrazine paper Culture Polymerase chain reaction |
Wood lamp
Wood lamp will show fluorescence in the presence of alkaline phosphatase in semen; however, many other materials fluoresce such as urine or surgical lubricating jelly. Therefore, it is the best initial test, but has poor specificity |
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A 13 yo F is brought to your office by her mother who is concerned about her sexual development and is seeking your advice.
PE of the young girl shows breasts with secondary mound development and pubic hair that is dark and coarse covering the pubic bone but is limited elsewhere. Based on your evaluation you should inform the mother that: The child is Tanner stage 5 and is developing faster than average The child is Tanner stage 4 and is appropriate The child is Tanner stage 4 and is delayed The child is Tanner stage 3 and is appropriate The child is Tanner stage 3 and is delayed |
The child is Tanner stage 4 and is appropriate
Tanner 4 constitutes "MOUND ON A MOUND" breast development (areola projects out from the breast tissue) and pubic hair to the pubic bone Average age of Tanner 4 is 13 Tanner 1 = Only nipple is raised, no growth of pubic hair Tanner 2 = Bud-shaped elevation of the areola, Scarcely pigmented straight pubic hair along the medial border of the labia Tanner 3 = Breast and areola enlargement but no contour seperation, Sparse, dark, visibly pigmented, curly pubic hair Tanner 4 = "Mound on a mound" as the areola forms a secondary elevation above the breast, MENSTRUATION BEGINS, pubic hair is coarse and curly Tanner 5 = The areola is part of the general breast contour and is slightly pigmented, pubic hair extends to inner thigh |
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3 weeks after being involved in a fatal motor vehicle accident, where he witnessed the death of his mother and brother, a 24 yo M presents with nightmares and flashbacks of the accident.
These symptoms started one week ago. Due to his new fear of motor vehicles he refuses to leave his neighborhood. His father states that for the past week his son has been irritable and easily startled. Immediately after the accident the pt states that he experienced a feeling of numbness, as if he had just watched the event on television. The most likely diagnosis is: Post-traumatic stress disorder Schizophreniform disorder Adjustment disorder Acute stress disorder Acute anxiety disorder |
Acute stress disorder
The biggest differentiating factor between acute stress disorder and PTSD is the timeframe Acute stress occurs up to 4 weeks following an event, whereas PTSD can occur years after the event. |
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A 22 yo M presents to the ED with a two day Hx of abdominal pain, nausea, and diarrhea.
He reports the pain initially started near his umbilicus and then eventually localized to the RLQ of his abdomen. On PE the pt has rebound tenderness in the RLQ after deep palpation of the LLQ. There is also a positive psoas sign. His vitals include a temp of 102.1, a pulse of 92, and a BP of 138/92 The most appropriate initial step in management of this pt is: Colonoscopy CT Rectal exam Surgical consult Abdomina ultrasound |
Rectal exam
All pts. with GI complaints should have a rectal exam performed first to rule out a GI bleed, even if this pt is presenting with obvious signs of acute appendicitis |
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A 22 yo M presents to the ED with a two day Hx of abdominal pain, nausea, and diarrhea.
He reports the pain initially started near his umbilicus and then eventually localized to the RLQ of his abdomen. On PE the pt has rebound tenderness in the RLQ after deep palpation of the LLQ. There is also a positive psoas sign. His vitals include a temp of 102.1, a pulse of 92, and a BP of 138/92 The best test to help confirm the suspected diagnosis is: Colonoscopy CT Rectal exam Surgical management Abdominal ultrasound |
CT
CT is the best means to help confirm the dx of acute appendicits prior to surgery |
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During rounds, your attending physician asks you the reason why gram negative bacteria are more commonly associated with septic shock.
You responsd that gram negative bacteria are: More likely to be associated with osteomyelitis in pediatric patients More likely to be missed by gram staining More likely to initiate a primary immune response More likely to be associated with drug resistance Rarely associated with urinary tract infections |
More likely to initiate a primary immune response
Gram negative bacteria are more likely to initiate a primary immune response because of the lipopolyssacharide (LPS) component of the cell wall The LPS initiates an immunologic cascade, which includes the release of IL-1 & IL-6 E. Coli (a G neg bacteria) is the most common cause of UTIs G negs are associated with septic shock due to their induction of the immune system, not because they are bacterial resistant G neg bacteria appear PINK on gram stain H. Influenzae is a more common cause of osteomyelitis in kids than in adults; however, S Aureus is still the most common bacteria overall |
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A 75 yo nursing home pt is admitted to the hospital for altered mental status and impiared consciousness for the past 2 days.
These symptoms fluctuate throughout the day. The pt has a history of seizure disorder, urinary retention, and Parkinson's disease. Which of the following is the most likely cause of her symptoms? Benztropine Bethanecol Carbamazepine Propranolol Haloperidol |
Benztropine
The elderly pt is suffering from delirium. Anti-cholinergic drugs are a common cause of delirium Other drugs which cause delirium are DIPHENHYDRAMINE & TCA's Haloperidol is a typical antipsychotic and blocks dopamine receptors, leading to PARKINSON'S-like side effects Beta-blockers don't cause delirium Carbamazapine can cause sedation, but not delirium Bethanacol is a cholinergic agonist |
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A 64 yo M complains of heartburn and pain in the upper abdomen.
In addition to these symptoms, the pt reports intermittent vomiting that tends to occur several hours following a meal. He admits to an 8 pound weight loss since his last visit to your office one month ago. The pt's diet consists mainly of fruits and whole grain fuoods. Based on this information, the most likely diagnosis is: GERD Diverticular disease Gastroparesis Celiac disease Post-obstructive ileus |
Gastroparesis
Gastroparesis is very common in diabetes pts and typically presents with heartburn, abdominal pain, nausea, vomiting of undigested food, bloating, satiety, and weight loss Gastroparesis should be considered in all pts with DM who present with abdominal symptoms and weight loss Ileus also results in slow transit times, but is typically seen following surgery Celiac disease is usually associated with grains and diarrhea, steatorrhea, weight loss, and feelings of bloatedness Diverticular disease will present with pain during flairups and is associated with low fiber, high fat diets GERD is associated with epigastric pain 30-90 mins after eating, regurgitation, and pain worse in the supine position |
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A 60 yo M presents to the hospital with dyspnea and cough.
While obtaining a H&P, you learn that he worked in a shipyard for 25 years. An X-ray of his chest shows diffuse infiltrates. Which of the following statements is most accurate? He likely has distant mets He has an increased risk of developing TB Lung biopsy will stain positive with Prussian blue Lung biopsy will show diffuse alveolar damage Smoking increases his risk of malignant mesothelioma |
Lung biopsy will stain positive with Prussian blue
The pt has ASBESTOSIS exposure, due to his work history Asbestosis exposure is common in SHIPYARD WORK, INSULATION, DEMOLITION & BRAKELINE INSTALLATION Lung biopsy classically shows FERRUGINOUS BODIES, which arise from iron and protein Ferruginous bodies stain positive with Prussian blue Smoking increases the pts chances of developing BRONCHOGENIC CANCER, not malignant mesothelioma Note: the most common cause of malignant mesothelioma is asbestos, BUT the most common lung cancer in people exposed to asbestos is BRONCHOGENIC CARCINOMA Diffuse alveolar damage is more common with respiratory distress syndrome Exposure to SILICA DUST increases the risk of developing TB |
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A 3 yo M is brought to the ED by his mother with vomiting and severe disorientation.
While in the ED, he is witnessed having a seizure and is subsequently transferred to the ICU where he is noted to have cerebral edema. His CBC reveals the following: WBC 4700, Hg 7.8, Hct 19%, MCV 74. Questions for the mother should be directed toward the possible ingestion of: Methanol Zinc Lead Talidomide Iodine |
Lead
Lead classically causes NEUROLOGIC SYMPTOMS as well as IDA & VOMITING in children Lead poisoning is treated with SUCCIMER, or DIMERCAPROL/EDTA Methanol and iodine toxicity may induce vomiting and altered mental status (but not IDA) Thalidomide is an immunomodulatory agent that is used for myeloma Symptoms of toxicity include fatigue, constipation, drowsiness, and peripheral neuropathy...it can also cause "flipper deformities" during pregnancy Zinc toxicity includes fever, N/V/D, cough, fatigue, neuropathy, and dehydration |
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A 15 yo F comes to your office for follow up of her treatment for acne vulgaris.
The pt is currently using benzoyl peroxide, topical retinoids, and erythromycin and unfortunately she doesn't seemt o be responding to the current treatment. You decide to start the patient on oral retinoids but warn the pt that she may develop the side effect of: Suicidal ideations Increased incidence of hepatocellular carcinoma Increasd incidence of cholangiocarcinoma Encephalitis Pancreatitis |
Suicidal ideations
Retinoids are associated with SUICIDAL IDEATIONS, TERATOGENICITY, HYPERTRIGLYCERIDEMIA, HYPERCHOLESTEROLEMIA, ELEVATED LIVER ENZYMES Risk factors for cholangiocarcinoma are: PRIMARY SCLEROSING CHOLANGITIS, CLONORCHIS SINESIS INFECTION & ULCERATIVE COLITIS Hepatocellular carcinoma risk factors include: Cirrhosis, chemicals (VINYL CHLORIDE, AFLATOXIN, THOROTRAST), hemochromatosis, WILSON'S DISEASE, alpha-1-antitrypsin deficiency, SCHISTOSOMIASIS, hepatic adenoma, cigarette smoking, glycogen storage disease type 1 |
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A 56 yo M presents to your clinic complaining of gross hematuria, increased urinary frequency and dysuria.
Cystoscopy with biopsy is diagnostic and shows transitional cell carcinoma in situ. What is the best treatment for this pt's condition? Oral & IV chemotherapy Radiation therapy Radical cystecotmy Transurethral resection Intravesicular chemotherapy |
Intravesicular chemotherapy
Bladder cancer that is carcinoma in situ, superficial, or large/high-grade recurrent lesions are all treated with intravesicular chemotherapy. Invasive cancers without mets are treated with radical cystectomy or radiotherapy Invasive cancers with mets are treated with oral & IV chemo |
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A 28 yo F presents to your office with concerns after noticing grayish discoloration of her hair and changes in the texture of her nail beds.
She reports having a history of "fatty stools" and complains of her tongue being sore. Following laboratory evaluation, the pt is diagnosed with IDA The most likely etiology responsible for her condition is: PUD Pregnancy Menorrhagia Malabsorption syndrome Long-term ABX |
Malabsorption syndrome
Any case that describes "fatty stools" is a malabsorption case |
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An 18 yo F rape victim is brought to the ED by police after being found crying in an abandoned alleyway.
She is met at the hospital by her mother who insists that she take a "morning after pill" to prevent pregnancy. After discussion about post-coital contraceptive methods, you inform her that the most effective means of preganancy prevention at this time would be: Observation as post-coital contraception is contraindicated in this pt D&C Oral therapy with 0.5 mg of levonorgestrel and 100 mcg of ethinyl estradiol Oral therapy with 750 mcg levonorgestrel Insertion of a Copper IUD |
Insertion of a Copper IUD
Copper IUD placement can prevent pregnancy up to 7 days after unprotected sex 750 mcg of levonorgestrel taken in 2 seperate doses is also effective 0.5 mg of levonorgestrel and 100 mcg of ethinyl estradiol taken in two seperate doses is also effective D&C is not an effective method |
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a 65 yo M with a Hx of poorly controlled HTN presents to your office complaining of swelling in his feet and SOB.
He takes lisinopril, ASA, and HCTZ. PE shows 3+ pitting edema in the lower extremities bilaterally and rales in the lower lung bases bilaterally. Lab analysis shows hyponatremia, BNP 42, hyperkalemia, BUN 35, Cr 3.2, and a microcytic anemia. UA shows a pH of 4.9 and no WBCs, no RBCs and no nitrates. An EKG is normal and he was recently given a "clean bill of health" by his cardiologist. What is the most likely diagnosis? RTA type IV RTA type III RTA type II RTA type I CHF |
RTA type IV
RTA type IV is characterized by HYPERKALEMIA, HYPONATREMIA, URINARY pH <5.5 RTA (aka distal tubular acidosis) is due to defect in sodium reabsorption and hydrogen ion & potassium ion excretion. It can be caused by ALDOSTERONE DEFICIENCY, ACEi's, NSAIDs, AMILIORIDE, SPIRONOLACTONE or HEPARIN Tx = Furosemide, steroids & low K+ diet RTA type I is characterized by HYPOKALEMIA, URINARY pH >5.5 RTA I is caused by a defect in HYDROGEN SECRETION and can be associated with CIRRHOSIS, AUTOIMMUNE DISORDERS (SJOGRENS, SLE), SICKLE CELL, LITHIUM, & NEPHROLITHIASIS Tx = K+ RTA type II is characterized by HYPOKALEMIA, URINARY pH <5.5 RTA II is caused by a PROXIMAL TUBULAR DEFECT IN BICARB REABSORPTION and is associated with CARBONIC ANHYDRASE INHIBITORS, MYELOMA, AMYLOIDOSIS Tx = K+ |
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A worried mother brings her 10 yo daughter to the outpatient clinic with CC of rash.
She returned home from gymnastics camp 2 days ago and now has multiple flesh-colored, dome-shaped papules around her eyes and inner forearms. The papules are not pruritic or painful. Histological analysis of this papule is most likely to reveal? Sarcoptes scabiei mite Pseudohyphae and budding yeast Owl's eye inclusion bodies Henderson-Paterson (inclusion) bodies Atypical lymphocytes |
Henderson-Paterson (inclusion) bodies
This child has MOLLUSCUM CONTAGIOSUM, which is caused by the POXVIRUS. The lesions develop just as they are described in the case. It is spread by direct contact (gymnastics, daycares, close contact etc) in children and is considered an STD in adults Scratching can spread the virus Lesions are self-limited and resolve within 9 months Atypical lymphs are characteristic of MONO Remember, mono may develop a rash if incorrectly treated with AMPICILLIN Owl's eyes are pathomnemonic for CMV CMV can present as sero-negative mono or retinitis, colitis, pneumonitis, or encephalitis. It is treated with GANCICLOVIR Pseudohyphae and budding yeast are pathomnemonic for CANDIDA Candida skin infections present as pink, circular, erythematous macules with small satellite lesions and is treated with an -AZOLE Sarcoptes scabiei is the causative agent for scabies. Scabies presents with pruritis and burrows in the interdigit area and wrist flexor region It is treated with PERMETHRIN |
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a 4 yo boy is brought to your office by his mother who is concerned because the child is unable to recite his own name, address, and phone number.
She would like your opinion on whether there should be concern for delayed language development. Based on your knowledge of developmental milestons, you correctly inform her that the child should develop theses skills by: 5 yrs 4 yrs 3 yrs 12 mos 6 mos |
5 yrs
6 mos a child should be alert to sounds and coo 12 mos a child should say mama and dada (1 by 1) 3 yrs a child should use 3 word sentences (3 by 3) 4 yrs a child should know colors and some numbers |
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An 18 yo F complains of amenorrhea for the past 6 mos, acne, constipation, and wt gain.
Her BP is 150/90. Labs reveal an elevated LH/FHS ratio Which of the following is most likely associated with her condition? Elevated thyroid binding globulin Decreased thyroid hormones Elevated intracranial pressure Infertility due to ovarian failure Coarcation of the aorta |
Elevated thyroid binding globulin
This is a classic presentation of POLYCYSTIC OVARIAN SYNDROME (PCOS). Elevated androgens and obesity lead to HIGH ESTROGEN LEVELS. Estrogen increases TBG levels and also increased total thyroid hormone, but free levels remain the same (just like pregnancy) Coarctation of the aorta is associated with Turner's Infertility in PCOS is due to anovulation from excessive estrogen feedback Elevated intracranial pressure would have presented with HA, papilledema, or cranial nerve palsies |
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An obese 56 yo M ocmplains of pain and swelling in his legs, especially at rest.
He has 2+ edema and has developed ulcerations on his lower extremity and admits to chewing tobacco. The most likely diagnosis is: Thrombangitis obliterans Necrobiosis lipoidica Lymphedema DVT Arterial insufficiency |
Thrombangitis obliterans
The development of ulcerations in this patient is the key to answering this question correctly The condition is strongly associated with heavy tobacco use Typical presentations are REST PAIN, UNREMITTING ISCHEMIC ULCERATIONS, GANGRENE OF THE DIGITS Atherosclerosis may cause rest pain, but would be unlikely to cause ulcerations DVT may also cause pain, but again the ulcerations would not be present Lypmhedema is generally slow in onset and would not be associated with ulceration Necrobiosis lipoidica is a vasculitis associated with DM and produces WELL DEMARCATED AREAS OF ATROPHY THAT GRADUALLY ENLARGES, PRIMARILY ON THE SHIN The patches are initially red-brown and progress to yellow, depressed, atrophic plaques |
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A 21 yo F is admitted to the hospital after a week of severe refractory migrain pain.
The pt is treated and reports significant relief. Later in the day the physician is urgently called to the room. The pt is found screaming in pain with her head bent to the side and eyes deviated and fixed to the right. The most appropriate treatment is: Levetiracetam Hydrocodone/acetaminophen Haloperidol Diphenhydramine Botulinum toxin injection |
Diphenhydramine
Acute TORTICOLLIS can be a side effect of PROCHLORPERAZINE (or any ANTIPSYCHOTIC) a D2 antagonist (typical antipsychotic) Drug-induced torticollis is treated FIRST-LINE with DIPHENHYDRAMINE or benztropine or benzodiazepine A common migraine treatment cocktail in hospitals includes Prochlorperazine, Diphenhydramine, and Toradol Botulinum would be used if the torticollis were due to trauma Haloperidol is another typical antipsychotic and may exacerbate the symptoms Levetiracetam (Keppra) is used to treat seizures |
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A 25 yo F presents with her 5 week old daughter.
The mother states that her baby "is always hungery" and "throws up everything with vomitus flying across the room." She states that it occurs after feeding and the emesis only contains formula. On PE a small round mass is palpable in the medial aspect of the RUQ. Labs show hypochloremia and mild metabolic alkalosis. Which of the following medications has been associated with this diagnosis? Nitrofurantoin Macrolide Cephalosporin Tetracycline Penicillin G |
Macrolide
Especially ERYTHROMYCIN have been associated with PYLORIC STENOSIS Erythromycin may be used as post-exposure prophylaxis for pertusis |
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A newborn baby is found to have major birth defects involving the lower spine including partial absence of the pelvis and lower vertebrae.
PE also shows incontinence, flaccid paralysis of the lower extremities and an imperforate anus. Which of the following most likely lead to these findings? Maternal alcohol use Maternal cocaine use Maternal diabetes Folic acid deficiency Folic acid over-supplementation |
Maternal diabetes
This neonate has signs of CAUDAL REGRESSION SYNDROME. Signs = absence of the tail bone, malformations of the pelvis & lower vertebrae, flaccid paralysis of the lwoer extremities, incontinence or imperforate anus. Folic acid deficiency is more likely to cause neural tube defects Maternal cocaine use is associated with placental abruption, fetal addiction, bowel atresia, microcephaly Maternal alcohol use is associated with MR, IUGR, midfacial hypoplasia and renal/cardiac defects |
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You are called to perform a newborn exam in the nursery.
On PE of the neonate, you observe a bulging, yellow-gray mass at the level of the vaginal introitus. Urinary obstruction is suspected. The most likely diagnosis is: Clitoral hypertrophy Imperforate hymen Periurethral cyst Sarcoma botryoides Labial adhesions |
Imperforate hymen
This is the MOST FREQUENT OBSTRUCTIVE ANOMALY of the female GU tract Boards descriptions = YELLOW-GRAY MASS, bulging, at the level of the vaginal introitus Labial adhesions will result in inflammation of the vulva, but do not appear as a bulging mass and likely wont cause obstruciton Sarcoma botryoides is an interlabial mass and is the most commona malignant tumor of the lower GU tract and is most commonly associated with VAGINAL BLEEDING and the appearance of GRAPELIKE VAGINAL MASS protruding throught he introitus |
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You are called to perform a newborn exam in the nursery.
On PE of the neonate, you observe a bulging, yellow-gray mass at the level of the vaginal introitus. Urinary obstruction is suspected. The best test to confirm your clinical suspicion is: CT Hormone analysis Pelvic examination Direct needle aspiration Pelvic ultrasound |
Pelvic ultrasound
Imperforate hymen is best diagnosed with a pelvic ultrasound Needle aspiration would be utilized for a periurethral cyst Pelvic exam could be used if the ultrasound were unclear Hormone analysis would be used for diagnosing clitoromegaly if androgen excess were suspected CT would be used to dx Sarcoma Botryoides |
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A 65 yo G2P1 F comes to the office for a health maintenance exam.
She is very healthy and has no Hx of abnormal Pap smears or STDs. She has a Hx of endometriosis and has been postmenopausal for 10 yrs. On pevlic exam, the pt has a palpable left adnexal mass. An ultrasound was obtained, which showed a 3 cm complex left ovarian cyst. What is the most appropriate next step in the management of this patient? Repeat ultrasound in 6 months CT MRI Exploratory surgery Observation |
Exploratory surgery
This pt is at increased risk for ENDOMETRIAL or OVRAIN CANCER, due to her age and Hx of endometriosis Any COMPLEX ovarian cyst on ultrasound should be explored Observation for any period would not be recommended CT & MRI would not be useful, besides US is the most sensitive modality for pelvic masses |
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A 67 yo M with a Hx of CHF presents to your clinic complaining of polyuria, polydipsia, and weight gain.
he tells you he gets little exercise and eats a poor diet. Initial labs show a fasting blood glucose of 156 and 164 on two seperate occasions, HbA1C 12.2%, BUN 16, and Cr 1.2. Which of the following medications is contraindicated in this patient? Exenatide Glipizide Insulin Pioglitazone Metformin |
Pioglitazone
TZDs (Rosiglitazone & Pioglitazone) are contraindicated in pts. with CHF Insulin is the 1st line tx in pts with an HbA1C >10.0 Metformin is contraindicated in pts with a GFR<30 Glipizide is a sulfonylurea which stimulates beta cells to release insulin Exenatide is a GLP-1 agonist which activated glucagon-like peptide receptors, leading to increased insulin secretion and decreased glucagon secretion |
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A 79 yo F is brought to your office by her daughter who states the patient has had multiple recent near-syncopal events and sleeps most of the day.
During your discussion with the pt, she admits to being fatigued and complains of feeling weak and lightheaded at times. Laboratory analysis reveals iron-deficiency anemia. Colonoscopy shows angiodysplasia This diagnosis has a known association with the development of : Peritonitis Intestinal performation Intestinal obstruciton Aortic stenosis Liver metastasis |
Aortic stenosis
Angiodysplasia + aortic stenosis = Heyde's syndrome Intestinal obstruction, perforation, and peritonitis would be expected if the pt has diverticulitis (which is the #1 cause of GI bleeding in the elderly) |
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A 62 yo F presents with cough, rigors, and dyspnea that have been present for approximately 3 months.
She recently underwent hospitalization for presumed pneumonia and was treated with macrolide and lfuoroquinolone ABX with little improvement. The pt has known aortic stenosis and had valve replacement sx approximately 1 year ago. She also has a Hx of V-tach. The pt is most likely suffering from: COPD Atypical pneumonia CHF Medication toxicity Bacterial pneumonia |
Medication toxicity
Given the pt's Hx of V-tach and prolonged pneumonia-like illness that is unresponsive to treatment, it is likely they have developed AMIODARONE TOXICITY Amiodarone toxicity develops interstitial and alveolar infiltrates on plain films and pneumonia-like symptoms (cough, rigors, dyspnea) |
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A 40 year old man presents to your office complaining fatigue and shortness of breath that has been worsening over the past two months. He has no history of smoking. Chest X-ray reveals several bullae in the lower lobes and an increased anteroposterior diameter. Spirometry shows an obstructive pattern.
There is a FHx of cardiovascular, liver, and lung disease. Which of the follwoing is the most likely diagnosis? Chronic bronchitis Alpha-1-antitrypsin deficiency Hereditary hemochromatosis Wilson's disease CHF |
Alpha-1-antitrypsin deficiency
Alpha-1 is an AR disease that causes EMPHYSEMA in NON-SMOKERS and liver disease Given his X-ray findings and family Hx of liver & lung disease, it is likely Alpha-1 CHF gives rise to pulmonary HTN and pleural effusions on X-ray Wilson's (copper) leads to liver failure Hereditary hemochromatosis causes cirrhosis, DM (bronze DM), cardiomyopathy, and pigmentation Chronic bronchitis would not account for the FHx |
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A 40 year old man presents to your office complaining fatigue and shortness of breath that has been worsening over the past two months. He has no history of smoking. Chest X-ray reveals several bullae in the lower lobes and an increased anteroposterior diameter. Spirometry shows an obstructive pattern.
There is a FHx of cardiovascular, liver, and lung disease. Which of the following is this pt at the highest risk for? Pulmonary fibrosis Pancreatitis Lung cancer DM CHF |
CHF
This pt has alpha-1 and is at risk of EMPHYSEMA, which can lead to R-sided heart failure (i.e. CHF) which is AKA cor pulmonale DM & Pancreatitis would be associated with Hereditary Hemochromatosis Pulmonary fibrosis is a RESTRICTIVE lung disease, whereas Alpha-1 is an OBSTRUCTIVE |
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A 62 yo M with a Hx of renal disease requiring dialysis presents to the ER complaining of the worst headache of his life.
He said he was watching TV and his head started throbbing. PE shows 2+ pitting edema in the lower extremities bilaterally and a normal neurological exam. Vitals are: BP 185/89, HR 102, RR 21, T 99.1. Labs are Na 141, K 4.5, Hb 9.2, Hct 28.1, BUN 32, Cr 4.2 What do you expect to see on an abdominal CT scan? Prostate mass Beaded apperance of renal arteries Decreased kidney size Ureteral dilation with caliceal blunting Multiple bilateral cycsts throughout the renal parenchyma and pancreas |
Multiple bilateral cycsts throughout the renal parenchyma and pancreas
This pt most likely has ADPKD based on his Hx of renal disease and now a likely berry anuerysm rupture ("worst headache of his life"). ADPKD will develop dilated kidneys with multipel cysts Ureteral dilation with caliceal blunting is a description scene following vesicoureteral reflux Decreased kidney size is seen in CKD or ESRD Beaded appearance or renal arteries is a buzzword for POLYARTERITIS NODOSA |
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A 31 yo M arrives to the ED following a motorcycle accident.
The pt opens his eyes to pain but not to speech. His verbal response to questioning is inappropriate and he withdraws from pain but is unable to localize where it hurts. Based on this info, you calculate his Glasgow Coma Score or: 10 9 8 7 6 |
9
Eye opening: Spontaneous = 4 To speech = 3 To pain = 2 (our pt) None = 1 Verbal response: Oriented = 5 Confused = 4 Inappropriate/Incoherent = 3 (our pt) Incomprehensible = 2 None = 1 Motor: Obeys commands = 6 Localizes pain = 5 Withdraws from pain = 4 (our pt) Flexion to pain = 3 Extension to pain = 2 None = 1 |
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A 25 yo M presents to your office after noticing several white patches on his upper back and chest.
He works as a roofer. He states that he noticed the patches at the end of last summer bu as the weather got cooler they disappeared. This summer the patches appeared as soon as he started working, and he is concerned that they are contagious. The most appropriate treatment is: Metronidazole Mebendazole Ketoconazole 2% shampoo Itraconazole Griseofulvin |
Ketoconazole 2% shampoo
This pt has Tinea Versicolor, caused by Pityrosporum Orbiculare (formerly Malassezia furfur). KOH wet mount description = "Spaghetti and meatballs" Treatment = Ketoconazole 2% shampoo or Selenium sulfide 2.5% suspsension, or Oral Ketoconazole Griseofulvin has no activity against tinea versicolor, but could be used for Tinea pedis, corporis, capitis, or cruris Itraconazole is a weak -azole and won't work Mebendazole is an anti-parasitic used to treat PINWORM, WHIPWORM, HOOKWORM, AND ROUNDWORM Metronidazole is used for bacterial vaginosis, trichomoniasis, C. Diff, and PID |
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A 34 yo M is found to have a solitary pulmonary nodule on CXR.
The nodule is centrally-located and 1.5 cm in diameter with smooth margins. The pt is a non-smoker. Based on this information, the most appropriate course of action is: Reassurance without follow-up CT of the chest in 2 months Immediate surgical resection Reassurance with follow-up chest film in 3-6 mos Fine needle biopsy |
Reassurance with follow-up chest film in 3-6 mos
This is most likely a benign lung nodule Benign characteristics = CENTRAL location, NON-SMOKER, <35, NO CHANGE from prior films, <2cm, SMOOTH MARGINS or uniform shape Nodules which are NOT thought to be benign should be first compared to old films, then biopsied or resected |
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A 42 yo M presents to your office complaining of ED.
His PMH is significant for poorly controlled DM and PVD. He currently take Metoprolol and Tamsulosin. He tells you he sometimes wakes up with an erection. What is the most likely cause of his complaint? Metoprolol Tamsulosin Psychological Diabetes PVD |
Psychological
The distinction between psychological ED and organic ED is based on the presence of NOCTURNAL or EARLY-MORNING ERECTIONS If these are present, the pt has psychological ED ED can also be caused by DM, Atherosclerosis, Beta-blockers (metoprolol), Alpha-blockers (tamsulosin), SSRI's, TCA's, Diuretics, HTN, Heart disease, Surgery, or Radiation |
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A 32 yo primigravida presents to the L&D in labor.
Cervical examination shows the following: Cervical dilation of 4 cm, 60% effacement, 0 fetal station, soft cervical consistency and an middle cervical position What bishop score does she have? 0 8 10 2 13 |
10
Bishop score is based on 5 criteria: Dilation, Effacement, Station, Position, and Cervical consistency Dilation scores 0,1,2,3 based on closed, 1-2, 3-4, >5 Effacement scores 0,1,2,3 based on <40%, 40-59%, 60-79%, >80% Station scores 0,1,2,3 based on -3, -2/-1, 0, >+1 Position scores 1,2,3 based on Posterior, Middle, Anterior Cerical consistency scores 0,1,2 based on Firm, Medium, Soft This pt scored 2 in each category |
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A 34 yo F presents to the ED with a two day Hx of worsening nausea, non-bloody bilious emesis and diffuse abdominal discomfort.
Her exam is significant for mild abdomina distention and tenderness in all quadrants with no periotneal signs. She previously underwent laparoscopic repair of a symptomatic ventral hernia. The next best step in management is: Diagnostic laparoscopy CT of the abdomen EGD Supine and upright abdominal radiographs Exploratory laparotomy |
Supine and upright abdominal radiographs
The first-line step in a pt suspected of having a small bowel obstruction is RADIOGRAPHS, which will show "AIR-FLUID LEVELS" and dilated loops of small bowel. Initial management of small bowel obstruciton includes NG suction, fluid resuscitation, and supine/upright abdominal films CT may be ordered after X-ray |
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A 16 yo F presents to the ED after her boyfriend broke up with her.
She complains of perioral pallor and tingling. PE reveals tachypnea, hyperpnea, and carpopedal spasms. Which of the following would be most associated with these symptoms: Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis Hypocalcemia |
Respiratory alkalosis
Carpopedal spasm is caused by hypocalcemia. Hypocalcemia develops during times of hypocarbia, which is caused by tachypnea/hyperpnea as the H+ ions are released from their binding sites on albumin. The now negatively charged albumin binds to calcium and causes a hypocalcemia |
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A 30 yo F with severe menorrhagia has a hemoglobin of 6.
She feels weak and dizzy. Her Dr orders 3 units of PRBCs. Two hours into the transfusion, she develops hypotension, wheeezing, diaphoresis and a rash. The transfusion is stopped. Which of the following additional findings is most likely? IgA deficiency Elevated creatinine Pulmonary edema Elevated direct bilirubin Elevated LDH |
IgA deficiency
This pt has sypmtoms of anaphylaxis. Any pt who has an anaphylactic reaction from a blood transfusion should be suspected to have IgA deficiency. People with IgA deficiency are at increased risk for anaphylactic reactions. IgA deficiency is generally benign, but may appear during transfusions The managment for the anaphylactic reaction is to stop the transfusion and give Epi. Elevated LDH would suggest an acute hemolytic reaction. Symptoms would include fever, chills, and hypotension. Elevated direct bili would suggest a biliary obstruction Pulmonary edema would suggest transfusion-related acute lung injury Elevated creatinine suggests kidney failure which can occur with prolonged hypotension |
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A 55 yo M presents to the ER with chest pain and dyspnea for the past 3 hours.
He has a Hx of CHF, MI, and HTN. Chest pain worsens with inhilation. His HR is 150, BP 150/89, T 99.7. The best test to rule out PE is: Angiogram Spiral CT V/Q scan Chest X-ray D-dimer |
D-dimer
This question asks for the best test to RULE OUT a PE. Tests which rule out disease are highly sensitive and often poorly specific. D-dimer is highly sensitive for PE, but poorly specific. It is also the best 1st line test to diagnose PE Angiogram is the GOLD STANDARD for diagnosing PE, and can be used for CONFIRMATION |
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A 78 yo demented M who resides in the Alzheimer's unit of a nursing home is noted to have cough and mild fever over the past 3 days.
Upon exam, you note that he has multiple focal neurological deficits and is unable to respond to your questions. After ordering a portable chest x-ray, you notice blunting of the right hemidiaphragm suspicious of a right lower lobe infiltrate. Given this pt's neurolgic compromise, along with his x-ray findings, which of the following organisms would you expect to grow in abundance on sputum culture? Anaerobic bacteria G negative rods Streptococcus pyogenes Klebsiella pneumoniae Streptococcus pneumoniae |
Anaerobic bacteria
Under normal conditions, one would expect to find S. Pneumoniae in the pt's sputum; however, pts suffering from neurologic conditions (Pick's disease, Parkinson's, dementia, Alzheimer's, CVA) are at increased risk of ASPIRATION PNEUMONIA caused by anaerobes Pseudomonas is endemic to nursing homes An appropriate ABX which would cover anaerobes and pseudomonas would be Piperacillin-Tazobactam or Cefepime |
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A 45 yo M is seen by you in the hospital for evaluation of dizziness and is found to have a BP of 91/64.
The pt has a long-standing Hx of seizures, which have been controlled with phenytoin. An ECG reveals 3rd degree heart block. The most appropriate next step in management is: Metoprolol Discontinuation of phenytoin Repeat ECG Ventricular pacemaker Observation with reassurance |
Ventricular pacemaker
All pts with 3rd degree heart block require immediate ventricular pacemaker placement |
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A 17 yo F is seen for a routine physical.
When examining her legs, you notice dermatography and she says the response is common when she scratches. The mechanism behind this reaction is: T-cell mediated Arthus reaction Immune complex Cytotoxic IgE mediated |
IgE mediated
Dermatography is a form of Type I Hypersensitivity Type I's are caused by IgE binding to mast cells and releasing histamine in an anaphylactic reaction and includes food allergies, bee stings, utricaria, hives, edema Cytotoxic reactions are Type II and include anemias, ITP, Goodpasture's, bullous pemphigoid, Grave's disease and MG Immune complex reactions are Type III and include SLE, RA, PAN, and post-streptococcal glomerulonephritis Arthus reaction is a form of Type III and is caused by an inflammatory reaction when antigen is injected under the skin T-cell mediated reactions are Type IV and include TB skin test, DM, MS, Guillian-Barre, Hashimoto's & contact dermatitis |
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A 46 yo M presents to the ER after being shot in the abdomen.
The pt is unconscious, his skin is clammy and cool and he looks dehydrated. Vitals are BP 67/45, HR 132, RR 21, T 99.1. A foley catheter is placed and you notice a very dark brown urine accumulate in the collection bag. What type of renal casts are most likely associated with this pt's condition? Hyaline casts Waxy casts Granular casts WBC casts RBC sacts |
Granular casts
This pt's presentation is consistent with hypovolemic shock, leading to ATN ATN is associated with Granular (muddy brown) casts. RBC casts are associated with ATN, malignant HTN, and glomerulonephritis WBC casts are associated with tubulointerstitial inflammation, acute pyelonephritis and transplant rejection Waxy casts are associated with advanced renal disease or chronic renal failure Hyaline casts are non-specific |
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Painless, progressive visual field loss with an increased cup to disc ratio on exam:
Retinal detachment Open-angle glaucoma Closed-angle glaucoma Macular degeneration Cataracts |
Open-angle glaucoma
Open-angle glaucoma is a painless, progressive visual loss due to increased intraocular pressure Cataracts is due to a yellowing and hardening of the natural lens and pts will complain of a GLARE WHEN DRIVING AT NIGHT Macular degeneration results in a BLIND SPOT THAT FORMS IN THE VISUAL FIELD Closed-angle glaucoma is a SUDDEN, PAINFUL LOSS OF VISION DUE TO INCREASED INTRAOCULAR PRESSURE Retinal detachment is usually UNILATERAL & PAINLESS LOSS OF VISION, often described as a CURTAIN DESCENDING OVER THE VISUAL FIELD |
