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Question 1

70 yo with pain and stiffness of neck, shoulders and hips for last 3 months. workse in morning and lasts 1-2 hrs. general malaise and weight loss. PE: normal ROM, normal arteries
Lab: platelet 450, ESR 85, CK 33. dx and next step?

Answer 1

Polymyalgia rheumatica
- >50 yo w/ 2 or more:
neck/torso, shoulders/arms, thigh/hip, constitutional
- dec active ROM
- ESR >40, inc CRP
- txt: low doseglucocorticoids.

Question 2

28 yo woman w/ F, chills, weakness. Hx of R arm cellulitis 6 months ago. T 104, holosystolic murmur at lower sternum that inc with inspiration.dx and txt?

Answer 2

Infective endocarditis in IV drug user

• tricuspid regurg
• S. aureus
• txt: vanco
• can have septic pulmonary emboli

Question 3

34 yo with easy fatiguability, difficulty concentrating, insomnia, muscle pain, R hand clumsiness. PE: externsor weakness of R hand. dx and test, txt?

Answer 3

Lead poisoning

• CBC, lead level, X-ray fluorescence
• occupational hx
• p/w nonspecific, HTN, neuropathies, neuropsych, nephropathy
• absorbed via respiratory (adults) or GI (children)
• microcytic anemia
• txt: chelation therapy

Question 4

55 yo with 1 wk of pain in MCP, PIP and wrise, worse in morning and takes 10-15 to recover. no systemic symps. works in day care center. ESR 12. nl exam. dx?

Answer 4

Parvovirus B19 infection

- resolves w/in 2 months

Question 5

19 yo p/w F, joing pain, rash from face to body sparing palms and soles. arthralgias. From Romania. T101, mild bilateral conjunctival infection .dx?

Answer 5

Rubella

• low F, conjunctivitis, cervical LAD, cerphalocaudal spread of maculopapular rash
• adults with athralgias
• test: anti-rubella IgM and IgG

Question 6

40 yo M w/ 2 wks F, malaise, weakness, weight loss. L sided chest and upper abdominal pain. asymp mitral valve prolapse. T103. cardiac - 2/6 systolic murmur at apex. L sided pleural effusion and splenomegaly with splenic fluid collection. Dx? Txt?

Answer 6

Splenic abcess

• F, leukocytosis , LUQ pain
• L sided pleuritic chest pain, effusion, splenomegatly
• risk factor: IE, immunosuppression, IVDU, trauma, Hgbpathies
• 10-20% incidence of splenic abcess with L sided endocarditis
• due to STaph, Strep, Salmonella
• txt: Abx, SPLENCTOMY

Question 7

3 months continuous burning, upper abominal pain w/ recent-onset constipation and urination. father w/ stomach ulcers and kidney stones. stool + occult blood. Ca 11.4.dx?

Answer 7

MEN syndrome

- pituitary adenoma, primary hyperparathyroidism, gastrinoma (zollinger-ellison syndrome)

Question 8

47 yo woman with lower abdominal pain relieved with urination for 2 months . voiding more. painful intercourse. PE: palpation of anterior vaginal wall is very painful. no CMT. dx and treatment?

Answer 8

Interstitial cystitis (painful bladder syndrome)

• a/w anxiety and fibromyalgia
• p/w bladder pain w/ filling, relief w/ voiding, dyspaneunia.
• dx: bladder pain w/ no other cause for >6 wks
• nl UA
• txt: amitriptyline, analgesics, behavior modification

Question 9

48 yo HIV w/ floaters and blurred vision in R eye. no pain, F, HA. funduscopic exam: yellow-white exudates adjacent to fovea and retinal vessels. dx and txt?

Answer 9

CMV retinitis

• blurred vision, floaters, flashing lights
• inc risk retinal detachment
• dx by fundoscopy
• txt: Valganciclovir
• if near fovea or optic nerve, intraveitreal injxns