IM 4 Flashcards
CF 18. 27yo W @ ER complaining of retrosternal chest pain for past 2 days. Constant pain, not associated with exertion, worsens when she takes a deep breath, and is relieved by sitting up and leaning forward. Denies any shortness of breath, nausea, or diaphoresis. On examination, her temp 99.4, heart rate 104, blood press 118/72. She is sitting forward on the stretcher, with shallow respirations. Her conjunctivae are clear and her oral musoca is pink, w/ 2 aphthous ulcers. Her neck veins are not distended, her chest is clear to auscultation and is mildly tender to palpation. Her heart rhythm is regular, w/ a harsh leathery sound over the apex heard during systole and diastole. Her abdominal examination is benign, and her extremities show warmth and swlling of the proximal interphalangeal (PIP) joints of both hands. Lab studies: WBC 2100, hemoglobin conc 10.4 with MCV 94, and platelet count 78k. Her blood urea nitrogen (BUN) and creatinine levels are normal. Urinalysis shows 10 to 20 WBCs and 5 to 10 RBCs per hpf. A urine drug test is neg. Chest x-ray is read as normal, with a normal cardiac silhouette and no pulmonary infiltrates or effusions. The ECG is shown in fig 18-1. Dx?
Acute pericarditis as a consequence of SLE
68yo M w history of end-stage renal disease is admitted to hospital for chest pain. On exam, a pericardial friction rub is noted. His ECG shows diffuse ST-segment elevation. Treatment?
Dialysis. Uremic pericarditis is considered a medical emergency and an indication for urgent dialysis.
Patient described in 18.1 (previous) is hosp, but there is a dealy in initiating treatment. You’re called to the bedside b/c he has become hypotensive with systolic blood pressure of 85/68, a heart rate of 122, and you note pulsus paradoxus. A repeat ECG is unchanged from admission. Intervention?
Echocardiographic-guided pericardiocentesis. Clinical picture suggests the patient has developed pericardial tamponade.
25 yo W compl of pain in her PIP and MCP joints and reports recent pos ANA lab test. Which of the following clinical features would not be consistent with a diagnosis of SLE?
Sclerodactyly, which is thickened and tight skin of the fingers and toes is a classic features of patients with scleroderma (who may also have a positive ANA test), but it not seen in SLE
CF 19. 27 yo M presents to the outpatient clinic compl of 2 days of facial and hand swelling. He first noticed swelling around his eyes 2 days ago, along with diff putting on his wedding ring bc of swollen fingers. Additionally, he noticed that his urine appears reddish-brown and that he has had less urine output over the last several days. He has no significant medical history. His only medication is ibuprofen that he took 2 wks ago for fever and a sore throat, which have since resolved. On exam, he is afebrile, w heart r8 85 and bld press 172/110. He has periorbital edema; his funduscopic exam is normal w/o arteriovenous nicking or papilledema. His chest is clear to auscultation, his heart rhythm is regular with a nondisplaced point of maximal impulse (PMI), and has not abdominal masses or bruits. He does have edema of his feet, hands, and face. A dipstick urinalysis in the clinic shows specific gravity of 1.025 with 3+ blood and 2+ protein, but it is otherwise neg. Dx? Nxt dx step?
Acute glomerulonephritis (GN)/examine a fresh spun urine specimen to look for RBC casts or dysmorphic RBCs.
19.1// 18yo M. marathon runner has been training during the summer. He is brought into ER disoriented after collapsing on the track. His temp is 102F. A Foley catheter is placed and reveals reddish urine w/ 3+ blood on dipstick and no cells seen microscopically. Which of the following is the most likely explanation for his urine?
Myoglobinuria. Individual suffering from heat exhaustion, which can lead to the rhabdomyolysis and release of myoglobin.
19.2// Which of the following lab findings is most consistent with poststreptococcal glomerulonephritis?
Elevated ASO titers. The antristreptolysin-O titers typically are elevated and serum complement levels are decreased in poststreptococcal GN.
19.3// A 22yo M compls of acute hemoptysis over the past week. He denies smoking or pulmonary disease. His blood pressure is 130/70, and his physical examination is normal. His urinalysis also shows microscopic hematuria and RBC casts. Which of the following is the most likely etiology?
Goodpasture disease (antiglomerular basement membrane). This disease typically affects young males, who present with hemoptysis and hematuria.
CF 20// 48yo Hispanic W presents to office compl of persistent swelling of her feet and ankles, so much so that she cannot put on her shoes. She first noted mild ankle swelling approximately 2 to 3 months ago. She borrowed a few diuretic pills from a friend; the pills seemed to help, but now she has run out. She also reports that she has gained 20 to 25 lb over the last few months, despite regular exercise and trying to adhere to a healthy diet. Her med history is significant for type 2 diabetes, for which she takes a sulfonylurea agent. She neither sees a doctor regularly nor monitors her blood glucose at home. She denies dysuria, urinary frequency, or urgency, but she does report that her urine has appeared foamy. She had no fevers, joint pain, skin rashes, or gastrointestinal (GI) symptons. Her physical exam is significant for mild periodbital edema, multiple hard exudes, and dot hemorrhages on fundoscopic examination, and pitting edema of her hands, feet, and legs. Her chest is clear, her heart rhythm is regular w/o murmurs, and her abdominal exam is benign. She has diminished sensation to light touch in her feet and legs to mid-calf. A urine dipstick performed in the office shows 2+ glucose, 3+ prot, and neg leukocyte esterase, nitrates, and blood. Dx? Intervention to slow disease progression?
Nephrotic syndrome as a consequence of diabetic nephropathy// Angiotensin-converting enzyme (ACE) inhibitors
20.1/ 49yo W w/ type II diab presents to your office for new onset swelling in her legs and face. She has not other medical problems and says that at her last ophthalmologic appointment she was told that the diabetes had started to affect her eyes. She takes glyburide daily for her diabetes. Physical examination is normal except for pitting edema of bilateral upper and lower extremities, hard exudates and dot hemorrhages on funduscopic examination, and diminished sensation to the mid-shin bilaterally. Urine analysis shows 3+ prot and 2+ glucose (otherwise neg). Best treatment?
Start lisinopril. Beta blockers are a good first-choice agent for a patient with hypertension and no comorbidities.
20.2/ 19yo M was seen at univ health center a week ago compl of pharyngitis, and now returns because he has noted discoloration of his urine. He is noted to have elevated blood press 178/110 and urinalysis reveal RBC casts, dysmorphic RBCs and 1+ proteinura. Dx?
Post-streptococcal glomerulonephritis. The patient has hypertension, and a urinary sediment consistent with nephritic rather than nephrotic syndrome (RBC casts, mild degree of proteinuria).
20.3/ Which of the following is the best screening test for early diabetic nephropathy?
Urine microalbuminaria. Although a 24-hr urine collection for creatinine may be useful in assessing declining GFR, it is not the best screeing test for the diagnosis of early diabetic nephropathy.
20.4 / 58yo M with type 2 diab is normotensive but has a persistent urine albumin/creatinine ratio of 100, but no proteinuria on urine dipstick. Best mgmt fr patient?
Start ACE inhibitor. The albumin/creatinine ratio of 100 is indicative of microalbuminuria.
CF 21// 48yo M comes compl of severe right knee pain for 8 hrs. He states that pain, which started abruptly at 2AM and woke him from sleep, was quite severe, so painful that even the weight of the bed sheets on his knee was unbearable. By the morning, the knee had become warm, swollen, and tender. He explains that he prefers to keep his knee bent, and extending his leg to straighten the knee causes the pain to worsen. He has never had pain, surgery, or injury to his knees. A yr ago, he did have some pain and swelling at the base of his great toe on the left foot, which was not as severe as this episode, and resolved in 2 or 3 days after taking ibuprofen. His only medical history is hypertension, which is controlled with hyddrochlorothiazide. He works as a financial analyst; he is married and does not smoke, but he does consume one or two drinks after work one to two times per week. On exam, his temp is 100.6F, hear rate 104bpm, and blood press 136/78. His head and neck exams are unremarkable, his chest is clear, and his heart is tachycardic, but regular, with no gallops nor murmurs. His right knee is swollen, with a moderate effusion, and appears erythematous, warm, and very tender to palpation. He is unable to fully extend the knee because of pain. He has no other joint swelling, pain, or deformity, and no skin rashes. Dx? Nxt step? Best initial treatment?
Acute monoarticular arthritis, likely crystalline or infectious, most likely gout because of history// Aspiration of the knee joint to send fluid for cell count, culture, and crystal analysis// If the joing fluid analysis is consistent with infection, he needs drainage of the infected fluid by aspiration and administration of antibiotics. If analysis is suggestive of crystal-induced arthritis, he can be treated with colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), or corticosteroids.
21.1/ A previously healthy 18yo F (college freshman) presents to health clinic compl of pain on the dorsum of her left wrist and in her right ankle, fever, and a pustular rash on the extensor surfaces of both her forearms. She has mild swelling and erythema of her ankle, and pain on passive flexion of her wrist. Less than 1mL of joint fluid is aspirated from her ankle, which shows 8000 polymorphonuclear (PMN) cells per high-power field but no organisms on Gram stain. Best initial treatment?
Intravenous ceftriaxone. The patient described best fits the picture of disseminated gonococcal infection.
21.2/ Which of the following dx tests is most likely to give the dx for the case in Question 21.1?
Synovial fluid cultures usually are sterile on gonococcal arthritis (in fact, the arthritis is more likely caused by immune complex deposition than by actual joint infection), and blood cultures are positive less than 50% of the time.
21.3/ 30 yo M is noted to have an acutely swollen and red knee. Joint aspirate reveals numerous leukocytes and polymorphonuclear leukocytes, but no organisms on Gram stain. Analysis shows few neg biregringent crystals. Which of the following is the best initial treatment?
Intravenous antibiotic therapy. Corticosteroids should not be used until infection is ruled out.
CF 22// 32yo F compl of intermittent episodes of pain, stiffness, and swelling in both hands and wrists for approximately 1 year. The episodes last for several weeks and then resolve. More recently, she noticed similar symptons in her knees and ankles. Joint pain and stiffness are making it harder for her to get out of bed in the morning and are interfering with her ability to perform her duties at work. The joint stiffness usually lasts for several hours before improving. She also reports malaise and easy fatigability for the past few months, but she denies having fever, chills, skin rashes, and weight loss. Physical exam reveals a well-developed woman, with blood press 120/70, heart 82, and resp rate 14 breaths per min. Her skin does not reveal any rashes. Head, neck, cardiovascular, chest and abdominal exams are normal. There is no hepatosplenomegaly. The joint examination reveals the presence of bilateral swelling, redness and tenderness of most proximal interphalangeal (PIP) joints, metacarpophalangeal (MCP) joints, the wrists, and the knees. Lab studies show a mild anemia with hemoglobin 11.2, hematocrit 32.5%, MCV 85.7, WBC 7.9 with a normal differential, and platelet count 300,000. The urinalysis is clear with no protein and no RBC. The erythrocyte sedimentation rate (ESR) is 75, and the kidney and liver function tests are normal. Dx? nxt dx step?
Rheumatoid arthritis (RA)/ Rheumatoid factor and antinuclear antibody titer.
22.1/ 72 yo M develops severe pain and swelling in both knees, shortly after undergoing an abdominal hernia repair surgery. Physical exam shows warmth and swelling of both knees with large effusions. Arthrocentesis of the right knee reveals the presence of intracellular and extracellular weakly pos birefringent crystals in the synovial fluid. Gram stain is negative.Dx?
Pseudogout is a diagnosed by positive birefringent crystals
22.2/ 65 yo M w history of chronic hypertension, diabetes mellitus, and degenerative joint disease presents with acute onset of severe pain of the metatarsophalangeal (MTP) joint and swelling of the left first tow. Physical examination shows exquisite tenderness of the joint, with swelling, warmth, and erythema. The patient has no history of trauma or other significant medical problems. Synovial fluid analysis and aspiration is most likely to show which of the following?
Needle-shaped, negatively birefringent crystals. The involvement of the great toe is most likely gout, and the syntovial fluid is likely to show Needle-shaped, negatively birefringent crystals.
22.3/ 17yo sexually active M presents with a 5-day history of fever, chills, and persistent left-ankle pain and swelling. On physical exam, maculopapular and pustular skin lesions are noted on the trunk and extremities. He denies any symptons of genitourinary tract infection. Synovial fluid analysis is most likely to show which of the following?
WBCs 75,000 with 95% polymorphonuclear leukocytes. This history is suggestive of gonoccocal arthritis, and the rash is suggested of disseminated gonococcal disease.
22.4/ 22 yo M compls of low back pain for 3 to 4 months and stiffness of the lumbar area, which worsen with inactivity. He reports difficulty in getting out of bed in the morning and may have to roll out sideways, trying not to flex or rotate the spine to minimize pain. A lumbosacral (LS) spine Xray film would most likely show which of the following?
Sacroiliitis with increased sclerosis around the sacroiliac joints. A young man is not likley to have osteoporosis, osteoarthritis, or compression fractures.
22.5/ 36 yo W was seen by her physician due to pain in her hands, wrists, and knees. She is diagnosed with rheumatoid arthritis. Which of the following treatments will reduce joint inflammation and slow progression of the disease?
Methotrexate. Although NSAIDs and corticosteroids may help to relieve symptons, they typically do not alter the disease course significantly.
CF 23// 36 yo man comes to the office compl of 7 to 10 days of low-grades fevers with fatigues, myalgias, and headaches, which he attributes to the “flu.” When he awoke this morning, he noticed that he had weakness of th eright side of his face. He denies couch, congestion, sore throat, abdominal pain, diarrhea, or any urinary symptoms. He has had a mildly pruritic rash near his waist for the last several days, which he thought was “jock itch.” He’s a trader, married, and monogamous. He recently accompanied his son on a weekend Boy Scout camping trip to NJ, but does not recall any bites or injury. On physical exam, his temp is 100.8F, heart 94, blood press 128/79. He is alert and talkative, and he appears comfortable. He has drooping of the right corner of his mouth and inability to elevate his eyebrow on the right. His conjunctivae are clear, and he has no oral lesions. His neck is somewhat stiff when passively flexed. His chest is clear, and his heart rhythm is reg w/o murmurs. He has a 10X6cm raised erythematous annular plaque with partial central clearing at his waistline (fig 23-1). He has no joint swelling or erythema, and except for the facial weakness, he has no focal neurologic deficits. Dx? Nxt step?
Lyme disease, probably early disseminated stage// Lumbar puncture to evaluate for meningitis and look for antibody production against Borrelia burgdorferi.
