Q2 Flashcards
A 56-year-old man comes to the emergency department with right leg swelling. He noticed the swelling yesterday and has not had injury to that leg or a recent fall. The patient has no chronic medical conditions and takes no medications. On review of systems, he endorses frequent nosebleeds and occasional gum bleeding, which began recently. He has also had persistent hagging epigastric and back pain! The patient has lost 4.5 kg (10 lb) over the past 3 months despite no change in diet or activities. He has smoked a pack of cigarettes daily for 30 years. The patient does not use alcohol or illicit drugs.
Temperature is 36.9 C (98.4 F), blood pressure is 110/80 mm Hg, pulse is 96/min, and respirations are 16/min. Chest examination is unremarkable. Mild epigastric tendemess is present. There is moderate, asymmetric right lower extremity edema. Peripheral pulses are full and symmetric. Further evaluation is most likely to reveal which of the following?
A. Antiphospholipid-antibodies
B. Consumptive coagulepathy
C. Cryoglobulinemia [20%]
D. Inherited activated protein C resistance
E. Thrombeangitis-obliterans
Consumptive coagulopathy - chronic Dic due to a malignancy (pancreatic cancer) . PTT, PT, platelets, fibrinogen tends to be normal but high ddimers and hight risk of thromboembolism (LIKE DVT which this person has hence unilateral leg swelling
A 5-year-old boy is brought to the emergency department due to an chronic medical conditions, but he had nasal congestion, sore throa blood pressure is 108/66 mm Hg. pulse is 110/min, and respirations oropharynx is unremarkable, and the neck is supple with no lymphadd the abdomen is soft and nontender. There is no hepatospionomegaly.
along the lower extremities and trunk
Complete blood count
Hemoglobin low
Reticulocytes 0.1%
Platelets low
Leukocytes low
Serum chemistry
Creatinine normal
Urinalysis
•Protein none
Leukocyte esterase. Neg
Nitrites neg
Red blood cells many
Casts none
Which of the following is most appropriate in management of this patient?
A. Abdominal ultrasenography
B. Bone marrow evaluation
C. Intravenous immunoglobulin therapy
D. Plasma exchange
E. Renal biopsy
F. Serum complement levels
Bone marrow evaluation- pancytopenia and reticulocyets are low ; possibly aplastic anemia or leukemia
4/40
REVIEW
A 20-year-old woman comes to the emergency department in January due to severe myalgias, fever, headache, and nausea that developed 4 hours ago. She has also had several episodes of nonbloody amesis over the past hour. The patient was feeling well this morning before her symptoms started. She does not use tobacco, alcohol, or illicit drugs. The patient has no known medication allergies. Temperature Is 40.3 C (104.5 F), blood pressure is 100/70 mm Hg, and pulse is 115/min. She is confused and has difficulty concentrating. Lung examination is normal. There is marked tenderness to palpation of the muscles along her extremities, which are mottled and cool to the touch. Complete blood count reveals a White blood count of 28.000mm° with 12% bands. A noncontrast head CT is unremarkable. Which of the following is the pest next step in management of this patient? Treatment
A. Discharge home with symptomatio-management-only
B. Give intravenous fluids- and antiemetics. hold-for-observation
C. Order CT chest-with contrast
D. Perform lumbar puncture
O E. Send rapid influenza test and discharge with oseltamivir if positive
** Perform lumbar puncture **
Meningococcal meningitis
- sxs (initial- headache, fever, myalgia, sore throat and within 12-24 hours: petechiae/ purpura, AMS, meníngeas signs
Diagnostic; LP and blood cx
Treatment : Ceftriaxone to patient and droplet precautions
Chemoprophylaxis to close contacts: rifampin, ciprofloxacin, ceftriaxone
A sS-year-old man is brought to the emergency department after a witnessed seizure 1 hour prior. The patient lives in a group home and was observed by the staff to suddenly become stiff and unresponsive during lunch. He was then noted to have brief jerking movements of his arms and was lowered to the floor. The patient regained consciousness after 1-2 minutes.
Medical history includes schizoaffective disorder with multiple hospitalizations for psychotic and mood episodes beginning at age 22. Vital signs are within normal limits. On physical examination, the patient is awake and alert. A 1-cm laceration is noted on the right side of the tongue. Musculoskeletal, cardiopulmonary, and neurologic examinations show no abnormalities. Serum chemistry is normal. ACT scan of the head reveals no abnormalities. Which of the following medications most likely contributed to this patient’s presentation? other adverse effects
A. Buspirene
B. Carbamazepine
C. Gitalopram
D. Clozapine
E. Phenelzine
CLOAZAPINE
- tonic clinic seizures( May or May not be dose dependent and can occur at any dose, myocarditis, neutropenia/agranulocytosis
Clozapine adverse effects
CLOAZAPINE
- tonic clinic seizures( May or May not be dose dependent and can occur at any dose, myocarditis, neutropenia/agranulocytosis
A 55-year-old man is hospitalized after a massive hemorrhage from a duodenal ulcer. The bleeding is stopped with endoscopic manipulation. The patient receives 2 L of intravenous fluids; followed by 2 units of packed red blood cells. Two hours after the transfusion is started, he develops chills and malaise. Temperature is 38.7 C (101.7 F). biood pressure is 120/76 mm Hg. pulse is 100/
min, and respirations are 20/min. The tränsfusion is stopped, and the patient is given acetaminophen. Direct antiglobulin and plasma-free hemoglobin level tests are negative. Urinalysis is within normal limits. The symptoms resolve within 6 hours of transfusion discontinuation.
Which of the following is the best procedure for preventing this type of transfusion reaction?
O A. Careful cross-matching of blood
O B. Infusing-ealeium gluconate
O C. Premediating-with diphenhydramine
O C. Premedicating with diphenhydramine [21%]
O D. Using a leukoreduced blood product
O E. Warming the -blood-precuet
Using a leukoreduced blood product - febrile non hemolytic transfusion reaction
A 24-year-old woman comes to the office due to episodic sweating, palpitation, and tremor for 3 weeks. , The
symptoms typically occur aftor sho skips moals and aro rolloved by oating carbohydrate-containing (ood
The patient has
had no abdominal pain, weight change, or excessivo urination. Three months ago, she was diagnosed with diabetes mellitus. and treatment with insulin dogludes was started. Sho refuses to monitor glucose levels at home. Medical history is notable for chronic pancreatitis resulting from acult-onset cystie fibrosis, the patient has no other organ involvement from this disease. Her only other medication is oral lipase for pancreatic exocrine Insufficioncy. Examination shows no abnormalities BMI is 24 kg/m°, Laboratory results show a hemoglobin A1c of 7.5% and serum creatinine 61 0.75’mg/diL, which of the following is the primary contributor to this patient’s symptoms?
•
A. Decreased-olearance-ofinsulin
B. Depleted hepatic glycogen stores
C. Glucagon deficiency
D. Malabsorption-of nutriente
E. Upregulation of insulin-receptors in the peripheralissues
Glucagon deficiency
- CF caused pancreatic exocrine insufficiency and destroys beta cells leading to pancreatogenic diabetes (also would have damage to alpha cells so no glucagon)
- insulin taken is unopposed
Management of binge eating, anorexia, bulimia
Anorexia -CBT, nutritional rehabilitation, olanzipine if they don’t work
Bulimia -CBT, nutritional rehabilitation with SSRI (FLUOXETINE)
Binge eating - CBT, behavioral weight loss therapy , SSRI (maybe sertraline) or Lisdexamfetamine
A 28-year-old woman comes to the office for evaluation of nipple discharge. The patient has had bilateral yellow nipple discharge for the past month. She has gained 5 lb (2.3 kg) in the past year. The patient has had no missed menses, and her last menstrual period was 2 weeks ago. She takes sertraline for anxiety and depression. The patient’s mother had breast cancer at age 59. She does not use tobacco, alcohol, or illicit drugs. BMI is 29 kg/m. Blood pressure is 122/74 mm Hg and pulse is 78 /min. On examination, there is dense breast tissue with ho palpable dominant masses. The breasts are nontender and the nipples have bilateral white-yellow crusting. There is no axillary or clavicular lymphadenopathy. The remainder of the physical examination is unremarkable. Urine pregnancy test is negative. Laboratory results are as follows:
Prolactin, serum 15 ng/mL
..
TSH
3.8 wU/mL.
Which of the following is the best next step in management of this patient?
A. Bilateral-core needle biepsies
B. Cytolegy-of the diseharge
C. Discontinue sertraline
D. Mammography
E. MRIefthe-pituitary
F. No additional management indicated
Nada
Physiologic nipple discharge- bilateral plus non bloody and normal breast exam (Check TSH AND PRL AND OR MEDS to see if cause of galactorrhea
Pathological- pathological discharge feature (unilateral or bloody) or nipple discharge plus an abnormal breast exam
DO imaging . If less than 30 do mammogram, if 30-39 mammogram and maybe US, >40 mammogram AND US
Pregnant women with HG and 110lb and below prepregnancy weight . Pt at greatest risk for
FGR or preterm delivery
A 24-year-old primigravida with a twin pregnancy at 30 weeks gestation comes to the emergenty department due to severe opigastric and right upper quadrant pain. The patient first developed the pain yesterday morning after eating breakfast. She look acetaminophen and an antacid but had no relief. She now has severe stabbing pain, has vomited 7 times today, and continues to have nausea, The patient has no chronic medicat conditions or previous surgeries. Temperature is 37.2 C (99
F), blood prossure is 136/B6 mm Ho, and pulse is 108/min., BMI is 23 kc/m?. Fotal heart rate monitoring shows 2 fetal hear/ rates with baselines of 160/min and moderate variability. The patient appéare pale and has scleral icterus. The abdomen has tenderness to paipation over the right upper quadrant and epigastric region, but no rebound, The uterus is hontender and has
no palpable contráctions.
CBC- low platelets and leukocytosis
Chemistry - cr-1.4, glu- 48
Liver- total bili-5.3, alk phos 170, ast and alt 87/99
Next step in management
Immediate delivery - acute fatty liver of pregnancy
- defective fetal fatty acid metabolism
- hepatic inflammation (RUQ pain, elevated lft
- fuliminat liver failure (hypoglycemia, sclera icterus, hyperbili
- can progress to dic (low platelets and hemolytic anemia and AKI
Management of dehydration in child if mild- moderate vs severe
Mild- moderate - oral (decreased urine output, delayed refill 2-3 seconds , decreased skin turgor
Moderate- severe(sunken eyes , no urine output - isotonic crystalloid (bolus of 20 ml/kg of normal saline IV bolus )
Man with ADPCKD WJRH AN ARTERIOVENOUS FISTULA
AFTERLOAD, preload, CO
AFTERLOAD/SVR- low
Preload, VENOUS RETURN and CO HIGH
- blood gets to the RA faster
29/40
A 35-year-old woman comes to the office with a 3-day history of sore throat. À day after the sore throal started, she developed runny nose and cough. The patient has had difficulty sleeping due to the severity of the cough. She has smoked; pack of cigarettes daily for the last 10 years. Temperature is 37.1 C (98.8 F) and blood pressure is 115/65 mm Hg. Oxygen saturation is 98% on room air. The tympanic membranes are clear and intact. The tonsils are red and without exudate. The uvula is midline. There is no cervical lymphadenopathy. The lungs are clear to auscultation, and the abdomen is nontender
Which of the following is the best next step in management of this patient?
A. Amoxicillin
B. Chest x-ray
C. Strepteceecal rapid-antigen-detectien test
D. Symptomatic treatment only
E. Throat culture
D. Symptomatic treatment only (viral hence rhinorrhea, nasal congestion, cough )
Pharyngitis
- CENTOR criteria — no cough, tonsillar exudates, anterior cervical lymphadenopathy, fever by history
- 0-1 (viral so no testing or treatment for strep infection) SYMPTOMATIC TX
-2-3 (DO Rapid streptococcal antigen test) if positive give amoxicillin or penicillin - if negative do throat culture in kids
-3-4 (DO Rapid streptococcal antigen test) or give empiric amoxicillin or penicillin
31/40 V
A 2-day-old boy is being evaluated in the nursery. The patient was born at 39 weeks gestation
mall
delivery to a 17-year-old primigravida. The pregnancy was complicated by lack of prenatal care uncomplicated, and the patient had Apgar scores of 9 and 9 at 1 and 5 minutes, respectively. He is for
ding well and
has stooled twice but has had only a single wot diaper in the first 48 hours, Weight is 2.89 kg, (6Ib 6 02), down 3% from birth weight. Physical examination is unremarkable. Which of the following is the best next step in the evaluation of this patient?
A. Abdominal-radiegraph
B. Bladder estheterization
C. Continued observation
D. Intravenous fluid bolus
E. Renal and bladder ultrasound Veiding-eysteurethregram
E. Renal and bladder ultrasound - in all babies with oliguria (AKI)
• History and physical examination to evaluate for possible risk factors (eg, nephrotoxins, family history, renal anomaly) and volume status (volume overload vs hypovolemia)
Renal and bladder ultrasound (RBUS), which documents the number, shape, and size of the kidney(s) and detects vascular abnormalities or congenital anomalies, which are particularly concerning in this patient with no prenatal care
nlarged kidneys; however, ultrasound is the pri naging modality because it provides more detailed anatomy of the entire urinary tract and does not involve radiation.
