Q5) Flashcards
A 74-year-old woman is brought to the emergency department after acute onset of abdominal pain followed by syncope. The patient was in an exercise class when she suddenly had pain in the left side of her abdomen, quickly followed by loss of consciousness for 30 seconds. She has persistent nausea, dizziness, and diffuse abdominal pain. The patient had no seizure-like activity, chest pain, palpitations, rectal bleeding, or incontinence. There was no trauma. She was diagnosed with chronic lymphocytic leukemia 5 years ago. Other medical conditions include recurrent infections, atrial fibrillation, diverticulosis, and hypertension. Medications include apixaban, metoprolol, and amlodipine, and she has been taking them as prescribed. The patient drinks 4 glasses of wine daily. She does not use tobacco. On examination, the patient is lethargic, pale, and in moderate distress due to abdominal pain. Temperature is 37.3 C (99.1 F), blood pressure is 80/54 mm Hg. pulse is 120/min, and respirations are 14/min. The abdomen is diffusely tender. Bowel sounds are decreased.
**diagnostic and treatment **
Laboratory results are as follows:
Hemoglobin 8.4 g/dL (10.8 one month ago)
Platelet 120,000/mm
Leukocytes 27.800/mm
Lymphocytes 90%
Which of the following is the most likely diagnosis?
Atraumatic Splenic rupture
- acute onset abdominal pain , shock and acute anemia (sometimes peritonitis signs and referred pain to diaphragm and phrenic nerve to shoulder) as a CLL and apixaban complication- other causes hematologic malignancy, infection (cmv ebv malaria) inflammatory (SLE pancreatitis) , meds like anti coag and gcsf
- Dx: CT: Intra peritoneal free fluid
- Tx- stable catheter angioembolization and unstable (splenectomy emergency
Child stung by bee then and full body hives , difficulty breathy and vomiting and received IM epinephrine. After getting IM dose reeemrgence of symptoms . NBSIM
Give another IM epi
(Can give a total of 3 IM and if doesn’t work give IV epinephrine
18 yo has worsening headaches for the last several months often brought on by physical activity , cough, or straining. Oak. Is usually accompanied by nausea and dizziness
Diagnosis
Complication
Chiari 1- can present as back neck pain , dizziness wosrsened by Vasalva or asymptomatic during child hood
- complication: syriomelia which can present as scoliosis
4 month old boy . At 2 months old diagnosed with cervical lymph adenitis . Ct showed areas of cavitation and cultures grew filamentous, partially acid fast gram positive rod. Immunodeficiency suspected. What test to identify the immune disorder
Flow cytometry assessment of phagocyte oxidative respond (dihydrhodamine 123 is the flow cytometry - rhodamine derivative fluoresces green when oxidation occurs and colorless air respiratory burst is absent
- CGD
Casuales of lichen
Hep c
ACEi and thiazides , BB hydroxychloroqujne
Most common comorbidity associated with afib
Chronic HTN
First trimester infection with Bv. NBSIM
Give metronidazole it’s not teratogenic
35 week GA, with no fetal movement for 24 hours and placenta previa. NSR -130s with moderate variability and no decel. No accelerations after 1 hour of monitoring . NBSIM
Do Bpp and not C-section
- reactive NST (>2 accels within 20 minutes. Reactive NST has a high NPV
- non reactive NST has a high FP and low PPV so need to do either BPP or contraction stress test (this patient can’t do contraction stress test do to the placenta previa or patients with uterine rupture) . IF BPP is low do CS
32 yo female underwent a laparoscopic BTL and they found signs of endometriosis in multiple areas. Menses regular q30dats, cramping relieved with ibuprofen after 1st day; lasts 5 days . NBSIM?
Reassurance and observation- since asymptomatic
A 56-year-old man comes to the office due to burning pain in his foet. The patient initially began exper needles in his toes several months ago, which graduälly worsened to involve the entire foot. Lately, he cramping pain daily in both feet, which is more pronounced at night. The patient has had o chronic medical conditions and takes no medications. He is a construction worker and is frequently expos machinery. He does not smoke but grinks 4-6 beers daily and more on the weekends. Vital signs are within norm imits Physical examination shows loss of bilateral ankle reflex and impaired light touch and vibration sensation in both feet. The remainder of the examination reveals no abnormalities. Hemoglobin A1c and meinylmalonic acid levels are within normal limits. Which of the following is the most likely cause of this patient’s symptoms?
Toxic neuropathy due to alcohol 45%] I thought compressive neuropathy
- peripheral neuropathy presenting as tingling numbness , stocking glove distribution meaning starts at le. May see loss of DTR usually ankle first . Gait ataxia and loss of light touch and prioception
Treatment - dc etoh and give thiamine bc b1 def can lead to neuropathy on its own .
Maybe gabapentin and TCA for refractory pain
Older male with ascites now has abdominal tenderness without rebound or rigity, subtle AMS (can’t do timed connect the numbers test) , low grade fever, bowel loops of small and large with air in colon and rectum, decrease bowel sounds . No n/v/c/d
Diagnosis
Diagnostic
Treatment (prophylaxis and empiric
SBP
- diagnostic : paracentesis ->=250 neutrophils, protein <1, SAAG >=1.1
- ppx- fluoroquinolone and empiric is 3rd gen
- May have signs of paralytic ileus (dialted bowels and decreases bowel sounds
23/40V
REVIEW
9-year-old woman comes to the office due to vaginal spotting and a positive pregnancy test. The patient has no medical ditions, and her only surgery was a cesarean delivery 8 years ago. The patient was seen 2 days ago for vaginal spotting had a quantitative -hG level of 3,033 ml/mL. Transvaginal ultrasound at that time showed a thickened endometrial with no intrauterine pregnancy or adnexal masses. Today, she continues to have vaginal spotting but no pelvic pain or ping. Vital signs are normal. Pelvic examination shows a minimal amount of dark red blood in the posterior vaginal The quantitative -CG level today is 3,582 mlU/mL, and the results of a repeat ultrasound are unchanged from the us findings. Diagnostic dilation and curettage is performed and examination of the intrauterine contents reveals benign etrial tissue and no chorionic villi. Which of the following is the most likely cause of this patient’s presentation?
Ectopic pregnancy
- next step after urine HCg are they stable if yes do TVUS - if see adnexal mass ectopic confirmed, if see intrauterine it’s normal pregnancy , if non diagnostic like patient check Bhcg again. If <3500- recheck in 2 days and if >3600 recheck and do TVUS again in 2 days
No chorionic bili so not an intrauterine pregnancy, mole, or spontaneous aborto
Man accidentally amputated thumb with saw. Best way to transport the thumb?
In cases of traumatic amputation, the amputated part should be transported by wrapping it in saline-moistened gauze, sealing it in a plastic bag, and placing the bag in a bath of ice water. Cooling of the amputated part prolongs the window for replantation.
27140
REVIEW
A 2-year-old boy is brought to clinic by his parents for a routine well-child visit. He
Acal conditions and is
growing and developing appropriately. The patient is starting to put words into sho
sleeps well at night. His
diet consists mostly of cheese and yogurt. He drinks approximately five 8-oz cups (11851
Chole cow’s milk each day.
Two months ago, the patient’s family moved from Greece to the United States. He has no allergies and immunizations are up to date. Height and weight are at the 25th percentile. Temperature is 36.7 C (98.1 F). The conjunctivae and mucous membranes are pale. The lungs are clear to auscultation bilaterally. Cardiac examination reveais tachycardia and a 216
Systolic murmur along the left upper sternal border. Complete blood count
Hemoglobin
8 g/dL
Mean corpuscular volume 70 um?)
Erythrocytes
3.1 million/pL
Platelets
260,0001
Leukocytes
8,200/mm
What additional findings?
Elevated RDW- children who consume >24 oz/day of cows milk daily are at risk of IDA
- tachycardia and flow murmur because increased CO to compensate for the lack of oxygen carrying capacity of iron deficient RBC
Ulcerative skin lesion developed form a single papule (central eschar)and tender regional lymphadenopathy over the past week.
In an animal control officer. Lymph node aspirate shows intracelular gram negative coccobaccilli.
Diagnosis
Treatment
Francisella tularemia - handling wild animals infected by tick or mosquito
- other causes of ulcerated lesion and regional lymphadenopathy-a—-Sporothrix and Bartonella henselae
Pasteurella - facultative Intra cellular gram. Negative coccobacullus , cellulitis occurs within 24 hours and no lymphadenopathy
