2mo infant is exclusively breastfed. What nutritional supplement? Correct Answer: Oral VitD to prevent
rickets
What HTN drug causes peripheral edema, flushing, dizziness? Correct Answer: CCB eg nifedipine
15yo girl with recurrent candida infections of skin and mucous membranes since childhood. Dx? Correct
Answer: Chronic mucocutaneous candidiasis (T cell dysfunction)
57yoM with impotence for 1 year rand bronze colored skin. Ferritin concentration is 4050 NG/ml.
Increased risk for what complication? Correct Answer: 1. Liver (primary organ)--hepatocellular
carcinoma
2. Others: pancreas (DM), heart (CHF), skin, thyroid (hypo), gonads, joints (arthritis)
87yo's daughter: "we want my mother to receive hospice care at home but no one wants her to die at
home. Can she still have hospice services?" Correct Answer: Yes. Hospice can provide home based care
and attempt to transfer the pt to another site before death.
32yoF with 4d of fever with lymphatic obstruction. PE: the left lower extremity is diffuse lay red and
edematous from just below the knee to the ankle, with a sharp demarcation separating the
erythematous area from the normal skin at the knee. The erythematous area is painful and
hyperesthetic to touch. The left oral nodes are enlarged and painful. Dx and cause? Correct Answer:
Erysipelas
- usually caused by group A strep
- Tx: IM or oral penicillin/erythromycin
16yo girl with painful genital lesions or 2d. Lots of sexual partners. Exam shows two 3x3mm ulcerated
lesions on the anterior vaginal vault. How prevent transmission with new partner? Correct Answer:
Consistent condom use (NOT pharmacological treatment)
37yo primigravid at 25 weeks' gestation with confusion for 12 hours. Fever and intermittent nausea and
vomiting over the past 2 weeks. No contractions, but decreased fetal movement. Family Hx of T1DM,
seizure disorder. T 38.8, P 168/min, BP 187/84. Mildly enlarged thyroid gland. Lungs clear. 3/6 systolic
ejection murmur. Fetal heart rate 182/min. Labs show: Hb 9.9, platelets 282k, Serum: Na 134, Cl 94, K
2.9, Thyroid-stimulating hormone 0.01, AST 33, LDH 112, Uric acid 5.4. Dx? Correct Answer: Thyroid
storm
- Precipitants: infection, DKA, stress (childbirth, trauma, surgery, illness)
- Sx: fever, tachycardia, agitation, confusion, GI symptoms (n/v/d)
- Tx: supportive therapy with IV fluids, cooling blankets, glucose; PTU ever y2h, follow with iodine; beta
blockers to control HR; dexamethasone to impair t3 from T4
37yo F with 4-month history of numbness, burning, and tingling of the toes and soles of her feet. 3-year
hx of recurrent mouth sores. Numerous oral apthous ulcers, genital ulcers, and several 2.5-cm red
,lesions over the left anterior tibial region. Photophobia. Ankle reflexes are absent. Proprioception and
sensation to pinprick and vibration decreased in lower ext. Dx? Correct Answer: Behcet syndrome
- autoimmune vasculititc disease
- Sx: recurrent oral and genital ulcerations (usu painful), arthritis (knees, ankles), eye involvement
(uveitis, optic neuritis, conjuncitivitis), CNS involvement (intracranial HTN, meningoencephalitis), fever,
wt loss; erythema nodosum-like lesions, pseudofolliculitis
- Dx: bx
Tx: steroids
*NOT polyarteritis nodosa
- can be associated with hep B, HIV, drug reactions
- Sx: fever, wt loss, myalgias, abdominal pain (bowel angina)
- Dx: bx; elevated ESR and pANCA
- Tx: corticosteroids (if severe, cyclophosphamide)
87yo F with fever for 1 day. Urinary catheter was placed 2 weeks ago. Has dementia, Alzheimer type,
and is unable to communicate verbally. T 37.8 C, P 86/min, BP 120/74. Mucous membranes are moist
and pink. Urinalysis shows: Color cloudy brown, Ph 8.8, Blood 2+, Glucose negative, Protein 2+, RBC
numerous, wbc 20-25, Nitrites 3+, leuk esterase 3+, bacteria many. Gram stain shows gram-negative
bacilli. Which would have prevented? Correct Answer: Use of incontinence briefs instead of the
catheter (NOT changing catheter daily)
32yo M with AIDS with 1-week history of T to 40 C and cough. Current medications include trimethopim-
sulfamethoxazole and three antiretroviral agents. Moist crackles over right lung base. X-ray of the chest
shows an infiltrate in the right lower lobe. Causal org? Correct Answer: Stretococcus pneumoniae (NOT
Pneumocystitis jiroveci b/c taking prophylactic oral bactrim)
77yo F with lesions on her left arm for the past 2 months. Underwent modified radical mastectomy of
the left breast for breast cancer 20 years ago complicated by chronic edema of the LUE. Two r-mm,
raised, hard, purple lesions just above the left elbow. Dx? Correct Answer: Lymphangiosarcoma
- rare malignant tumor which occurs in long-standing cases of primary or secondary lymphedema. It
involves either the upper or lower lymphedematous extremities but is most common in upper
extremities.
57yo F with 2-week history of progressive jaundice and a 5-kg weight loss. Dark urine and pale stools. No
meds. BP 120/80. Gallbladder palpated in the RUQ. Urine dipstick is positive for bilirubin.
Ultrasonography shows a dilated gallbladder and dilated intrahepatic and extrahepatic biliary ducts. No
calculi. Next step? Correct Answer: CT scan of the abdomen (Obstructive jaundice due to carcinoma
head of pancreas)
- Courvoisier's sign: palpably enlarged gallbladder which is nontender and accompanied with mild
painless jaundice, the cause is unlikely to be gallstones.
(NOT Lap Cholecystectomy)
One hour after splenectomy, 42yo M has severe shortness of breath. Additional injuries include left rib
and pelvic fractures. T 36.3, P 133/min, BP 80/60. Breath sounds are absent on the left. Bowel sounds
are absent. Next step? Correct Answer: Needle thoracostomy (pneumothorax; severe)
NOT CXR
, 67yo M with alcoholism. 15-year history of poorly controlled hypertension; takes hydrochlorothiazide,
not compliant. BP 170/102. Funduscopic examination shows arteriovenous nicking and tortuosity of the
arteries. Risk for? Correct Answer: MI
- hypertensive retinopathy: AV nicking and tortuosity of the arteries
NOT subarachnoid hemorrhage
32 year old woman with 1 month of diarrhea, 8lb weight loss, three to four semiliquid stools daily. No
fever, abdo pain or rectal bleeding. Just returned from scuba diving in Mexico 6 weeks ago. Boyfriend is
symptom free. Abdo and rectal exam are normal. What is organism? Correct Answer: Giardia lamblia
NOT V cholerae (up to 15 stools per day)
37yo F from Guatemala with joint pain, swelling, and stiffness of her wrists and hands for 2 years.
Ibupforen ineffective. No fever, cough, or weight lossl. Received all immunizations. BMI 20. Spleen tip is
nontender and is palpated 4 cm below left costal margin. Grip strength is decreased. Labs: Hb 10,
Leukocyte count 2.5k, Platelets 125k. Cause of the leukopenia? Correct Answer: Felty syndrome
- disorder that involves rheumatoid arthritis, a swollen spleen, decreased white blood cell count, and
repeated infections. It is rare.
37 yr old woman, sudden onset fever 7 days after splenectomy for ITP. T 102.4, mild distension and
diffuse tenderness, no rebound, rigidity or guarding. No bowel sounds. Labs hg 9.8 Leuks 21,300 Platelet
105, 000, amylase 124. chest xray shows left pleural effusion. what is the most likely cause of the
findings? Correct Answer: subphrenic abscess (Post-splenectomy subphrenic abscess, phrenic nerve
impingement cause refered shoulder pain, abscess fits the Fever, Increase Leukocyte count)
NOT pneumonia
3yo girl with fever and ear pain for 1 day. Has had clear nasal discharge and cough for 3 days. History of
several ear infections and one episode of streptococcal pharyngitis over the past 12 months. Father
smokes in the house, family has two cats. Swims frequently. T 38.5, P 110/min, BP 80/50. Clear nasal
discharge, erythema and bulging of the right tympanic membrane, and erythema of the throat without
exude. Recommendation to prevent recurrence? Correct Answer: Avoidance of passive smoke exposure
sensitivity Correct Answer:
62yo M with fatigue for 9 weeks. Drinks moonshine. HCT 29%, MCV 78, and mean corpuscular
hemoglobin concentration is 25%. Blood smear shows hypochromic, microcytic erythrocytes and
normochromic, normocytic erythrocytes. Bone marrow shows greater than 10% normoblasts containing
iron-laden mitochondria that surround the nucleus and appear as rings on Prussian blue staining. Iron
and transferrin saturation increased. Cause? Correct Answer: Sideroblastic anemia
- caused by abnormality in RBC iron metabolism
- hereditary or acq (drugs eg INH, alcohol, chloramphenicol; exposure to lead; neoplastic disease)
- Labs: increased serum iron and ferritin, normal TIBC, ringed sideroblasts in bone marrow
- Tx: remove offending agents; consider pyridoxine
NOT hemochromatosis
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