TEST 39

QId: 2300
Pulmonary Embolism

ss: acute dyspnea & pleuritic chest pain = mc sx.

Hemoptysis; DVT
exam: PE (tachypnea, tachycardia, low fever)

EKG: prominent S in lead I, Q in lead III, inverted T in lead III (S1Q3T3)

AFib (irregular RR intervals, absent P waves, narrow QRS complexes) a/w PE

Low O2 saturation & AFib a/w poor prognosis in PE.

ss: sudden short of breath, pleuritic chest pain, low fever, hemoptysis

-----
wrong:
*Bronchoconstriction (asthma, emphysema) ss: dyspnea, tachypnea, tachyc, low O2 saturation.
+wheeze, pleuritic CP.

*Tamponade ss: dyspnea, tachynpea, tachyc, distant heart sounds, HoTN, alternans on EKG
(not chest pain and hypoxemia)

*Mitral valve stenosis - middiastolic rumble & opening snap at apex on cardiac auscultation

*MI risk factors: HTN, DM, fam hx (yes EKG changes)

vs
Pulm Emboli: pleuritic chest pain on movement, acute resp distress, hypoxia WITHOUT
pulmonary edema, NO EKG changes

tension pneumothorax -sob/pleuritic CP (trach deviate,HoTN)

Medicine - Pulmonary & Critical Care

QId: 2346
Inflammatory Breast Carcinoma = (easy to confuse w/mastitis)
rare aggressive cancer
ss: rapid-onset edema skin thickening w/"peau d'orange" (nipple DIMPLING, fine pitting)

breast: edema, erythematous, painful

ss: itching, palpable breast mass, nipple changes (flattening/retraction) present.
Axillary Lymphadenopathy = Mets

next step
dx = mammogram & ultrasound....then tissue BIOPSY to confirm

case 42yoF, left breast swelling & pain worsening.

h/o mastitis given abx.
exam: breast diffusely warm, erythematous with some DIMPLING.
----

1
wrong:
Infectious process (breast abscess; Mastitis *) dt ss: warm, pain, erythema (common symptoms)
**infxn has FEVER + improves with abx*** (will not see peau d'orange)

*Fat necrosis = ill defined, firm breast mass w/irregular borders. h/o local breast trauma or
surgery. ss: local bruise (NOT diffuse edema and erythema)

*Fibroadenoma - benign, palpable breast mass (young women); Estrogen sensitive

tumor....firm/mobile w/regular borders & spherica
Obstetrics & Gynecology - Female Reproductive System & Breast

QId: 2732
Ventricular remodeling occurs & gradually causes Dilatation of LV with thinning of Ventricle
walls.....can result in CHF

occurs ***weeks to months following a myocardial infarction.

? dilated Left ventricle...thinning walls/scar on anterior wall.
tx = ACE-i will limit ventricular remodeling (pril)
Medicine - Cardiovascular System

QId: 3046
Sarcoidosis

30sF intermittent dizziness & unsteadiness

several near-syncope episodes

episode of UVEITIS 6 months ago treated with topical therapy.

EKG 2:1 atrioventricular block & left bundle branch block
CXR: bilateral midfield lung opacities.
Q = likely diagnosis?
A = Sarcoidosis

why: sarcoid ? cardiac noncaseating granulomas... undiagnosed; surrounding inflammation ?

conduction defects (AV block = MC); restrictive CM (early); dilated CM (late manifestation);
valve dysf; heart failure.

SUSPECT Cardiac sarcoid in young pt <55age w/unexpalined 2nd or 3rd degree heart block
Medicine - Cardiovascular System

QId: 3117
Oxytocin

indications: induction or augmentation of labor; prevent/management of postpartum hemorrhage

SE:
-hyponatremia***; HoTN; tachysystole

Pregnant - preeclampsia
Given magnesium for seizure ppx that was discontinued 24hrs after delivery****
had vaginal delivery complicated by postpartum hemorrhage*** that's treated with BIMANUAL

2
MASSAGE & OXYTOCIN BOLUS & INFUSION.
exam: lethargic, no neuro deficits. mg 6.3mg; sodium 112
Which is most likely cause of pt's seizure?

A = oxytocin toxicity.

why? sodium low

----
wrong:
*mg toxicity - presents: HYPOREFLEXIA, lethargy, HA, resp failure, (NOT SEIZURE)....it stops
seizure****
Obstetrics & Gynecology - Pregnancy, Childbirth & Puerperium

QId: 3193
Galactosemia - newborn or young infant w/failure to thrive, Bilateral Cataracts, jaundice, &
Hypoglycemia
risk: liver cirrhosis & mental retarded

early diagnosis & treat by:

***remove GALACTOSE from diet!!**

recognise:
ss: 2wk gold poor feeding & persistent vomiting. Episode of jerky movements limbs. Lethargic,
irritable, jaundiced.
Large liver & spleen. BL cataracts seen.
Q = consistent with findings?
A = Galactose 1 Phosphate Uridyl Transferase dificiency

----wrong:
*Galactokinase deficiency ss: CATARACTS only

*Uridyl diphosphate galactose 4 epimerase def rarer than (uridyl transferase def above) ss:
hypotonia & nerve deafness**
Pediatrics - Nervous System

QId: 3260
Otitis Externa

teen
ss: right ear pain, pruritus, DC for past week.
swam & surfed daily****

touch ear = pain.

Ear canal purulent & crusty debris. TM nml.
Q = causative bug?
A = Pseudomonas

-------------
*Actinomyces - slow growing, indurated mass forms multiple sinus tracts to skin & purulent DC

3
w/yellow "sulfur granules"

*Fungal otitis (aspergillus)

*Hib, Moraxella, Strep pneumonia = MCCO Otitis MEDIA (not externa)

*Klebsiella = opportunistic infxns hospitalized or immunocompromised

*Proteus -urease anaerobe

Pediatrics - Ear, Nose & Throat (ENT)

QId: 3562
Scaphoid Avascular Necrosis (Snuffbox)

scaphoid fractures = MC carpal bone fractures

- falls onto outstretched hand cause axial compression or wrist hyperextension.

Arterial supply to scaphoid (from radial artery)

case: 23yoM wrist pain....outstretched hand & palm facing down.

exam: mild swelling at dorsum of right wrist.
Max tenderness proximal to base of 1st metacarpal, and pain worsens w/radial deviation of
wrist.
XR: wrist in multiple view reveal no fracture or dislocation
Q = most next step?
A = Thumb spica splint and repeat radiography in 2 weeks

XR of injury is low sensitivity for scaphoid fracture

so**** if negative xray ? do CT scan or MRI wrist to confirm fracture.
Then immobilize it ? repeat image 7-10days.
----
wrong:
*
Surgery - Rheumatology/Orthopedics & Sports

QId: 3787
Sickle Cell disease (african, sickle cell)
Q most common complication?
A = Hematuria****

Hemoglobin electrophoresis
Sickle Cell is hemoglobinopathy AUTOSOME RECESSIVE

ss: *painless microscopic or gross hematuria (from SICKLING of renal medulla)****

*Hyposthenuria (impaired concentrating ability of urine) = ss: nocturia & polyuria**** clue

WRONG: Spleen infarction = not common!

4
Pediatrics - Hematology & Oncology

QId: 4073
Parapneumonic Effusions

-Right pleuritic chestpain

-had pneumonia for 5 days****

chext image: large, loculated right plerual fluid collection

Q = which pleural fluid findings likely in this pt?
A = Glucose 40 pH7.1 pr 4.5

why: Complicated pleural effusion (bacterial pneumonia)...parapneumonia effusion or

empyema....
pleuritic pain despite abx

LOCULATION = walled off pleural fluid

thoracentesis EXUDATE:
-low glucose <60 dt consumed by Nphils & bacteria
-low pH <7.2 dt anaeroobic use of glucose by Nphils & bacteria
-High protein - dt incr microvascular permeability & cell destruction
WBC >50,000
Surgery - Pulmonary & Critical Care

QId: 4114
Histoplasma capsulatum

Midwest: Ohio and Mississippi (maybe northeast)

Soil contaminated w/bat or bird droppings (chicken coops, farm buildings, bird roosts, or caves)

ss presents 2-4wks after exposure w/subacute fever, chills, malaise, HA, myalgias, dry cough

CXR: mediastinum or Hilar Lymphadenopathy with focal, reticulonodular infiltrates.

Histoplasma antigen test: Urine or blood + serology

***granulomas w/narrow-based budding yeasts
tx = Amphotericin B

------
wrong:
*Coccidioidomycosis - arizona UL infiltrate w/ipsilateral hilar LAD....spherules w/endospores

*Intranasal steroids
Medicine - Pulmonary & Critical Care

QId: 4237
Septic Shock

80sF lethargy & confusion

5
smoked 30yrs quit after MI 10yrs ago.
BP 74/48mm; pulse 124/min; resp 24/min
Sacral decubitus ulcer w/purulent DC & surrounding erythema

neuro exam: confused; Na 134; cr 2.2

PWCP: 6mmHg
mixed venous o2 sat 82% (nml 60-80%)
Q = likely be a/w pt's HoTN?
A = Reduced Cardiac Afterload.

septic shock
*decr SVR (reduced afterload) dt peripheral vasodilation
*decr (or low nml) pulm capillary wedge pressure (PCWP) (ie: left atrial pressure) dt capillary
leak ? cause decr preload
*elevated mixed venous oxy (MvO2) saturation dt hyperdynamic circulation (Cardiac output is
incr in response to reduced SVR to keep peripheral tissue perfusion)....inability of tissue to
extract oxygen (risk lactic acidosis from tissue hypoperfusion)
------
wrong:
*decr cardiac contractility have cardiogenic shock LV dysf (MI) = poor pump

*Incr intrapericardial P ? cause obstructive shock dt tamponade.... (incr RA pressure, RV

pressure, PCWP increased....?C.O ? low MvO2
Medicine - Cardiovascular System

QId: 4418
Elderly
SOB, nonproductive cough
ss: fever, HA, sore throat, runny nose 3 days ago. was AT MALL**
CXR: reveals bilateral, diffuse reticular opacities. (interstitial infiltrates)

Q = which is most likely underlying cause of pt's current condition?

A = Influenza virus

ss: abrupt systemic ss (fever, malaise, myalgias, headache) & upper/lower resp (rhinorrhea,
sore throat, nonproductive cough)

----
wrong:
*Group A strep: fever, sore throat w/tonsillar exudates (pharyngitis)....lung involved, rhinorrhea,
myalgias

*Pneumocystis pneumonia: immunocompromise (solid organ transplantation, HIV w/CD4 <200)

*Strep pneumonia, staph aureus, (less common: pseudomonas) ? secondary bact pneumonia in
INFLUENZA infxed pt. ss: high fever, WBC >15,000****, lobar infiltrates; mild wbc?, BL, diffuse
reticular infiltrates on CXR
Medicine - Infectious Diseases
QId: 4807

6
Interstitial Cystitis (bladder pain syndrome)

Lower abdominal pain relieved with urination. Voiding more frequently than usual.
Intercourse if painful.
Exam: lower abdominal pain w/no rebound or guarding.
exam: palpation of anterior vagina wall elicits severe pain.

Leukocyte esterase neg

nitrites neg
bacteria none
Q = diagnosis?
A = Interstitial Cystitis

epi: MC in women; a/w psych & pain disorders (fibromyalgia)

sx: bladder pain w/filling, relief w/voiding****; ?urine frequency, urgency; pain with sex

dx = bladder pain w/no other cause for >6wks; nml UA

tx = not curative, focus on improving quality of life.; behavior modification.; amitriptyline.

------
wrong:
*Cystocele - bladder prolapse into anterior vag wall - vagina pressure, pain w/sex; urine
frequency and urgency, incontinence

*pelvic inflammatory dz = pelvic pain, cervical motion tenderness, fever (NO URINE ss)

*Stress incontinence - leaks urine w/exertion, sneezing, or cough (NO PAIN)

*UA (done to rule out UTI)

Medicine - Renal, Urinary Systems & Electrolytes

QId: 11417
HYPOTHERMIA from cold exposure. ss: BRADYCARDIA and refractory to ATROPINE.....
improves with?
tx = active rewarming. (warmed IV fluids)
Medicine - Poisoning & Environmental Exposure