TEST 38

QId: 2819
32yoF
weakness, tingling, and numbness of her extremities.
K 2.9
Cl 88; Bicarbone 37
pH 7.56
Q = likely cause of pt's condition?
A = Self-induced vomiting

-------
why: urine chloride; metabolic alkalosis....
sline responsive met alk = low urine chloride & vol contraction (corrects w/saline infusion alone)

Saline-unresponsive metabolic alkalosis (ss: urine chloride >20)****

Medicine - Renal, Urinary Systems & Electrolytes

QId: 3085
DIURETIC ABUSE ?? water excretion & electrolytes....?dehydrated, wt loss, orthostatic HoTN,
hyponatremia, hypokalemia

Young woman + dizziness dt ORTHOSTATIC HYPOTENSION

abnml serum & UA: hyponatremia, hypokalemia, hypochloremia, & increased UA Na & K.
DIURETIC ABUSE

Na: 73 (~20)
K 68 (5-15)
Q = likely etio of pt's sx?
A = Diuretic abuse

increased excretion of water & electrolytes by kidneys results in dehydration.

----wrong:
*low caloric intake causes wt loss 2/2 wasting....elevated UA Na K not seen.
Medicine - Renal, Urinary Systems & Electrolytes

QId: 3322
Systemic Sclerosis

49yoF swelling & stiffness of hands

intermittent episodes of pain & bluish discoloration of fingers...exposed to cold

Takes PPI & LISINOPRIL**** for htn.

exam: puffiness of hands & skin thickening in fingers
lung: bibasilar fine inspiratory crackles
Q = which tests is likely to be positive?
A = anti-topoisomerase I antibodies

1
ss: skin telangiectasia, sclerodactyly, finger ulcers, calcified skin; joint pains, msk pains. esoph
dysmotility, dysphagia, dyspepsia; raynaud

dx = antinuclear antibody; anti-topoisomerase abx; anticentromere

risk: interstitial lung dz; pulm art HTN. kidney: htn, scleroderma renal crisis (oliguria, plt low,
MAHA) heart fibrosis, pericarditis; effusion

-----
*anti-smooth msk abx a/w autoimmune hepatitis.... LFT ? hepatosplenomegaly, cirrhosis, liver
failure
Medicine - Rheumatology/Orthopedics & Sports

QId: 3325
Tetanus prophylaxis

stepped on nail
additional interventions for tetanus prevention is appropriate in pt?
A = single dose of Tdap vaccine

-------
Medicine - Infectious Diseases

QId: 3575
Lateral Epicondylitis (tennis Elbow)
dt: noninflammatory angiofibroblastic tendinosis @ extensor origin....caused by repetitive,
forceful wrist extension

exam: tender @ lateral epicondyle & pain w/passive flexxion or resisted extension @ wrist.

Elbow Pain.....vague, achy pain at left elbow radiates to forearm; airport baggage handler

Elbow held in extension, passive flexion @wrist cause pain**

Q = diagnosis?
A = Lateral epicondylitis
--------

wrong:
*Olecranon bursitis dt repetitive pressure or friction on elbows

*Radial tunnel syndrome - cause posterolateral elbow pain...similar to lateral epicondylitis;

EXTENSION @ wrist = weakness...pain w/supination resistance of forearm
Medicine - Rheumatology/Orthopedics & Sports

QId: 3910
QT Prolongation...risk for syncope, ventricular arrhythmias, sudden cardiac death

6yoM congenital deafness....comes after fainting. Suddenly dropped to ground.

2
h/o for BL cochlear implantation @age 2 for sensorineural hearing loss.
EKG shown....
Q = which is for pt?
A = Propranolol and pacemaker

QT prolongation:
acquired: E-lytes (hypocalcemia, hypokalemia, hypomagnesium)
Acquired: medication-induced (antibiotics -eg: macrolide, fluoroquinolones) psychotropics (eg:
antipsychotics, TCAs, SSRIs); opioids (methadone, oxycodone); antiemetics (ondansetron);
antiarrhythmics (quinidine, procainamide, flecainide, amiodarone, sotalolol)

------
wrong:
*
Pediatrics - Cardiovascular System

QId: 4101
AORTIC REGURGITATION

20yoF routine physical exam. no sx.

exam: early diastolic murmur at left sternal border best heard w/expiration.
Carotid pulses are normal bilaterally, no bruits.
Q next step management?
A = Echocardiogram

Diastolic & Continuous murmurs

further eval: transthoracic echo
Midsystolic murmurs in young, asx adults are benign.

------------
Medicine - Cardiovascular System

QId: 4204
ANTERIOR CORD SYNDROME:.....complication of aortic aneurysm repair
Spinal cord infarction ? neuro exam: flaccid paraplegia & loss of pain sensation over lower limbs
(UMN spasticity & hyperreflexia...develops over days to weeks)
BILATERAL deficits

Bladder (urinary retention) & bowel dysfunction....resulft from autonomic dysfunction.

DC: vibration & proprioception preserved @dorsal column of spinal cord

Elderly had SURGERY REPAIR of descending thoracic aortic aneurysm. Weakness in both
lower limbs & urinary retention.

--
wrong:
*Epidural hematoma - NOT COMMON complication of aortic aneurysm

*Lumbar plexopathy - peripheral neuropathy (asymmetrical focal weakness, numbness,

3
paresthesias)

*Ischemic stroke dt right carotid artery atherosclerosis ss: contralateral neuro deficits

*Acute vertebral compression - old men with osteoporosis (MC in postmenopause women)
Surgery - Nervous System

QId: 4304
Calcium high...... Primary HYPERPARATHYROID

Adult
recurrent kidney stones
CALCIUM 10.8***
Parathyroid hormone 800
T score -2.5 at lumbar spine...consistent w/osteoporosis
Q = likely cause of pt's hypercalcemia?
A = Primary hyperparathyroidism

------
Medicine - Endocrine, Diabetes & Metabolism

QId: 4447
Osler-Web-Rendu syndrome
hereditary hemorrhagic telangiectasia (Autosome Dominant)....diffuse telangiectasias (ruby-
colored papules that blanch w/pressure); recurrent epistaxis; widespread arteriovenous
malformations

AVMs in lungs can shunt blood from right to left side of heart, causing chronic hypoxemia, digital
clubbing, & reactive polycythemia.

-----
wrong:
*Polycythemia vera - myeloproliferative disorder causes increased production of all 3 blood cell
lines & splenomegaly. (NO telangiectasias & digital clubbing); median age for pts w/P vera is
60.

*MCCO decreased plasma volume = diarrhea, vomiting, poor oral intake

*Pulm htn & polycythemia ? pulm htn by increases blood viscosity in pulm vessels.

*Carbon monoxide poison decreases O2 that can be carried by blood.... body reflexes by
pushing out 2ndary polycythemia more RBC.

*Lots CO2 (lung conditions) can cause Polycythemia.....but it's not the hypercarbia itself that
causes ?RBC production****
Medicine - Hematology & Oncology

QId: 4562

4
ARDS

76yoM confusion, high fever, decreased oral intake.

Bladder polyp 3 days ago.
on admission: resp failure requires endotracheal intubation & mechanical ventilation

Tidal Volume of 370

R22; PEEP 5; FiO2 70%
CXR: bilateral alveolar opacities***

PaCO2 30; HCO3 21mm

Q next step mgmt?
A = Increase positive end-expiratory pressure
(oxygenation may be improved by INCREASE fraction inspired O2 or increasing PEEP)

IF >60% Fio2 needed to maintain oxygenation.....adjust PEEP INCREASE to reduce Fio2 as

oxygenation improves!
Medicine - Pulmonary & Critical Care

QId: 4649
Acute arterial occlusion
of lower limb....dt thromboembolism in setting of Afib

ss: acute pain, paresthesia, pallor, pulselessness.

(Tingling sensation in his leg...painful)

Lower leg skin mottled & cool to touch

distal pulses of left leg are NOT palpable
Q = meds to best prevent pt's acute problem?
A = Apixaban

Warfarin or non-vitamin K antagonist oral anticoagulants (eg: Apixaban, dabigatran,

rivaroxaban)....should be used to reduce risk of systemic thromboembolism if ppl w/AFib..... to
risk strokes (CHAD2DS2-vasc score >2)
-------
Phosphodiesterase inhibitor (Cilostazol)
treats intermittent claudication
Medicine - Cardiovascular System

QId: 4714
Spleen abscess case: dt Infective Endocarditis...blood spread/seeding...septic emboli to spleen

2 weeks fever, malaise, weakness, unintentional wt loss

Upper abdominal pain.

travels to mexico
smoked 20 yrs....103F
Left lower lung field w/dullness to percussion
WBC 27,000

5
Nph 60%; bands 15%

Images show: left pleural effusion & splenomegaly w/spleen fluid...

Q = Underlying diagnosis in this pt?
A = Infective endocarditis

-----wrong
*Malaria ss: fever, chills, fatigue; anemia, plt low; jaundice

*Hodgkin Lymphoma ss: fever, chills, wt loss. Lymphoma a/w splenomegaly (but doesn't cause
splenic abscess or infarction)

*Lung adenocarcinoma - ss: fever, wt loss, dyspnea, pleural effusion..... mets to liver, bone,
brain, adrenal glands
Splenic abscess is not seen in absence of additional infxn process

*TB ss fever & wt loss. GI TB (mc involves liver, intestine, peritoneum)..... (DOES NOT
INVOLVE spleen)
Surgery - Infectious Diseases

QId: 4848
Bipolar + depression

30sF h/o Bipolar disorder w/psychotic features to eval infertility.

Q = which meds most likely responsible for pt's infertility?

A = Risperidone

moa: blocks dopamine 2 receptors in CNS @tuberoinfundibular pathway....prolactin increases ?

galactorrhea, menses irregularities, infertility

1st gen: Haloperidol, fluphenazine

2nd gen: ripseridone & paliperidone;
2nd gen: aripiprazole & quetiapine

--------
wrong:
*Carbamazepine & Lamotrigine to treat Bipolar disorder & seizures
Carbamazepine ? APLASTIC ANEMIA & SiADH
Lamotrigine ? Rash (mild to Stevens=Johnson sd)

*Lithium = mood stabilizer to treat Bipolar disorder

SE: wt gain, nausea, tremor, polyuria....cause Hypothyroid
Psychiatry - Psychiatric/Behavioral & Substance Abuse

QId: 4875
1yrM

MCV 60
RCDW 13% (nml 11.5-14.5%)

6
Reticulocytes 4% (nml 0.5%-1.5%)
Q = most likely cause of pt's anemia?
A = Thalassemia minor

----
wrong
*folate def ss: macrocytic anemia (MCV >100) & occurs in ppl w/poor diet intake of vegetables
or increased requirements dt chronic hemolysis

*Hereditary spherocytosis dt RBC membrane instability ss: anemia, jaundice, splenomegaly.

Lab: show reticulocytosis, ?MCHC, nml or slight low MCV, nml to elevated RDW &
spherocytosis
Pediatrics - Hematology & Oncology

QId: 10301
22yoM

screened for sexually transmitted STDs check.... had no prior STD screening.
Routine HIV testing
one time testing between age 15-65.

Annual test or more frequent if individuals in high risk groups: men ses men, IVD users, sex
workers, sex partners of HIV positive ppl, h/o of anotehr STD, unprotected sex...porn

A = PREFERRED HIV SCREEN:

HIVp24 and HIV antibodies testing****
Medicine - Infectious Diseases

QId: 11790
Medication induced psychotic disorder ss: onset delusions and/or hallucinations a/w use of new
medication

Steroids (high dose) implicated in new onset psychotic symptoms in pts who have no underlying
psych illness

case:
he sees "evil children" there.... doctor ***added a new oral medication***
Exam: responds to internal stimuli.
Q = likely diagnosis?
A = Medication induced psychotic disorder

-----
wrong:
*Brief psychotic disorder - psychotic ss >1 day -<1month

*Cannabis (marijuana) ss: euphoria, perceptual changes, increased appetite, red eyes, slowed
reflexes, dizziness, impaired coordination
Psychiatry - Psychiatric/Behavioral & Substance Abuse