2 63 y/o man with long standing HTN, hyperlipidemia arrives in office Friday afternoon with chest pain 80 pack-year smoker1 year ago: cardiac cath: 3v CAD, not amenable to CABG/PCI – medical management (beta blocker, ASA, statin)Severe pain centrally, to left arm and back
3 BP 180/110, pulse 90, resp 14, afebrile No CHF, new AI murmurOtherwise unremarkable exam
8 Aortic dissection h/o HTN, “tearing” pain, radiation to back Can dissect into renal / mesenteric / carotid / coronary arteries (presents as acute MI, as in this case)New AI murmur from aortic dilatationPITFALL:no thrombolytics/anticoagulation if dissection suspectedDiagnosis confirmed with ECHO, CT, MRICall CT surgery
9 Objective: recognize the clinical presentation of aortic dissection
10 27 year old man is admitted with chest pain after a rear-end motor vehicle accident 6 days ago belted, 10 mphHistory of HIVOccasional thrush, no other opportunistic infections
12 Tube thoracostomy2. Bactrim for presumed PCPObjective: recognize PCP as a cause of spontaneous pneumothorax in patients with HIV
13 50 year old man is admitted with chest pain Becomes confused, clammyBp 90/58, pulse 106, rr 22Which ABG below would most likely fit the clinical picture?a) /40/100 c) /52/82b) /26/90 d) /28/88Objective: identify the blood gas findings in a patient with acute MI / cardiogenic shock
14 You evaluate a 47 year old woman with chronic kidney disease for hypertension. She has no history of diabetes, no cardiac problems, and other medical problems. She has followed a low sodium diet. She does not smoke or drink alcohol.She is 5’ 8” tall and weighs 230 lbs. BMI is 35.Blood pressure is 158/92, pulse 70. The exam is unremarkable. She appears well hydrated.Creatinine is 3.2, glucose 90, and the remainder of the metabolic panel is normal.Urinalysis shows 2+ proteinuria.
15 Which of the following interventions is most likely to reduce this patient’s risk of requiring dialysis in the future?a) implementing a low protein dietb) starting hydrochlorothiazidec) starting an ACE inhibitord) starting amlodipinee) weight reduction until BMI is ≤ 30
16 Which of the following interventions is most likely to reduce this patient’s risk of requiring dialysis in the future?a) implementing a low protein dietb) starting hydrochlorothiazidec) starting an ACE inhibitord) starting amlodipinee) weight reduction until BMI is ≤ 30
17 ACE inhibitors and kidney disease Clearly reduce progression to ESRD in diabetic patients (especially with proteinuria – micro or macro)Nondiabetic patients have similar benefit:MDRD trialBenazapril trialREIN trialREIN 2 trialAASK trialEven patients with creatinines up to 5.0 mg/dL had reductions in progression to ESRDBe sure the patient is well hydrated, evaluate diuretic use.AARBs – similar antiproteinuric effect, but outcome trials lackingObjective: Rx to limit progression renal disease in a 47 y/o woman w/chronic renal insufficiency
18 64 year old woman with DM II for 20 years, gout, HTN seen in the office No S3, no displacement of PMI, no increased JVD, no ralesHistory of “blood clot,” very high cholesterol (TC 320)Findings below on BOTH legs:Most likely cause of the exam finding?CHFNephrotic syndromeDVTGoute) An overly aggressive GT3 examObjective: identify cause of edema in patients with diabetic nephropathy
19 What are you likely to find on stool gram stain? a) normal flora 35 year old woman with malaise, abdominal pain, diarrhea, nausea/vomitingRecentlyvisited hereWhat are you likely to find on stool gram stain?a) normal florab) large parasites with few eggs, many RBCc) gram positive rods which are germ tube positived) gram positive cocci in grape-like clusterse) the lost colony of AtlantisObjective: understand the most common cause of traveler’s diarrhea and how to identify it
20 You see a 32 year old man in the emergency department for fever, stiff neck and malaise. He has a petechial rash on his ankle. Gram stain of his CSF shows the following:
21 What therapy is warranted for the household family members of this patient? a) no therapy, watchful waiting is appropriateb) Penicillin V-K, 500 mg orally three times daily x 7 daysc) Ciprofloxacin, 500 mg x1 (adults), oral rifampin x 2 days (children)d) meningococcal vaccine, post-exposure dosee) respiratory isolation, culture anterior nares, no therapy
22 What therapy is warranted for the household family members of this patient? a) no therapy, watchful waiting is appropriateb) Penicillin V-K, 500 mg orally three times daily x 7 daysc) Ciprofloxacin, 500 mg x1 (adults), oral rifampin x 2 days (children)d) meningococcal vaccine, post-exposure dosee) respiratory isolation, culture anterior nares, no therapyObjective: recognize drug treatment for the family of a patient with meningococcal meningitis.
23 Meningococcal prophylaixs Indicated for high risk exposure:household contacts>4 hours spent with patient for 5 of 7 days priordorms, barrack roommates, day caremouth-to-mouthProphylaxis regimens:rifampin (600mg q 12h x 4) – there is resistance to rifampin in some areascipro mg x 1ceftriaxone 250 mg IM x 1
24 35 year old man with this finding on tuberculin skin testing: He begins treatment. Which of the following will help prevent symptomatic side effects of therapy?a) Vitamin B12, 1000mcg monthlyb) Vitamin B3, 1 mg dailyc) Vitamin B6, 50 mg dailyd) folic acid, 1 mg dailye) Jack Daniels, nightlyObjective: recall the management of side effects of anti-TB medications
25 You are consulted to see a 72 year old man whose urine output has diminished 48 hours after aortofemoral bypass grafting. He has Type II diabetes and hypertension, and has had claudication for 1 year, which was angiographically confirmed the morning of surgery.He appears well hydrated. Blood pressure is 148/84; otherwise vital signs are normal. There is an S4 on exam, but no other abnormalities. Distal pulses are 1+ and symmetric.Serum creatinine is 2.5 (baseline 1.2).
26 What is the most likely cause of the renal failure? a) contrast-induced nephropathyb) surgical errorc) renal artery thrombosisd) atheroembolism to the renal arterye) post-op MI with congestive heart failure
27 Objective: recognize contrast nephropathy. What is the most likely cause of the renal failure?a) contrast-induced nephropathyb) surgical errorc) renal artery thrombosisd) atheroembolism to the renal arterye) post-op MI with congestive heart failureObjective: recognize contrast nephropathy.
28 He has no other past medical history, and takes no medications. You are called to admit a 50 year old man from the emergency department for obtundation. The family states he has been complaining of fatigue for nine months, and two weeks of vomiting. He has also lost approximately 20 lbs. over the previous two months.He has no other past medical history, and takes no medications.Vital signs:BP 96/60 P R T COn exam, the patient is obtunded but responds to painful and loud verbal stimuli. He grimaces when you palpate his abdomen. You notice dark coloration of his palmar creases.
29 What is the best initial management for this patient? a) Broad spectrum antibioticsb) Vasopressorsc) Glucocorticoidsd) L-thyroxinee) Thiamine
30 What is the best initial management for this patient? a) Broad spectrum antibioticsb) Vasopressorsc) Glucocorticoidsd) L-thyroxinee) ThiamineObjective: Understand initial treatment for a 50 y/o man w/fatigability/vomiting/wt loss/obtunded/brown palmar creases.
31 You see a 65 year old woman with Type II Diabetes who complains of exertional pain in the chest for the past three weeks. The episodes last a few minutes, are not associated with nausea or dyspnea, and resolve either with rest or spontaneously. She has no history of cardiac or pulmonary disease. She now presents with a similar episode of chest pain which has lasted about 35 minutes.Her exam is normal.EKG is completely normal.
32 What is the best initial management for this patient? a) Admission, cardiac enzymes, medical therapy for acute coronary syndromeb) Reassurance, prescribe GI cocktailc) Begin aspirin, schedule outpatient stress testd) Send for CT of the chest with PE protocole) Immediate cardiac catheterization
33 What is the best initial management for this patient? a) Admission, cardiac enzymes, medical therapy for acute coronary syndromeb) Reassurance, prescribe GI cocktailc) Begin aspirin, schedule outpatient stress testd) Send for CT of the chest with PE protocole) Immediate cardiac catheterization
34 EKG in Acute Coronary Syndrome Initial ECG is often not diagnostic in patients with an ACSIn two series,not diagnostic in 45 percentnormal in 20 percent of patients subsequently shown to have an acute MIPatients with history suggestive of ischemia / ACS should be managed as such despite a normal or non-diagnostic EKGObjective: Manage a 64 yo woman w/type 2 DM with 3 weeks of exertional chest pressure and a normal ECG.
35 Vital signs on admission: A 62 year old man with a history of chronic bronchitis is admitted to the hospital with lobar pneumonia. He presented to his physician after one day of cough and shortness of breath. He has no other chronic medical conditions. Baseline arterial blood gas is as follows:pH pCO pO2 60Vital signs on admission:BP 130/ P R afebrilePulse oximetry shows an SAO2 of 84% on room air.He is begun on cefuroxime and azithromycin, oxygen therapy (40% by face mask), and IV fluids.Twelve hours later, he appears somnolent. Arterial blood gas shows the following:pH pCO pO
36 What is the most likely reason for the blood gas findings in this patient? a) Worsening pneumonia; non-responsive to chosen antibioticsb) Antibiotic-induced respiratory depressionc) Exacerbation of chronic COPDd) Reduction in ventilation caused oxygen therapye) Exacerbation of heart failure from excessive IV fluids
37 What is the most likely reason for the blood gas findings in this patient? a) Worsening pneumonia; non-responsive to chosen antibioticsb) Antibiotic-induced respiratory depressionc) Exacerbation of chronic COPDd) Reduction in ventilation caused oxygen therapye) Exacerbation of heart failure from excessive IV fluidsObjective: Understand the cause of blood gas changes in a 62 y/o man w/lobar pneumonia and chronic bronchitis.
38 A 48 year old man with no past medical history complains of six months of pain in his buttocks, especially when walking. He has had no chest pain or shortness of breath, and no leg pain. He is a smoker (1-2 packs per day) since high school but does not drink alcohol. He takes no medications.Review of systems is positive only for erectile dysfunction; he asks you for a prescription for the “blue pill.”
39 Further studies would be most likely to show which of the following? a) Central disc herniation in the L4-L5 areab) A hard, nodular prostate exam with an elevated PSAc) Colonic dilatation on CT scand) Reduced arterial blood flow in the distal legse) Loss of the sacroiliac joint space on plain X-rays
40 Further studies would be most likely to show which of the following? a) Central disc herniation in the L4-L5 areab) A hard, nodular prostate exam with an elevated PSAc) Colonic dilatation on CT scand) Reduced arterial blood flow in the distal legse) Loss of the sacroiliac joint space on plain X-raysObjective: Diagnosis in a 48 y/o man with a 6-month history of pain in the buttocks w/walking and erectile dysfunction.
41 An 80 year old woman complains of fatigue and weakness for the past two months. She has otherwise been in good health, and takes no medications. Her age-appropriate cancer screening is up to date.She appears well but pale. Vital signs are normal. There is loss of vibratory and position sense of both legs.Initial labs show a hemoglobin of 9.0 g/dL; peripheral smear is shown below:What is the most likely diagnosis in this patient?
42 Pernicious anemia Vitamin B12 deficiency Megaloblastic anemia (hypersegmented PMN)MCV often very high (>110)Other cell lines may be affected in severe disease“Subacute combined degeneration of the posterior (and lateral) columns” - neurologic disease not seen with folic acid deficiencyParesthesias, ataxia, vibratory/position senseObjective: diagnose a patient with fatigue / anemia, a hemoglobin of 9, and an abnormal peripheral blood smear
43 You see a patient with knee pain and this joint aspirate You see a patient with knee pain and this joint aspirate. His liver is slightly enlarged and his blood glucose is How do you work up the underlying hereditary disorder?Transferrin saturation (UIBC): Fe/TIBC [HFE gene]DX: CPPD/hemachromatosis (hyperparathyroidism, hypomagnesemia, hypophosphatemia)
44 A 59 year old man with a history of alcoholism is admitted to the hospital for cellulitis. He is coherent, and MMSE is 28/30.Upon admission, his blood alcohol level is 10 mg/dL (BAC = 0.01). He is begun on antibiotics.24 hours later, you are called to evaluate him for “altered mental status.” He is afebrile; no rash is noted. His MMSE is 27/30, and his neurologic exam is non-focal. He describes “spiders” crawling on the walls and on his arms, and thinks he saw his dead mother sitting in the nurses station.WBC is normal.
45 What is the most likely cause of this patient’s change in mental status? a) Delirium tremensb) Vitamin B12 deficiencyc) Acute Wernicke’s encephalopathyd) Alcoholic hallucinosise) Adverse effect of antibiotics
46 What is the most likely cause of this patient’s change in mental status? a) Delirium tremensb) Vitamin B12 deficiencyc) Acute Wernicke’s encephalopathyd) Alcoholic hallucinosise) Adverse effect of antibiotics
47 Alcohol withdrawal syndromes Acute Wernicke’s usually rapid onset after administration of glucose in patients with underlying thiamine deficiencyHallucinosis:usually visual, but may be auditoryNo clouding of sensoriumDTs:Later manifestationObjective: explain the change in mental status 24 hours after admission in a patient with alcoholism
48 You see a 28 year old man with hyperlipidemia You see a 28 year old man with hyperlipidemia. His father, grandfather, and uncle all had coronary artery disease at an early age, and multiple family members have Type II diabetes. He does aerobic exercise regularly.On exam, he appears well. Height 67 inches, weight 180 lbs. (BMI = 28)Vital signs: bp 126/78 p r t 35.9His exam is normal.Labs: TC LDL HDL TG 220You start a statin. In addition to checking liver enzymes in a month, and a fasting serum glucose, what other lab tests would you order?Objective: recognize secondary causes of hyperlipidemia (hypothyroidism - up to 4% of patients with hyperlipidemia).TSH
49 60 year old man, in good health, has a positive FOBT Colonoscopy at age 51 was “normal”Sent for colonoscopy – one polyp is found (pedunculated, hyperplastic by pathology)When is his next colonoscopy due, assuming no abnormal signs/symptoms and negative FOBT in the interval?6 months1 year3 years7-10 yearsDepends upon polyp size
50 Hyperplastic polyps No malignant potential “routine” screening intervalNeed to differentiate from adenomatous polyp (ALL have malignant potential)TubularTubulovillousVillous (highest potential)Sessile polyps – harder to fully remove than pedunculated (but this is simply descriptive, no relation to malignant potential)
51 You are asked to see a 23 year old man, s/p repair of a torn medial collateral ligament, who has become yellow.He is healthy, with no chronic medical problems, no medications, no exposures or travel outside the U.S. Up to date with immunizations. No alcohol or drugs.ROS: recalls similar eye discoloration after “the flu” 2 years ago.Exam: normal except for eye changes above, yellowish skin discolorationHBsAg Anti-HBS Anti HBc HAV ab –AST 40 ALT 36 AlkPhos Bili (T) Bili (D) CBC, Chem 7 normalWhat do you do next?Reassurance, no testingCT abdomenRUQ ultrasoundd) Liver biopsyObjective: recognize common benign causes of hyperbilirubinemia (Gilbert’s)
52 A 22 year old woman is seen for a rash A 22 year old woman is seen for a rash. She was on a camping trip in the Shenandoah Valley one month ago. She has no other symptoms.On exam, vital signs are normal, and the exam is normal except for the rash pictured below:
53 What treatment should be begun? a) doxycyclineb) erythromycinc) dicloxacillind) vancomycin plus bactrime) no treatment warranted at this time
54 What treatment should be begun? a) doxycyclineb) erythromycinc) dicloxacillind) vancomycin plus bactrime) no treatment warranted at this time
55 A 22 year old woman comes to you because she is worried about Lyme disease. One week ago, she went on a camping trip to the Shenandoah valley. On the morning of the second day of the trip, she found a tick on her arm, and removed it with tweezers. She stated it was not easy to remove, but she thinks she removed the entire tick.On exam, vital signs are normal. There is no redness and no signs of retained tick parts at the site of the bite. There is no rash.
56 What treatment should be begun? a) doxycyclineb) erythromycinc) dicloxacillind) vancomycin plus bactrime) no treatment warranted at this time
57 What treatment should be begun? a) doxycyclineb) erythromycinc) dicloxacillind) vancomycin plus bactrime) no treatment warranted at this time
58 Lyme disease Treatment: Evaluation & treatment after a tick bite Early localized (EM): doxycycline, amoxicillin, cefuroxime“more serious disease” (neurologic, cardiac, arthritis): ceftriaxoneEvaluation & treatment after a tick biteRare disease unless tick attached for >48 hoursPatients who meet all guidelines for antibiotic prophylaxis should be treated:Attached tick identified as an adult or nymphal I. scapularis tickTick is estimated to have been attached for 36 hoursProphylaxis is begun within 72 hours of tick removalPatient was in an endemic areaNo contraindication to treatment (single dose doxycycline)
60 Objective: recall the clinical / lab findings in TTP You see a 40 year old woman with fever, weakness, pallor, confusionBlood smear is below:Chem-7:PT 11.6, PTT 28HIV testing is negativeAll cultures are negative104Objective: recall the clinical / lab findings in TTPWhat is the most likely diagnosis?AIHA (autoimmune hemolytic anemia)West Nile meningitisDIC (disseminated intravascular coagulation)TTP (Thrombotic thrombocytopenic purpura)e) Chronic renal failure with sepsis
61 37 year old woman is seen for eye and abdominal pain, and nausea 37 year old woman is seen for eye and abdominal pain, and nausea. Her eye feels hard to the touch.Has this finding:Objective: recognize clinical presentation of acute angle closure galucomaAcute angle closure glaucoma
62 What is the underlying illness? 24 year old woman with acute flank pain, hematuria.History of weight loss, intermittent bloody diarrhea over past 12 months.What is the underlying illness?Has this skin rash:And this urinalysis:Objective: identify extraintestinal manifestations of inflammatory bowel disease (Crohn’s) – Calcium oxalate crystals / nephrolithiasis, pyoderma gangrenosum
63 78 year old man with BPH admitted with anuria. Foley inserted, 2100 cc urine in bladder.Creatinine 4.6EKG:Initial treatment?
64 23 year old nurse sees you for a painful finger: Herpetic Whitlow
66 Which vitamin should NOT be used alone in this patient? Folic acid (folate)
67 To which non-ID specialist should you send this patient immediately: Ophthalmologist (herpes ophthalmicus– nasociliary branch)
68 What immune system dysfunction might be found in this 19 year old man with fever, headache, stiff neck, photophobia, and gram negative diplococci on gram stain of lumbar fluid:Terminal complement deficiency (neisseria meningitidis)
69 What is the antibiotic of choice for this 42 year old man who was bitten by his cat? Amoxicillin/clavulanate (Augmentin) – pasteurella maltocida
70 A 45 year old CDC scientist presents with fever, headache, malaise, vomiting, and this rash: What is her mortality?Variola major: 20-30% if unvaccinated (probably much less if vaccinated – widespread smallpox vaccines stopped around 1972)Variola minor: 1%
78 Sulfa-based antibiotics Contact with children under age 5 18 year old patient developed this rash after treatment for an upper respiratory infection. He is febrile, very fatigued, and has tender lymph nodes in the back and front of the neck. There is a pharyngeal exudate, a few small red spots on the palate, and a slightly palpable spleen tip. What do you advise him to avoid?AlcoholContact sportsSulfa-based antibioticsContact with children under age 5Sex, drugs, Rock & RollMorbilliform rash common with mono after amox/ampicillin, palatal petechiae + exudates virtually diagnostic of EBV.
79 What treatment might be helpful for this patient with malaise, fatigue, anemia, thrombocytopenia, elevated PT/PTT and a positive d-dimer?All Trans Retinoic Acid (ATRA) – PML (M3), associated with DIC. Auer rods seen, t15:17 mutation common.
80 Objective: identify the diagnostic test of choice for cystic fibrosis 19 year old man with weight loss, diarrheaRecurrent “bronchitis”This exam finding:What is the diagnostic test of choice?Objective: identify the diagnostic test of choice for cystic fibrosisSweat chloride – elevation supports diagnosis of cystic fibrosis
81 Objective: recognize TB as a causes of upper lobe pneumonia 48 year old man with cough (bloody), alcohol abuseX-ray:What is the diagnostic test of choice?Objective: recognize TB as a causes of upper lobe pneumoniaSputum for AFB (TB)
83 Objective: recall common causes of meningitis in adults Gram stain shows this organism:During treatment, she becomes confused. What do you do next?Objective: recall common causes of meningitis in adultsLumbar puncture (pneumococcal meningitis)
84 67 year old woman with ESRD has these lesions on exam: What is the most likely finding on lab testing?a) normal PT/PTT, platelet count 25Kb) prolonged PT and PTT, normal plateletsc) PT normal, PTT elevated, platelets 400Kd) PT/PTT normal, platelets 130KObjective: identify lab findings in patients with chronic kidney disease
85 You see a 27 year old woman for an annual visit You see a 27 year old woman for an annual visit. Her blood pressure is 176/88. She is otherwise healthy, no significant family history, no drugs, tobacco or alcohol. Her only exam abnormality is shown on the next slide.
87 You begin working her up for secondary causes of hypertension You begin working her up for secondary causes of hypertension. What would you be most likely to find?Creatinine 4.1, creatinine clearance of 18 cc/hrNa 152, K 2.8, adrenal mass on CTc) Diffuse atherosclerosis of right renal artery on duplex ultrasoundd) Vanillomandelic acid levels of 2,200, metanephrines 1,750 in a 24-hour urine collectione) A “string of beads” appearance in the distal two thirds of the left renal artery on renal angiographyObjective: recognize the most common cause of secondary HTN in young women (fibromuscular dysplasia)
88 You admit a 55 year old, alcoholic man s/p tonic–clonic seizure You admit a 55 year old, alcoholic man s/p tonic–clonic seizure. He is hemodynamically stable, and post-ictal. Chest X-ray findings are below:Objective: understand the antibiotic management of aspiration pneumoniaWhat antibiotics do you begin?ClindamycinMetronidazolec) Amoxicillind) Cefuroxime + azithromycinNo antibiotics, watchful waitingf) GORILLAcillin, 8 grams hourly until rash spreads to entire hospital floor
89 An 80 year old woman complains of fatigue and weakness for the past two months. She has a history of frequent skin infections, which have responded slowly to treatment. Currently, she takes no medications. Her age-appropriate cancer screening is up to date.She appears well but pale. A few petechiae are noted on the posterior pharynx.Initial labs show a hemoglobin of 9.0 g/dL; peripheral smear is shown below:What is the most likely diagnosis in this patient?
90 Myelodysplastic syndrome Malignant hematologic disorder with abnormal / inefficient cell productionInfection common (abnormal WBCs)Anemia, fatiguePetechiae (thrombocytopenia)Classification:RARARSRAEBCMMLRAEB-tPseudo-Pelger-Huet anomaly shown
91 A 19 year old man complains of knee pain for 2-3 months A 19 year old man complains of knee pain for 2-3 months. He recalls a motorcycle accident 3 months ago, where he “layed down his Harley,” and had multiple contusions and abrasions, but did not seek medical care. He has no chronic medical problems, does not use drugs or alcohol, and takes no medications. Review of systems is positive only for occasional “sweating” episodes.On exam, vital signs are as follows:110/ ° CThere is pain with active and passive range of motion of the right knee, but no overlying erythema.X rays show periosteal elevation near the tibial plateau.
92 What is the most likely diagnosis? a) Osteonecrosisb) Avascular necrosisc) Osteomyelitisd) Osteosarcomae) Stress fracture
93 What is the most likely diagnosis? a) Osteonecrosisb) Avascular necrosisc) Osteomyelitisd) Osteosarcomae) Stress fractureCauses of periosteal elevation:OsteomyelitisOsteosarcomaHypertrophic pulmonary osteoarthropathyFamilial pachydermoperiostosisCaffey’s diseaseScurvySarcoidObjective: diagnose a young man with knee pain three months after trauma
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