1. A 65-year-old male comes to the office on a hot summer afternoon.

He complains of blisters and intense itching ait over his body for the past 2 days. He has been having "itchy red swelling all over" for the past 2 months, which he thinks is due to the summer heat. His pulse is 82/min, blood pressure is 140/80 mm Hg, respirations are 14/min, and temperature is 36.8C(98.4F). On examination, lesions are seen on both normal and erythematous skin overflexural areas of the groin, axilla and legs. An image of one of these lesions is shown below. Which of the following is most likely seen with this patient's condition? A. IgG and C3 deposits at the dermal-epidermal junction, B. igG deposits intercellularly in the epidermis. C. IgG deposits in a linear band at the dermal-epidermal junction. D. C3atthe basement membrane zone. E. Intradermal edema with leukocyte infiltration. PICTURE OF A TENSE BLISTER ON THE LEG. The answer is A. its bullous pemphigoid, wich is m/c in elderly pts. causes are u.v.rays,sulfa drugs,penicillamines n frusemide. blisters r tense,at dermo-epidermal jn.on biopsy shows IgG and c3. 2. A 24-year-old woman, who has not conceived after two years of unprotected intercourse, presents because she is concerned she may have endometriosis. This concern has arisen because she has a friend who was recently diagnosed with this condition. Which one of the following symptom profiles is most likely if endometriosis is actually present in this woman? A. Dysmenorrheal from the time of the menarche. B. Dyspareunic C. Menorrhagia. D. Mid-cycle vaginal bleeding. E. No abnormal bleeding or pain. 3. A full-term 6-day-old boy presents to a physician’s office for routine care. He is tolerating breast milk well. He is urinating, defecating, and sleeping normally. Physical examination reveals an alert newborn with mild eczema,good skin turgor, normal refl exes, and a musty odor. His newborn laboratory screen is notable for phenylketones in the urine. What is the best advice to give his parents regarding the boy’s diet? (A) Increase iron (B) Increase niacin (C) Increase phenylalanine (d) Increase tyrosine (E) Increase vitamin D its PKU ans is D (def of Phenylalanin hydroxylase) no conversion of Ph ala to tyrosine… so treatment should be reduced Ph ala in diet and incresed Tyrosine. The musty odour is typical of PKU 4. A 64-year-old female presents with complaints of lesions over her breasts and thighs. She had been experiencing severe pain in those areas prior to developing redness and blisters. Her past medical history is significant for valvular heart disease with atrial fibrillation, ulcerative colitis diagnosed 20 years ago, and a resection of part of her colon. She is a known patient of yours, and four days ago, you started her on treatment for atrial fibrillation with

(Choice D) Pyoderma gangrenosum is an ulcerative skin lesion. thighs. Her pulse is 82/min.0/mm3 Hemoglobin: 7. pancreas and testis. (Choice A) Necrotizing fasciitis is a rapidly spreading infection involving the fascia of deep muscles.4F). Malaise and arthralgia may also be present. you notice well-demarcated lesions with bullae and necrotic changes over her thighs and breasts. and abdomen are commonly involved. venous return and capillary response to pressure. organs such as the gall bladder. 5.antiarrhythmics and oral anticoagulants. He also notes he has had a nonproductive cough for about 2 weeks and has experienced several episodes of drenching night sweats. Few patients require skin grafting.Pyoderrma gangrenosum E. The commonly involved sites are the breasts buttocks. It occurs after trauma or recent surgery. On examination he has several large bruises on his extremities but recalls no injuries. Typically. Cholesterol embolisation syndrome warfarin skin necrosis Warfarin-induced skin necrosis is a serious complication of oral anticoagulants. followed by bullae formation and skin necrosis. It mostly occurs within weeks after starting therapy. followed by bullae formation and skin necrosis. hypertension or distal ischemia following an invasive arterial procedure. The initial lesion is often described as a bite. Warfarin-induced necrosis D. The involved area changes color from pale gray to greenish-black or black. A 56-year-old man presents to his physician complaining of severe fatigue. Pain is the main complaint. buttocks. The breasts. Protein C deficiency is sometimes associated with this condition. (Choice E) Cholesterol embolization syndrome should be suspected in patients who develop worsening renal function.like reaction with a small papule or pustule. respirations are 14/min. He began to feel increasingly tired about 6 months ago. What is the most likely diagnosis? A. there is a history of sudden onset of pain and swelling.8C (98. and rarely. thighs. Educational Objective: Warfarin-induced skin necrosis presents with pain. Vitamin K should be promptly administered in the early stages of the lesion. without any lymphadenopathy. Venous gangrene C. Laboratory studies show: WBC count: 1200/mm3 Neutrophils: 58% Eosinophils: 7% Lymphocytes: 30% Monocytes: 0% Basophils: 5% RBC count: 3. (Choice B) Venous gangrene usually affects the distal part of the limb. small intestine. and abdomen. but believes that his fatigue has been worsening over the past 3 weeks. which progresses to purplish discoloration of the injured area with bullae and serosanguineous discharge. blood pressure is 140/90 mm Hg.5 mg/dL . Heparin should be used to maintain anticoagulation unfit the necrotic lesions heal. appendix. Abdominal examination reveals massive enlargement of both the liver and the spleen. Females are most commonly affected. and warfarin is discontinued if the lesion progresses. and temperature is 36. Livedo reticularis can be seen on skin examination. It is characterized by poor or absent peripheral pulse. The initial complaint is pain. On examination. Necrotizing fasciitis B.

as well as cytoplasmic projections. flatulence. It is an infectious disease caused by bacillus Tropheryma whippelii. Tropical sprue (Choice B) is a chronic diarrheal disease. possibly of infectious origin that should be considered in patients who have lived for more than a month in a tropical area. Intermittent low-grade fever. and myocardial or valvular involvement leading to congestive failure or valvular regurgitation. Crohn’s disease D. chronic cough. His BP is 120/80 mm Hg. abdominal distension and flatulence. PAS positive material in lamina propria of small intestine is a classical biopsy finding of Whipple’s disease.000/mm3 Peripheral blood smear reveals irregular nuclei and cell membranes.8C (100F). and malabsorption with distension. Upon questioning he also describes arthralgias and chronic cough. What is the most likely diagnosis in this patient? A. He also complains of diarrhea with bulky. Small bowel biopsy is done which shows numerous PASpositive materials in lamina propria with villous atrophy. skin hyperpigmentation and a diastolic murmur in the aortic area. most commonly seen in white men in fourth to sixth decade of life and often presents with weight loss. Whipple’s disease E. Tropical sprue C. although associated with malabsortion. Celiac disease (Choice A). foul smelling stools. diarrhea. Also. . Cystic fibrosis Whipple D? arthralgia + fever + diarrhoea with CVS involvement i think this is a classical presentation of whipple PAS positive [5/28/2010 9:53:01 PM] mydoctor: Whipple’s disease (Choice D) is a rare multi systemic illness. Which of the following is the most likely diagnosis? (A) Acute lymphocytic leukemia (B) Hairy cell leukemia (C) Idiopathic thrombocytopenic purpura (d) Infectious mononucleosis (E) Nodular sclerosing Hodgkin’s lymphoma : is it B??? 6. and Temperature is 37. Physical examination reveals generalized lymphadenopathy. Celiac disease B. RR is 18/min. Extra intestinal manifestations include migratory polyarthropathy. and steatorrhea. is not associated with pigmentation and lymphadenopathy. Later stages of disease may be characterized with dementia and other central nervous system findings such as supranuclear ophthalmoplegia and myoclonus.Platelet count: 18. PR is 80/min. Gastrointestinal symptoms of Whipple’s disease include abdominal pain. pigmentation and lymphadenopathy may also be occasionally seen in Whipple ‘s disease. A 50-year-old white male presents to the family physician for weight loss and abdominal pain.

Axillary to rectal temperature difference is not specific for appendicitis (Option C). He has . chronic cough and the biopsy findings in this patient. Laboratory results are: Hb 10. but would not explain skin hyperpigmentation. Rectal exam is positive for some mucus. Vital signs are: PR: 100/min. A 2-month history is too long for acute appendicitis and she doesn’t have any other signs of that disease like rebound tenderness and guarding.6F). Also colon cancer is unlikely in a young patient. fever. RR: 12/min.5lb) weight loss. Educational Objective: Always suspect Crohn’s disease as a cause for chronic diarrhea in a young patient.4F). PAS positive material in lamina propria on small intestine is a classical biopsy finding of Whipple’s disease. It is not associated with arthralgias or skin hyperpigmentation. Educational Objective: Whipple’s disease is a multi systemic illness characterized by arthralgias. Chronic ulcerative colitis Chrons The clinical picture is most consistent with Crohn’s disease exacerbation (Option D). Rectosigmoidoscopy is unremarkable. Ulcerative colitis nearly always involves the rectal mucosa and it usually produces bloody diarrhea (Option E).500/cmm ESR 38/hr ALT 97mg/dL AST 82mg/dL Most likely the diagnosis is: A. Since the last 48 hours the pain has worsened and she has had fever. He states that he has had these symptoms intermittently since 5 years. A 41-year-old male presents to his family physician for heartburn. Colon cancer rarely causes pain unless it is very advanced (Option B). She has had a 2kg(4. Diverticulitis is associated with constipation rather than diarrhea and it usually produces left lower quadrant pain (Option A).. Cystic fibrosis (Choice E) can be associated with chronic cough and malabsorption. diarrhea and abdominal pain.6C(99. Her abdomen is tender in right lower quadrant without rebound. Temperature: 37. Crohn’s disease E. Diverticulitis B. weight loss.. fever and arthralgias. Rectal temperature is 38.2gm/dL WBC 16. Hepatic enzymes could be elevated in Crohn’s disease.Crohn’s disease (Choice C) can be associated with malabsorption. Also.4C(101. Colon cancer C. Acute appendicitis D. BP: 120/70mm Hg. abdominal pain. Abdominal film shows gas in small and large bowel. A 27-year-old Caucasian woman has had intermittent moderate to severe right lower quadrant pain and diarrhea for 2-months. gnawing abdominal pain and diarrhea. every chronic inflammatory disease can result in anemia.

the stenosis is mild.3 and 1.3 cm2. His past medical history is suggestive of chronic renal stones. the stenosis is moderate.0 cm2. if the valve area is between 1.tried H-2 blockers without any relief. the stenosis is mild. (However. P/E: cervix is closed. Duodenal ulcer D.6 and 2.and she was found to have ovarian mass. Biopsy was done. if the valve area is between 0. A normal aortic valve area is >2 cm2. heart failure or co-existent aortic regurgitation.she is not in labour. if the valve area is between 1. which one is the most probable cause of this? A) sensorineural deafness B) recurrent acute supurative otitis media C) otitis extra D) conduction of deafness A pregnant woman in 36 weeks. what is the management? A)induce the next day B) talk to her husband to stay C) refuse her resquest D) admit her and induce when her cervix is ready to labour.7 cm2 constitute severe aortic stenosis. He has an extensive family history of peptic ulcer disease. the stenosis is mild-moderate. this gradient can be abnormally low in the presence of mitral stenosis. the pressure gradient across can be calculated by the modified Bernoulli's equation:Gradient = 4(velocity)² mmHg A normal aortic valve has no gradient. What is the most likely diagnosis in this patient? A.0 and 1.7 and 1. the stenosis is critical. . if the mean gradient is >50 mm Hg the stenosis is severe. The aortic valve area can be calculated non-invasively using echocardiographic flow velocities. Chronic pancreatitis Echocardiogram Echocardiogram (heart ultrasound) is the best non-invasive test to evaluate the aortic valve anatomy and function.6 cm2. and when the gradient is greater than 70 mm Hg. On exam. Gastrinoma C.0 cm2. Using the velocity of the blood through the valve. the stenosis is moderate. areas of less than 0. GERD E. If the mean gradient is <25 mm Hg. He has history of 3 ear infection before. which of the following primary tumor will most likely to metastasize to the ovaries? A) breast B)lung C)liver D)kidney E)bowel 3 year old boy doesn't say any word. Physical exam is unremarkable. If the valve area is between 1. Gastric ulcer B. the stenosis is moderate-severe. she wants to labour now because her husband is leaving in a few days. if the mean gradient is between 25 mm Hg and 50 mm Hg. and it is confirmed that the mass is a metastatic tumor.) Collection A 65 years old woman had abdominal USG. hearing decreased.

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