TEST 42

QId: 2634
Myasthenia Gravis

30F intermittent episodes of double vision

-ss: during dinner 2months ago.
no associated eye pain or redness
vision was nml the next morning

pupils are 3mm, round, reactive to light. Pt has no ptosis, ocular movements are normal.
Found antibodies directed against nicotinic receptors on the motor endplate.
Q = most appropriate next step in management of pt?
A = CT scan of the chest

causes of exacerbations:
meds: abx: FQ, AG; anesthetics: NM blocking; cardiac meds: Beta blockers, procainamide;
taper immunosuppressive meds; pregnancy/childbrith

Dx = bedside: endrophonium (tensilon) test, ice pack test; Acetylcholine receptor antibodies
(specific); CT scan of chest to eval for THYMOMA

----
wrong:
*cerebral angiogram - in ischemic stroke however,Cerebrovascular disease unlikely in young pt
w/fluctuating diplopia & positive acetylcholine receptor antibodies

*Cr phosphokinase CPK (checks polymyositis, statin-induced myopathy)...weak

shoulders/thighs; pain/tenderness.
Medicine - Nervous System

QId: 2754
Rough, dry, scaly skin.
Winter months
a/w mild itching but no erythema or exudates
pic image:
Q = diagnosis?
A = Ichthyosis Vulgaris

*chronic, skin: diffuse dermal scaling; simple dryness

-----wrong:
*Ichthyosis have atopic dermatitis, can aggravate ss.
Atopic dermatitis cause patchy

*Impetigo =acute skin infxn Staph & strep

erythema papules; vesicles; pustules w/honey-colored crusting

*irritant contact dermatitis - from exposure to irritating chemicals: soaps, detergents, solvents

*Psoriasis: silvery scales on extensor surfaces of elbows, knees, scalp, trunk

1
Medicine - Dermatology

QId: 3195
Bruton agammaglobulinemia

15month old boy....4 Episodes of otitis media & 2 episodes of lobar pna
WBC 8,000; lymphocyte 2,000
Immunoglobulins
IgG 80; IgA 31mg; IgM 11; IgE 18mg
Q = diagnosis?
A = Bruton agammaglobulinemia

low serum immunoglobulins....& few B lymphocytes

ss: recurrent sinopulmonary (acute otitis media, pna)

GI (salmonella, campylobacter)
-----
wrong:
*Common variable immunodeficiency CVID - teen

*DiGeore triad ss: T-cell def, congenital heart dz, hypocalcemia

Impaired T-cell production lead to deficient cell immunity (recurrent viral & fungal infxns)

*SCID: severe combined immunodef. by impared T-cell devel & B-cell dysfunct.
Pediatrics - Allergy & Immunology

QId: 3613
Pneumocystic pneumonia PCP & cytomegalovirus (CMV)
ss: fever, malaise, progressive dyspnea on exertion, dry cough, abdominal pain, watery
diarrhea.

Renal transplantation 6 mo ago.

plt 118,000; wbc 3,800
alkphos; alt/ast 1402
CXR = BL interstitial infiltrates
Q =likely cause of pt's current condition?
A = Cytomegalovirus

receiving solid organ transplantations...prevents organ rejection

systemic immunosuppression...= risk for opportunistic infxns

ppx for PCP (TMX-SMX) & CMV (valganciclovir)

Lung sx: (dyspnea on exertion, dry cough)

GI sx: (abdominal pain, diarrehea, hematochezia)
pancytopenia, mild hepatitis, interstitial infiltrates on CXR
CMV invades tissue (pneumonitis, gastroenteritis, hepatitis)**

-------
wrong:

2
*Cryptosporidium - cause diarrhea in immunosuppressed pts usually doesn't involve lung

*Legionella ss: high fever >102.2, GI ss: diarrhea, lung ss....( NOT BLOODY DIRRHEA!!) CMV
mor common than legionella

*mycoplasma: HA, fever, sore throat, cough (doesn't causeGIss

Medicine - Infectious Diseases

QId: 4416
SLE (pancytopenia dec RBC, WBC, plts)

African American woman..... diffuse joint pain & rash on face.

Hb 10.8
Plt 60k; wbc 2,500
Q = likely cause of thrombocytopenia in pt?
A = peripheral destruction

imm destroys all 3 cell lines.

BM bx done on SLE ppl to r/o other causes.
---
wrong:
*Hypersplenisms = sequesters RBC in spleen then destruction of cells. = pancytopenia &
splenomegaly.

*Invasion of BM - in leukemia & lymphoma...can occur in SLE

*Dilutional thrombocytopenia - occur in massive blood transfusion needs more packed RBC
transfusions...(have no plts)

*Ineffective hematopoiesis refers to RBC breakdown in BM before release into circulation

MC in thalassemias & myelodysplastic sd....not SLE.
Medicine - Hematology & Oncology

QId: 4417
Nocardia
-immunocompromised pt has systemic ss, lung nodules, brain abscess (cause seizures), cx
grows gm +ve...partially acid-fast, filamentous, branching rods.

ss: wt loss, fever, night sweats

CXR: nodules often cavitations

nocardia disseminate from lungs to other organs....(Brain & skin MC)

tx = TMP-SMX****
if @ brain = tx: carbapenems

---wrong:
*Actinomyces - tx pcn G

*Mycobacterium TB (acid-fast rods)...WILL NOT Gram Stain

3
*voriconazole = DOC for aspergillosis
Medicine - Infectious Diseases

QId: 4527
mva.
HoTN. has brusies over chest, collapsed neck veins bilaterally.
CXR: large left hemothorax & a widened, rightward deviating mediastinum
Q = diagnosis?
A = aortic injury

ss: rapid deceleration blunt chest trauma = risk for aortic injury... minority of pts w/aortic injury
have an incomplete or contained rupture

*Containe rupture.
AMS common

dx = upright chest xray....aortic injury - widened mediastinum, large left-sided hemothorax,

deviation of mediastinum.... disrupted nml aortic contour.

confirmed via CT scanning

tx = aortic injury includes antihypertensive meds
---
wrong:
*esophageal rupture follows blunt trauma is rare. ? pneumomediastinum & pleural effusion.
confirm w/water-soluble contrast esophagography

*myocardial rupture, death quick.... rupture contained by pericardium...? cardiac tamponade -

muffle heart soudns, HoTN & JVD

*Myocardial contusion - ss: tachycardia, new BBB or arrhythmia a/w sternal; sternal fracture.

*Diaphragm rupture ss: abdominal pain

Surgery - Cardiovascular System

QId: 4669
IV drug use or recent incarceration
+ ss: fatigue, fever, wt loss, cough
CXR: diffuse reticulonodular patter (millet seed)

40yoM nonproductive cough...2 months fatigue, intermittent fever,decreased appetite. Loss

13.2lb.
Q = diagnosis?
A = Tuberculosis

-----
wrong:
*Hodgkin dz ss: painless LNpathy & B sx: fatigue, wt loss, night sweats, mediastinal mass

4
*Mets disease to lung: multiple masses; lymphagitic carcinomatosis (have reticulonodular
appearance)
(fevers...uncommon in mets cancer); multiple rf for TB

*Mycoplasma pneumonia - subacute fever, lung ss: reticulonodular pattern on CXR. (doesn't
cause ss for 2months)...most cases are limited to 2-3wks
Medicine - Infectious Diseases

QId: 4738
3.5cm infrarenal abdominal aortic aneurysm in elderly man.
h/o htn, DM2. meds: thiazide.
smoked 1-2packs of cigs/day.
BP 160/90.
Q = which is a/w highest rate of aneurysm expansion & rupture in pt?
A = active smoking

strongest predictors of Abdominal Aortic Aneurysm expansion & rupture are large Aneurysm
diameter...rapid expand rate, current SMOKING. size >5.5cm.
----
wrong
*htn has a weak a/w AAA formation & its rate of expansion and rupture.
Medicine - Cardiovascular System

QId: 4772
Massive Embolism (h/o mets cancer....HoTN, shock)

Elderly
BP 80/40mm
Upper & lower limbs cold & clammy
RAP 18 (nml 0-8mmHg)
Pulm artery pressure 43/21mm (nml 15-28/5-16mm)
PCWP 9mm (nml 6-12mmHg)

Q = diagnosis
A = pulmonary embolism
----
wrong:
*Aortic dissection cause syncope...doesn't affect heart hemodynamic.....unless complications:
pericardial tamponade.

*Hypovolemic shock (or vol depleted)...have low Intravascular vol causes decreased RA, PA,
PCWP....SVR is increased to maintain adequate perfusion to vital

*LAD cause anterior MI...can lead to cardiogenic shock; increases PCWP, decr CO, incr SVR

*Septic shock...leads to peripheral vasodilation & decr SVR....low BV to heart cause decr RA,
PA, PCWP (CO incr tissue perfusion)
Medicine - Pulmonary & Critical Care

5
QId: 8815
Postnasal drip, GERD, Asthma account >90% of chronic cough in nonsmokers
Tx = inital empiric: first generation antihistamin CHLORPHENIRAMINE or brompheniramine &
pseudoephedrein

30s...hacking nonproductive cough, frequently at night.

Liquid Dripping into back of throad.
No runny nose, chest pain, heartburn, difficulty breathing, wheezing.
Q = best inital management for pt?
A = oral first-generation antihistamines

*recent URI...mainly @night w/o expectoration

best diagnostic approach:

= oral first generation antihistmine (chlorpheniramine) or combined antihistmine -decongestation
(brompheniramine & pseudoephedrine)

Pt do not respond after 2-3weeks requires more investigation (sinus imaging, pulmonary
function tests, high-resolution CT scan of chest) or empiric sequential therapy for GERD, cough-
variant asthma, chronic sinusitis, non-asthmatic eosinophilic bronchitis
Medicine - Pulmonary & Critical Care

QId: 8871
Refeeding syndrome (chronic starvation & acute refeeding....life threatening in ppl w/anorexia
nervosa)

17yoF - purging behavior, wt loss, syncope

2nd day of admission. SOB & recurrent episodes of ventricular tachycardia
K 2.1
Q =Surge in which hormones best explains pt's deterioration?
A=Insulin

why: carb ingestion...IV or enteral...causes pancreatic insulin secretion & cell uptake of
phosphorus, K, Mg
(can potentiate cardiac arrhythmias)
Pediatrics - Endocrine, Diabetes & Metabolism

QId: 10904
Meningococcal vaccination

Regular schedule (vaccinate @11-18age)

-primary vaccination @11-12age
-Booster at age 16-21 (if primary vaccination at age<16)

High risk pts (vaccinate even if age >18)

-complement deficiency, asplenia
-college students in residential housing (age <21); military recruits; travel to endemic
area...exposure to community outbreaks

6
18yoM had Crohn disease 3yrs ago.... on methotrexate & adalimumab.
Miningococcal polysacchardie vaccine @age 11
Received all childhood vaccines prior to taht.
Q = vaccines should be recommended for pt?
A = Meningococcal booster dose

----
wrong:
*Live-attenuated vaccines....receive tumor necrosis factor (antagonists -adalimumab)
Medicine - Infectious Diseases

QId: 11894
Panic Disorder

32yoM
sudden heart pounding, SOB, Chest pain, dizziness, shaking.
Episodes last about 10mins.
Pt fears having episodes....
Extensive w/u...found nothing wrong.
Q = likely diagnosis?
A = Panic disorder

*make it difficult to differentiate panic disorder from a somatic symptom disorders

---
wrong:
*deveopment of a neur sx is inconsistent w/recognized neuro disease

*Depersonalization/derealization disorder...should not be diagnosed when ss occur only during

panic attacks that are part of panic disorder

*Illness anxiety disorder - excessive anxiety about having or acquiring a serious ilness....
multiple somatic ss
Psychiatry - Psychiatric/Behavioral & Substance Abuse

QId: 12056
Ectopic preganancy

-32yoF...abdominal pain & nausea began 2 days earlier

she was diagnosed w/"heart shaped uterus" 2 yrs ago.
BP 90/55mmHg.
UA preg test positive.
transvag US shows gestational sac @upper left uterine cornu & free fluid in posterior cul-de-
sac.
Q = next step management?
A = Surgical exploration

rf: previous ectopic preg/pelvic/tubal surgery, pelvic inflammatory dz

ss: abdominal pain, amenorrhea, vagina bleeding; hypovolemic shock in ruptured ectopic

7
pregnancy; cervical motion, adnexal or abdominal tenderness; Palpable adnexal mass

dx = positive hCG; transvag U/S

tx = stable: Methotrexate; Unstable: surgery

-acute abdomen (eg: guarding w/decreased bowel soudns) likely dt hemoperitoneum from a
ruptured ectopic pregnancy in let uterine cornu

aka cornual or interstitial ectopic pregnancy

uterine anomalies (bicornate "heart shaped" uterus)

---wrong:
*D&C performed to remove uterine contents for spontaneous or incomplete abortion.

*methotrexate tx STABLE ectopic preg

Obstetrics & Gynecology - Pregnancy, Childbirth & Puerperium

QId: 12204
Tardive Dyskinesia

(involuntary movement disorder a/w dopamine-blocking agents)

-moa: dopamine D2 receptor upregulation & supersensitivity results from chronic blockade of
dopamine receptors

Man....sticking out tongue, smacking his lips, twisting body from side to side....
h/o schizoaffective disorder treated w/risperidone
Q = likely underlying cause of pt's sx?
A = Dopamine receptor supersensitivity

Tardive Dyskinesia - prolonged exposure to dopamine blocking agents....results in upregulation

& supersensitivity of dopamine receptors.
----
*Chronic use of dopamine receptor-blocking agents like antipsych...a/w upregulation
Psychiatry - Psychiatric/Behavioral & Substance Abuse

QId: 12284
Fetal Growth Restriction

38wks gestation w/contractions & spontaneous ROM w/green fluid

*elevated 2hr glucose tolerance test 6 weeks after that delivery but did not follow up afterwards.
BP 150/90mm
Pt delivers 4.8lb girl.
exam: infant appears thin w/loose skin & large anterior fontanel
Placenta is meconium stained & umbilical cord is thin.
Q = step management?
A = send placenta for histopathologic examination

-placenta HISTOPATHOLOGIC EXAM: check for infarction/infection (spirochetes)

8
wrong
*intraventricular hemorrhage: gestation age <30wks at delivery (resp distress) tachypnea,
grunting & HoTN

*
Obstetrics & Gynecology - Pregnancy, Childbirth & Puerperium