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If you find an incorrect answer, or an answer that I have not included here, let me know, and I'll make the change. A correct answer means that you correctly selected it on your version and it did not show up in your 'extended feedback.' You can discuss question topics here, or in a separate thread. It’ll take some time to transcribe all the questions, so I’ll continue to edit/update/add questions ove r the next few days. Block 2: Pg 7; Block 3: pg 13
Block 1 part 1 1. 22yo Primi admitted in labor. Pregnancy was complicated by 3 UTIs, the last one at 22 weeks gestation. She’s now taking daily nitrofurantoin. Pt is otherwise healthy. What’s causing the recurrent UTIs? - Urinary Stasis 2. 4yo boy with 3-day hx of cough, fever, runny nose. No wheezing, vomiting, or diarrhea. 75th %ile for height, and 10th %ile for weight. T 37.5. Cap refill is 2 sec. Exam shows clear rhinorrhea. Breath sounds normal. There is a media tab to view the cardiac exam. Dx? - URI 3. 42yo woman with generalized weakness, lethargy, and double vision for 2 weeks. Chest X-ray shows upper anterior mediastinal mass. Dx? - Thymoma 4. 4mo old brought to ER after an apparent seizure. Pt has h as vomiting 6 times over the last 2 days, d ays, feeding poorly, and sleeping more than usual. Pt is lethargic and afebrile. Anterior fontanel is tense, bilateral retinal retinal hemorrhages. Dx? - Child abuse 5. 52yo man with excruciating pain/swelling of his great toe since undergoing appendectomy 10 days ago. Celecoxib has provided no relief. Temp is 37.6. Exam shows red/swelling great toe and tender MTP joint. Most appropriate next step? - Indomethacin 6. During a sports physical, a healthy 14-yo boy has a BP of 150/90. Previous BP checks have been normal. 6 ft 2 in and weights 180 lb. BMI is 24. Exam is normal otherwise. Most appropriate next step? - Repeat BP check in 4 weeks 7. 19yo man brought to ER by police after found standing in his neighbor’s living room in the middle of the night. He is conscious but remains mute during questioning. Temp 37C, respirations 18/min, BP 160/95. Exam shows bilateral nystagmus, constricted pupils, hypertonia, and de creased sensation to pinprick. Substance? - PCP 8. Officer investigates an outbreak of illness at a p icnic. Onset of nausea and vomiting v omiting 3 to 4 hours after attending the picnic. All those affected recover without Rx. Egg salad was the vehicle of transmission. What is the factor most commonly contributing to an outbreak o utbreak of this type? - Inadequate refrigeration of implicated food 9. 2 days after beginning ACTH therapy for MS, a 47yo woman exhibits bizarre behavior. She is easily angered and thinks the nurses are terrorists. She’s been pulling out her IV and walking down the halls at night. Muscle strength in lower extremities is 2/5. On mental status exam, she is fidgety, labile affect, and is easily distracted. Oriented to person, but not place or time. Most appropriate Rx?
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- Haloperidol 10. 50yo F with 5-year Hx of metastatic breast cancer has SOB for 8 hours. Pulse 116/min, resp 32/min, BP 90/60. End-inspiratory crackles heard at base of both lungs. JVD present. Distant heart sounds. ABG shows: pH 7.50; Pco2 28; Po2 78. XR shows cardiomegaly, ECG shows alternating QRS amplitude patterns. Echo shows paradoximal motion of the interventricular septum and a pericardial effusion. Most appropriate next step? - Pericardial window. 11. 14 month boy brought in for well-child exam. Mother is worried because he is not yet walking on his own. He will stand for several seconds before falling. He c an empty raisins from a cup and tries to eat with a spoon. 25th %ile for length and 30th %ile for weight. Exam shows no abnormalities. Most appropriate next step? - Reassurance 12. Asymptomatic 23yo M in for preemplyoment evaluation. Exam shows normal findings. PPD shows 1 6 mm of induration & erythema. He has had no previous PPD tests and hasn’t been exposed to anyone with active TB. XR shows no abnormalities. abno rmalities. Sputum contains no acid fast bacilli. Most appropriate next step? - Treat latent TB now 13. Previously healthy 26yo M in ER with SOB for 3 weeks and painful bumps on his legs for 1 week. T 38.2, P 80/min, BP 140/85. Exam shows 2- to 3-cm tender, red nodules on anterior shins. CXR shows bilateral hilar fullness. Which serum abnormalities is most likely in this patient? - Increased calcium 14. 47yo F with fever, nausea, vomiting, and severe headache for 24 hours. T 39. Exam shows weakness of right upper extremity and nystagmus, optic fundi ca nnot be visualized. Kernig sign is present. Most appropriate next step in diagnosis? - CT of head 15. 47yo F brought to ER 30 minutes after a MVC, unrestrained driver. Severe neck pain and mild chest and abdominal pain. P 95/min, Respirations 20/min, and BP 120/80. Exam shows severe tenderness of the cervical spine at C5. Bruise and mild tenderness ove r lower sternum and upper abdomen. Neuro exam is normal. CXR is normal except for slightly widened mediastinum. Cervical spine XR shows C5 facet fracture. Abdominal XR is normal. Most likely location of the life-threatening cardiovascular injury? - Thoracic aorta 16. 18yo primi at 37 weeks’ wee ks’ gestation admitted in labor. Regular contractions every 3 minutes. Pregnancy complicated by several episodes of genital he rpes, most recent episode 6 weeks ago. ago . No lesions or prodromal symptoms since last episode. Vaginal exam shows no lesions. Membranes are intact. Fetal movement has been appropriate. Cervix 100% effaced, 5cm dilated, vertex at -1 station. Most appropriate next step? - Amniotomy and vaginal delivery 17. 4yo girl with 5lb weight loss during the last 2 months. No Hx of illness, on no medications, immunizations up to date. 50th %ile for height, he ight, 25th %ile for weight. Occasional crackles ove r right middle lung field. Intradermal testing with PPD, tetanus, and antigens for candida and trichophyton is nonreactive at 72 hours. WBC count is 5100. Nucleic acid hybridization testing of gastric aspirates shows TB. Most likely explanation? - T lymphocyte dysfunction 18. 27yo F with 5 day history of headache, severe, diffuse abdominal pain, nausea, vomiting. Pain is exacerbated by eating and relieved by vomiting. Vomitus originally had semisolid content with green fluid,
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and now only contains clear yellow fluid. Hx of Crohn dz treated with prednisone, tapered over the last 2 weeks, mesalamine, and azathioprine. LMP 7 weeks ago. Sex w/ 1 partner, use condoms inconsistently. Temp 38.4, P 120/min, Resp 22/min, BP 90/50. Dry oral mucosa, pale conjunctiva, distended abdomen, diffusely tender and tympanic. Decreased bowel sounds. Pelvic exam is normal. Labs: HCT 31% WBC 15k, amylase 300, lipase 9. Dx? - SBO 19. 37yo F with malaise, muscle aches, painful vulvar blisters, vaginal discharge, and dysuria for 3 days. Had sex with new partner 7 days ago. T 38. Exam shows bilateral painful inguinal lymphadenopathy and numerous 1-3 mm vesicles and ulcers on labia majora and minora, perineum, vulva, mons pubis. Next step in diagnosing these lesions? - Cx for herpes 20. 52yo F with personality change cha nge since death of close friend 2 weeks ago. Irritable, less sleep, speaks rapidly, jumping from topic to topic. She’s had past episodes excessive sleeping, decreased energy, and loss of interest, but never thought these symptoms were severe enough to seek medical attention. Mental status exam shows loud, rapid speech, and a nd flight of ideas. She says she is not sad, but rather uplifted by her he r friend’s death. She hears her friend’s voice and communicates with her. Dx? - Bipolar d/o 21. 6 hours after CABG, 62yo experiences drop in BP from 120/80 to 100/85. Urine output decreases from 60 to 10 mL/h, and cardiac output decreases from 6 to 3 L/min. Pulmonary artery diastolic pressure has decreased . CXR shows widened mediastinum. Most appropriate next step? -? 22. Homeless 66yo M with jaundice for 1 week. Eats irregularly, 20lb weight loss, ove r the past year. 20-year Hx of alcoholism. Icteric sclerae, palmar erythema, and spider angiomata. Serum Mg is 0.8. Serum studies most likely to show? - Decreased Calcium 23. 24yo F with amenorrhea for 7 days. 8-year Hx of anorexia. Compared to other women her age, she has an increased risk for? - Osteoporosis 24. 62yo F with 3-mon Hx of difficulty swallowing solids and liquids, occasionally regurgitates undigested food. Exam shows foul-smelling breath. Most appropriate next step in diagnosis? - Barium Swallow 25. 24yo M with shortness of breath 2 days after ORIF of a midshaft femoral fracture. Abrasions over left anterior chest wall. Initial CXR is normal. P 96/min, resp 24/min, BP 130/74. Exam shows petechial hemorrhages of the conjunctivae and petechiae over the chest and upper extremities. ABG shows pH 7.48; Pco2 30; pO2 56; HCO3 23. CXR now shows fluffy infiltrates in both lung fields. Dx? - Fat embolism syndrome 26. 160yo F brought in by her mom requesting birth control. Mom wants to talk to doc alone because daughter is staying out late, receiving many calls from several different boys, and wear tight clothing and excessive makeup. Daughter confides many details de tails of the dates to her. Father is furious and berates daughter, so mother doesn’t want to tell father about what is going on. On interview, she says she doesn’t doe sn’t know why she is doing this, but would like to understand. Most appropriate n ext step in management? - Family therapy
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27. 82yo F with metastatic breast cancer with low back pain and left thigh pain for 5 days despite taking 5 mg of morphine syrup q4 hours. She S he says morphine wears off after 2-3 hours. She is otherwise tolerating morphine without side effects. Most appropriate next step in management? - Increase the frequency of the dose to every 3 hours 28. 17yo F with 4-month history of persistent rash over face and upper b ack (photo). Which structure is primarily involved in the development of this rash? - Pilosebaceous follicles 29. 42M in ER, 6 hours after onset of severe flank pain. T 37C P 110/min, resp 12/min, BP 130/90. Tenderness over RLQ of abdomen and costovertebral angle. UA shows 50-100 RBC and 3-5 wbc. 2 hours after morphine, symptoms subside. In addition to analgesics, most appropriate ne xt step in management? - Discharge and encourage fluid intake 30. 72yo M with 3 month Hx of difficulty climbing stairs, arising from chair, and combing hair. 4-year Hx of hypercholesterolemia treated with simvastatin. Cranial nerves intact. Tenderness to palpation over UE and thighs. Strength 4+/5 in deltoid, biceps, triceps, hip flexor, and quads. DTR and sensation are normal. Most likely location of the abnormality? - Muscle 31. 72yo F with indigestion while walking uphill or briskly, relieved with rest. Sx are no t related to eating and not relieved by antacids. Most appropriate next step in management? - Exercise stress test 32. 67yo M with 1 mo Hx of recatal bleeding. Passes bright red blood with bowel movements. No other Sx. Hx of HTN and osteoarthritis. Current meds: losartan, metoprolol, amlodipine, and naproxen. Father had colon cancer at age 70 and died at 74. 89yo mother had breast cancer 20 years ago and has survived. 183cm tall, weighs 91kg; BMI 27. Vitals are wnl. Mass palpated in rectum, remainder of exam is wnl. Colonoscopy shows ulcerating rectal mass, bx shows rectal cancer. Review of which clinical study is most useful in developing treatment plan? - RCTs 33. 6mo boy with diaper rash for 3 days. Otherwise healthy. Breast-feeds 6x a day. T 37.4C, P 100/min, resp 25/min. On exam, 2-cm crusted, popular, popu lar, honey-colored lesion with clear discharge in left groin. Most appropriate next step in management is topical application of? - Mupirocin 34. 27yo M and wife unable to conceive for past 10 mo. Wife conceived from previous marriage, husband with no children. Wife’s menses and are normal, an d her exam is wnl. Exam of husband shows ill-defined soft masses palpated bilaterally, high in scrotum. Most likely cause of these masses? - Bilateral varicoceles 35. 9yo boy with low back pain for 4 months, present throughout the day, but most severe when he awakens and after physical activities. Pain described as dull a che. Walks with a stooped gait, but b ut appears well. Exam shows tenderness of right SI joint, paravertebral muscle spasm, decreased flexion at waist. Skin exam normal, CK normal, ESR is increased. XR of spine shown. Dx? - Ankylosing spondylitis 36. 15yo girl with low back pain for 2 mo, dull ache ac he present all day and night, making it difficult to find comfortable sleeping position. Hx of asthma for 2 ye ars treated with prolonged courses of oral prednisone. Cushingoid and hirsute appearance. Tenderness from T11 to L2 and paravertebral muscle spasm. CK and ESR
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wnl. XR shown. Dx? - Compression fracture 37. 6yo boy with cramping abdominal pain & right-sided scrotal pain for 4 hours. Vomited once, Exam shows distended abdomen. BS decreased, and deiffuse tenderness to palpation with involuntary guarding. Right hemiscrotum discolored with swelling & tenderness superiorly. Left hemiscrotum is wnl. Most appropriate next step in management? - Operative procedure 38. 62yo F with SOB for 12 hours. 15y Hx of type 2 DM and 3y hx of chronic renal insufficiency. Meds include insulin and captopril. T 38.2C, P 88/min, respt 16/min, BP 144/70. Exam shows no adenopathy. Inspiratory crackles greater on right than left. Cardiac exam: d iscrete PMI, S1/S2 wnl, intermittent S4. Trace pedal edema. Pulse ox on room air shows o2 sat of 90%. 13,000 leukocytes, creatinine is 2.2. CXR shows patchy infiltrate in right midlung. Rx ith IV ceftriaxone and heparin is begun. She has poor oral intake, and temp ranges from 37 – 38.4C, and BP range from 112/60 to 146/84. Glucose range from 140-320 despite insulin control. 4 days later, Cr is 3.6. What could have prevented renal deterioration? - IV fluids 39. 24yo W with intermittent double vision and drooping of the eyelids for 3 weeks wee ks and difficulty chewing and swallowing for 1 week. Sx worse late in day. Eyelid ptosis worse on the right, weakness of abduction of right eye, adduction of left eye, and eye closure. Weakness of forehead and mouth. Speech is nasal. DTR and sensation are normal. Dx? - decreased acetylcholine receptors 40. 37yo M with progressive weakness over ove r the past 5 days, started at ankles a nkles and spread to proximal muscles of lower extremities, hands, forearms, and face. Mild tingling of feet and fingers. Had URI 2 weeks ago. Exam shows moderate weakness of facial muscles and muscles of extremities and marked weakness of distal muscles of extremities. DTR absent, hypotonia of knees/ankles. SLT and vibration mildly decreased over feet. Dx? - Demyelination of axons? Could be incorrect. Answer is NOT E, loss of motor neurons 41. 32yo F abdominal pain, N/V for 6 hours. Cholesystectomy 2 years ago. Menses wnl, LMP 2 weeks ago. No smoking/drinking. Appears acutely ill. T 37.4 resp 14/min, P 110/min BP 130/70 while supine, p 135 BP 90/60 when standing. Exam: guarding with rebound, BS decreased. Labs: NA 146, K 3.3, Ca 8.9, T bili 1, alk phos: 120, AST 64 Amylase 1022. Most appropriate next step to determine cause is mea surement of? - Triglycerides 42. 4yo boy with fatigue since viral illness 3 weeks ago. Pale for 1 week, gums bled yesterday when brushing. Cervical, axillary, and inguinal adenopathy and hepatomegaly. Hb is 8, leukocytes 3000, platelets 30k. Most appropriate next step in management? - Bone marrow aspiration 43. 1 day after removal of o f large meningioma, 42yo F is comatose, intubated. Groans/moves extremities to painful stimuli. T 37.2, p 96/min, resp 14/min, BP 110/72. Neuro exam shows no focal findings. Labs: Na 155, Cl 120, K 3.6, HCO3 24, urea nitrogen 16, Cr 0.8, Urine specific gravity 1.004. In last 24h, she’s received 2L IV 0.9% saline and had urine output of 6 L. Explanation for the hypernatremia? - Diabetes insipidus 44. 82yo F with visual loss in left eye since awakening. HTN treated with Lisinopril, and takes daily aspirin. Pupils are 2 mm bilaterally and reactive to light. Visual acuity is 20/30 on R and 20/400 on L. Fundoscopic
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exam of L eye shows dilated retinal veins and widespread retinal hemorrhages intermixed with patches of white exudate. R optic fundus wnl. Dx? - central retinal vein occlusion 45. 47yo F with fatigue for 1 week. 10y Hx of type 2 DM Rx with short-acting insulin before each meal needed and 12 U of intermediate acting insulin at bedtime. Over past week, glucose levels >250. BMI 27. T is 38.5C, P 90/min BP 110/70 when supine, P 120/min bp 90/40 when standing. Urine is pos for glucose, neg for protein and ketones. UA shows 6-10 wbc and no RBC casts. Cause of postural hypotension? - intravascular volume depletion 46. 18yo F with 3-day hx of fatigue and yellow eyes. Hx of anemia, but otherwise healthy. 16yo brother also has anemia. T 36.7C, p 82/min, resp 14/min, BP 105/69. Scleral icterus, ex am shows mildly tender 1-cm cervical lymph nodes. Spleen tip palpated 3 cm below costal margin. Hb 8.6, MCHC 38%, retics 8%, Serum T Billi 3. Negative coombs. Blood smear shown. What would have prevented symptoms? - Splenectomy
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Block 2 part 1 1. 37yo M with end-stage Duchenne Duch enne muscular dystrophy. Life expectancy less than 6 months. Patient tells physician that he is “tired of living like this” and requests a DNR with no further antibiotics. antibiotics. He has considered this decision for 3 weeks, but has h as not discussed it with family. On mental status exam, he shows sadness about his health, but has a normal thought process. He expresses no ambivalence about his decision. Most appropriate next step in management? - Determine if patient wants to discuss his decision with anyone else 2. 36yo G1P1 with heavy vaginal bleeding since delivery of placenta 15 minutes ago. Had vaginal delivery of full term 4200g baby after 3-hour second stage of labor. P 110/min, BP 90/60. Fundus palpated 3 cm above umbilicus. No evidence of genital tract injury. Placenta appears complete but torn. Dx? - Uterine atony 3. 57yo F with factor XI and IgA deficiencies is scheduled to undergo resection for colon cancer. Preop HCT is 24% and requires transfusion with 2 unites of PBRC. 3 minutes after beginning the first unit, patient develops severe shortness of breath and urticarial with swelling of tongue and throat. She appears anxious. BP 90/60. Dx? -Anaphylactic transfusion reaction 4. I DO NOT HAVE THIS QUESTION. IF SOMEONE KNOWS WHICH QUESTION I’M MISSING, PLEASE LET ME KNOW! 5. 32yo nulligravid with PCOS trying to conceive for 3 years. Menses occur occ ur at irregular intervals. She is 165 cm tall and weighs 100 kg. BMI is 37. Most appropriate Rx? - Clomiphene 6. 25yo primigravid at 27 weeks week s gestation with severe contractions for 6 hours that hav e not resolved despite changing positions and increasing fluid intake. Small amount of vaginal spotting the last time she voided. v oided. External fetal monitoring shows contractions every 2 – 3 minutes and a fHR of 130/min with no n o decels. Cervix is 1 cm dilated and 10% 1 0% effaced. Fetal presenting part is high. During the next hour, she receives oral hydration. Temp 37.2C, P 110/min, resp 16/min, BP 110/70. Lungs are clear, fundal height is 27 cm. Cervix is now 1 – 2 cm dilated and 70% effaced; vertex at -2 station. Positive GBS culture. Most appropriate next step in management? -IM betamethasone 7. 37yo M with 6-month Hx of SOB and fatigue. SOB after walking 2 blocks. Sleeps 6 hours nightly but doesn’t feel well-rested. No smoking/drinking. Worked as teacher for 15 years. BMI is 59. P 86/min, resp 14/min, BP 146/92. Lungs clear, breath sounds are decreased. Normal cardiac exam. ABG shows pH 7.32, Pco2 56, Po2 70. CXR is normal. Most likely cause of hypoxemia? - Alveolar hypoventilation 8. 27yo asymptomatic HIV positive F requesting a dvice for immunization. All childhood immunizations up to date. MMR 4 years ago, last tetanus vaccine 6 years ago. Hep B antibody was positive 3 weeks ago. CD4 count was 450 3 weeks ago. Which immunization is most appropriate? -Pneumococcal vaccine 9. Afebrile 32yo F with cramping abdominal pain and watery stools for 4 days. Exam is normal. Her Hb is 12.5, and leukocyte count is 8500. Exam of stool shows no neutrophils. Organism? - Enterotoxic E. Coli? Answer is NOT S. Aureus
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10. 67yo M with uncontrollable nosebleed for 6 hours. No Hx of HTN and takes no meds. Smokes 1-2 packs for 45 years. BP is 220/120. Exam shows lesion in left naris controlled with cauterization. Bilateral bruits over flank. Rental arteriography shows 13 cm kidney s with single renal arteries. Ostial lesions of both kidneys that occlude 85% of vessel orifice. After ACE inhibitor, BP drops to 140/80. Mechanism of response? -No cleaving of C-terminal peptides on angiotensin I 11. 62yo F in for resection of ovarian tumor. 25 lb weight loss over past 2 months. Exam shows adnexal adne xal mass, and no other abnormalities. Preop labs: Serum - BUN 80; Cr 5.7; Urine – Glucose none; protein trace; WBC 0-2; RBC 0-2; Casts none; crystals none; bacteria none . Most appropriate next step to determine cause ca use of renal failure? -Renal U/S 12. 57yo F with pain over left groin and anterior thigh for past pa st year. Active range of motion of hip joint reproduces pain. 20-degree hip flexion contracture. ESR is 20; pelvic XR shown; Dx? - Osteoarthritis? Not Osteonecrosis 13. 32yo F with headache, joint pain, fatigue, fever for 2 weeks. 3 weeks ago, she had a bright red rash on right calf for 7 days. No Hx of illness, no meds. T 37.7C. Physical Ph ysical normal except for pain on hyperextension of knees. Neuro exam normal. Positive IgM antibody assay to Borrelia burgdoferi. Administration of which of the following is most appropriate next step to prevent long-term complications of this disease? -Amoxicillin 14. 17yo girl in MVC as unrestrained u nrestrained driver. Arrives on a backboard with C-collar. During a ttempts to administer 100% O2, patient is combative. Facial trauma and open facial fractures. Chest severely bruised. Makes gurgling sounds when she breathes. Most a ppropriate initial step in management? -Cricothyrotomy? Answer is NOT Elevation of bed 15. 52yo F with 5-day Hx of abdominal pain, nausea, decreased appetite. Nine days ago, underwent lap cholecystectomy for stones. Discharged 7 days ago. T 38.2, P 108/min, resp 20/min, BP 102/64. Exam shows jaundice, RUQ tenderness. Bowel sounds present. Labs: Hb 12.2, HCT 36%, Leukocytes 17,200 BUN, 48; Glucose 186; Cr 1.5; T bili 7.2; alk phos 251; AST 84. U/S is normal; Most appropriate next step in management? -ERCP 16. 32yo M with 3-month Hx of burning substernal chest pain and sour taste in his mouth. Sometimes awakens at night with acidic liquid in his mouth. Nonproductive cough for 2 months. Smoked 1 pack daily for 14 years. Drinks 6 beers every week. wee k. BMI 31. Exam is otherwise normal. Most app ropriate next step in management? - Trial of omeprazole therapy 17. 47yo M with 6-month Hx of progressive weakness that began in his right leg and gradually spread to his other extremities. Mild difficulty swallowing solids and liquids. Exam shows atrophy of right quads an d both deltoid muscles and fasciculations in both quad muscles. Babinski sign present bilaterally. EMG and nerve conduction studies are most likely to show? - Fibrillation potentials in multiple muscles of multiple extremities 18. 22yo M exposed to unknown gas, now vomiting and has diarrhea. Pulse 96/min, resp 20/min, BP 115/65. Exam shows miosis, copious oral secretions, rhinorrhea, and muscular fasciculations. Diffuse wheezing bilaterally. Clothing is removed. While being washed, he has a generalized tonic-clonic seizure. Most appropriate Rx? - Atropine
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19. 2 hours after repair of perforated gastric ulcer, 75yo W has multifocal PVCs. Hx of CHF treated with Digoxin and diuretics. Most likely abnormal serum concentration? - Decreased potassium 20. 55yo F with metastatic breast cancer canc er admitted for confusion progressing to obtundation over p ast 24 hours. Barely arousable. Most likely abnormal serum concentration? - Increased sodium 21. 57yo F with HTN in ER for 8-hour Hx of nausea, vomiting, diarrhea, abdominal pain, and weakness. Slight blurred vision, double vision, dry mouth, a nd tingling and numbness of her legs. 32 hours ago, consumed pork, shrimp, rice, and home-canned preserves. 1 week ago, had URI that resolved without treatment. Current meds: Lisinopril and 81-mg aspirin. No smoking or drugs. T 36.9C, Pulse 64/min, resp 16/min, BP 124/72. Pulse ox shows O2 saturation of 94%. Pupils slightly dilated, sluggishly reactive. Mucous membranes are dry. Normal cardiopulmonary exam. Weakness of oculomotor and facial nerves. Muscle strength 4/5 in lower extremities. DTR 2+. Dx? - Botulism 22. 75yo M with confusion and lethargy for 2 days. Was gardening on a 100F day before symptoms. 15-year Hx of DM treated with glyburide and 25-y Hx of HTN treated with HCTZ. Underwent lap chole 6 weeks ago. Smokes 1 pack daily and 2 drinks nightly. Traveled to Hawaii 2 months ago. T 41.5C, pulse 120/min, BP 90/60. Skin is hot and dry but not erythematous. Muscle tone decreased Serum CK is 8000, AST is 400. Cause? -Heat stroke 23. 4yo boy in ER for not using his left arm. No known injury to arm. Comfortable, but resists attempts to move arm due to pain. Holds left UE with elbow flexed and forearm in pronation. No evidence of injury, radial pulses normal. Sensation is full. Most appropriate next step in ma nagement? - Supination of forearm with elbow in slight flexion 24. 37yo F with alcoholism alcoho lism in ICU for pancreatitis. During first 12 hours, vitals: Pulse 100-130/min; resp 2836/min; SBP 90-110. 14 liters of crystalloid solution infused to maintain urine output of 30 mL/h. She is intubated for low O2 saturation. Lungs are clear. Pulmonary cath shows: Cardiac index 4.2L/min; 4.2 L/min; CVP 11; PCWP 10. ABG on FiO2 of 60% and PEEP of 10: pH 7.32; Pco2 38; Po2 78. CXR shows bilateral, diffuse, hazy densities with cephalization of the pulmonary vasculature and perihilar fullness. Dx? - ARDS 25. 43yo M with 3-day Hx of Temp 38.4C, left-sided chest pain, malaise, loss of appetite, and a cough productive of yellow phlegm and SOB. Smoked 2 packs/day for 25y. He appears ill. Pulse 112/min, resp 22/min, BP 118/72. Crackles and wheezes at left base, breath sounds decreased. d ecreased. Increased tactile fremitus and dullness to percussion at left base. CXR shown. Gram neg bacilli and leukocytes on stain. Dx? - H. influenza 26. 32yo F at 16 1 6 weeks’ gestation with 6-hours of fever and waxing/waning consciousness. Only meds is multivitamin with iron. T 38.3C. Neuro exam shows waxing/waning consciousness. HCT is 11%, platelets 52K, Cr is 3.5. Blood smear shows schistocytes. Dx? - TTP
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27. 4 days after right hemicolectomy, 67yo 6 7yo F has leakage of serosanguineous fluid b/w incision staples; the dressing is soaked. Meds include corticosteroids for COPD, T 37.5C, pulse 73/min, BP 140/90 Abdominal exam shows distension with minimal incisional tenderness and no erythema. Dx? - Wound dehiscence 28. Sexually active 24yo M with painful sores on his penis for the past 5 days. There’s lymphadenopathy. No fever/chills. Lesions are shown. Dx? -Genital herpes 29. 22yo F nulligravid for routine exam. Concerned about risk for ovarian cancer because her mother was diagnosed at age 42. Doesn’t know of anyone else in her family who has had acancer. No Hx of serious illness, no meds, Menses normal, no smoking, occa sional alcohol. Sexually active at 16. Uses condoms for contraception. Plays tennis 2-3X a week. BMI is 21. Temp 37C, P 60/min, resp 20/min, BP 100/60. Physical is normal. Most appropriate recommendation? - Oral contraceptive therapy 30. 72yo M with SOB for 3 days. Hx of HTN and CAD. Receiving 2 L/min of O2 via nasal canula. Temp 37C, P 110/min, resp 20/min, BP 150/80. Bilateral crackles and wheezes. HCT is 28%, leukocyte count is 8000. Pulmonary artery cath shows cardiac index of 2 L/min (N = 2.5 – 4.2) and a pulmonary artery occlusion pressure of 28. ABG shows pH 7.49; Pco2 30; Po2 58. Most appropriate next step in management? - Diuretic therapy 31. Over the past 2 years, ye ars, 67yo M with gradually progressive difficulty walking. Good health, no meds. Smoked 1.5 packs per day X 50 years and 3 drinks per night. Wide-based gait and tends to reel from one side to the other. Cannot walk more than three steps heel-to-toe in a straight line. Which wou ld have prevented this condition? -Abstinence from alcohol 32. 15yo boy brought by mother for changes in behavior since he was transferred to new school 4 months ago. He has become withdrawn, poor sleep, daytime fatigue, 10-lb weight loss, declining academic performance. His maternal uncle and grandmother treated for de pression. Denies alcohol or illicit drugs. Physical is normal. Cooperative, but flat affect. Dx? - Major depressive disorder 33. 11yo girl brought by parents for noticeable body odor. 3-month Hx of arguing and acting secretive at home. Exam is normal except for mild facial acne. Sexual development is Tanner stage 2. Mental status exam is normal. Most appropriate next step in management? - Education about puberty for the child and parents 34. 50yo F with Hx of hypothyroidism has tingling in hands and feet and difficulty maintaining her balance over last 2 months. Pale complexion, easy fatigability, and SOB. Labs show megaloblastic anemia. Anormal Schilling test corrected by oral intrinsic factor. What’s causing her anemia? -Atrophic gastritis 35. 12mo boy with 4-hour Hx of temp to 40.6C and a nd irritability. Two previous infections during past 8 months: pneumococcal bacteremia at age of 4 mo and periorbital cellulitis caused by H influenze type b at 7mo. All immunizations were given. LP shows CSF with leukocytes of 500, 95% neutrophils. Gram stain shows gram positive diplococci. Cell type involved in Dx? - B lymphocyte
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36. 12mo boy with persistent S. aureus a ureus abscess despite 2 weeks of cephalexin. cephalex in. 3rd infection since birth, including inguinal abscess with S. aureus, pneumonia and empyema. Cell type involved in Dx? - Neutrophil 37. 6 hours after undergoing left thoracotomy for coarctation of aorta, 10-day-old newborn is fussy and irritable. Sedated and mechanically ventilated. Temp is 37.2C, pulse 160/min, resp 30/min, BP 110/70. Most appropriate next step in management? -Analgesic therapy 38. 42yo F with intermittent loss of urine ove r past 3 weeks. Sx only after voiding. Pelvic exam shows 3-cm, midline, cystic, tender mass in the midthird of vagina. U/A is normal. Posvoid residual volume is 50 mL. Dx? - Urethral diverticulum? Answer is NOT interstitial cystitis 39. 17yo boy unresponsive after using heroin at a party. He is obtunded. Temp is 35.9C, pulse 75/min, resp 6/min, BP 100/60. Administration of which of the following is most appropriate initial step? -Naloxone 40. 27yo male stuck with needle ne edle while drawing blood from patient positive for h epatitis B antigen. Physician was vaccinated against hep B 2 years ago. Labs show adequate antihepB antibodies. Most appropriate management to prevent hep B infection in the physician? - No treatment necessary 41. 32yo M with depression has sensation of insects crawling under his skin for 2 weeks. Initially treated for scabies, but then told he had herpes zoster. Using acyclovir and topical scabies preparation, but Sx have worsened, and he now sees tiny worms crawling out from his skin. Appears anxious but healthy. Scattered excoriations over his face, head, abdomen, and upper and lower extremities. Lesions are punched-out sores on a clean base. Tox screen most likely to show? - Methamphetamine 42. 57yo M with mild left flank pain p ain and intermittent blood in his urine for 3 days. No meds. He appears app ears to be in mild distress. Temp 37.2C, pulse 88/min, resp 12/min, BP 146/94. Mild left costovertebral angle tenderness. Serum Ca is 10.9, phosphorus 2.3, intact parathyroid hormone is 1020 (N=10-65). Ct shows renal calculi bilaterally. Cause of calculi? - Increased urinary excretion of calcium 43. 27yo M brought to ER 30 minutes after a 10minute episode of loss of consciousness; during episode, pulse 45/min, occurred while viewing body of his brother at the morgue. LOC was preceded by sweating and light-headedness. Pulse is 100/min and regular, resp 12/min, BP 140/80. He hasn’t eatin in 14 hours. Dx? - Vasovagal syncope 44. 32yo M brought to ER after syncope while jogging. On arrival, he is alert and conversant. BP is 140/84. Grade 3/6 systolic murmur at LSB, intensity increases when he stands from a squatting position. Explanation? - Hypertrophic obstructive cardiomyopathy 45. 54yo M with weakness and numbness of the left upper and lower extremities for 1 week; he is now asymptomatic. BP is 150/80. Carotid duplex shows 90% stenosis of right internal carotid. Serum cholesterol is 200. Most appropriate management to prevent subsequent stroke? - Carotid endarterectomy 46. 8-hour-old newborn develops jaundice and respiratory distress. Born at 39 weeks’ following
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uncomplicated pregnancy and delivery. He is pale and edematous. Hepatosplenomegaly and scattered petechiae. Labs show Hb of 4, total bilirubin of 15, with a direct component of 0.3. Dx? - Rh incompatibility
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Block 3 part 1 1. 15yo girl with finger pain and swelling for 6 months. Appears well nourished, erythema over the cheeks. Minimal redness, tenderness, and swelling around proximal interphalangeal joints of the hands. Labs show Hb 10.3; leukocytes 2500; C3 27 (N=72-120); ANA positive 1:60; RF negative; Urine blood 1+, protein 4+, RBC 30-50. Dx? - SLE 2. 14yo boy with 6-month Hx of left knee pain exacerbated by activity. No Hx of injury. He has grown 3 inches over the past 6 months. His older o lder brother had similar Sx at the age of 13 years. Normal gait, ROM is normal. Tenderness over left tibial tubercle. No joint effusion, knee joint is stable. Mechanism? - Repeated microfracture at the tendon insertion 3. For 12 hours, 25yo F G2P1 at 20 weeks’ has severe epigastric pain that radiates to the back. Vomited once. Temp 37.8C, pulse 92/min, BP 120/80. Fundus is nontender, fundal height is 21 cm. FHR is 138/min. HCT is 42%, leukocyte 9000, platelets 220k. Most appropriate next step in management? - Measurement of serum amylase activity 4. 21yo primi at 37 weeks’ with mild epigastric pain and moderate headache for 24 hours. Temp 37C, BP 150/98. Fundus nontender, fundal height is 36 cm. FHR is 130/min. DTR are 3+, urine protein is 3+. Most appropriate next step in management? - Measurement of platelet count 5. 3 days after total hip replacement, 50yo M is unable to move his legs and has urinary incontinence. Sx began immediately following removal of epidural catheter inserted for pain control. His meds include ketorolac, enoxaparin, and morphine. Dx? - epidural hematoma 6. 47yo M with 9-mo Hx of constipation and 2-mo hx of o f blood in stool. Sx partially relieved by stool softeners and laxatives. Has hypercholesterolemia rx with atorvastatin, and had appendectomy at age 26. Vitals normal. Cardiopulmonary, abdomen exam normal. Rec tal exam shows external hemorrrhoids. Positive occult blood test. HCT is 35%. Most appropriate next step in management? - Colonoscopy 7. 67yo M with fatigability & generalized weakness for 3 mo and chest ch est pain for 1 mo, which is worse on deep inspiration. He appears slightly pale. Tenderness over left 8th and 9th ribs. HCT 28%. SPEP and UPEP show monoclonal spike. BM biopsy shows greater than 50% plasma cells. CXR shows 1.5cm areas of o f radiolucency in 8th/9th ribs. He's most susceptible to infection with? - S. Pneumoniae 8. 4 CAGE questions are used to screen for alcoholism. If the number of "yes" "y es" responses needed for test to be positive is decreased to one, how will it effect sensitivity sensitivity and specificity? - Increase sensitivity, decrease specificity
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9. 32yo F with asthma and 3-mo Hx of progressive cough. Initially, nonproductive cough every 2-3 days. For the past month, cough occurred daily and has been productive of thick yellow sputum/tinged w/ blood. 1mo Hx of SOB after walking two blocks. Meds include albuterol and budesonide inhalers, used more frequently over the past month. No smoking. Today, in mild resp. distress. T 37C, P 88/min, resp 17/min, BP 110/65. Pulse ox: O2 sat 93%. Scattered end-expiratory wheezes bilaterally with corase rhonchi at bases. Labs: HCT 42%, WBC 10k (67% PMNs, 8% eosinophils, 25% lymphos). platelets 160k, serum IgE 1250. CXR shows linear atelectasis at bases and thickened airways with irregular cystic opacities. Dx? - Allergic bronchopulmonary aspergillosis 10. 62yo M with intermittent painless rectal bleeding for 3 weeks. Hx of angina and taking inhaled corticosteroids for COPD. Smoked 1.5 packs daily for 45 years. Vitals normal. Crackles and wheeze s bilaterally. Heart sounds normal. Rectal exam shows palpable mass 2-3 cm inside anal verge. Anoscopy shows 5-cm ulcerated mass, bx shows adenocarcinoma. Most appropriate next step in management? - Colonoscopy to the cecum 11. 62yo M brought in 30 min after onset of severe chest che st pain. Tearing sensation in midchest radiating to his back. P 104/min, resp 24/min, BP 200/120 in RUE and 180/100 in LUE. Decreased left brachial pulse. Grade 2/6 diastolic decrescendo murmur at RSB. CXR shows widened mediastinum. Most appropriate initial pharmacotherapy? - IV labetalol 12. 37yo F G3P3. Exam shows 3-cm, nontender, fluctuant mass involving left posterior vulva underlying the mucosa of the vestibule and external to the hymenal ring. Dx? - ??? I know the answer an swer is NOT vestibular gland cyst, and probably NOT a bartholin duct cyst (which would be tender) 13. 18yo F with fever, mild nonproductive cough, sore throat, general malaise, and anorexia for 5 weeks. Exudative pharyngitis with a whitish membrane, cervical LAD, and splenomegaly. Dx? - EBV 14. 42yo M scheduled to undergo MRI for hemoptysis and abnormal abno rmal CXR. During MRI, he yells to get out, o ut, and appears pale. No chest pain or SOB, but had tunnel vision and tingling in his fingers while in the machine. Hx of hypothryroidism Rx with levothyroxine and occasional heartburn rx with rantidine. P 10 4/min, resp 22/min and shallow, BP 140/09. No evidence of paranoia. Most appropriate next step in management? - Lorazepam therapy 15. 72yo M hospitalized because of dyspnea for 6 weeks. Hx of type 1 DM and angina. Meds include insulin and warfarin. During past 4 months, was hospitalized o nce for DVT and another time for PE. Exam shows JVD, ascites, pitting pretibial edema. CXR shows mild cardiomegaly and no pulmonary edema. Cause? - Cor pulmonale 16. 24yo F primi at 38 weeks' gestation admitted in labor. Spontaneous ROM 2 hrs ago. Contractions are moderate and occur every 5-6 5 -6 min. Was treated at 20 wks with ampicilin a mpicilin for GBS UTI. Temp 37C, p 82/min, resp 18/min, BP 122/74. Cervix 2 cm dilated and 80% effaced; vertex at -1 station. Most appropriate rx to prevent GBS infection in the newborn? - ?? Answer is NOT 'No prophylaxis indicated' so it might be IV penicillin G
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17. 27yo M with 2-month history of a rash on his face, neck, and torso. Rash began with couple tiny spots, and now there are more than 100. Exam shows 2-8 mm flesh-colored papules with central umbilication over face, neck, back, and chest. Dx with molluscum contagiousum is made. In addition to Rx, most appropriate intervention? - HIV antibody testing 18. 14yo boy with sickle cell trait with 1-day hx of severe pain in left thigh and knee. Unable to bear weight. No swelling, locking, or catching. 6 days ago, twisted his knee playing basketball. Knee XR was taken (shown), and he was was given NSAIDS, ice, and crutches. His sx had improved for 3 days. BMI 32. Temp 37C, BP 110/70. Joint line tenderness tende rness of the knee, no effusion. ROM of left hip limited by pain. WBC 8k, ESR 10. Most appropriate next step in management? - XR of the left hip 19. 70yo F with peeling, pee ling, scaling, and cracking of the right nipple for 2 months. Breast exam shows no masses, and mammography shows no masses or calcifications. Dx? - ?? Not eczema, so I'm assuming it's Paget disease of the breast 20. 40yo F with few drops of yellow discharge from her left nipple while p erforming a breast selfexamination 4 days ago. No spontaneous discharge, only when squeezing. No masses, and mammography shows no masses or calcifications. Dx? - Physiologic discharge 21. 3 hours after repair of leaking AAA, 72yo F has following hemodynamic hemod ynamic findings by pulmonary artery cath: Cardiac index: 1.2L/min MAP: 55 (N = 80-90) PCWP: 30 (N=5-16) CVP: 28 (N=5-8) Pulmonary arterial pressure: 55/35 IV dopamine begun intraoperatively. Surgery complicated by hypotension, metabolic acidosis, and oliguria. ECG shows supraventricular and ventricular arrhythmias, each causing hy potension. Cause of these hemodynamic findings? - Cardiogenic shock 22. 67yo M with aching in the calves while walking during the past 2 months, relieved by rest. Decreased pedal pulses. Symptoms due to narrowing of? - femoropopliteal arteries 23. 16yo girl comatose next to a suicide note. Unresponsive. Temp 37.2C, p 100/min, resp 28/min, BP 100/66. Pupils reactive to light; doll's eye reflex present. Labs: Na 140, Cl 104, K 3.5, HCO3 6. ABG: pH 7.32, Pco2: 12; Po2: 92. What substance had she used in her suicide attempt? - Aspirin 24. 72yo M with decreased UOP 2 days after Rx for cholecystitis. ch olecystitis. UOP has been 15 mL/h for 3 hours. On admission, results showed gram neg bacteremia and DIC. CUrrently receiving IV fluids, cefoxitin, and gentamicin. Temp 38.5C, Pulse 110/min, resp 24/min, BP 90/64. Mild RUQ tenderness. Serum Cr increased from 1.5 2 days ago to 3. Urinalysis findings? - ?? It's NOT A, but could be D: Blood 1+, Protein 1+, RBC 0-5, WBC 0-5, Casts pigmented granular, g ranular, Other microscopic findings renal tubular epithelial cells. ATN due to ge ntamicin.
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25. 27yo primi F at 39 weeks' admitted in labor. spontaneous ROM 1 hour ago. Cervix was 3 cm dilated and vertex at -1 station. Point A on labor curve shown, FHR tracing shows recurrent late decels and decreased variability. Most appropriate next step in management? - Cesarean delivery 26. 24yo F with pain in th eleft hemithorax for 2 days; the pain began after she moved heavy furniture. The pain is worse with inspiration. She has used an oral contraceptive for 16 years and smoked 1 pack daily for 18 yrs. Pulse 110/min, resp 24/min, BP 110/70. Lungs clear, tenderness to palpation lateral to the sternum on the left. Cardiac exam normal. Dx? - Costochondritis 27. Missing this question 28. 37yo F with 1-year hx of irregular menses, occurring at irregular 3-month intervals and lasted for 10 days with moderately heavy flow. No hx of illness and no meds. BMI 24, Temp 37.1C, pulse 70/min, resp 12/min, 1 2/min, BP 90/50. Visual field test shows outer field deficits bilaterally. Milky white discharge from both breasts. Stool for occult blood is neg. Prolactin P rolactin concentration is 40 ng/mL. MRI of the brain shows pituitary microadenoma. Most appropriate next step in management? - Bromocriptine therapy 29. Five days after open splenectomy for ITP, 57yo F has SOB. Only med is morphine. Temp 37.3C, p 80/min, resp 20/min, BP 120/80. Surgical wound appears normal. BS decreased at left lung base. WBC 15.6K, platelets 112k, amylase is 90U/L. Most appropriate next step in management? - CXR 30. 19yo African American man with 9-month Hx of watery diarrhea associated with abd ominal cramps and bloating. Has occasionally had diarrhea after meals since age of 12, but has been worse since he started college 1 year ago. Exam shows no abnormalities. Cause of diarrhea? - ?? Answer is NOT "immunologic damage to the microvilli of the bowl," so I'm assuming it's " Digestive enzym deficiency" 31. 42yo F left eye is red since she awoke 4 hours ago. NO changes in vision and no trauma. NO meds. BP 110/70. Left eye is shown. Visual acuity 20/20 in both eyes, pupils equal and reactive. Most appropriate next step in management? - Reassurance 32. 72yo M for follow-up exam 4 weeks after 10-day quinolone Rx for UTI. Has been drinking 12 to 15 glasses of water daily to prevent another infection. 3 0-year hx of schizoaffective d/o. On Reisperidone. Oriented to person but not to place or time. P 80/min, BP 128/60, with no orthostatic changes. Exam shows dry oral mucosa and no JVD. Lungs clear. No peripherla edema. Muscle strength 5/5, sensation intact. Reflexes 1+ bilaterally. Labs: Na 122, K 4, Cl 94, HCO3 22, BUN 16, Cr 1.1; Urine: blood neg, glucose neg, protein neg, sodium 20, osmolality 200. Cause of hyponatremia? - Psychogenic polydipsia
