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03-31-2005, 01:59 AM
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set 6(Nasi)
few saved q's
[ Follow Ups ] [ Post Followup ] [ Forum 2 ] -------------------------------------------------------------------------------- Posted by img03 from IP 172.161.211.165 on September 07, 2003 at 09:29:29: orbit's q from 276-525 may help u in ur initial prep, Good luck *******************Orbit Qquestions*************************** q435. A 71 yo man with carotid artery stenosis develops severe depression with anergy& hypersomina.The best choice for initial Rx? A:amitriptyline B:doxepine C:nortriptyline D  henelzineE:trazodone Ans: C:nortriptyline elderly pts r often sensitive to the hypotensive,sedative and anticholinergic effects of antidepressants,this pt is at special risk for hypotension bcoz of his carotid artery stenosis,Nortryptiline is least likely to cause these SEs Q An 85yo widow who lives alone presents with weight loss,decreased energy,insomnia and a lack of interest in her usual activities.Her PMH is positive for HTN,AF,urge incontinence and contact dermatitis.She’s taking oxybutynin that she refuses to discontinue bcoz of its effectiveness.With diagnosis of depression and excluding other possible diagnosis,which drug is the best choice for this pt? a:thioridazine b:amitriptyline c:imipramine d:doxepine e:trazodone f:either d or e Ans: e:trazodone trazodone without anticholinergic effects(to avoid cumulative anticholinergic interaction effect with oxybutynin),its sedative SE may also be helpful in managing her insomnia.other antidepressants without anticholinergic effects r:fluoxetine,bupropion if the pt accepts to discontinue oxybutyn in,imipramine a good choice,bcoz its anticholinergic effect could be useful in controlling incontinence Q.A 43 yo woman has depressive rumination,hypersomnia,hyperphagia and a subjective sense of heaviness in her limbs that have not responded to trials of fluoxetine& nortriptyline.The most appropriate next step of management of this case is initiate: A:desipramine B:methylphenidate C:sertaline D:tanylcypromine E:trazodone Ans  :tanylcypromineagain case of MDD with atypical features Q. a 26 yo woman complains of binge eating& chronic depression that becomes worse when she feels rejected.She has not responded to a trial of sertraline.Rx: a:methylphenidate b:fluoxetine c henelzined:ECT Ans: c henelzineMDD with atypical features,may respond particularly well to MAOIs Q. a 54 yo hospitalized woman who has severe recurrent MDD improves dramatically after her first 2Rx with bilateral ECT.after the 4th ECT she's disoriented to the date.The best choice for furthur Rx? a:administer 2more ECT and then initiate antidepressant medications b:discontinue ECT&treat with antidepressant medication c:discontinue ECT until her cognitive status improves and then resume ECT d:initiate a mood stabilizing medication and continue ECT e:switch to unilateral ECT for 4 additional Rx Ans: a:administer 2more ECT and then initiate antidepressant medications the pt is responding well to ECT but needs atleast 2 additional Rx to minimize the risk of a quick relapse.some degree of transient cognitive impairment is common with ECT& often becomes more severe as Rx progresses,but it usually resolves within wk following the conclusion of a course of ECT and in this case doesn’t preclude 2 additional Rx.After conclusion of Rx,antidepressant usually continued for 6mo to lessen the chance of relapse. unilateral ECT less effective&often reserved for pts at special risk for severe cognitive compromise like elderly indivisuals,not indicated in this case! Q. Atropine is administered before the sessions of ECT,why? Ans: atropine is administered 30min before each session of ECT to reduce oral secretions that may interfere with airway maintenance& to reduce the postconvulsive bradychardia caused by vagal stimulation. Q. Which condition is not associated with abnormal maternal alpha-FP levels? A:maternal liver disease B:multiple gestation C:intrauterine fetal death D:fetal congenital nephrosis E:fetal hydrocephalus F  mphaloceleG:fetus-to-mother bleeding H:trisomy 18 I:trisomy 21 A: E:fetal hydrocephalus closed NTD including those associated with hydrocephalus in the fetus,r not *** with abnormal AFP levels in maternal serum. Q. which of the following can’t be used in the emergency Tx of acute toxic reaction secondary to PCP? A:alkalinization of the urine B hentolamine dripC:benzodiazepines D:haloperidol E:gastric lavage Ans: A:alkalinization of the urine phentolamine to treat serious HTN,acidification of urine to a PH less than 5 will decrease the T1/2 of PCP from 72 to 24hr. Q. A 37 yo male hunter from a rural area of South Carolina presents with fever and headache for 7days.Ph.E unremarkable,WBC:2800,plt:102,000.The most likely cause of illness? a:Ehrlichia canis b:Borrelia burgdorferi c:Rickettsia rickettsii d:Neisseria meningitides e:Parvovirus B19 Ans: a:Ehrlichia canis mild version of RMSF(spotless RMSF):with leucopenia,thrombocytopenia Q. A 55 yo married professor without a previous psychiatric history is early in her menopause.In addition to experiencing hot flashes&some irritability,she complains of episodes of dizzy spells&memory lapses which she had experienced on several occasions early in life.She denies depressive symptoms either now or in the past.Next step of management? Ans: EEG to rule out possible temporal lobe epilepsy,her symptoms r consistent with psychomotor epilepsy:that’s exacerbated at menopause Q. A 37 yo man develops arthralgias,fever,urticaria 2wk after a heart transplant.The immunosuppressive agent most responsible is: a:azathioprine b:cyclosporine c rednisoned:antitymocyte globulin Ans: d:antitymocyte globulin serum sickness Q. A 45yo man has an excretory urogram for investigation of microscopic hematuria discovered on a routine U/A(with no protein).He’s healthy without complaints.Kidneys r of normal size with calcification& dye collection in dilated medullary structures.Serum electrolytes,BUN,Cr,Ca,P,UA normal.Cr clearance:103ml/min.Which one is not true about this condition? A:there’s significant chance that symptomatic renal stones will develop B:there’s significant chance that he has hypercalciuria C:there’s significant chance of UTI D:He’s likely to have impaired urine concentrating ability E rogression to renal sufficiency is uncommonF:His children each have a 50% chance of experiencing the same condition Ans: F:His children each have a 50% chance of experiencing the same condition case of medullary sponge kidney,it’s congenital not heredity disease Q. A 55 yo woman is being treated for ARDS with mechanical ventilation.She has gradually improving gas exchange,is afebrile & has minimal sputum.She’s receiving no antibiotics& a routine sputum culture,obtained on the 10th day of mechanical ventilation shows gr- rods,non-lactose fermenters.Her Cxray unchanged from 3days earlier.What’s the most appropriate management for this pt? Ans: case of psedomonas do nothing,in the absence of clinical signs of invasive infection,this represents colonization,Ab therapy could predispose to superinfection with resistant gr- organisms or fungal agents Q. which one is not a feature of analgesic associated nephropathy? A:normal-sized kidney B:anemia out of propotion to azotemia C:strile pyuria D apillary necrosisE:female predominance Ans: A:normal-sized kidney anemia due to chronic GI blood loss,so out of propotion to azotemia Q. A 25 yo homosexual man presents with diarrhea.Acid-fast stain of stool reveals large acid fast+ oval organisms,culture negative for enteric bacterial pathogens.An assay for Clostridium difficile toxin is normal.Treatment? Ans: isospora belli,TMP-SMZ diff diagnosis:cryptosporidium also acid fast with no response to TMP-SMZ,size less than 1/4 size of isospora,so may be the answer but bcoz of large cysts isospora most likely MAV complex also acid fast,but rods not cysts Q. A 20yo woman resuscitated after multiple organ trauma sustained in an auto accident,requiring over 30units of packed RBCs and volume expanders within 24hr.She now develops spontaneous bruising,bleeding at venipuncture sites,and GIB.Rx? a DAVPb lt transfusionc:aminocaproic acid d:IV gammaglobulin e:FFP Ans: b lt transfusion dilutional thrombocytopenia Q. Which of the following pharmacokinetic factors is least affected by age? A:GI absorption B lasma protein bindingC:tissue distribution D:hepatic metabolism E:renal excretion Ans: A:GI absorption Age-related changes r:increased gastric PH,decreased gastric emptying:could potentially affect the absorption of medications,but GI absorption overall is changed little,bcoz most drugs r absorbed through passive diffusion and their bioavailability is unchanged Q: A 68 yo white man is reffered to u for evaluation of renal failure.Lab: Na:135,K:4.2,Cl:109,HCO3-:24,glucose:101,Ca:10.9,P:4.3,Albumin:4,Hct:29% Cr clearance:55ml/min,urine protein:6.2g/day Next step of Mx? Ans: this pt has multiple myeloma and his renal failure most likely is related to overproduction of Ig light chains.the pt has anemia,he has significant proteinuria WITH NORMAL serum albumin so nephrotic syndrome excluded!and the presence of LMW protein that's readily filterated at glomerulus such as Ig light chain,could explain the proteinuria first step of Mx:immunofixation electrophoresis of the serum&urine confirmation by BMA&biopsy&bone survey Q. Which one is not a side effect of cyclosporine? A:HTN B:hyperkalemia C:hypoglycemia D:nephrotoxicity E:tremor Ans: C:hypoglycemia Q. A 54 yo woman presents with abrupt decline in urine output& RF.Her PMH is positive only for hysterectomy 1mo earlier& chronic migraine headaches controlled with methysergide.Lab: Na:130,K:6.2,Cl:99,HCO3-:16,glucose:101,Ca:7.9,P:6.3,Albumin:4,Cr:3.2 U/A:PH:1.010,protein&Hgb:trace,sediment:unremark able Urine output over the past 12hr:60cc Next step of Mx? Ans: this pt has a presentation typical of retroperitoneal fibrosis:clear association with methysergide CT generally confirms the Dx by showing medial deviation&extrinsic compression of the ureters,so diagnostic test of choice Q. A 24 yo man known to be HIV+,currentlt receiving no treatment,develops the acute onset of petechiae and oropharyngeal bleeding.Plt count:2000,No RBC fragmentation is noted on exam of peripheral blood smear.Rx? a DAVPb lt transfusionc:aminocaproic acid d:IV gammaglobulin e:FFP Ans: d:IV gammaglobulin acute thrombocytopenia:ITP Q. A previously well 24 yo woman from Colorado presents with high fever,headache and large ecchymoses on the buttocks and trunk.Her BP is 90/60mmHg,WBC:6000,PLT:75000,PT:18s(control 12s),ESR:3mm/hr.The most likely cause of illness? a:Ehrlichia canis b:Borrelia burgdorferi c:Rickettsia rickettsii d:Neisseria meningitides e:Parvovirus B19 A: d:Neisseria meningitides fever,hypotension,DIC due to bacteriemia Q. a 34yo African-American woman,who’s G4P3 at 36wk gestation,presents with complaints of worsening shortness of breath&fatigue of 2wk duration.She has noticed swelling in her legs and exacerbation of the dyspnea when she lies flat.On exam:u detect an extra heart sound following S2 at the apex,jugular venous distention and bilateral basilar rales.The most likely Dx? A: peripartum cardiomyopathy seen commonly from the last mo of pregnancy until 6mo postpartum with a peak incidence at 2mo postpartum RFs:increasing age,multiparity,African-American race,HTN,multiple gestation Q. which one is not capable of increasing plasma levels of lithium? A henylbutazoneB:thiazide diuretics C:indomethacin D:high intake of coffee E:fasting&low salt diet A: D:high intake of coffee All increase plasma levels of lithium,high intake of coffee interferes with achieving therapeutic levels of lithium Q. A 37 yo man presents to the ER with a history of alcoholism& recent onset of obtundation.He lives alone and can provide no other information.On arrival he has a grand mal seizure that lasts for 2 minutes.Ph.E:BP:120/70,HR:110,and no evidence of head trauma,papilledema or focal neurologic findings.His mental status doesn’t change with IV injections of thiamine& 50% dextrose.Lab:Na:136,K:5,Cl:99,HCO3-:12,BUN:42,Cr:4.2,Arterial PH:7.10,PaCO2:40,PO2:85. Next step of Mx? A: Classic presentation of ethylene glycol ingestion(methanol toxicity in diff diagnosis but acute renal failure due to oxalate deposition and tubular obstruction).the case is an alcoholic pt who substituted ethanol with antifreeze,symptoms like alcohol intoxication but with progression to stupor,obtundation,coma and seizures.There’s also a severe anion gap metabolic acidosis,bcoz ethylene glycol is metabolized to glycolic acid&oxalate. Tx:alkaline diuresis,IV infusion of ethanol:now fomepizole is prefered,it's more expensive but doesn't cause CNS depression or metabolic abnormalities seen with ethanol,hemodialysis in cases fail to respond to antidotal therapy. Q. A 10 yo girl presents to the ER with polyuria,polydipsia,nausea and vomiting for 2 days,9hrs after Tx for DKA,she’s complaining of a severe diffuse headache and she becomes stuporous within minutes.No electrolyte abnormality is seen.Next step of Mx? A:emergent head CT B:head xray C rder EEGD rder LPE:IV heparin F:IV naloxane G:IV mannitol infusion H:start IV antibiotics immediately after taking B/C I:IV corticostroids A: G:IV mannitol infusion cerebral edema is a feared complication of DKA Tx in children.The pathogenesis is ill-defined but correlates with aggressive fluid replacement,especially with hypotonic fluids.Typicaly children have headaches that progress to obtundation&coma,focal neurologic defecits r rare.therapy must be initiated immediately before any diagnostic tests. Tx:reduction of ICP with mannitol,raising the head of the bed,hyperventilation and if needed neurosurgical decompression Q. A 32yo man was treated with doxycyline for Lyme disease 2mo ago and now completely recovered.Now he wants to donate blood.What do u say? A: He can donate 12mo after the last dose of Abs was taken Q. A 27yo woman G2P1 at 34wk gestation presents for prenatal visit.She had a primary outbreak of herpes at 26wk gestation.She has no complaint now,her Ph.E and fetus condition all normal.The next step of Mx? A: recommend acyclovir prophylaxis starting at 36wk gestation to prevent another outbreak that may lead to do C/S(ONLY INDICATION OF C/S IS resence of active lesions at birth)it’s safe drug during pregnancy Q. Which of the following lab abnormalities is not present with lead poisoning? A:microcytic anemia B:basophilic stippling on the peripheral smear C roteinuriaD:elevated ALP E:elevated erythrocyte protoporphyrin A: D:elevated ALP both glycosoria&proteinuria r seen Q. A 34yo schoolteacher woman with history of hepatitis(asymptomatic)due to blood transfusion in the past,now feels well,with no complaints,Ph.E nomal,LFTs all normal. Her medical records show: Hepatitis A Ab -,HBs Ag -,HBs Ab+,Hepatitis C Ab+ Next step of Mx? A:hepatitis A vaccination B:hepatitis B vaccination C:liver biopsy D:abdominal US E:referral for interferon/ribavirin Tx F:do nothing,just disease education&consuling A: A:hepatitis A vaccination case of chronic asymptomatic hepatitisC,she’s schoolteacher at high risk for hepatitis A,if infected at much higher risk for fulminant liver disease,so needs protection Q. A 18 yo woman without any significant PMH presents for pre-college Ph.E.She’s healthy with no complaints.On Ph.E u find a single nodule on the left lobe of thyroid gland,all other Ph.E r normal.First step of Mx? A rder TSHB rder thyroid uptake scanC:fine needle biopsy D:repeat exam in 6mo A. A rder TSHfirst TSH,if normal then needle biopsy Q. In the dark,a pt’s right pupil is 3mm greater in diameter than the left pupil.In bright light,the right pupil is only 1mm larger than the left pupil.Which pathway contains the lesion? a:afferent sympathetic b:efferent sympathetic c:afferent parasympathetic d:efferent parasympathetic A. b:efferent sympathetic anisocoria Q. A 2yo child has a 2day history of fever&pain in the right ear.Ph.E reveals bulging&marked erythema of the right tympanic membrane as well as bilateral scleral injection and purulent conjunctivitis,what’s the pathogen most likely responsible? A: nontypable H.influ Q. U visit a 5day old son who brings by her mother bcoz of red,tearing eyes with yellow sticky discharge that prevents him from opening his eyes after sleeping.A Gr stain of purulent material show gr- diplococci.Next stp of Mx? A:topical silver nitrate B:topical erythromycin C:systemic ceftriaxone D:systemic erythromycin A: C:systemic ceftriaxone gonococcal conjunctivitis topical silver nitrate&erythro for prophylaxis at birth systemic erythro for chlamydial conjunctivitis that usually occurs 5-14days after birth Q. A 52 yo recipient of a cadaveric renal graft develops bleeding gums and easy bruising.The immunosuppressive agent most responsible is: a:azathioprine b:cyclosporine c rednisoned:antitymocyte globulin A: a:azathioprine with BM suppression Q. a 33yo woman,G4P4 presents to the ER with abdominal pain.She has a history of asthma,tobacco and alcohol abuse&STD.She had a cholecystectomy 7mo ago and a tubal ligation after the birth of her 4th child.On exam the pain is primarily located in the right lower quadrant,it increases when a hand is quickly removed from the abdomen.The pt has a positive Rovsing sign.Next step of Mx? A:abdominal xray B:US C:CBC D:serum beta-HCG E elvic exam A: D:serum beta-HCG abdominal pain in sexually active women should always raise the suspicion of EP.RFs include:a history of salpingitis or EP,increasing age,multiparity&African American or Hispanic race.A history of tubal ligation may increase risk Q. A pt with GIB on postoperative day 1 after repair of an AAA.What’s the diagnostic study of choice for this condition? A:esophagogastroduodenoscopy B:barium enema C:colonoscopy D:abdominal CT E:upper GI series A: C:colonoscopy the common cause of GI hemorrhage after an AAA repair is colonic ischemia.The inf mesenteric A is often sacrificed during the procedure,if the pt doesn’t have adequate collaterals from the left colon,ischemia will occur. Colonoscopy is the diagnostic study of choice for colonic ischemia Stress gastritis may occur post op but on post-op day1 the problem is likely colonic ischemia Q. A 67 yo man presents with midabdominal colicky pain,nausea,anorexia and vomiting for the past 48hr.T:37C,BP:100/60,HR:103.On Ph.E he has a distended&tympanic abdomen.Abdominal Xray shows multiple distended loops of small bowel and distention of the right colon,up to the middle of the transverese colon.Stool is positive for occult blood.What's the most appropriate next diagnostic step? a:doppler US b:abdominal CT c:laparoscopy d:exploratory laparotomy e:upper GI endoscopy A: b:abdominal CT mesentric venous thrombosis Q. A 19yo woman with 2 previous episodes of mania develops a major depressive episode.Which of the following is the most appropriate initial pharmacologic management? A:imipramine B:lithium C:divalproex D:venlafaxine E:venlafaxin&divalproex A: E:venlafaxin&divalproex CASE OF BIPOLAR DISORDER,DEPRESSED PHASE the depressive episode should be treated with an antidepressant:venlafaxine,and a mood-stabilizing agent:divalproex should also be initiated to minimize the risk of inducing a manic episode Q. Which of the following ECG findings is most characteristic of carbamazepine toxicity? A:QRS duration of 0.160 msec B:QT interval of 310 msec C:PR interval of 0.210 msec D:ST elevation E eaked T waves A: A:QRS duration of 0.160 msec carbamazepine a tricyclic compound has Na channel blocking characteristics,QRS prolongation&QT interval lengthening the most characteristic ECG changes seen in carba toxicity Q. A 16yo high school student presents with a syphilitic chancre for 8 days.He currently has 3sexual partners and doesn't use protection with any of them.Mx for the pt and his partners? A: treat him with benzatine penicillinG 2.4million units IM in a single dose,bcoz sexual partners might be infected even if seronegative,presumptive Tx should be given to those who were exposed within 90days. Q. A 42yo woman is referred for evaluation of a liver mass that was found on a CT ordered as a part of nephrolithiasis work up.The 3cm mass has a central hypodense region with progressive peripheral to central enhancement.Her medical history includes only nephrolithiasis,and her medications include OCPs and multivitamins.The most appropriate next step of Mx? A:FNA B:CT-guided biopsy C bservation with a follow up CTD:hepatic artery ligation E:surgical removal A: Cavernous hemangioma:the most common benign livr tumor These tumors may enlarge over time,if greater than 4cm in size they r termed giant hemangiomas.in some cases they r hormone-responsive& occasionally undergo spontaneous thrombosis& lead to pain&elevated liver transaminases.But most of these tumors r asymptomatic& spontaneous rupture is rare.surgical removal is recommended if they r associated with pain. so the ans in this case is:C bservation with a follow up CT Q. A 34 yo primigravid woman at 10wk gestation has a urine dipstick positive for nitrates&leukocyte esterase and a U/C:50,000 CFU/ml of E.coli.Next step of Mx? A: according to BRS the definition of asympto bacteriuria is CFU>100,000 of single organism,but kaplan says that Tx indicated in this case...??? Q. A 4 yo boy falls from the jungle gym at preschool.He sustains minor abrasions& contusions and is taken care of by the school nurse.He presents with his parents for a complete check up for possible internal injuries.Comple Ph.E is normal,Hgb:14g/dl,U/A:microhematuria.What's the most appropriate next step of Mx? a:US b:CT of abdomen& pelvis c:IVP d:retrograde urethrogram&cystogram e:serial Hct&Hgb f:reassurance the parents A: a:US microhematuria after trivial trauma in children may be a sign of a congenital anomaly that makes the urinary tract unusually vulnerable,The first noninvasive test should be the US Q. The most common cause of thyrotoxicosis in pregnancy is: a:subacute thyroiditis b:hydatiform mole c:thyrotoxicosis factitia d:toxic diffuse goiter e:choriocarcinoma A: d:toxic diffuse goiter Q. A 33 yo male recent immigrant from Mexico presents with multiple white spots on his arms&legs that slowly appeared over the past 2yr.The spots used to be reddish& scaly but were replaced by patches without any pigment.He's otherwise healthy with no FH of skin disease&no medication.Ph.E all normal except skin lesions:multiple confluent vitiligolike depigmented macules and patches over the elbows,shins and ankles,VDRL postivie.The most likely Dx? A: PINTA spirochetal disease caused by Treponema carateum,endemic in Mexico,Central&South America Q. The drug used in Tx of autonomic symptoms of heroin withdrawal is: a:methylphenidate b:diphenhydramine c:alprazolam d:clonazepam e:flumazenil A: b:diphenhydramine Q. which of the following electrolyte abnormalities is not associated with ALL or its Tx? A:hypokalemia B:hyperphosphatemia C:hyperuricemia D:hypercalcemia E:hyperkalemia A: D:hypercalcemia Q. A 1400 gr infant born at 35wk gestation,is 42cm in length and has a head circumference of 28cm.One day after birth she becomes very irritable,tremulous and inconsolable.Her cry is high-pitched.Her pulse is 174/min.There r no dysmorphic facial features.Her mother had inconsistent prenatal care and has a history of multiple inpatient hospitalizations for substance overdoses.The infant was most likely exposed to which substance in utero? A: The most commonly abused drug by pregnant mothers is cocaine,infants r usually SGA &sometimes have microcephaly and neurodevelopmental abnormalities.Exposed infants r very irritable and inconsolable to the withdrawal period,the cry is often high pitched,they r also at increased risk of SIDS,periventricular leukomalacia is also associated with cocaine exposure Q. a 27 yo woman G2P1 at 26wk gestation,comes for routine care.Her pregnancy has been without complications.She feels consistent fetal movement,has had no contractions and has experienced no bleeding.She complians of burning chest pain that worsens at night and after meals.Lab:AST:50U/L,ALT:55U/L,ALP:125U/L,Albumin:3.5gr/dl.The next most appropriate step of Mx? A:RUQ US B:esophagogastroduodenoscopy C:ERCP D:abdominal CT E:reassurance A: E:reassurance GER ALP normally elevated in pregnancy AST,ALT may be slightly elevated in normal pregnancy Q. A term male infant is found to be cyanotic shortly after birth and requires endotracheal intubation.On Ph.E his BP:65/30mmHg(equal in 4 extremities)PR:175,RR:30.His precordium is dynamic,has a grade III sys murmur and a single S2.Cxray shows a normal heart size and increased pulmonary vascular markings.ABG on an FIO2 100%shows:PH:7.34,PaCO2:47,PaO2:46.What’s the most likely Dx? A: total anomalous pulmonary venous return with obstruction of course,pls read the explanation from blue print:good explanation  Q. A 47yo man complains of numbness&pain in the lower extremities.He works as a pipe fitter.His PMH is positive for HTN for the past 7yr&consumption of 6 to 8 beers/day for the past 25yr and 50 pack-yr of cigarette use.He also complains of frequent urination.On Ph.E he has 5-/5 strenght in plantar& dorsiflexion,with diminished light touch distally.What’s the likely cause of his complaint? A MB:Alcohol abuse C:Hypothyroidism D:Tobacco abuse E:Asbestosis A: B:Alcohol abuse alcoholic neuropathy:damage to both sensory&motor fibers,initial symptoms r plantar pain&paresthesia often described as burning.distal weakness can occur&ankle jerks r first reflexes lost. this condition is unlikely to be due to DM,diabetic polyneuropathy is uncommon at the time of diabetes Dx,it usually begins with sensory loss in the feet. Q. A 34yo woman presents with a dry,hacking cough of 6mo duration.The cough initially began after an URI but has never completely improved.It’s particularly bad at night and in the early morning.The woman doesn’t complain of rinorrhea,dyspnea,fatigue,fever or weight loss.Her PMH positive for an appendectomy at age12.Her FH significant for lung cancer in her father and maternal grandfather.She doesn’t smoke and works as a secretory for a software manufacture.OTC cough syrups have provided only minimal relief.Ph.E&Cxray r normal.The first step of Mx? A:PFTs B:Chest CT C:PPD D:trial of antihistamine or decongestant with intranasal steroid E:upper endoscopy A: D:trial of antihistamine or decongestant with intranasal steroid case of chronic cough:more than 3wk in nonsmoking pts the first most common cause of chronic cough is PND,if this pt doesn't show improvement with trial of Tx PFTs is done,bcoz the second most common cause of chronic cough is asthma Q. A 59yo woman who’s hospitalized for palliative Tx(chemo+radiation Tx)of metastatic laryngeal carcinoma develops a fever,T:39,BP:105/60,HR:114,RR:16.Ph.E completely normal(no localizing symptom,no site of infection identified),no foreign indwelling cathaters.Lab:Hgb:9,WBC:800(neutrophil:46%,lymphoc yte 32%,bands:12%)plt:19000.Pan culturing was done.Next step of Mx? A:start Tx with ceftazidime B:start Tx with vancomycin C:start Tx with ceftazidime&vancomycin D:start Tx with ceftazidime,vancomycin& amphotericinB E:wait for culture results A. A:start Tx with ceftazidime neutrophils:[800x(46+12)(<500)]=464 case of neutropenia(<500) fever greater than 100.9F,or 100.4F>1hr:IS SIGNIFICANT IN NEUTOPENIC PTS If pt continues to be febrile after 72hr Tx with ceftazidime,then Tx with vanco should be started,ampho after 5days if unresponsive Q. A 22yo woman G1P0 at 12wk gestation with an intrauterine pregnancy,complains of burning when she urinates,she also has increased urgency&frequency.A urine dipstick shows leukocyte esterase& a small amount of blood.Which of the following steps should be next? A:urine microscopy B:Antibiotics C:urine culture D:CBC E:renal US F elvic exam A: A:urine microscopy although CBC,U/C,Antiniotic Tx all necessary urine microscopy is essential to assess for WBC casts,it may also suggests an atypical cause of infection Q. A 77yo woman has widely disseminated breast cancer.She's being followed at home bcoz she has refused any furthur specific anti-cancer therapy.Her Hct drops from a previously stable 43% to 26% over a 2mo period.Review of the blood smear shows normochromia,anisocytosis,poikilocytosis and nucleated RBCs,rare immature cells r also seen in the smear.What’s the most likely cause of her anemia? A: myelophtisic anemia the underlying disease process here is an end-stage cancer Q. A 62yo woman presented with closed communicated femur Fxs and underwent operative fixation with an intramedullary nail.On postoperative day 2 she’s confused,oriented only to name,has diffuse rales&scattered petechiae on the upper chest&arms.T:39C,BP:120/90mmHg,PR:135regular,RR:30 with O2 saturation 85% on room air,wound is clean&dry.Which of the following tests would be likely to yield the most diagnostic information? A oppler US of the lower extremitiesB:U/A&CBC C:Abdominal CT D:Pulmonary angiogram E:radiograph of the femur A: B:U/A&CBC serum&urine eosinophilia,as well as fat droplets in the urine&blood also trombocytopenia Q. What’s the underlying cause that leads to hypokalemia in pts with ALL? A: hypokalemia secondary to a renal tubular defect hyperkalemia as a part of tumor lysis syndrome:a complication of Tx Q. U see a 6yo boy at ur office for the first time.His parents note that he seems to tire easily and complain of weakness in his legs,they have attributed this to his shyness and his preference for watching videos rather than playing outside.Ph.E reveals a healthy-apearing boy with a BP:138/94mmHg in his right arm.His lower extremities r slightly atrophic and mottled-appearing.What’s the pathophysio mechanism of HTN in this pt? A: HTN secondary to decreased renal blood flow Q. Which of the following agents would not be expected to increase HDL? A:simvastatin B:niacin C:Gemfibrozil D:Alcohol E:Vit E A: E:Vit E Q. A 76 yo woman is admitted to ICU for respiratory failure.She requires 100% fractional concentration of O2 & has a PaO2 of 56mmHg.A central venous catheter indicates a PCWP of 8mmHg.Her Cxray is notable for a bilateral alveolar filling process.What’s the most likely cause of the woman’s respiratory failure? A:aspiration B:sepsis C:trauma D:multiple transfusions E neumoniaF:MI A: B:sepsis case of ARDS:it’s defined by the presence of the following 3 criteria: 1-bilateral diffuse opacities on Cxray 2-PCWP<18mmHg 3-PaO2/FIO2<200mmHg the most common causes in descending order r:sepsis,aspiration,multiple transfusions,pneumonia,near-drowning,pancreatitis,cardiopulmonary bypass Q. A 23 yo woman presents with severe LLQ abdominal pain of 6hr duration that’s associated with some moderate vaginal bleeding.She’s sexually active&she doesn’t use contraception.Her last period was 6,1/2wk ago. Which of the following provides the least help in confirming ur clinical Dx? A:quantitative beta-HCG B:vaginal US C:abdominal US D:culdocentesis E:laparascopy A: C:abdominal US abdominal US can identify a tubal gestational sac in only 25%of cases Q. A 52 yo man with a long history of alcohol dependence,characterized by frequent binge drinking,is started on 50mg/day of naltrexone and has no binges during the next 6mo. By which mechanism naltrexone decreased his binge drinking? A: Naltrexone ia an opoid antagonist,it's most likely effective in the Tx of alcohol dependence bcoz it blocks the euphoric effects of alcohol-mediated release of endogenous opoids. Q. A 25yo woman complains of severe anexiety when she has to speak at business meetings or attend social events.She’s unable to host or attend even small parties and this has narrowed her social life&decreased her chances of networking in her carrier.She feels isolated and inadequate.What’s the best choice of Tx? A:assertiveness training&paroxetine B:supportive psychotherapy&lorazepam C sychodynamic psychotherapy&imipramineD:stimulus flooding and lorazepam E:systemic desensitization A: A:assertiveness training&paroxetine case of social phobia assertive training a version of cognitive psychotherapy includes educating the indivisual about anexiety-controlling techniques,role playing and desensitizing the indivisual to anexiety provoking social stimuli. Q. The brain structure most closely associated with sleep architecture is: a:hypothalamus b:amygdale c:dorsl raphe nucleus d:hippocampus e:cingulated gyrus A: c:dorsl raphe nucleus Q. A 22 yo woman G1P0 32wk pregnant complains of bilateral kneepain&hip pain.At 28wk she had contractions that were controlled with terbutaline.On furthur questioning she complains of shortness of breath while lying flat.Ph.E:BP:150/90mmHg,tachycardia,lungs clear,neck exam normal.Homans sign negative,no lower extremity swelling or edema is present.Hyperpigmentation is apparent on her nose&cheeks.Lab:ESR:65,HCT:31%,Hgb:10,plt:300, 000.Next step of Mx? A:ANA B:Echocardiogram C:Anti-dsDNA D:V/Q scan E:reassurance A: E:reassurance knee&hip complaints r common as pregnancy proceeds and the exam is normal,so a rheumatologic disease unlikely.the facial hyperpigmentation is melasma due to elevated estrogen&MSH levels.ESR is elevated in normal pregnancy.dyspnea is a common complaint secondary to diaphragmatic displacement(cardiovascular exam is normal)so peripartum cardiomyopathy unlikely,based on Ph.E pulmonary TE is unlikely too. Tachycardia a side effect of terbutaline(beta-agonist) Q. A newborn girl is evaluated for jaundice.At the age of 4days,her bilirubin is 8mg/dl and nearly all unconjugated.Which of the following tests is most appropriate? A:CBC B:blood smear C:blood culture D:ALT,AST E:TSH A: B:blood smear this pt has primarily unconjugated bilirubin& the most important next step is a peripheral smear to evaluate for hemolysis. if hemolysis is present the most likely causes includes a congenital erythrocyte disorder,an erythrocyte enzyme defect,or a blood group incompability. if no hemolysis exists and no infection is evident,the probable Dx is either physiologic jaundice or breastmilk-induced jaundice after ruling out hemolysis TSH,ALT,AST would be useful to rule out hypothyroidism&liver disease. Q. A 63 yo pt presents with left leg pain after fa,lling.the leg is abducted,externally rotated and shortened.The most likely Dx? A ost.hip dislocationB:ant.hip dislocation C:femoral neck Fx D:knee lateral dislocation A: C:femoral neck Fx both ant.hip dislocation& femoral neck Fx can present in this way but fx more common Q: A 74yo man has pain,swelling and redness of the right hand 2wk after a stroke involving the left hemisphere.The hand is warm and has pitting edema.Any motion of the wrist and shoulder produces pain.Radiographs of the shoulder,wrist and chest r normal.Mx? A: shoulder-hand syndrome:reflex sympathetic dystrophy can occur following stroke,MI,trauma to shoulder.it’s characterized by pain,swelling,erythema,increased skin T and limitation range of motion of shoulder,arm and hand on affected side,usually unilateral.Tx hysical therapy to the arm Q. A 76 yo woman admitted to the ICU with diagnosis of ARDS.After approximately 10days on a ventilator,she develops fever&RUQ pain.On Ph.E:vital signs normal,she has lost 7kg during hospitalization.US shows pericholecystic fluid&a thickened gallbladder wall with no visible stones.The next step of Mx? A:cholecystostomy B:Antibiotics&observation C:ERCP with sphincterotomy D:cholecystectomy E:CT scan A: D:cholecystectomy case of acalculous cholecystitis Q.A 19yo white male has periapism of 12hr duration.He has no history of trauma or drug use.His Ph.E except for his periapism is unremarkable.The lab study which will most likely establish the etiology of periapism is: a lt countb:Hgb electrophoresis c:sickle cell prep d:BT e:CBC A. e:CBC leukemia a well-recognized cause of periapism in young men,in the absence of an obvious etiology for the periapism,WBC count should be performed to rule out leukemia.he’s white&sickle cell unlikely Q. A 48 yo man complains of left shoulder pain.He has no associated trauma.On Ph.E,he experiences the most pain with crossed arm adduction with applied resistance.The most likely Dx is: a:acromioclavicular join inflammation b:subacromial bursitis c:supraspinatous syndrome d artial rotator cuff teare:biceps tendinitis A. a:acromioclavicular join inflammation Q. A 31 yo man presents to the ER after a head on collision in which he was a front seat passenger wearing a seatbelt.On Ph.E he’s conscious,BP:110/70mmHg,PR:96,RR:14.The most appropriate method for suspecting the Dx of injury to the small bowel is: a:abdominal exam b:supine&upright abdominal xray c:abdominal CT d PLe:serum amylase measurment A: a:abdominal exam he’s conscious!!!so the first step is exam Q. Which of the following adverse effects occurs most frequently during Tx with clozapine? A:seizure B:renal failure C:agranulocytosis D igmentary retinopathyE:anticholinergic delirium A: A:seizure the incidence of seizure with a daily dosage of clozapine greater than 600mg is more than 5%.Agranulocytosis incidence is 1% Q. A 55 yo white man presents for routine sigmoidoscopy to screen for colon cancer.A single 3mm sessile polyp is found,biopsy performed and pathology reports hyperplastic polyp.Next step of Mx? A:colonoscopy B:Air-contrast barium enema C:repeat sigmoidoscopy in 6mo to evaluate for recurrence D:continued regular sigmoidoscopic screening at the usual interval A: D:continued regular sigmoidoscopic screening at the usual interval hyperplastic polyp<5mm no potential risk of malignancy Q. A 78 yo woman currently authoring successful cookbooks is gicen codeine for a severe toothache.After taking several doses,she’s found confused,disoriented and frightened,cowering in her bedroom and describing huge ants crawling on her floor.Which of the following is the most likely diagnosis? A:alcohol withdrawal B:brief psychotic disorder C:codeine-induced delirium D:codeine-induced psychotic disorder E:vascular dementia A: C:codeine-induced delirium,opoid analgesics r known occasionally to induce delirium in elderly indivisuals Q. A breast lump is found on routine exam in a 42yo woman.Mamography shows a density in left breast.A biopsy finds lobular carcinoma in situ.The most appropriate Tx is? A:lumpectomy alone B:lumpectomy& radiation therapy C:lumpectomy& LN dissection D:screening mammography and perhaps tamoxifen E:left modified radical mastectomy F:bilateral modified radical mastectomy A: D:screening mammography and perhaps tamoxifen lobular carcinoma insitu is not a PREMALIGNANT lesion!!but like early menarche,late menopause,nulliparity,FH or personal history of breast cancer is considered a RISK FACTOR for breast cancer....so the most appropriate Tx for a pt with lobular carcioma insitu is follow up like a pt with RF for breast cancer(mammo,may be tamoxifen) if the pt has an additional RF like FH+...as i mentioned above,bilateral total mastectomy may be considered. Q. A breast lump is found on routine exam in a 42yo woman.Mamography shows a density in left breast.A biopsy finds ductal carcinoma in situ.The most appropriate Tx is? A:lumpectomy alone B:lumpectomy& radiation therapy C:lumpectomy& LN dissection D:screening mammography and perhaps tamoxifen E:left modified radical mastectomy F:bilateral modified radical mastectomy A: 1-first DCIS is a PREMALIGNANT LESION!so D is not the answer! 2-LN dissection is not necessary to do in pts with ductal carcinoma insitu,so C is not the answer! 3-it's often unilateral,so F is not the answer! 4-u should choose between A,B,E A:lumpectomy alone is associated with high recurrence rate,but wide exicision alone may be suitable in selected cases with small lesion(<25mm),favorable histology(not comedocarcinoma) and clear margins in histology B:lumpectomy& radiation therapy:reduce the local recurrence to 2%:good option E:left modified radical mastectomy:can be done,but may be too much for some pts!as it's not an invasive cancer in summary! we need more information about the lesion,pathology report and also the Tx depends on pt choice with just this limited info the best Tx here is B Q: Shortly after admission to the ER bcoz of persecutory delusions&belligerence,an 18yo man demonstrates fatigue,dysphoria,unpleasant dreams and psychomotor agitation. What’s the most likely responsible substance that lead to these withdrawal symptoms? A:alprazolam B:caffeine C:cannabis D:cocaine E:hallucinogens F:heroin G:mescaline H:nicotine I:PCP J:toluene A: D:cocaine cocaine withdrawal is characterized by fatigue,dysphoria,hyper or hyposomnia,disturbed dreams& psychomotor agitation or retardation Q: Which of the following symptoms is most likely associated with phenothiazine antipsychotic medication? A:hyperreflexia B hotosensitivityC:diarrhea E:weight loss F:urinary incontinence A: B hotosensitivity Q: What’s the most common cause of tubal ligation failure? A reoperative adhesionsB:human error C:use of permanent suture materials D:spontaneous fistula formation E:mistaking the round ligament for the oviduct on the part of the physician A: D:spontaneous fistula formation Q: A 49yo healthy woman,G6P6 with back pain on standing that’s relieved by lying down,on Ph.E a small bulge is noted in the upper post vaginal wall,what’s the most likely diagnosis? A.Enterocele Symptoms often vague in presentation Backache or a pulling sensation when standing that’s relieved by lying down The pouch of Douglas is herniated and the vagina contains loops of small bowel. Upper ant vaginal wall herniation:cystocele Lower ant vaginal wall herniation:urethrocele Upper post vaginal wall herniation:enterocele Lower post vaginal wall herniation:rectocele Q. A 52yo woman underwent a colonoscopy for hemoccult+ stools.A 2cm pedunculated polyp was found in the transverse colon.it was resected with a snare and electrocautery.the pathologist reports that the polyp is adenomatous with dysplastic changes.What’s ur management for this pt? A. Most pedunculated polyps r completely removed during endoscopy,so furthur Rx like partial colectomy is not indicated unless the polyp had invasive carcinoma extending beyond the margins of the resected specimen. After endoscopic removal of a large neoplastic polyp,continued surveillance is indicated bcoz the pt is now identified as being at increased risk of colon cancer.So a repeat surveillance colonoscopy is warranted in 3-5yrs. Q. A pregnant woman decides to travel to a malarious area,what do u recommend? A. It is best if travel to a malaria-risk area be postponed until after parturition. If travel cannot be postponed, taking an antimalarial drug and preventing mosquito bites is recommended to reduce, but not eliminate, the risk of developing malaria. Experience with the antimalarial chloroquine and limited experience with the antimalarial mefloquine indicate that they are safe to take during pregnancy, including the first trimester. Pregnant women should take their antimalarial exactly on schedule without missing doses. The antimalarial prescribed will depend on where the patient is traveling. intermittent Rx with pyrimethamine-sulfadoxine can also be used primaquine&atovaquone-proguanil should not be used in pregnancy Q. A 45yo man presented to the ER after an episode of massive hematemesis.On Ph.E:HR:112,BP:90/40mmHg.After initial hemodynamic stabilization,an urgent endoscopy was done,which revealed large esophageal varices,what’s the best management for this pt? A. About 2/3 of the episodes of variceal hemorrhage will cease spontaneously,but a rapid onset of bleeding is common without any intervention,thus endoscopic hemostasis is required. Two endoscopic methods r equally effective in controlling active bleeding in more than 95% of pts:endoscopic variceal ligation&endoscopic sclerotherapy. Endoscopic variceal ligation is associated with lower frequency of esophageal ulceration&more rapid obliteration of varices and currently is the method of choice. Pharmacologic therapy with octerotide,somatostatin or (vasopressin infusion+nitroglycerin)r also highly effective in controlling hemorrhage. The Sengstaken-Blakemore tube can be used for controlling hemorrhage after failure of endoscopic techniques or when urgent endoscopic therapy is not available. TIPS can be used as salvage therapy in pts who r unresponsive to endoscopic&pharmacological treatments. Beta blockers have been found useful in preventing rebleeding. Where available,ENDOSCOPIC INTERVENTION should be employed as the first line of treatment to control bleeding acutely Q. A 55yo man presents with increasing fatigue.Ph.E shows hyperpigmentation of the skin,tenderness &deformity of the metacarpophalangeal and interphalangeal joints of both hands.Abdominal exam reveals hepatosplenomegaly.Lab:AST:66U/L,ALT:76U/L,ALP:132U/L. all hepatitis viral serologies r negative,what’s the next most appropriate step for management of this pt? A. the most likely diagnosis:hereditary hemochromatosis ferritin&transferrin saturation should be measured,elevation of transferring sat>62%M,>50%F&ferritin twice normal r suggestive of heredity hemochromatosis.diagnosis is confirmed by liver biopsy to quantify hepatic iron. Q. A 7yo boy from Oklahoma presented to the office 2 days ago with a 2 day history of fever, headaches, malaise, and generalized myalgias. He was diagnosed with a "viral syndrome" and given instructions for home symptomatic care. He is now in the emergency department with a rash that started on his hands and feet, spreading up his arms and legs. The fever, headaches, and myalgias have persisted. Mother states that today her son seems "out of it ". Exam: VS: T:40.2 C, HR:100, RR:26, BP 115/70. He is laying in a hospital gurney, awake and responsive, but tired and ill appearing. His skin has a maculopapular rash that blanches under pressure on the upper and lower extremities, including his palms and soles, and a few scattered macular lesions located on the upper trunk and back. There is a small 3mm round healed scab lesion on the left calf. His head is atraumatic and nontender. He has no mucosal (eye, nose, mouth, and throat) lesions. He does not exhibit any meningeal signs. His heart, lung, and abdominal exams are normal. There is tenderness to gentle palpation of his thigh and calf muscles. He is oriented and responds appropriately. Laboratory studies reveal a normal white blood cell count that is slightly left shifted. He has a platelet count of 105,000. His serum sodium is 132mEq/L. Cerebrospinal fluid is normal. A. RMSF EXPLANATION: There is no laboratory test that definitively diagnoses RMSF in the early phase of illness. Thus, an early diagnosis depends on a high index of suspicion, a compelling clinical presentation, and suggestive ancillary laboratory data. The CBC WBC may be high, normal, or low but is usually left shifted. Thrombocytopenia is common in RMSF. Mild thrombocytopenia is probably related to platelet adherence to affected endothelial cells. Severe thrombocytopenia usually represents a consumptive coagulopathy. Hyponatremia is common. CSF is usually normal but may demonstrate a mild pleocytosis. Diagnosis is made by serologic studies. The most sensitive and specific tests are indirect immunofluorescent antibody (IFA), enzyme immunoassay (EIA), and compliment fixation (CF). Other available serologic studies are latex agglutination (LA), indirect hemagglutination (IHA), and microagglutination (MA). Antibodies can be detected 7 to 10 days from disease onset. A single serum IFA titer of 1:64, CF titer of 1:16, or LA, IHA, or MA titer of 1:128, are highly suggestive of RMSF. A 4-fold rise between acute and convalescent antibody titers is diagnostic. Early treatment is necessary and often empiric based on index of suspicion considering history, clinical course, and epidemiology. Treatment should not be withheld until a definitive diagnosis is made. Delay in initiating treatment leads to a poorer prognosis. Without treatment, RMSF can be fatal. Chloramphenicol, tetracycline, and doxycycline are effective against R. ricketttsii. Doxycycline is the drug of choice for treatment of RMSF in patients of any age. Historically, chloramphenicol was recommended for children <8 years of age. Tetracycline and doxycycline were not favored because they bind to calcium of developing teeth and bones causing permanent discoloration. However, there are several reasons why doxycycline is the recommended first-line therapy. It does not bind to calcium as readily as tetracycline. A single course of doxycycline treatment carries little risk of teeth staining. Chloramphenicol has been associated with the development of irreversible aplastic anemia, and has been shown to be less effective than doxycycline for treatment of RMSF. Doxycycline is also active against ehrlichiosis, which may be clinically indistinguishable from RMSF. The efficacy of chloramphenicol in ehrlichiosis has not been established. ABOUT THIS CASE: The patient is asked about the scab on his calf. Four days prior to the onset of illness,he noticed an engorged tick on his calf. The tick was removed by "squeezing and scratching" causing a small abrasion that he soon forgot about.READ THIS:Proper skin removal of ticks is important in decreasing the risk of infection. Squeezing, crushing, pinching, or the folk remedy of burning the tick with a cigarette may actually facilitate rickettsiae transmission. The tick should be removed with a fine-tipped tweezer grasped as close to the skin as possible and pulled upward with a slow steady pressure. The skin site should be cleaned and disinfected. If possible, the tick should be saved for identification if illness develops. SUMMARY of management for this pt: order RMSF serology test:IFA Rx oxycycline is given at a dose of 2 to 4 mg/kg/day, divided every 12 hours, with a maximum dose of 200mg/day. The dose is the same regardless of oral or intravenous administration. Duration of therapy is for a minimum of 5 to 7 days and until the patient has been afebrile for at least 48 hours.if multiple COURSES of therapy! needed consider chloramphenicol as he's younger than 8yo. Q. A 49yo male farmer from Arkansas presents with a 6wk history of a slowly enlarging paranasal skin lesion,5kg weight loss,low grade fever,and a nonproductive cough.He has no underlying medical illness.On exam he has a 6*4cm right paranasal verrucous lesion that has a heaped up warty appearance with a violaceous hue.There’s an area of central healing.A Cxray reveals a 5*4cm right parahilar noncavitary mass lesion.what’s the most appropriate next step for diagnosis? A. The most likely diagnosis is BLASTOMYCOSIS,male gender,occupation,residence in a high-incidence area r considered RFs.So the next best step for diagnosis is skin biopsy with special stains for fungi,also do stain for acid fast bacili! Q. Which stool fluid electrolyte result is associated with diarrhea due to magnesium citrate use? a:Na+:5mEq/L,K+:5mEq/L,STOOL OSMOLARITY:22 b:Na+:90mEq/L,K+:35mEq/L,STOOL OSMOLARITY:280 c:Na+:40mEq/L,K+:20mEq/L,STOOL OSMOLARITY:280 d:Na+:40mEq/L,K+:20mEq/L,STOOL OSMOLARITY:500 A. c,the diff in value between the measured stool osmolarity minus the calculated stool osmolarity[which is (Na+K)*2] is called osmolarity gap.this value is usually around 50mOsm/kg and never more than 125.this gap results from the presence of unmeasured osmoles.in a pt with osmotic diarrhea caused by a nonmetabolizable substance:Mg citrate,stool osmolarity will be equal to plasma,but the presence of unmeasured osmoles:Mg will result in a high osmolar gap. Osmotic diarrhea caused by a metabolizable substance:lactose malabsorption will result in fecal fluid with a stool osmolarity higher than plasma and a significant osmotic gap:choice d Q. A pt with myasthenia gravis that has been well controlled with pyridostigmine for 2yrs comes to the ER complaining of progressive muscle weakening during the last 24hrs.He has trouble swallowing and suffers from double vision.The pt has had flu-like symptoms for the past wk.Which of the following is the most appropriate next step of management? A:increase the dose of pyridostigmine B:decrease the dose of pyridostigmine C:replace pyridostigmine with physostigmine D;give a small dose of edrophonium E:administer succinylcholine A. D,there's no need to explain more,just add that influ diz may changed absorption(increase or decrease)of drug in the gut with possible GI involvement and edrophonium test helps us to decide about change in dose of drug Q. A 10-year-old boy complained of leg cramps and clumsiness. His motor development was normal. He was in the fifth grade and was performing well academically. At age seven, he had begun to walk on his toes. He had sprained his right ankle twice in the last year and had also complained of hand cramps after long periods of writing. His maternal grandfather had "weak feet" and his maternal uncle had leg braces. His mother had no complaints, except for occasional leg cramps after long walks. Two younger siblings had no neurological complaints. He appeared healthy, and his gait showed toewalking and, that he was unable to walk on his heels. His heel cords were tight and there was weakness (4/5) of the dorsiflexors of both feet. The legs showed mild atrophy of the anterior tibialis and peroneal muscles. There was no atrophy or weakness of the intrinsic hand muscle. The stretch reflexes were absent in the upper and lower limbs. The plantar responses were flexor. There was decreased pricking sensation distally in stocking distribution. The great auricular nerves were enlarged on both sides, but the left was more visible. When palpated, the ulnar and peroneal nerves were found to be enlarged. He had mild pes cavus deformity. Motor nerve conduction velocities were performed: the motor NCV of the right peroneal nerve,the left ulnar nerve&the right median nerve were decreased. He had motor distal latencies that were proportionately prolonged and absent sensory nerve action potentials. There was no electrophysiological evidence of motor conduction blocks. What's the most likely diagnosis? A. a case of Charcot-Marie-Tooth it's very HY!i had similar case in step1 exam!!!! Q. Decrease in all hemodynamic parameters:JVD,CO,PCWP,SVR is seen in which kind of shock? A:hypovolemic B:cardiogenic C:septic(early phase) D:septic(late phase) E:neurogenic A. neurogenic shock Q. Which of the following scenarios would be most suspicious for possible child abuse? a. A 2 year old who presents with a tibial fracture after reportedly fa,lling down a few steps. b. A 1 year old who presents with a forehead hematoma after reportedly fa,lling out of a stroller. c. A 3 month old who presents with a nondisplaced femur fracture after reportedly rolling off the changing table. d. A 3 year old who presents with a spiral fracture of the tibia after reportedly getting his leg twisted while fa,lling off a tricycle A. the answer is C the injury in this option is incompatible with the infant's development,as he can't roll off at this age! Q. A 24 yo old motorcyclist presents to ER with BP:90/60mmHg after hiting by car.He’s anxious, confused, skin is warm and well perfused, breathing rapid and shallow, pulse slow but weak,he’s unable to move arms or legs.management? A. case of neurogenic shock,he has paralysis may be due to cervical vertebral Fx,do ABC,stabalize neck,do xrays of head&neck... for Rx of shock:the initial intervention is volume infusion,if hypotension is refractory to volume infusion alone,a peripheral vasoconstrictor like phenylephrine or norepinephrine is administered.bcoz spinal shock pts tend to equilibrate body T with their environment,fluids&ambient room T must be kept warm(washington) Q.A 28 yo female heroin addict found by friends barely responsive.She’s hypotensive, gasping for breath,her pulse is rapid and weak,JVP elevated,skin moist, pale.fingertips and lips are blue.pupils are dilated.What’s the most likely diagnosis? A.cardiogenic shock due to bacterial endocarditis --> valvular rupture consider also septic shock in diff diagnosis,but with elevated JVP in this case it's less likely! Her altered mental status is likely due to shock and not heroin bcoz of dilated puplis!(classically, heroin causes pupil constriction) Q.A motorist decelerates rapidly after striking a stalled vehicle.He’s traveling at 55mi/h at the time of impact.he’s wearing a seatbelt and his car is equipped with an air bag.which abdominal organs r most likely to be injured in this pt? A.Deceleration injuries commonly result from high speed MVAs and falls from considerable heights.the mechanism of injury is the shearing of pediculated organs from their points of attachment to the retroperitoneum,bcoz these pedicles r usually vascular,the injury results in bleeding&ischemia of the affected organ.pediculated organs in the abdomen include the intestines(small&large)&kidneys Q.A 22 yo male medical student complains of severe sore throat for 3days&of inability to ingest solid foods for the past 2days.He appears moderately ill and in pain with his head held in a sniffing-type position,lips slightly parted grimacing while swallowing saliva.His T:38.3C,His cervical LNs r visibly&palpably enlarged.His tonsolis show a mixed white&yellowish exudates against an erythematous&edematous background.The rim of epiglottis appears normal in size&color.No other adenopathies visible and abdominal exam is negative for masses&organomegaly.A rapid streptococcus test&monospot test for mononucleosis r negative.what’s the next step of management? A. Order:EBV-VCA IgM Ab EBV-specific Ab testing is used for pts with suspected acute EBV who lack heterophil Abs. Titers of IgM&IgG Abs to VCAs(Viral Capsid Antigens)revealed in the serum of more than 90% of pts at the ONSET of disease (Abs to early Ags:EA-D,EA-R r detectable 3-4weeks after the onset of symptoms in pts with IM.)So not indicated in this case! If EBV-VCA IgM Abs r negative,CMV mononucleosis should be considered(CMV IgM Ab+),other diff diagnosis with infectious mononucleosis-type syndrome r toxo,HHV-6,HIV Q. A mother brings her 18-month-old girl to the clinic with a history of recurrent blister formation after minor trauma,mostly limited to acral areas. The mother states that the blisters will develop into mild ulcerations, and then heal without scarring. The patient had no significant past medical history. There was no family history of blistering disorders, psoriasis or atopy. The child's parents were related as second cousins. An interview with the mother reveals that the father is an alcoholic,a heavy smoker and has temper tantrums.What’s the most likely diagnosis? A. epidermolysis bullosa Q. The starquarterback for a university football team presents 2weeks after the onset of symptoms of infectious mononucleosis.He wants to return to playing football,when he can return to playing football? A. He may return to football 4weeks after the onset of illness if splenomegaly&fever r not present,liver tests r normal &all complications have resolved. Because blunt abdominal trauma may predispose patients to splenic rupture, it is customary and prudent to advise against participation in contact sports and strenuous athletic activities during the first 2–3 wk of illness or while splenomegaly is present. Q. In order to prevent rheumatic fever in children infected with beta-hemolyic strep pyogenes,Rx must begin within how many days after onset? A. within 7-9days Q. A 12yo male presents with history of recent tick bite in North Carolina,he's asymptomatic.what do u recommend for prevention of RMSF? A. There is no licensed vaccination for prevention of RMSF. Prophylactic therapy for asymptomatic individuals with a recent tick bite or exposure to a tick infested area is not recommended. Q. A 17 yo high school football player suffered concussion with loss of consciousness for 5seconds.what’s the next step of management?when he can return to play? A. GRADE 3:neurologic exam,CT/MRI,can return to play after 2 weeks Concussion: Grade I: transient confusion NO loss of consciousness Concussion symptoms or mental status abnormalities resolve in <15 minutes *the pt can return to play after 15 minutes Grade II: transient confusion NO loss of consciousness Concussion symptoms or mental status abnormalities resolve in >15 minutes *the pt can return to play after 1 week Grade III: Any loss of consciousness:brief(seconds)or prolonged CT,MRI should be done to rule out other conditions * the pt can return to play after 2 weeks but there is difference between different sources,all ur answers can be right... Q. A 24yo hockyplayer suffered contusion with transient confusion,impaired attention,incoherent speech and memory defecit that lasted 20minutes.What’s the next step of management?when he can return to play? A. GRADE 2:neurologic exam,no indication of CT/MRI!!,can return to play after 1 asympto wk at rest&with exertion Concussion: Grade I: transient confusion NO loss of consciousness Concussion symptoms or mental status abnormalities resolve in <15 minutes *the pt can return to play after 15 minutes Grade II: transient confusion NO loss of consciousness Concussion symptoms or mental status abnormalities resolve in >15 minutes *the pt can return to play after 1 week Grade III: Any loss of consciousness:brief(seconds)or prolonged CT,MRI should be done to rule out other conditions * the pt can return to play after 2 weeks Q. A 58yo pt undergoes a craniotomy for a benign meningioma.on the 10th postoperative day,he’s noticed to have a swollen left calf&thigh,DVT documented &IV heparin therapy started.While he’s on heparin at a therapeutic level,begins to bleed from a stress ulcer in the stomach.what’s the most appropriate management for his DVT? A. IVC filter thrombolytic therapy contraindicated bcoz of craniotomy Q. A 31 yo primigravida complains of headache,restlessness,sweating&tachycardia.She 's 18wk pregnant and her BP is 200/120mmHg. what's the best next step for diagnosis? a:exploratory laparotomy b:mesenteric angiography c:head CT scan d:abdominal CT scan e:abdominal US What's the most appropriate treatment for this pt? A. e:case of pheo pheo can initially be symptomatic during pregnancy,US is sufficient to localize the tumor to the R or L adrenal.abdominal CT should be avoided during pregnancy.This clinical picture can also be seen in pts with mole:HTN&hyperthyroidism symptoms but again e is the best choice and no history of bleeding,passage of vesicles,hyperemesis,and no lab finding of elevated beta-HCG…so it seems that pheo is the better diagnosis... Pheo management in pregnancy:alpha&beta blocker followed by vaginal delivery or CS with excision of tumor at the same time as delivery or electively after delivery. Q. A 31yo man with diabetic nephropathy undergoes an uneventful renal transplant from his sister.his immunosuppressive regimen includes azathioprine,steroids&cyclosporine.on postoperative day3 the pt is doing well,but u notice on his routine lab tets that his WBC is 2000.What's the most appropriate next step of management? a:start gancyclovir b:start broad-spectrum Antibiotics c:Administer filgrastim d:Administer FK50 e:d     
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