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32 yo - routine exam last office visit - 5 yrs ago appendectomy 8 yrs ago no PMHx or FHx for serious illnesses most app screening test for pt? --------- CORRECT ANSWER --------- measurement of serum cholesterol concentration according to USPTF: should screen this dude for HIV, BP, syphillis, alcohol misuse, depression, diet, hep B/C, TB, obesity, and other STDs
37 yo - 3 months of int fever and nonproductive cough > 30 lb weight loss
2 months ago: ophthalmologist tx him for L.ant uveitis
PE: gucci
labs: WBC WNL; inc AST 100; inc alk phos 200
CXR: hilar adenopathy
DLCO: 70%
PPD neg most likely dx? --------- CORRECT ANSWER --------- sarcoidosis AI disorder - very common in African American women restrictive lung dz w/ *classic CXR pattern - BL hilar LND*
dx: biopsy of lung tissue - noncaseating granulomas
common manifestations: uveitis; heart block; Bells palsy; erythema nodosum
tx: steroids
37 yo - 2 days of painful bumps on R.index finger > similar episode 3 yrs ago - resolved w/o tx no PMHx; no meds
SHx: resp therapist
PE: tendern lesions on distal phalanx of R.index finger
photo shows most app tx? --------- CORRECT ANSWER --------- oral acyclovir therapy homegirl has herpetic whitlow HSV infection of finger caused by inoculation into open skin surface > *common in healthcare workers* painful vesicular lesions at fingertip can cause fever and axillary LND
dx: Tzanck smear (multinucleate giant cells); cx - gold standard
tx: acyclovir; DO NOT DO I&D
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37 yo - mult episodes of HoTN during hemodialysis
PMHx: CRF
PE: distended neck veins; lungs clear; distant heart tones w/o murmur/gallop
echo: large pericardial effusion
what physical sign is associated w/ cause of HoTN episode? --------- CORRECT ANSWER --------- paradoxical pulse
Beck's triad: distant heart sounds; JVD; HoTN
pericardial effusion prevents normal distension of the heart w/ filling inspiration: inc VR in RV pushes IV septum into LV > prevents LV from filling the same > dec stroke volume for that moment = dec in sys BP
symptoms similar to CHF: dyspnea on exertion, orthopnea, and PND
can lead to tamponade > if effusion is rapid or if there's ventricular hemorrhage > Beck's triad, clear lungs, and pulsus paradoxus (>10 mmHg)
> tx: EMERGENT PERICARDIOCENTESIS; if can't get pt into surgery - IVF +
pericardial window (make a gd hole in the pericardium)
37 yo - F/U after BP was 152/110 mmHg
PMHx: mild asthma (albuterol MDI prn); levonorgestrel IUD
no FHx of CVD or HTN
SHx: no drugs
BMI: 22
BP: 155/108 mmHg in R.upper ext; 154/106 mmHg in L.
labs: WNL Na, HCO3, BUN, Cr, glucose (72); dec K, Mg; inc Cl
most likely mechanism of pt's inc BP? --------- CORRECT ANSWER --------- mineralocorticoid excess homegirl has FMD renal artery stenosis = MC cause of secondary HTN > old guys will have atherosclerosis > young girls will have FMD
features: sudden onset of HTN w/o FHx; dec renal function; abd bruit
(RUQ/LUQ/epigastrium)
dx: renal arteriogram; MRA; doppler US
tx: revascularization w/ PRTA; surgery; anti-HTN (typically don't work tho)
37 yo - mole on L.leg > has it for 15 yrs
FHx: uncle recently dx w/ widely met melanoma
PE: 0.5 cm, slightly raised, young, brown nevus w/ symmetric borders on L.lower ext; 4 mm, smooth, moveable R.inguinal LN palp next step in dx? --------- CORRECT ANSWER --------- observation remember ABCDE for malignant melanoma I have no clue what is happening w/ the LN
classic: jet black, smooth lesion on sun-exposed skin
dx: never do a shave biopsy
> large lesion or low suspicion - punch biopsy 2 / 3
> small lesion or high suspicion - wide excisional biopsy
tx: no tx if it has met
38 yo - low grade fever and gen rash for 4 days > cefazolin therapy for chronic osteomyelitis
100.8 F
P: 100/min
BP: 150/108 mmHg
PE: faint diffuse maculopapular rash; back - no CVA tenderness; cardiac/pulm - gucci
labs: WBC WNL (inc bands, eosinophils, monocytes; dec lymphocytes); inc BUN, Cr
UA: inc WBC (12), inc RBC (8), no RBC casts, rare WBC casts
urine sediment: eosinophils
most likely location of pt's lesion? --------- CORRECT ANSWER --------- renal tubule homegirl has AIN > acute int renal inf pyuria (classically eosinophils) and azotemia > occurs after administration of certain drugs (diuretics, PCN derivatives, PPIs, sulfonamides, rifampin, NSAIDs) less commonly 2/2 other processes like systemic infections or AI dz features: fever, rash, hematuria, pyuria, and CVA tenderness; can be asymptomatic P's: Pee (diuretics), Pain-free (NSAIDs), PCNs and cephalosporins, PPIs, rifamPin
40 yo - F/U exam after PPD skin pos
SHx: health-care worker
current test: 17 mm after erythema and 11 mm of induration at max measurement
points annual PPD over last 5 yrs - neg
CXR: gucci
most app next step in mgnt? --------- CORRECT ANSWER --------- administration of isoniazid
+PPD screen if:
> 5 mm - "immunosuppressed" (HIV/AIDs, organ transplant, steroids, close contacts of TB) > 10 mm - "exposed" (incarcerated/homeless, health care provider, travel to endemic areas) > 15 mm - "shouldn't be screened" pt symptomatic, pos PPD, or pos IFNy - get CXR to assess for active dz > CXR will be annual screen > if CXR neg + never been tx = INH + B6 x 9 months > if CXR pos = rule out active dz w/ AFB smears; isolate pt ~ tx w/ RIPE if AFB pos ~ tx INH + B6 x 9 months if AFB neg
42 yo - 6 months of mild bloating/diarrhea > 8 large, foul-smelling stools daily - difficult to flush > last 3 months - 25 weight loss; no changes in diet/appetite
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