Growing Pains
1. This next step in management is appropriate for a patient without risk factors for MRSA infection who has a diabetic foot of moderate severity that is currently being managed with daily dressing changes and foot baths.
- Clinda and Cipro for 14 days
- Linezolid for 10 days
- Amoxicillin for 14 days
- Hospital admission of IV Vanc and Zosyn
- Local wound care with inc freq of dressing changes ( BID)
What is Clindamycin and Ciprofloxacin for 14 days?
2012 IDSA guidelines- systemic antibiotics.
Coverage for Beta Hemolytic strep, MRSA, aerobic gram negative bacilli and anaerobes.
2. This electrolyte abnormality is most likely to occur in an 8 yr old girl with Type 1 DM who presents with DKA, triggered by gastroenteritis, receiving Rx by IV insulin drip and NS + 20 meq/L KCL.
- Hyponatremia
-Hypocalcemia
- Hyperkalemia
- Hypercalcemia
- Hypokalemia
What is hypokalemia?
DKA patients have total body K deficit due to transcellular shifts associated with osmotic diuresis, urinary losses and losses from vomiting. Gastroenteritis- more loss from vomiting and diarrhea.
Initial recommendation - K in IV fluids should be 40 Meq/L.
A 42-year-old nonsmoker comes to clinic due to daily heartburn for the past 3 months. He also has dry cough and wheezing. The patient has no swallowing difficulty, nausea, vomiting, or weight loss. He has tried over-the-counter calcium carbonate with no significant relief. His father suffered from colon cancer at age 68, and his mother died of breast cancer at age 72.
BMI is 30 kg/m2, and physical examination is unremarkable. Complete blood count and renal function are within normal limits.
Which of the following is the most appropriate next step in management of this patient?
A) Barium swallow
B) Metoclopramide
C) Proton pump inhibitor
D) Pulmonary function testing
E) Upper GI endoscopy
What is Proton pump inhibitor?
A 78-year-old woman comes to the physician following treatment for a peptic ulcer. She was seen for melanotic stools 8 weeks earlier. A 1-cm duodenal ulcer was found on endoscopy; biopsy specimens had a positive urease test but no evidence of malignancy. The patient was treated with a 10-day course of omeprazole, amoxicillin, and clarithromycin. She reports no further symptoms.
Which of the following is the most appropriate next step in evaluation of this patient?
A) Long-term proton pump inhibitor therapy
B) Reassurance and periodic follow-up
C) Repeat endoscopy
D) Serologic test for Helicobacter pylori
E) Urea breath test
What is Urea breath test?
3. A 31 M presents with numbness, tingling, pain in L wrist when he is typing, as well as puffiness around his eyes. He reports fatigue and a depressed mood in the past year, which were accompanied by constipation and a 6.8 kg weight gain. PMH- Celiac disease as a adolescent, still maintains a gluten free diet.
P/E- Bp 130/100 mm Hg,HR =55/ min, Some difficulty with thumb abduction of left hand. Which is the most likely diagnosis?
- Vit B12 deficiency
- T- cell lymphoma
- Hypothyroidism
- Minimal-Change disease
- Acromegaly
What is hypothyroidism?
4. Previously healthy 14 F CC with Rt sided neck mass X 1 month. She has had no pain, erythema, difficulty swallowing, fevers, voice changes and no FHx of thyroid cancer.
P/E- nodule, 2cm over Rt lobe of thyroid, no regional LNpathy. TSH =2.5 MicroU/ml (N=0.5-4.0). U/S reveals 1.8 cm hypoechoic nodule with microcalcifications in the Rt thyroid nodule and no LNpathy.
What is the most approp next step in evaluation?
- Refer for thyroid lobectomy
- measure thyroid peroxidase and thyroid antibodies
- Obtain U/S FNAC
- Repeat thyroid US in 3-6 months
- Obtain nuclear thyroid scintigraphy
- What is Obtain U/S FNAC?
A 40-year-old man comes to the emergency department with black, tarry stools for the past 2 days. He is otherwise in good general health and takes no prescription medications.
His supine blood pressure is 120/80 mm Hg and pulse is 84/min; after 1 minute of standing they are 118/76 mm Hg and 90/min. Physical examination is remarkable for pallor. Upper gastrointestinal endoscopy shows a nonbleeding duodenal ulcer with visible vessel, and endoscopic therapy is performed.
Which of the following values for hemoglobin represents the optimal threshold for initiating blood transfusion in this patient?
What is <7 g/dL?
A 45-year-old man comes to the emergency department with upper abdominal pain. He describes it as "nagging" and constant and rates it 6/10. The pain started 6 hours ago and was not relieved by over-the-counter antacids. It gets somewhat better when he sits up and leans forward. The patient has had 2 episodes of vomiting since the pain started. He smokes a pack of cigarettes daily. He drinks 4-6 cans of beer a day and several more on weekends. He does not use illicit drugs. The patient's temperature is 37.8 C (100 F), blood pressure is 100/70 mm Hg, pulse is 110/min, and respirations are 20/min. Abdominal examination shows mild epigastric tenderness without guarding or rebound. Electrocardiogram shows sinus tachycardia and T-wave inversion in leads V4-V6. Chest x-ray shows a small left-sided pleural effusion.
Which of the following is the most likely diagnosis in this patient?
What is Acute pancreatitis?
5. Which one of the following diagnosis is most likely in a 40 F with a lean body type, Fhx DM in her mother and 24 Yr brother, a Hba1c of 8.3% and a normal C-peptide level?
- Type 2 Dm
- Latent autoimmune Diabetes of adulthood
- Ketosis prone diabetes
- Type 1 DM
- Maturity onset diabetes of the young.
What is Maturity Onset Diabetes of the young?
6. What is the estimated genetic height potential of a 14 Y boy presenting with short stature, delayed puberty, delayed bone age, Fhx of delayed puberty whose mother is 161 cm tall and whose father is 178 cm tall?
- 160 cm
- 176 cm
- 168 cm
- 192 cm
- 184 cm
What is 176 cm?
A 46-year-old woman is admitted to the hospital with diarrhea and generalized weakness. She has had several prior admissions for diarrhea, hypokalemia, and near-syncope. The patient has a history of hypertension, type 2 diabetes mellitus, and diverticulosis.
Vital signs and physical examination are within normal limits. Laboratory evaluation shows mild hypokalemia. Colonoscopy shows mild diverticulosis and dark pigmentation of the colonic mucosa with a striated pattern. There are no masses or polyps.
Which of the following is the most likely diagnosis?
A) Addison's disease
B) Diabetic autonomic neuropathy
C) Celiac disease
D) Hemochromatosis
E) Laxative abuse
What is laxative abuse?
A 32-year-old woman comes to the physician with bloating, abdominal pain, and diarrhea. The exclusion of dairy products from her diet results in significant symptomatic relief. The patient's physical examination and basic laboratory test results are unremarkable. Antitissue transglutaminase antibody is negative.
Which of the following is the most appropriate management of this patient?
A) Avoidance of nonsteroidal anti-inflammatory drugs
B) Complete exclusion of dairy products
C) Daily iron supplementation
D) Daily probiotic intake
E) Maintenance of calcium and vitamin D intake
What is Maintenance of calcium and vitamin D intake?
7. 14 yr boy, presents to the ED after multiple episodes of vomiting since the last 4 hours. PMH - significant for Addisons disease, which was diagnosed 4 yrs ago. Meds- Hydrocortisone TID and Fludrocortisone QD. Today he began vomiting shortly after taking his midday hydrocortisone dose and has been unable to tolerate anything PO since.
In the ER, T=39.1 deg C, HR =135/min, BP=90/58, RR=14/min, awake , alert, reports continued nausea and is very pale and dizzy.
In addition to NS, which one of the following meds is most imp intreating this patient?
- IV Epinephrine
- Oral Acetaminophen
- IV ondansetron
- IV hydrocortisone
- Oral Fludrocortisone
What is IV hydrocortisone?
8. Which one of the following management strategies is most approp for a F with type2 DM ( Hba1c 6.7%),who takes canagliflozin and metformin, reports vaginal burning and itching without dysuria or urinary frequency, and is experiencing vaginal discharge that reveals budding yeast on a wet mount?
- DC canagliflozin and recommend clotrimazole 2% cream vaginally X 3 days
- Continue canagliflozin, and prescribe oral fluconazole 150 mg as a single dose
- Switch to dapagliflozin, and prescribe oral fluconazole 150 mg as a single dose
- Continue canagliflozin and reassure patient that her vaginal condition will resolve as her glucose levels decline.
- Discontinue canagliflozin and recommend probiotics BID X 1 week.
What is Continue canagliflozin, and prescribe oral fluconazole 150 mg as a single dose?
A 60-year-old man with a 7-year history of gastroesophageal reflux disease undergoes screening endoscopy for Barrett esophagus. He has a 15-pack-year smoking history. Upper gastrointestinal endoscopy shows moderate esophagitis with red and velvety mucosa extending from the gastroesophageal junction into the distal esophagus. There is no evidence of gastritis. Biopsy results are confirmed by the pathologist as Barrett esophagus with high-grade dysplasia.
Which of the following is the most appropriate next step in management of this patient?
A) Endoscopic eradication therapy
B) Increased proton pump inhibitor use to twice a day with repeat endoscopy in 6-12 months
C) Intensive endoscopic surveillance in 3-6 months
D) Routine enoscopic surveillance in 3-5 years
E) Testing and treatment of helicobacter pylori infection
What is endoscopic eradication therapy?
39-year-old woman comes to the emergency department with intense upper abdominal pain that started after her dinner an hour ago. She also has right shoulder pain and feels nauseated. Her symptoms subside before she is examined by the physician. The patient describes 2 similar episodes of lesser intensity in the past 6 months.
Her vital signs are within normal limits. Abdominal examination shows no tenderness or guarding. Laboratory studies show normal liver function tests and lipase levels.
Which of the following is the most appropriate next step in management?
A. Abdominal ultrasound
B. CT of the abdomen with contrast
C. Omeprazole prescription and routine follow-up
D. Stool Helicobacter pylori antigen testing
E. Upper gastrointestinal endoscopy
What is Abdominal Ultrasound?
9. What diagnostic test is most likely to reveal the cause of new onset headache with palpitations, anxiety and diarrhea in a previously healthy 9 yr F whose exam is notable for slight diaphoresis, a blood pressure above the 99th percentile for her age and height, and a normal level of TSH?
- Measurement of Fractionated metanephrines
- CT of Abdo and Pelvis
- Genetic testing for Von-Hippel Lindau disease
- Abdominal U/S
- PET of the chest
What is Measurement of fractionated metanephrines?
A 66 yr M presents for his annual general medical evaluation with no specific concerns. He has a h/o of systemic HTN treated with amlodipine, as well as hyperlipidemia managed with diet. He has a 25 pack year h/o ciggaratte smoking and quit 15 years ago. His Blood pressure is 148/84 mm Hg and his BMI is 30. P/E - unremarkable.
Which of the following is most appropriate in this patient?
- Audiogram
- Bone densitometry
- Chest Xray
- Measurement of glycated hemoglobin
- Nuclear stress test
What is measurement of glycated hemoglobin?
A 61-year-old man comes to the emergency department with a 2-day history of lower abdominal pain. The patient has no nausea, vomiting, back pain, or urinary symptoms. His medical conditions include hypertension for which he takes lisinopril. Temperature is 37.8 C (100 F), blood pressure is 122/70 mm Hg, and pulse is 92/min. Mucous membranes are moist. There is moderate tenderness in the left lower quadrant without rebound tenderness. Laboratory results are as follows:
Leukocytes 13,000/mm3
Creatinine 0.7 mg/dL
CT scan of the abdomen shows localized wall thickening in the sigmoid colon with pericolic fat stranding.
Which of the following is the best treatment plan for management of this patient?
A) Hospitalization, intravenous (IV) antibiotics, and serial abdominal examinations
B) Hospitalization, IV antibiotics, and repeat CT scan in 2 days
C) Hospitalization, IV antibiotics, and sigmoidoscopy
D) Oral antibiotics with outpatient follow-up instructions
E) Peripherally inserted central line placement and outpatient IV antibiotics
What is Oral antibiotics with outpatient follow-up instructions?
A 42-year-old man complains of fatigue over the last 6 months. He has no abdominal pain, vomiting, fever, or weight loss. His past medical history is significant for ulcerative colitis diagnosed 3 years ago. The disease is controlled with oral 5-aminosalicylic acid and steroid enemas. His temperature is 37.0 C (98.6 F), blood pressure is 134/90 mm Hg, pulse is 74/min, and respirations are 15/min. Examination shows mild tenderness in the left lower quadrant. There is no hepatomegaly or splenomegaly.
Laboratory results are as follows:
Albumin
3.8 g/dL
Total bilirubin
1.7 mg/dL
Alkaline phosphatase
816 U/L
Aspartate aminotransferase (SGOT)
45 U/L
Alanine aminotransferase (SGPT)
54 U/L
Erythrocyte sedimentation rate is 102 mm/hr and antineutrophil cytoplasmic antibody screen is positive with a perinuclear pattern (perinuclear anti-neutrophil cytoplasmic antibodies).
Which of the following is the most likely diagnosis?
A) Bacterial cholangitis
B) Drug-induced hepatotoxicity
C) Metastatic colon cancer
D) Primary biliary cirrhosis
E) Primary sclerosing cholangitis
What is Primary sclerosing cholangitis?