Heme/Onc
A 6-year-old presents to the ED with his mom for ataxia, decreased activity, slurring of speech, and facial droop for the past 1-2 days. He has had difficulty keeping up with his karate class for the past month. the patient also has had "cross eyes". What is the most likely diagnosis?
a. acute cerebellar ataxia of childhood
B. viral meningitis
C. Brainstem glioma
D. Craniopharyngioma
E. ALL with CNS involvement
Brainstem glioma- abnormalities in cranial nerve nuclei in stem.
cerebellar ataxia- horizontal nystagmus and dysarthria
craniopharyngioma- HA, visual changes, endocrine issues
A 55-year-old man is evaluated for 1 yr hx of worsening personality and behavioral changes, compulsive tendencies and loss of empathy. no hx of etoh or smoking but not does both. he has lost more than 1/2 of his retirement in one month gambling. 2 weeks ago, he was arrested for breaking into a neighbor's house. results of cognitive screening are normal. No other meds or medical problems. Exam and vitals are normal.
A MRI of brain showed atrophy of frontal right lobe.
Which of the following classes of drugs is most appropriate for the pharmacologic treatment of this patient?
A. Acetylcholinesterase inhibitors
B. Atypical antipsychotic agents
C. N Methyl-D aspartate receptor antagonists
D. SSRI
SSRI-
can treat some symptoms including compulsivity.
A previously healthy 17-year-old male complains of persistent vomiting and anorexia for 1 week duration. Upon awakening, his eyes are yellow. He takes no meds or supplements. Denies drug and alcohol use. not sexually active. no immunizations due to religious beliefs. On exam, temp is 98.2 BP 120/70, RR 14 and HR 88. skin is jaundice and sclerae are mildly icteric. Which of the following would suggest that this patient is more likely to have Hep B rather than Hep A?
a. Arthralgia and arthritis
b. tender hepatomegaly
c. splenomegaly
d. extremity edema
e. acute liver failure
Arthralgia and arthritis
- Hep B- symmetrical polyarthralgia and arthritis
- macular and urticarial rashes
- thrombocytopenia
a 48-year-old male is evaluated as part of a routine annual exam. Medical history is significant for hyperlipidemia. He has a 28-pack year history. His only med is pravastatin. On exam, VSS and other findings are normal.
Labs: Hb 14.6, Leukocyte count 12,500, ANC 10,000, platelets 302,000. Smear is unremarkable.
Which of the following is the most likely cause of the patient's elevated leukocyte count?
A. CML
B. Occult infection
C. Pravastatin
D. Smoking
Smoking
A 29-year-old man is evaluated for hemorrhagic shock. He has OI and was admitted for right hip fracture repair 2 days ago. He was placed on LMW heparin post op. BP 84/44 and HR 132 RR 31. Oxygen saturation is 91% using a non-rebreather mask. Cardiac exam shows tachycardia, no murmur, no gallop. He has copious blood coming from nose and there is swelling, bruising and oozing from surgical site. He has a 18-gauge PIV in left forearm.
Which of the following is the most appropriate form of additional IV access for pt?
a. PICC
B. 18 Gauge PIV in R arm
C. IO in humerus
D. Triple lumen in left femoral vein
18 Gauge PIV in R arm
A 49-year-old man is evaluated for progressive fatigue and 13.6 kg weight loss in 4 months. PMHx is unremarkable and is on no meds. Exam and vitals are normal. on abdominal exam, his spleen is at 17 cm. Labs show Hb 11, Leukocyte count of 87,5000 (87% neutrophils, 2% bands, 2% metamyelocytes, 3% myeloblasts, 2% basophils, 2% lymphocytes) platelets of 465,000. BM bx shows hypercellular marrow with granulocytic hyperplasia and 6% myeloblasts. Chromosomal analysis and FISH show t(9;22)
Which of the following is the most appropriate treatment?
A. Hydroxyurea
B. Imatinib
C. Induction chemotherapy
D. Stem cell transplantation
Imatinib
-1st line treatment for patients in CML in chronic phase (< 20% blasts in BM)
A 5-year-old kid presents with nighttime episodes of facial twitching and difficulty talking. The episodes evolve into generalized shaking at all times. He is developmentally normal. Which of the following is the pattern you would expect to see on EEG?
A. 3 Hz generalized spike and wave
B. 4-6 Hx Poly spike and wave
C. Centrotemporal sharp waves
D. Occipital sharp waves
E. Hypsarrhythmia
Centrotemporal sharp waves= childhood epilepsy= benign Rolandic epilepsy.
3 Hz generalized spike= absence
4-6 Hz Poly spike - juvenile myoclonic epilepsy
Occipital - visual phenomena with seizures
Hypsarrhythmia- infantile spasms
A 43-year-old woman is evaluated in ED for confusion and 1 week history of yellow skin. She consumes 12 beers daily. Medical history is noncontributory. On exam, temp is 38.5, BP 120/50, HR 100 and RR 24. Her sclerae are icteric and skin is jaundiced. Tender hepatomegaly is present. She has asterixis and is oriented to person only. No source of infection has been identified. MELD score is 23.
WBC 14,000, INR 1.3, ALP 200, ALT 30, AST 62, Cr 1.3 and TBr 15. U/s of RUQ showed hepatomegaly, minimal ascites and liver echogenicity and no stones or ductal dilation.
in addition to NAC, which of the following is the most appropriate management?
A. Cefepime
B. Liver biopsy
C. Pentoxifylline
D. Prednisolone
Prednisolone
A 3-year-old boy with a hx of multiple episodes of OM and acute bacterial sinusitis was hospitalized for the 2nd time with pneumococcal pneumonia. He also has a history of moderate to severe asthma and severe atopic dermatitis. Labs include a decreased level of IgM and increased IgA and IgE. An immunodeficiency disorder is suspected.
Which of the following is most likely to be identified during additional evaluation?
A. Reduced number and size of platelets.
B. cyclic episodes of neutropenia
C. Decreased levels of CH50, C3, and C4
D. increased levels of SSA antibodies
E. Microscopic hematuria with intermittent gross hematuria.
Reduced number and size of platelets.
Wiskott-Aldrich syndrome
- X L recessive
-atopic dermatitis, thrombocytopenia and lots of infections
A 55-year man is in ED for abd pain and fever x 12 hours. PE showed temp 38.3, bp 90/60, HR 110 and RR of 26. Oxygen saturation is 95% on room air. he is confused. scleral icterus is noted. TTP in RUQ. rest of the exam is normal. WBC 22K, ALT 448, Tbili 5, Dbili 4, Cr 2 and lipase 56. U/s of RUQ is normal liver and GB but the biliary duct is dilated.
Which of the following is the likely diagnosis?
A. Acute cholangitis
B. Acute cholecystitis
C. Pancreatitis
D. Pyogenic liver abscess
Acute cholangitis
- F, jaundice, RUQ pain
A 6-year-old boy with a hx of Dev delay and hearing loss presents for additional evaluation. His teacher reports that both his cognitive and language skills are behind his peers. Both his teacher and mom also report that he is irritable and will frequently complain of stomach pain. During lab evals, a smear reveals the presence of blue granules of various sizes dispersed throughout the cytoplasm of red cells. which of the following lab findings is most likely to also be identified upon further evaluation of this patient?
A. Elevated amylase and lipase
B. Decreased ceruloplasmin
C. Decreased alpha 1 anti trypsin
D. Decreased levels of Zn protoporphyrin
E. Elevated blood erythrocyte protoporphyrin.
Elevated blood erythrocyte protoporphyrin.
smear = basophilic stippling. blue granules = ribosomal precipitates seen in lead and heavy metals
A 72-year-old man is evaluated for dementia with fluctuations in attentiveness, visual hallucinations, and slowness of movements over the past year. He has also acted out his dreams in his sleep a few times over the last 2 years. On exam, vitals are normal. Mild hypomimia, symmetrically increased tone in b/l UE and bradykinesia on rapid alternating movements are observed.
Which of the following is the most appropriate treatment?
A. Clonazepam
B. Haloperidol
C. Memantine
D. Rivastigmine
E. Zolpidem
Rivastigmine
used for dementia with Lewy bodies- dementia with motor symptoms = Parkinson disease dementia but in 1-2 years of each other.
- acetylcholinesterase inhibitors- improve cognition, global function and ADL.
During a well exam, an 8-month-old girl has not gained weight since 6-month exam. she is now 3rd % from 25%. She was sole breastfed to 6 month and now takes soy formula, rice cereal, and vegetables. On exam, she has a sharp demarcated and itchy rash in perineal and genital area with vesiculobullous and pustular lesions and some are dried and scaly eczematoid. Sweat test showed a level of 75. What is the most likely cause of this patient's rash?
A. Overgrowth of Pseudomonas
B. Contact dermatitis due to fatty acidic stools
C. Nutritional vitamin E deficiency
D. contact derm due to bile salt malabsorption.
E. Nutritional Zn deficiency
Nutritional Zn deficiency
CF- loss of fat-soluble vitamins and Zn
acrodermatitis enteropathica
A 45-year-old man is evaluated for dull, throbbing pain in left shoulder. Reports intermittent catching sensation with movement and a feeling of shoulder joint instability. there is no history of trauma and is an avid weightlifter. on exam, there is no pain with palpation of left shoulder, palpation of the biceps tendon elicits crepitus but no pain. passive range of motion is within normal limits and active range of motion is limited by pain. pronation of the forearm and abduction and external rotation of the left arm reproduce pain. Clicking in the glenohumeral joint is noted with passive range of rotation of the arm in an abducted position. Tests for rotator cuff injury are negative. Strength is 5/5 throughout the left arm.
Which of the following is the most likely diagnosis?
A. Acromioclavicular joint degeneration
B. Adhesive capsulitis
C. Biceps tendinopathy
D. Labral tear
Labral tear
SLAP tears - superior labrum anterior and posterior lesions = repeated overhead stress and over 40. pain is deep and hard to localize. notable for crepitus and joint instability.
An unconscious 16-year-old girl comes to the ED by parents. she is healthy but under a lot of stress due to HS demands. She is working hard but grades don't reflect her effort. She has extreme stress for 3-4 months. F Hx significant for anxiety and panic attack and she is on an anxiety med. On exam, she is slightly cyanotic. Temp 37, BP 80/50 and HR 59 RR 10. Nystagmus noted on exam. DTR are diminished and plantar reflexes are absent b/l. No response to pain and GCS 3. rest of her exam is unremarkable. EKG shows sinus tach. Gluc 80. other labs including etoh and UDS are pending. Which of the following is the most likely cause of this patient's symptoms?
A. SSRI tox
B. Benzo OD
C. Benzo withdrawal
D. Acute inhalant tox
E. Cocaine OD
Benzo OD
SSRi- fever, confusion, myoclonus, diaphoresis, vomiting
Benzo withdrawal - seizures, sweats, chills, agitation, anxiety, suicidality
inhalants- lacrimation rhinorrhea, salivation
cocaine- vasoconstrictor
A 58-year-old man is evaluated for possible smoldering myeloma. Hx is unremarkable. No meds. Exam and vitals are normal. Serum protein electrophoresis and immunofixation show IgA protein spike of 3.5. Bone marrow biopsy reveals 50% clonal plasma cells. whole body low dose CT scan is negative for bone lesions.
Which of the following is the most appropriate imaging test to perform next?
A. Bone scan
B. Skeletal survey
C. Whole body MRI
D. No further testing
Whole body MRI
parents of a 9-year-old boy bring their son to the ED because something is wrong with his face. There is no trauma or systemic symptoms. on exam, he can't wrinkle his forehead on left and also lost ability to close his left eye and raise the corner of his mouth. Decreased nasolabial fold prominence on the left is also noted. which of the following is the cause of this patient's findings?
A. LMN dysfunction of left 7th nerve
B. LMN dysfunction of left 5 th nerve
C. UMN dysfunction of right 5th nerve
D. LMN dysfunction of left 5 and 7th nerves
E. UMN dysfunction of right 7th nerve
LMN dysfunction of left 7th nerve
A 22-year-old woman is evaluated in ED for an episode of confusion, diaphoresis, and tremulousness. Similar symptoms have been present for 6 months but are becoming more frequent and severe. Glucose is 30. symptoms resolve with glucose. There is an elevated C peptide, plasma glucose of 45 and elevated fasting insulin level. A contrast enhanced multidetector CT scan shows a highly vascular mass consistent in appearance with a pancreatitic neuroendocrine tumor. Genetic testing for which of the following should be included in this patient's evaluation?
A. MEN1
B. MEN2
C. NF1
D. TS
MEN1
-remember predisposition for tumors in parathyroid, anterior pituitary and pancreatic islet cells (insulinomas)
A recently adopted unimmunized 4-year-old girl presents for her 1st health exam following arrival in the US. The child was adopted from an orphanage in Mexico City, where she had been living following discharge from the hospital after being hit by a car. Records show that she was treated for a hepatic laceration and also required splenectomy due to blunt abdominal trauma.
Which of the following regimens for prevention of invasive pneumococcal disease is the most appropriate option for this patient?
A. 1 dose of PCV 20 (conjugate vaccine) followed by 8 weeks later of 2nd dose
B. One dose of PCV 20
C. One dose of PCV20 followed by PCV 23 (polysaccharide vaccine) 8 weeks later
D. One dose of PPSV 23 followed 5 years later by 2nd dose PCV 23
E. One dose of PCV 20 followed 8 weeks later by a 2nd dose of PCV20, 1 dose of PPSV23 8 weeks after the 2nd dose of PCV20 and a 2nd dose of PPSV23 5 years after the 1st dose of PPSV 23.
1 dose of PCV 20 (conjugate vaccine) followed by 8 weeks later of 2nd dose
A 50-year-old woman was admitted to ICU 24 hours ago for mgmt of ARDS due to PNA. She is on a mechanical ventilator. She is receiving vasopressors for hypotension. Meds are norepi, fentanyl and propofol drip. On exam, VSS. O2 sats are 90% with Fi02 of 0.60 and PEEP is 12. the patient is deeply sedated and unresponsive to physical stimulation.
Which of the following is the most appropriate management?
A. Downward titration of sedation meds
B. EEG
C. Head CT
D. Hold sedation and analgesia.
Hold sedation and analgesia.
A Hb electrophoresis and lab are presented for a 3-year-old pt with microcytic anemia. Which of the following findings is the correct interpretation?
Hb A 30% (normal > 90%); Hb S 55% (normal 0%); Hb F 10% (normal < 2%); HbA2 5% (normal 2-3.5%), Hb 10, Hct 31, MCV 60
A. Sickle trait
B. Homozygous sickle cell anemia
C. Homozygous sickle cell anemia on hydroxyurea
D. Hemoglobin S Beta thal
E. Homozygous sickle anemia after prbc
Hemoglobin S Beta thal
Elevated Hb A, HbA2, Elev Hb F
Sickle trait = need Hb A and S but A > S
Homozygous sickle= not microcytic, A2 <3.5; Hb F 5-15; Hb S 85-5 and no Hb A
transfusions will not get you elevate HbA2
Hydroxyurea- elevates F. no increase in A2. in homozygous sickle causes macrocytosis
A 75-year-old man is evaluated for progressive cognitive impairment over the past year that has led to loss of daily function. He loses his train of thought and misplaces items at home. His gait is slowed, and his behavior has changed. He has HTN, hyperlipidemia, T2DM, and CAD. Current meds are lisinopril, carvedilol, atorvastatin, metformin, canagliflozin, and ASA. On exam, BP was 153/85 and HR 65. DTR are normal and gait is slowed. No hypomimia, hypophonia, tremor, rigidity, or shuffling gait is observed. he demonstrates slowed processing speed when generating word lists. MRI of the brain shows diffuse, confluent white matter hyperintensities and no significant hippocampal atrophy.
Which of the following is the most likely diagnosis?
A. Alzheimer's
B. Dementia with Lewy bodies
C. Frontotemporal dementia, behavioral variant type
D. Vascular cognitive impairment
Vascular cognitive impairment
A 18-month-old boy presents for a well visit. He speaks 15 words, engages in pretend play with others and makes a tower of 4 cubes. No food or med allergies. He is healthy. he is 15th % for length and 20% for wt. VSS, normal growth and exam parameters. Which of the following anticipated guidance is most appropriate in this patient?
A. drink 16-24% unflavored skim milk
B. Drink no more than 8 oz of almond milk
C. Drink no more than 4 oz of sugar sweetened drinks
D. Drink no more than 16 oz of water.
E. Drink no more than 4 oz of fruit juice
Drink no more than 4 oz of fruit juice
A 23-year-old man is evaluated for fever, abdominal pain, and arthritis of the right knee of 3 days that resolved 1 week ago. He has had more then 20 similar episodes, the last 3 occurring in the past year. The first episode was at 5 years and presented with abdominal pain; the pt underwent appendectomy but no appendicitis was found. his paternal GF and MGM had similar. Exam is normal including vitals. Labs show an ESR of 23 and normal Cr and 1+ protein on urinalysis.
which of the following is the most appropriate treatment?
A. Canakinumab
B. Colchicine
C. Indomethacin
D. Prednisone
Colchicine
FMF= abd pain, fever, rash and arthritis. Tx if colchicine
A 3-year-old boy is brought to the ED after taking a swallow from a bottle of pool cleaner. he initially gagged, cried, and then vomited. He has been irritable since the episode. the family immediately brought him to the ED. On exam, you note a crying child in no respiratory distress. HR 130, RR 24 and BP 120/70. Exam is the oropharynx reveals no burns or irritation. The child has minimal drooling. The chest is clear. The abdomen is soft. It is difficult to determine tenderness since the child cries during the exam. the family had offered fluids to the child prior to your arrival, but the child refused them. the active ingredient in the pool cleaner is sulfuric acid. In addition to pain management, which of the following is the next course of action?
Admit for endoscopy the following morning
Administer IV fluids
Place NG tube
D/c the patient with instruction for close observation
Administer sodium bicarbonate
Admit for endoscopy the following morning