CVS
A 55-year-old man presents to the clinic with complaints of shortness of breath and fatigue for the past two months. He has a history of hypertension and chronic obstructive pulmonary disease (COPD). On physical examination, his blood pressure is 140/90 mm Hg, heart rate is 88 bpm, and respiratory rate is 20 breaths per minute. Jugular venous distention is noted, and there are bilateral crackles heard on lung auscultation. A chest X-ray shows cardiomegaly and pulmonary congestion.
Which of the following is the most likely diagnosis?
A. Asthma
B. Pulmonary embolism
C. Chronic bronchitis
D. Congestive heart failure
E. Pneumothorax
D. Congestive heart failure
A 45-year-old man presents to the clinic with complaints of fatigue, weakness, and swelling in his legs. On physical examination, he has pitting edema in his lower extremities. Laboratory tests reveal the following:
- Serum albumin: 2.5 g/dL (normal: 3.5-5.0 g/dL)
- Urinalysis: +4 protein, no blood, no casts
What is the likely diagnosis?
Nephrotic Syndrome
A 45-year-old woman presents with a 6-month history of difficulty with fine motor tasks, such as buttoning her shirt and writing. She also reports occasional tremor in her right hand, which improves with movement. On examination, she has a resting tremor, bradykinesia, and rigidity on the right side. There are no significant sensory deficits, and her cognition is intact.
where is the lesion
BASAL GANGLIA
Name the nerve responsible for innervating the sole of the foot
TIBIAL nerve
A 60-year-old man with a history of hypertension and chronic stable angina presents to the clinic for a follow-up visit. His current medications include aspirin, atorvastatin, and metoprolol. His blood pressure today is 150/92 mm Hg, and his heart rate is 68 bpm. Despite adherence to his medication regimen, his blood pressure remains elevated.
Which of the following medications would be most appropriate to add to his current therapy to improve his blood pressure control?
A. Lisinopril
B. Nitroglycerin
C. Digoxin
D. Amiodarone
E. Furosemide
LISINOPRIL
A 55-year-old woman presents to the clinic with complaints of increased frequency of urination, urgency, and burning sensation during urination for the past three days. She denies fever or back pain. On physical examination, she appears well and afebrile. A urinalysis is performed and shows the following:
- Leukocyte esterase: Positive
- Nitrites: Positive
- White blood cells: 20-30 per high-power field
- Red blood cells: 0-2 per high-power field
- Bacteria: Many
Which of the following is the most likely diagnosis?
A. Acute pyelonephritis
B. Cystitis
C. Nephrolithiasis
D. Glomerulonephritis
E. Acute interstitial nephritis
B. Cystitis
A 58-year-old man presents to the emergency department with sudden-onset left-sided weakness and difficulty speaking that started 4 hours ago. His past medical history includes hypertension and atrial fibrillation. On examination, he has right-sided hemiparesis and expressive aphasia. A non-contrast CT scan of the head is performed and shows no acute hemorrhage.
Which of the following is the most appropriate next step in management to potentially improve this patient’s outcome?
A. Administer intravenous thrombolytics
B. Initiate anticoagulation therapy
C. Start high-dose corticosteroids
D. Perform urgent carotid endarterectomy
E. Begin physical therapy
A. TPA
A 30-year-old man presents to the emergency department with abdominal pain, nausea, and vomiting. He reports that the pain started suddenly and is localized to the right lower quadrant. On examination, he has rebound tenderness and guarding in the right lower quadrant. A complete blood count (CBC) shows an elevated white blood cell count with a left shift. Whatis the definitive treatment for this patient
Surgery - appendectomy
A parent walks into your office with their 7 year old daughter for a general check up. The parent is concerned that her daughter is “not as tall as other girls in her class”. On examination, you observe a short and wide neck, and widely spaced nipples. Her brachial pulse is stronger than her femoral pulse. What 2 cardiac problems are associated with this condition?
Bicuspid Aortic Valve and Coarctation of the Aorta
Turner’s Syndrome!!!!
Exhibit 1
A 30-year-old woman presents to the clinic with a 2-week history of frothy urine and swelling in her legs. She denies any recent infections, fever, or weight loss. Physical examination reveals bilateral pitting edema of the lower extremities. Laboratory tests show:
- Serum albumin: 2.0 g/dL (normal: 3.5-5.0 g/dL)
- Serum cholesterol: 280 mg/dL (normal: <200 mg/dL)
- Urinalysis: 4+ protein, no blood, no casts
A renal biopsy is performed, and the results reveal diffuse effacement of foot processes on electron microscopy with no immune deposits on immunofluorescence.
Which of the following is the most likely diagnosis?
A. Minimal change disease
B. Focal segmental glomerulosclerosis (FSGS)
C. Membranous nephropathy
D. Diabetic nephropathy
E. IgA nephropathy
A. Minimal change disease
A 45-year-old woman presents with a 6-month history of progressive difficulty with speaking and swallowing. On examination, she demonstrates dysarthria, dysphagia, and weakness in the bulbar muscles. Additionally, she has noticeable muscle wasting and fasciculations in her tongue. Her neurologic examination reveals normal cognitive function and no sensory deficits.
Which of the following is the most likely diagnosis?
A. Multiple sclerosis
B. Myasthenia gravis
C. Amyotrophic lateral sclerosis (ALS)
D. Guillain-Barré syndrome
E. Parkinson's disease
ALS
A 68 year old man comes to your office for evaluation of premalignant lesions caused by sun exposure. These are small, rough, erythematous or brownish papules on his forehead.
Exhibit 2
What cancer is he most likely to get?
Squamous cell carcinoma. these are Actinic Keratoses.
A 58-year-old man with a history of hypertension and type 2 diabetes mellitus presents to the emergency department with chest pain that started 2 hours ago. The pain is described as a pressure-like sensation radiating to his left arm. He is diaphoretic and nauseated. On examination, his blood pressure is 160/95 mm Hg, heart rate is 95 bpm, and respiratory rate is 18 breaths per minute. An electrocardiogram (ECG) shows ST-segment elevation in leads II, III, and aVF.
Which of the following is the most likely underlying cause of this patient's condition?
A. Coronary artery spasm
B. Embolization of atherosclerotic plaque
C. Aortic dissection
D. Rupture of an atherosclerotic plaque with subsequent thrombosis
E. Pericarditis
D. Rupture of an atherosclerotic plaque with subsequent thrombosis
This patient presents with symptoms and ECG findings consistent with an acute myocardial infarction (MI), specifically an inferior wall MI (ST-segment elevation in leads II, III, and aVF). The most common underlying cause of an acute MI is the rupture of an atherosclerotic plaque with subsequent thrombosis, leading to complete or near-complete occlusion of the coronary artery.
A 67-year-old man with a history of chronic hypertension and diabetes mellitus presents to the emergency department with altered mental status and decreased urine output for the past two days. He was recently discharged from the hospital after being treated for a myocardial infarction. On examination, he is confused and has a blood pressure of 90/60 mm Hg and a heart rate of 110 bpm. His laboratory results are as follows:
- Serum creatinine: 3.5 mg/dL (baseline: 1.2 mg/dL)
- Blood urea nitrogen (BUN): 50 mg/dL
- Fractional excretion of sodium (FENa): 3%
- Urinalysis: muddy brown granular casts, no red blood cells, no white blood cells
Which of the following is the most likely underlying pathophysiological mechanism for this patient's condition?
A. Immune-mediated tubular injury
B. Obstruction of renal tubules by crystals
C. Prolonged renal hypoperfusion leading to ischemic injury
D. Direct toxic effect on renal tubules by nephrotoxic agents
E. Glomerular basement membrane damage leading to proteinuria
C. Prolonged renal hypoperfusion leading to ischemic injury
ATN
Exhibit 3. Where is the lesion?
Left temporal lobe - dorsal optic radiation
A 59 year old obese man with hypertension and diabetes presents to your office with a red, swollen, painful greater toe. Serum uric acid levels are currently normal. Crystals observed under polarised light will have what configuration?
This is Gout
They will be needle shaped and have negative birefringence against polarised light.
yeLLow under paraLLel light
A 62-year-old woman with a history of hypertension and coronary artery disease presents to the emergency department with sudden-onset chest pain, shortness of breath, and syncope. She is found to have a blood pressure of 90/60 mm Hg and a heart rate of 120 bpm. Her ECG shows wide-complex tachycardia. Despite the administration of intravenous fluids, her blood pressure remains low. An echocardiogram reveals a large left ventricular thrombus.
Which of the following is the most appropriate initial pharmacological treatment for this patient's condition?
A. Intravenous nitroglycerin
B. Intravenous amiodarone
C. Intravenous heparin
D. Oral clopidogrel
E. Oral carvedilol
IV HEPARIN
A 40-year-old man presents to the emergency department with severe flank pain radiating to the groin, hematuria, and nausea. He has a history of recurrent kidney stones. On physical examination, he is in distress, and there is tenderness over the left costovertebral angle. Non-contrast CT of the abdomen and pelvis reveals a 6 mm calculus in the left ureter. Laboratory results show:
- Serum calcium: 11.2 mg/dL (normal: 8.5-10.2 mg/dL)
- Serum phosphate: 2.0 mg/dL (normal: 2.5-4.5 mg/dL)
- Serum parathyroid hormone (PTH): 150 pg/mL (normal: 10-65 pg/mL)
- Urinalysis: Microscopic hematuria, no casts
Further evaluation reveals a solitary parathyroid adenoma. Which of the following mechanisms is primarily responsible for the patient's recurrent nephrolithiasis?
A. Hypercalciuria due to increased intestinal absorption of calcium
B. Hypercalciuria due to decreased renal reabsorption of calcium
C. Hyperoxaluria due to increased dietary oxalate absorption
D. Hyperuricosuria due to increased purine metabolism
E. Hypocitraturia due to impaired citrate metabolism
A. Hypercalciuria due to increased intestinal absorption of calcium
Sure, here's an explanation for why option A is correct and why the other options are not:
**Correct Answer: A. Hypercalciuria due to increased intestinal absorption of calcium**
The patient's elevated serum calcium (hypercalcemia) and high parathyroid hormone (PTH) levels indicate primary hyperparathyroidism, typically due to a parathyroid adenoma. In primary hyperparathyroidism, increased PTH stimulates osteoclasts to release calcium from bones, kidneys to reabsorb more calcium, and intestines to absorb more calcium. This increased intestinal absorption of calcium leads to hypercalciuria, which is a significant risk factor for the formation of calcium-containing kidney stones, such as calcium oxalate stones.
**Incorrect Answers:**
**B. Hypercalciuria due to decreased renal reabsorption of calcium**
In primary hyperparathyroidism, PTH actually increases renal reabsorption of calcium, not decreases it. The hypercalciuria in this patient is mainly due to increased calcium absorption from the intestines and increased bone resorption, not decreased renal reabsorption.
**C. Hyperoxaluria due to increased dietary oxalate absorption**
Hyperoxaluria is an increased urinary excretion of oxalate, which can contribute to calcium oxalate stone formation. However, the patient’s primary issue is hypercalcemia and hypercalciuria due to primary hyperparathyroidism, not increased oxalate absorption. There is no indication from the history or labs that the patient has increased oxalate intake or absorption.
**D. Hyperuricosuria due to increased purine metabolism**
Hyperuricosuria, an increased excretion of uric acid in the urine, is typically associated with uric acid stones rather than calcium stones. The patient's history of recurrent kidney stones and the presence of hypercalcemia and elevated PTH suggest calcium oxalate stones rather than uric acid stones.
**E. Hypocitraturia due to impaired citrate metabolism**
Hypocitraturia, a low level of citrate in the urine, can indeed be a risk factor for kidney stones since citrate binds calcium and inhibits stone formation. However, the primary issue in this patient is hypercalciuria due to increased calcium absorption from the intestines driven by elevated PTH levels. There is no evidence from the patient's history or lab results that hypocitraturia is the main contributing factor.
Therefore, the correct mechanism leading to this patient's recurrent nephrolithiasis is hypercalciuria due to increased intestinal absorption of calcium, as indicated in option A.
A 32-year-old man presents to the emergency department with a 2-week history of worsening headache, fever, and neck stiffness. He also reports nausea and photophobia. On physical examination, he is febrile and has a positive Brudzinski sign. A lumbar puncture is performed, and the cerebrospinal fluid (CSF) analysis reveals:
What is the most likely causative organism in this patient’s condition?
Strep Pneumo
You are the chief resident at Johns Hopkins and your intern notifies you of a female patient who was started on Heparin 2 days ago who developed bruising and petechiae. She is also bleeding through her IV lines. CBC reveals profoundly low platelets. Your intern asks “Dr. Fatima, antibodies against WHAT are causing this?”
Platelet Factor 4 - Heparin induced thrombocytopenia