1
Q
34 yo waitress ptc w/productive cough started 14 weeks ago, feels tired and has chest discomfort from coughing. Had similar cough last year for 4 months, no night sweats or wt loss. Hx of smoking half pack of cigs for 16 yrs, vitals unremarkable, chest symmetric, no use of accessory Mm’s. PPD test = Neg., no imaging ordered.
Most likely Dx?
Also consider?
A
Case 40, Q1:
Chronic Bronchitis: Chronic prod. cough for 3 month in 2 consecutive yrs. Smokers at greater risk.
Consider:
Emphysema, bronchiectasis, small cell lung cancer
2
Q
34 yo waitress ptc w/productive cough started 14 weeks ago, feels tired and has chest discomfort from coughing. Had similar cough last year for 4 months, no night sweats or wt loss. Hx of smoking half pack of cigs for 16 yrs, vitals unremarkable, chest symmetric, no use of accessory Mm’s. PPD test = Neg., no imaging ordered.
Which test is most indicated to order 1st?
- Plain Chest xray
- Spirometry
- Alpha 1 antitrypsin levels
- Sputum culture
A
Case 40, Q2:
Spirometry
3
Q
34 yo waitress ptc w/productive cough started 14 weeks ago, feels tired and has chest discomfort from coughing. Had similar cough last year for 4 months, no night sweats or wt loss. Hx of smoking half pack of cigs for 16 yrs, vitals unremarkable, chest symmetric, no use of accessory Mm’s. PPD test = Neg., no imaging ordered.
Which drug is most indicated?
- Mometasone
- Amoxicillin
- Tamsulosin
- Tiotropium
A
Case 40, Q3:
Tiotropium - Long acting anticholinergic bronchodilator & antisecretory agent used in maintenance tx of bronchospasm in COPD.
- Mometasone - used in seasonal allergies
- Amoxicillin - Antibiotic used to tx upper respiratory infections
- Tamsulosin - Alpha 1 blocker used to relax smooth Mm’s in tx for BPH, bladder outlet obstruction & kidney stones (Ureteral Calculi).
4
Q
34 yo waitress ptc w/productive cough started 14 weeks ago, feels tired and has chest discomfort from coughing. Had similar cough last year for 4 months, no night sweats or wt loss. Hx of smoking half pack of cigs for 16 yrs, vitals unremarkable, chest symmetric, no use of accessory Mm’s. PPD test = Neg., no imaging ordered.
Rx’d Boswellia serrata, ephedra Sinica, Glazzhiraza glabra, inula helenium to tx (1:1:1:1) 1 tbs tid but is fearing nauseated & having HA’s, what do you do?
- Continue dosage & f/u in 1 wk
- Reduce to 1 tbs BID
- Increase to 1 tbs QID
- Remake and use (5:1:5:5) 1 tbs TID
A
Case 40, Q4:
- Remake and use (5:1:5:5) 1 tbs TID
Reduce Ephedra Sinica but continue to used for its Bronchodilating, antitussive and antisecretory actions.
5
Q
34 yo waitress ptc w/productive cough started 14 weeks ago, feels tired and has chest discomfort from coughing. Had similar cough last year for 4 months, no night sweats or wt loss. Hx of smoking half pack of cigs for 16 yrs, vitals unremarkable, chest symmetric, no use of accessory Mm’s. PPD test = Neg., no imaging ordered.
Which of the following supplements is indicated?
- 500mg Quercetin daily
- 1000 IU Vit. D daily
- 500mg N-Acetylcysteine BID
- 300mg Bromelain tid away from meals
A
Case 40, Q5
- 500mg N-Acetylcysteine BID
6
Q
31 yo F smoker ptc w/vaginal dryness and mild pain w/intercourse. Pap reveals High grade squamous intraepithelial lesion (HSIL) & is HPV (+) for high risk strain.
What is the next most appropriate step given her Pap smear results?
Repeat Pap in 3 yrs
Colposcopy w/biopsy
Repeat PAP in 6 months
Repeat PAP in 12 months
A
Case 50 - Q1
Colposcopy w/biopsy
7
Q
31 yo F smoker ptc w/vaginal dryness and mild pain w/intercourse. Pap reveals High grade squamous intraepithelial lesion (HSIL) & is HPV (+) for high risk strain.
Most common tx for condition?
Loop electrosurgical excision procedure
HPV Vaccination
Hysterectomy
Acyclovir
A
Case 50 - Q2
Loop electrosurgical excision procedure
HPV Vaccination - only for 13-26yo, not indicated for cervical dysplasia
Hysterectomy - Indicated for some cervical carcinoma
Acyclovir - Antiviral not indicated for HPV
8
Q
31 yo F smoker ptc w/vaginal dryness and mild pain w/intercourse. Pap reveals High grade squamous intraepithelial lesion (HSIL) & is HPV (+) for high risk strain.
Which supplement is indicated?
- Beta- carotene
- Folic acid
- Vitamin D
- Genistein
A
Case 50 - Q3
2. Folic acid (B9) - folate def is linked to cervical dysplasia & has been shown to improve or normalize cytologic smears in pts w/cervical dysplasia.
It is CONTRAINDICATED for her as she is a smoker, may increase chances on dev. lung CA
- Beta-Carotine: Carotiniods & retinoids improve the integrity & fxn of epithelial tissue, are antioxidants, and improve immune system fxn.
- Vitamin D: USED FOR INFLAMMATORY & Immune conditions.
- Genistein: Phytoestrogenic used in menopause and endometriosis not used in Cervical dysplasia.
9
Q
31 yo F smoker ptc w/vaginal dryness and mild pain w/intercourse. Pap reveals High grade squamous intraepithelial lesion (HSIL) & is HPV (+) for high risk strain.
You give her Astralagus membranaceus, Mahonia Aqualifolium, Ganoderma Lucidum (1:1:1) 1 tsp TID, but is now pregnant, what should she do with this formula?
- Continue it
- Discontinue immediately
- Discontinue at 3rd trimester
- Discontinue immediately but continue after 2nd trimester
A
Case 50 - Q4
- Discontinue immediately
Mahonia contains Burberine which crosses placenta & inhibits bilirubin metabolism in newborns which may cause bilirubin encephalopathy.
Astralagus is safe in preg.
Ganoderma may need more research but may be safe.
10
Q
31 yo F smoker ptc w/vaginal dryness and mild pain w/intercourse. Pap reveals High grade squamous intraepithelial lesion (HSIL) & is HPV (+) for high risk strain.
She is now pregnant and having morning sickness, nauseous w/smell of food, irritable and craving pickles. Which Homeopathic remedy is indicated?
Sepia
Nox Vomica
Pulsatilla
Arsenicum
A
Case 50 - Q5
Sepia- Used to treat morning sickness - craving acid foods, nauseated and irritable
- Nox Vomica - used to tx nausea -same indication but want Spicy foods
- Pulsitilla- tx nausea - are emotional but want FATTY foods
- Arsenicum - used for food poisoning vomitting
11
Q
60 yo M ptc w/complaints of freq. infections & reports increased susceptible to cold & flu’s over the past few months. Experiencing bladder discomfort and frequency of urination. Recently dx’d w/T2diabetes, refuses meds & is treating through diet & exercise. Labs pending, which lab would be most indicated to evaluate Glucose control?
- CMP
- Oral Glucose
- HA1C
- All of the above
A
Case 34 - Q1
- HA1C - for glycemic control
- CMP: Fasting glucose, Kidney fxn, liver damage, electrolyte imbalance
- NOT commonly performed in known diabetic pts
- Additional labs: Lipid panel, fasting insulin levels, cystitis-C, Urinary micro-albumin levels
12
Q
60 yo M ptc w/complaints of freq. infections & reports increased susceptible to cold & flu’s over the past few months. Experiencing bladder discomfort and frequency of urination. Recently dx’d w/T2diabetes, refuses meds & is treating through diet & exercise. What are possible sequelae of poorly managed diabetes w/hyperglycemia?
CKD
CVD - stoke, MI
Limb amputation
all of the above
A
Case 34 - Q2
all of the above
13
Q
60 yo M ptc w/complaints of freq. infections & reports increased susceptible to cold & flu’s over the past few months. Experiencing bladder discomfort and frequency of urination. Recently dx’d w/T2diabetes, refuses meds & is treating through diet & exercise.
Which herbal supplements would help him to tx diabetes?
- Vaccinium spp
- Momordica Charantia
- Berberus Vulgaris
- All of the above
A
Case 34 - Q3
- All of the above
- Vaccinium spp - potent antioxidant, microvascular protection
- Momordica Charantia - hypoglycemic & hypolipidimic agents often used to tx diabetes
- Berberus Vulgaris - hypoglycemic agent
14
Q
60 yo M ptc w/complaints of freq. infections & reports increased susceptible to cold & flu’s over the past few months. Experiencing bladder discomfort and frequency of urination. Recently dx’d w/T2diabetes, refuses meds & is treating through diet & exercise.
Which pharmaceutical would be best indicated?
- Erythrocyacin
- Metformin
- Januvia
- Tetracycline
A
Case 34 - Q4
- Metformin-a biguanide that decreasing inhibiting gluconeogenesis in liver increasing insulin sensitivity in peripheral tissues. May also cause mod. reduction in appetite and body wt.
- Erythrocyacin
- Januvia
- Tetracycline
15
Q
60 yo M ptc w/complaints of freq. infections & reports increased susceptible to cold & flu’s over the past few months. Experiencing bladder discomfort and frequency of urination. Recently dx’d w/T2diabetes, refuses meds & is treating through diet & exercise.
Which supplement is most appropriate when taking metformin?
Multivitmin & mineral
cholecalciferol
Chromium Picolinate
Methylcobalamin
A
Case 34 - Q5
Methylcobalamin (B12) - Metfomin may cause B12 deficiency which may worsen neuropathy.
16
Q
42 yo F ppc w/diff. breathing, dull & increasing chest pain when pushed on ( w/palpation) w/o referral pain. Last week, she was on antibiotics for a Salmonella infection which has now resolved & has no more diarrhea but the next day she felt pressure on her chest & had difficulty breathing. PMHX & vitals unremarkable, Labs show elevated Sed rate of 40mm/hr (0-29 norm) & C-reactive protein of 8.6mg/L (<3 mg/L).
Any pt who experiences a new sx of difficulty breathing should be:
Referred to pulmonologist
Referred to Cardiologist
Referred to ER
Instructed on proper breathing
A
Case 10, Q1/5
Referred to ER
17
Q
42 yo F ppc w/diff. breathing, dull & increasing chest pain when pushed on ( w/palpation) w/o referral pain. Last week, she was on antibiotics for a Salmonella infection which has now resolved & has no more diarrhea but the next day she felt pressure on her chest & had difficulty breathing. PMHX & vitals unremarkable, Labs show elevated Sed rate of 40mm/hr (0-29 norm) & C-reactive protein of 8.6mg/L (<3 mg/L).
While at ER an EKG was performed resulting in diffused PR depression on ante lateral leads w/o ischemia. Her clinical presentation suggests;
Amyotrophic lateral sclerosis
Acute pericarditis
Q fever
Oropharyngeal Pericarditis
A
Case 10, Q2/5
Acute pericarditis
18
Q
42 yo F ppc w/diff. breathing, dull & increasing chest pain when pushed on ( w/palpation) w/o referral pain. Last week, she was on antibiotics for a Salmonella infection which has now resolved & has no more diarrhea but the next day she felt pressure on her chest & had difficulty breathing. PMHX & vitals unremarkable, Labs show elevated Sed rate of 40mm/hr (0-29 norm) & C-reactive protein of 8.6mg/L (<3 mg/L).While at ER an EKG was performed resulting in diffused PR depression on ante lateral leads w/o ischemia. Her clinical presentation suggests Acute pericarditis.
You send her out for additional testing to r/o neoplastic processing, w/o hx of CVD, what do think the causative agent is?
St. Johns wort
Salmonella infection
Anbiotic use
FXH of HTN
A
Case 10, Q3/5
Salmonella infection
19
Q
42 yo F ppc w/diff. breathing, dull & increasing chest pain when pushed on ( w/palpation) w/o referral pain. Last week, she was on antibiotics for a Salmonella infection which has now resolved & has no more diarrhea but the next day she felt pressure on her chest & had difficulty breathing. PMHX & vitals unremarkable, Labs show elevated Sed rate of 40mm/hr (0-29 norm) & C-reactive protein of 8.6mg/L (<3 mg/L).While at ER an EKG was performed resulting in diffused PR depression on ante lateral leads w/o ischemia. Her clinical presentation suggests Acute pericarditis.
Her condition is self-limiting & will resolve over time, typical tx approach is:
Anti-inflammatories
Rest & exercise
Anti-microbial agents
Antihypertensives
A
Case 10, Q4/5
Anti-inflammatories
20
Q
42 yo F ppc w/diff. breathing, dull & increasing chest pain when pushed on ( w/palpation) w/o referral pain. Last week, she was on antibiotics for a Salmonella infection which has now resolved & has no more diarrhea but the next day she felt pressure on her chest & had difficulty breathing. PMHX & vitals unremarkable, Labs show elevated Sed rate of 40mm/hr (0-29 norm) & C-reactive protein of 8.6mg/L (<3 mg/L).While at ER an EKG was performed resulting in diffused PR depression on ante lateral leads w/o ischemia. Her clinical presentation suggests Acute pericarditis.
Giver her condition a conservative approach is warranted, so you suggest the following:
Simple diet, Vit. C & D
Simple diet, Mg & Calcium
Simple diet, Boswellia serrata & Angelica archangelica
Simple diet, Boswellia serrata & Curcuma longa
A
Case 10, Q5/5
Simple diet, Boswellia serrata & Curcuma longa
21
Q
40 lbs 5 yo asthmatic F ptc w/a wound in her rt arm from a dog bite which occurred 3 hrs ago. Grandma explains that she complains her arm is very painful & throbbing. Takes salbutamol q4hrs prn, PMhx & FHX unremarkable.
Allergies: Cat dander, Eggs, peanuts, Sulfa drugs, Pasteraceae plant family
Vitals: Temp. 99.6F, Pulse 114bpm, resp 26/min
PE: 4 deep Rt lateral puncture wound, minimal bleeding, distal pulses equal b/l, Hrt/Lungs unremarkable.
What is the most appropriate next step?
- Apply topical bacitracin, neomycin, polymyxin B ointment, cover the area w/clean guaze & allow it to heal as a 2nd intention.
- Apply lidocaine, epinephrine, tetracaine gel. Clean the wound with iodine solution & irrigate w/saline. cover the area w/clean guaze & allow it to heal as a 2nd intention.
- Apply liposomal lidocaine, suture w/4-0 nylon in vertical mattress stitch to repair wound.
- Apply lidocaine, epinephrine, tetracaine gel, suture w/6-0 vycril in simple interrupted stitch to repair wound.
A
Case 43 1/5
- Apply lidocaine, epinephrine, tetracaine gel. Clean the wound with iodine solution & irrigate w/saline. cover the area w/clean guaze & allow it to heal as a 2nd intention.
* salbutamol - short-acting, selective beta2-adrenergic receptor agonist used in the treatment of asthma and COPD.
22
Q
40 lbs 5 yo asthmatic F ptc w/a wound in her rt arm from a dog bite which occurred 3 hrs ago. Grandma explains that she complains her arm is very painful & throbbing. Takes salbutamol q4hrs prn, PMhx & FHX unremarkable.
Allergies: Cat dander, Eggs, peanuts, Sulfa drugs, Pasteraceae plant family
Vitals: Temp. 99.6F, Pulse 114bpm, resp 26/min
PE: 4 deep Rt lateral puncture wound, minimal bleeding, distal pulses equal b/l, Hrt/Lungs unremarkable.
Which pharmaceutical is appropriate?
Amoxicillin-clavulanate
Doxycycline
Trimethoprim-Sulfamethoxazole
Ciprofloxacine
A
Case 43 2/5
Amoxicillin-clavulanate - 1st line for prophylactic a/b therapy in animal bites.
- **Trimethoprim-Sulfamethoxazole - also 1st line for prophylactic a/b therapy in animal bites but is a sulfa drug.
- **Ciprofloxacine (fluroquinolones) - should be avoided in kids d/t irreversible arthropathies & Cartilage destruction.
23
Q
40 lbs 5 yo asthmatic F ptc w/a wound in her rt arm from a dog bite which occurred 3 hrs ago. Grandma explains that she complains her arm is very painful & throbbing. Takes salbutamol q4hrs prn, PMhx & FHX unremarkable.
Allergies: Cat dander, Eggs, peanuts, Sulfa drugs, Pasteraceae plant family
Vitals: Temp. 99.6F, Pulse 114bpm, resp 26/min
PE: 4 deep Rt lateral puncture wound, minimal bleeding, distal pulses equal b/l, Hrt/Lungs unremarkable.
Which intervention is most appropriate?
- DTap vaccine
- Rabbies immune globulin
- Rabbies vaccine
- Call child protective services
A
Case 43 3/5
- DTap vaccine - puncture wounds & animal bites are more at risk for tetanus infx so kids so get DTaP & adults TDaP.
- Rabbies immune globulin & Rabbies vaccine should also be considered but low risk d/t canine vaccinations in the USA.
- Animal control should be called as it is mandatory dog bite reporting when animal’s teeth break skin. Dog can be quarantined & observed for 10 days.
24
Q
40 lbs 5 yo asthmatic F ptc w/a wound in her rt arm from a dog bite which occurred 3 hrs ago. Grandma explains that she complains her arm is very painful & throbbing. Takes salbutamol q4hrs prn, PMhx & FHX unremarkable.
Allergies: Cat dander, Eggs, peanuts, Sulfa drugs, Pasteraceae plant family
Vitals: Temp. 99.6F, Pulse 114bpm, resp 26/min
PE: 4 deep Rt lateral puncture wound, minimal bleeding, distal pulses equal b/l, Hrt/Lungs unremarkable.
You decide to RX Arnica Montana, Symphytum Off, Calendula off & Capsella bursa-partoris. Which is true?
- Indicated & would be safe
- Indicated & would NOT be safe
- NOT Indicated & would be safe
- NOT Indicated & would NOT be safe
A
Case 43 4/5
- NOT Indicated & would NOT be safe
- Both Calendula & Arnica are in the Pasteraceae plant family.
- Symphytum Off is avoided w/infections as it may close wound too early & trap infection
- Capsella bursa-partoris - indicated for hemorrhages not for this case
25
40 lbs 5 yo asthmatic F ptc w/a wound in her rt arm from a dog bite which occurred 3 hrs ago. Grandma explains that she complains her arm is very painful & throbbing. Takes salbutamol q4hrs prn, PMhx & FHX unremarkable.
Allergies: Cat dander, Eggs, peanuts, Sulfa drugs, Pasteraceae plant family
Vitals: Temp. 99.6F, Pulse 114bpm, resp 26/min
PE: 4 deep Rt lateral puncture wound, minimal bleeding, distal pulses equal b/l, Hrt/Lungs unremarkable.
Child is clingy to GM, pupil are slightly dilated, flushed faced, chilly hands & whispers she'd like lemonade to GM on the way home. Which homeopathic remedy is best fit?
Apis
Aconite
Belladonna
Bryonia
Case 43 Q5/5
Belladonna - acute remedy for throbbing pain worse w/motion, fright, flushed face w/cold extremities and craving lemonade.
26
27 yo white M ptc w/abd pain worse on LRQ, daily watery diarrhea, up to 6 BM's/day in the last 5 Mo w/sig blasting & discomfort. Mucus stools w/ occ. blood & unintentional 10 lbs wt loss in last 3 months & low grade fever at night.
PMHX: Multiple Rx of antibiotics d/t Chr sinus congestion, hernia repair surgery & bronchitis.
Allergies: Erythromycin, clyndamicin & penicillin cause diarrhea & vertigo.
Fmhx: MI & lung cancer
PE: Hyperactive bowel sounds w/ttp all 4 quads, 2 Superficial shallow anal fissures,
LABS: Elevated hsCRP & ESR
Imaging: "Cobblestoning" & multiple linear ulcerations
What is the most like dx is & def. dx is made how?
1. UC, Biopsy
2. UC, stool test
3. Crohn's dz, Bx
4. Crohn's dz, stool test
Case 2 Q1/5
3. Crohn's dz, Bx - Colonoscopy shows Aphthous, linear or stellate ulcers: Strictures, "Cobblestoning", "Skip lesions" (wound or inflammation that is clearly patchy, typical form of intestinal damage in Crohn's disease),
Clinically, Crohn's disease tends to present more frequently with abdominal pain & perianal dz, whereas ulcerative colitis is more often characterized by GI bleeding.
Cobblestoning mucosa & aphthous or linear ulcers characterize the endoscopic appearance of Crohn’s disease.
Ulcerative colitis presents w/diffuse continuous involvement of the mucosa.
Radiographic studies of pts w/Crohn’s dz characteristically show fistulae, asymmetry, and ileal involvement. In contrast, radiographic studies of ts w/ulcerative colitis show continuous disease without fistulizing or ileal disease.
Pathologically, Crohn's disease features mucosal discontinuity, transmural involvement, and granulomas, whereas ulcerative colitis does not. Crypt abscesses and granulomas are present only in Crohn's disease.
27
27 yo white M ptc w/abd pain worse on LRQ, daily watery diarrhea, up to 6 BM's/day in the last 5 Mo w/sig blasting & discomfort. Mucus stools w/ occ. blood & unintentional 10 lbs wt loss in last 3 months & low grade fever at night.
PMHX: Multiple Rx of antibiotics d/t Chr sinus congestion, hernia repair surgery & bronchitis.
Allergies: Erythromycin, clyndamicin & penicillin cause diarrhea & vertigo.
Fmhx: MI & lung cancer
PE: Hyperactive bowel sounds w/ttp all 4 quads, 2 Superficial shallow anal fissures,
LABS: Elevated hsCRP & ESR
Imaging: "Cobblestoning" & multiple linear ulcerations
______ is used in mild/Mod UC & Crohn's dz w/ ileitis & colitis but contraindicated w/pts with allergies to _____ & _____?
1. Sulfasalazine, sulfa drugs & salicylate
2. Sulfasalazine, penicillin, acetaminophen
3. Celecoxib, sulfa drugs & salicylate
4. Celecoxib, penicillin, acetaminophen
Case 2 Q2/5
1. Sulfasalazine, sulfa drugs & salicylate
***Requires Folic acid (B9) supplementation
28
27 yo white M ptc w/abd pain worse on LRQ, daily watery diarrhea, up to 6 BM's/day in the last 5 Mo w/sig blasting & discomfort. Mucus stools w/ occ. blood & unintentional 10 lbs wt loss in last 3 months & low grade fever at night.
PMHX: Multiple Rx of antibiotics d/t Chr sinus congestion, hernia repair surgery & bronchitis.
Allergies: Erythromycin, clyndamicin & penicillin cause diarrhea & vertigo.
Fmhx: MI & lung cancer
PE: Hyperactive bowel sounds w/ttp all 4 quads, 2 Superficial shallow anal fissures,
LABS: Elevated hsCRP & ESR
Imaging: "Cobblestoning" & multiple linear ulcerations
Based on his hx, which supplement would be indicated?
1. Quercitin, potent antibacterial
2. Quercitin, potent anti-inflammatory
3. Althea off, potent antibacterial
4. Althea off, potent anti-inflammatory
Case 2 Q3/5
2. Quercitin, potent anti-inflammatory - (down regs.
29
27 yo white M ptc w/abd pain worse on LRQ, daily watery diarrhea, up to 6 BM's/day in the last 5 Mo w/sig blasting & discomfort. Mucus stools w/ occ. blood & unintentional 10 lbs wt loss in last 3 months & low grade fever at night.
PMHX: Multiple Rx of antibiotics d/t Chr sinus congestion, hernia repair surgery & bronchitis.
Allergies: Erythromycin, clyndamicin & penicillin cause diarrhea & vertigo.
Fmhx: MI & lung cancer
PE: Hyperactive bowel sounds w/ttp all 4 quads, 2 Superficial shallow anal fissures,
LABS: Elevated hsCRP & ESR
Imaging: "Cobblestoning" & multiple linear ulcerations
He also says he feels full after a few bites & then hungry right after. Increased flatulence, worse w/tight clothes & at night, better w/window open, nervous in front of crowds but is a teacher. Which homeopathic remedy is best?
1. Sulphur
2. Lycopodium
3. Arsenicum Album
4. Chamomile
Case 2 Q4/5
2. Lycopodium - common for GI complaints (Bloating, flatulence & day satiety). Worse w/tight clothes, aggravation 4-8pm, anticipatory anxiety. (Craves sweets adverse to cold beverage, milk, beans, cabbage, oysters) - better in open air.
1. Suphurs: Diarrhea worse in the mornings, craves sweet but overindulges in food & alcohol,
3. Arsenicum Album - GI remedy, anxious & controlling worse 12-2am, very chilly & worse if exposed to cold.
4. Chamomile - Diarrhea remedy, extreme irritability after 9am & green stools.
30
27 yo white M ptc w/abd pain worse on LRQ, daily watery diarrhea, up to 6 BM's/day in the last 5 Mo w/sig blasting & discomfort. Mucus stools w/ occ. blood & unintentional 10 lbs wt loss in last 3 months & low grade fever at night.
PMHX: Multiple Rx of antibiotics d/t Chr sinus congestion, hernia repair surgery & bronchitis.
Allergies: Erythromycin, clyndamicin & penicillin cause diarrhea & vertigo.
Fmhx: MI & lung cancer
PE: Hyperactive bowel sounds w/ttp all 4 quads, 2 Superficial shallow anal fissures,
LABS: Elevated hsCRP & ESR
Imaging: "Cobblestoning" & multiple linear ulcerations
Sulfasalazine which is used in mild/Mod UC & Crohn's dz w/ ileitis & colitis but it impairs the absorption of ____ and what would be dose indicated?
1. B12, 8ooomcg
2. B12, 800mcg
3. Folic acid, 8000mcg
4 Folic acid, 800mcg
Case 2 Q5/5
4. Folic acid, 800mcg - ASA component of Sulfasalazine impairs absorption of Folic acid transport decreasing absorption. Deficiency may cause extra intestinal complications such as Hyperhomocysteinemia (risk factor for DVT). 800mcg is common dosage.
31
53 yo F ptc w/weakness, fatigue and depression. Dev. Abd pain over the last few weeks w/nausea & few episodes of vomiting. Had intense abd & back a week ago and urinated multiple blood clots, went to ER & was dx'd with kidney stones. She complaints of more aches & pains in her joints recently.
PMXH: Major depressive d/o 5 MO ago.
MEDS: Calcium, Vit. D, MultiVIT., Fluoxitine 20mg qd
Vitals: BP 146/88, pulse 96, resp. 18
PE: Diffuse ttp w/o mass, rigidity & guarding
Labs: CMP - High glucose 120 (60-100), Low Phorphorus, HIGH Calcium, LOW GFR 43 (<60), high creatine
What further lab work is needed?
1. AM Cortisol
2. TSH
3. ParaThyroid Hormone
4. Adrenocorticotropic Hormone
Case 15, Q1/5
3. ParaThyroid Hormone
32
53 yo F ptc w/weakness, fatigue and depression. Dev. Abd pain over the last few weeks w/nausea & few episodes of vomiting. Had intense abd & back a week ago and urinated multiple blood clots, went to ER & was dx'd with kidney stones. She complaints of more aches & pains in her joints recently.
PMXH: Major depressive d/o 5 MO ago.
MEDS: Calcium, Vit. D, MultiVIT., Fluoxitine 20mg qd
Vitals: BP 146/88, pulse 96, resp. 18
PE: Diffuse ttp w/o mass, rigidity & guarding
Labs: CMP - High glucose 120 (60-100), Low Phorphorus, HIGH Calcium, LOW GFR 43 (<60), high creatine
What is most likely DX?
1. Hypoparathyroidism
2. Hyperparathyroidism
3. Adrenal Insufficiency
4. Carcinoid S/d
Case 15, Q2/5
2. Hyperparathyroidism
33
53 yo F ptc w/weakness, fatigue and depression. Dev. Abd pain over the last few weeks w/nausea & few episodes of vomiting. Had intense abd & back a week ago and urinated multiple blood clots, went to ER & was dx'd with kidney stones. She complaints of more aches & pains in her joints recently.
PMXH: Major depressive d/o 5 MO ago.
MEDS: Calcium, Vit. D, MultiVIT., Fluoxitine 20mg qd
Vitals: BP 146/88, pulse 96, resp. 18
PE: Diffuse ttp w/o mass, rigidity & guarding
Labs: CMP - High glucose 120 (60-100), Low Phorphorus, HIGH Calcium, LOW GFR 43 (<60), high creatine
She is dx'd w/Hyperparathyroidism but what condition all needs to r/o?
Parathryroid Carcinoma
Small cell lung Ca
Osteoporosis
Type 2 DM
Case 15, Q3/5
Parathryroid Carcinoma
34
53 yo F ptc w/weakness, fatigue and depression. Dev. Abd pain over the last few weeks w/nausea & few episodes of vomiting. Had intense abd & back a week ago and urinated multiple blood clots, went to ER & was dx'd with kidney stones. She complaints of more aches & pains in her joints recently.
PMXH: Major depressive d/o 5 MO ago.
MEDS: Calcium, Vit. D, MultiVIT., Fluoxitine 20mg qd
Vitals: BP 146/88, pulse 96, resp. 18
PE: Diffuse ttp w/o mass, rigidity & guarding
Labs: CMP - High glucose 120 (60-100), Low Phorphorus, HIGH Calcium, LOW GFR 43 (<60), high creatine
She is dx'd w/Hyperparathyroidism, what imagine must be ordered?
U/S check of the neck
Radiograph of the chest
MRI of the head
Both A & C
Case 15, Q4/5
U/S check of the neck - Parathyroid adenoma & Parathyroid hyperplasia are the most common causes of Hyperparathyroidism which are dx'd by U/S check of the neck.
*MEN 1 s/d which may includes Parathyroid adenoma, Parathyroid hyperplasia, Pituitary adenoma, Pancreatic islet cell adenomas, GI adenomas & Zollinger-Ellison s/d.
35
53 yo F ptc w/weakness, fatigue and depression. Dev. Abd pain over the last few weeks w/nausea & few episodes of vomiting. Had intense abd & back a week ago and urinated multiple blood clots, went to ER & was dx'd with kidney stones. She complaints of more aches & pains in her joints recently.
PMXH: Major depressive d/o 5 MO ago.
MEDS: Calcium, Vit. D, MultiVIT., Fluoxitine 20mg qd
Vitals: BP 146/88, pulse 96, resp. 18
PE: Diffuse ttp w/o mass, rigidity & guarding
Labs: CMP - High glucose 120 (60-100), Low Phorphorus, HIGH Calcium, LOW GFR 43 (<60), high creatine
She is dx'd w/Hyperparathyroidism, what is the tx?
Reduce Vitamin D
Estradiol therapy
Surgical resection of Parathyroid Glands
All of the above
Case 15, Q5/5
All of the above - Depending on the severity of the Hyperparathyroidism
36
30 yo F w/SOB & cough that began this morning which is worsening with chest pain. Broke ankle a week ago, is a 1 pack/day smoker, tased Ibuprofen for cramps & takes Oral contraceptives (Ethinyl estradiol & progestin).
Vitals: TEMP 99, BP 98/62, HRT rate 106, resp 22
PE: Lungs- rales w/diminished breath sounds on Right lung field.
```
What is most like dx?
Pulmonary Embolism
MI
Panic Attack
Esophagitis
```
Case 42 Q1/5
Pulmonary Embolism
37
30 yo F w/SOB & cough that began this morning which is worsening with chest pain. Broke ankle a week ago, is a 1 pack/day smoker, tased Ibuprofen for cramps & takes Oral contraceptives (Ethinyl estradiol & progestin).
Vitals: TEMP 99, BP 98/62, HRT rate 106, resp 22
PE: Lungs- rales w/diminished breath sounds on Right lung field.
Possible dx is Pulmonary Embolism, what is needed to confirm dx?
1. CT Pulmonary angiogram
2. Plain Chest xray
3. D-Dimer
4. Pulmonary fxn test
Case 42 Q2/5
CT Pulmonary angiogram
2. Plain Chest xray
3. D-Dimer - Non-specific screening for blot clots in PE & DVT I pts that dx is questionable but not good for clinical probable PE such as this.
4. Pulmonary fxn test - for obstructive or restrictive lung dz (Lung volume, capacity & expiratory flow)
38
30 yo F w/SOB & cough that began this morning which is worsening with chest pain. Broke ankle a week ago, is a 1 pack/day smoker, tased Ibuprofen for cramps & takes Oral contraceptives (Ethinyl estradiol & progestin).
Vitals: TEMP 99, BP 98/62, HRT rate 106, resp 22
PE: Lungs- rales w/diminished breath sounds on Right lung field.
Possible dx is Pulmonary Embolism, WHICH PHARMACEUTICAL IS INDICATED?
1. Aspirin
2. Salbutamol
3. Heparin
4. Alprazolam
Case 42 Q3/5
3. Heparin - an anti-coagulant
1. Aspirin - anti-platelet activity
2. Salbutamol- Short acting bronchodilator for asthma
4. Alprazolam- Benzodiazepine for anxiety & Panic d/o
39
30 yo F w/SOB & cough that began this morning which is worsening with chest pain. Broke ankle a week ago, is a 1 pack/day smoker, tased Ibuprofen for cramps & takes Oral contraceptives (Ethinyl estradiol & progestin).
Vitals: TEMP 99, BP 98/62, HRT rate 106, resp 22
PE: Lungs- rales w/diminished breath sounds on Right lung field.
Possible dx is Pulmonary Embolism, after tx began she rtc & says she is worried this may return and can't sleep at night or fxn during the day. You give her botanical of Avena Sativa, Hypericum perforatum, Passiflora incarnata, sculltelaria lateliflora (1:1:1:1) 1 tsp tid, which statement is true about this formula?
1. It would be safe and indicated for this pt.
2. It would be safe and but NOT indicated for this pt.
3. It would be contraindicated for this pt but indicated for this pt. w/these sx's.
4. It would be contraindicated for this pt & NOT indicated for this pt. w/these sx's.
Case 42 Q4/5
3. It would be contraindicated for this pt but indicated for this pt. w/these sx's.
(All are used for worry & anxiety)
* Hypericum perforatum is a CYP450 3A4 enzyme which effects clearance of warfarin, decreasing its effectiveness.
* *Also Contradicted in pts using Oral contraceptives- may lead to pregnancy.
40
30 yo F w/SOB & cough that began this morning which is worsening with chest pain. Broke ankle a week ago, is a 1 pack/day smoker, tased Ibuprofen for cramps & takes Oral contraceptives (Ethinyl estradiol & progestin).
Vitals: TEMP 99, BP 98/62, HRT rate 106, resp 22
PE: Lungs- rales w/diminished breath sounds on Right lung field.
Possible dx is Pulmonary Embolism, which of the following is most indicated recommendation for her condition?
Discontinue oral contraceptive
Increase dark leafy greens
Reduce cigarette intake
Start supplementing Vit. K 90mcg daily
Case 42 Q5/5
Discontinue oral contraceptive - increases risk of blood clots
41
46 yo biracial F (AA/White) ptc w/acne, flushed cheeks & increased fatigue. Acne & flushed cheeks have worsened in the past yr and half, also has unilateral pulsing HA's (Lt temporal) preceded by bright light & floaters in her eyes & have also become progressively worse & more frequent. She report dry, peeling skin on her face better after periods but odd sx's with periods like pain on her left shin that wakes her at night.
PMhx: Tx for HA's w/small white pill, facial lipoma removal surgery, recurrent strep throat & otitis media infxns., has eliminated dairy from her diet.
PE: Skin is dusky, papulopustular across both cheeks & forehead, prominent sebaceous glands noted w/greasy/yellow crusts on erythematous base. Dry scaling fissures noted on angles of mouth b/l. NEURO: B/L loss of vibratory sensation to lower ext.
LABS: CBC: (HIGH Lymphocytes, Eosinophils, MCV, RDW), (Low RBC's, HGB, HCT)
Which of the following Vitamin deficiencies are assoc. w/cheilosis & paresthesia?
1. Vitamin D & B12
2. Riboflavin & B12
3. B12 & Vit. A
4. Thiamin & Riboflavin
Case 72/Q1
2. Riboflavin (B2) & B12
* Riboflavin def. rarely is alone, usually presents w/cheilosis & B12 deficiency causing paresthesias.
42
46 yo biracial F (AA/White) ptc w/acne, flushed cheeks & increased fatigue. Acne & flushed cheeks have worsened in the past yr and half, also has unilateral pulsing HA's (Lt temporal) preceded by bright light & floaters in her eyes & have also become progressively worse & more frequent. She report dry, peeling skin on her face better after periods but odd sx's with periods like pain on her left shin that wakes her at night.
PMhx: Tx for HA's w/small white pill, facial lipoma removal surgery, recurrent strep throat & otitis media infxns., has eliminated dairy from her diet.
PE: Skin is dusky, papulopustular across both cheeks & forehead, prominent sebaceous glands noted w/greasy/yellow crusts on erythematous base. Dry scaling fissures noted on angles of mouth b/l. NEURO: B/L loss of vibratory sensation to lower ext.
LABS: CBC: (HIGH Lymphocytes, Eosinophils, MCV, RDW), (Low RBC's, HGB, HCT), Normal MCH
CBC shows possibility of _____ & can be tx by supplementing _____.
1. Megaloblastic/Macrocytic anemia - B12 & Folate
2. Pancytopenia - packed rbc & platelet transfusion
3. Spherocytosis - corticosteroids & retuximab
4. Hypochromic, microcytic anemia, iron & lead chelation therapy/disodium calcium versanate or CaNA2-EDTA.
Case 72/Q2
1. Megaloblastic/Macrocytic anemia - B12 & Folate
* Megaloblastic = High MCV
* Microcytic/hypochromic r/o by MCV & Normal MCH
43
46 yo biracial F (AA/White) ptc w/acne, flushed cheeks & increased fatigue. Acne & flushed cheeks have worsened in the past yr and half, also has unilateral pulsing HA's (Lt temporal) preceded by bright light & floaters in her eyes & have also become progressively worse & more frequent. She report dry, peeling skin on her face better after periods but odd sx's with periods like pain on her left shin that wakes her at night.
PMhx: Tx for HA's w/small white pill, facial lipoma removal surgery, recurrent strep throat & otitis media infxns., has eliminated dairy from her diet.
PE: Skin is dusky, papulopustular across both cheeks & forehead, prominent sebaceous glands noted w/greasy/yellow crusts on erythematous base. Dry scaling fissures noted on angles of mouth b/l. NEURO: B/L loss of vibratory sensation to lower ext.
LABS: CBC: (HIGH Lymphocytes, Eosinophils, MCV, RDW), (Low RBC's, HGB, HCT), Normal MCH
Which are included in DDX?
1. Rheumetoid arthritis, dermatitis herpetiforis
2. Migraines, rosaceae, megaloblastic anemia
3. Agne vulgaris, MS
4. CLuster HA's, menopause
Case 72/Q3
2. Migraines, rosaceae, megaloblastic anemia
44
46 yo biracial F (AA/White) ptc w/acne, flushed cheeks & increased fatigue. Acne & flushed cheeks have worsened in the past yr and half, also has unilateral pulsing HA's (Lt temporal) preceded by bright light & floaters in her eyes & have also become progressively worse & more frequent. She report dry, peeling skin on her face better after periods but odd sx's with periods like pain on her left shin that wakes her at night.
PMhx: Tx for HA's w/small white pill, facial lipoma removal surgery, recurrent strep throat & otitis media infxns., has eliminated dairy from her diet.
PE: Skin is dusky, papulopustular across both cheeks & forehead, prominent sebaceous glands noted w/greasy/yellow crusts on erythematous base. Dry scaling fissures noted on angles of mouth b/l. NEURO: B/L loss of vibratory sensation to lower ext.
LABS: CBC: (HIGH Lymphocytes, Eosinophils, MCV, RDW), (Low RBC's, HGB, HCT), Normal MCH
Which of the following recommendations should help her?
1. B12, folate, riboflavin, B-complex, MG, HTP supplementing, diet dairy to exclude triggers.
2. Vit. C, digestive enzymes, Vit E & anti-inflammatory cream w/calendula
3. Biofeedback w/elimination of gluten & dairy
4. Zinc & botanical w/Gymnema, Momordica, Trigonella
Case 72/Q4
1. B12, folate, riboflavin, B-complex, MG, HTP supplementing, diet dairy to exclude triggers.
45
46 yo biracial F (AA/White) ptc w/acne, flushed cheeks & increased fatigue. Acne & flushed cheeks have worsened in the past yr and half, also has unilateral pulsing HA's (Lt temporal) preceded by bright light & floaters in her eyes & have also become progressively worse & more frequent. She report dry, peeling skin on her face better after periods but odd sx's with periods like pain on her left shin that wakes her at night.
PMhx: Tx for HA's w/small white pill, facial lipoma removal surgery, recurrent strep throat & otitis media infxns., has eliminated dairy from her diet.
PE: Skin is dusky, papulopustular across both cheeks & forehead, prominent sebaceous glands noted w/greasy/yellow crusts on erythematous base. Dry scaling fissures noted on angles of mouth b/l. NEURO: B/L loss of vibratory sensation to lower ext.
LABS: CBC: (HIGH Lymphocytes, Eosinophils, MCV, RDW), (Low RBC's, HGB, HCT), Normal MCH
Which homeopathic is indicated to help?
1. Calcarea Carbonica
2. Rhus tux
3. Lachesis
4. Byonia
Case 72/Q5
3. Lachesis
********(GO BACK * WRITE INDICATIONS************
46
52 yo F ppc w/irritability & Lathargy w/bouts of hysteria & anxiety which has worsened over the past few weeks. She has felt "warm & Flushed" waking up drenched in sweat at night. Her BM's are inconsistent & fluctuate b/t constipation & Diarrhea.
PMHX: HTN, Hyperlipidimia, Anemia during pregnancy.
Meds: Melatonin 3mg po qhs (bedtime)
FMHX: Both parents HTN, Hyperlipidimia
LABS: HIGH FSH 100 mlU/ml (4.7-21.5) {Menopausal Female 25.8-134.8}
What Conditions are in your Ddx?
1. Hasimoto's
2. Menopause
3. Generalized anxiety
4. All of the Above
Case 37 Q1
4. All of the Above
47
52 yo F ppc w/irritability & Lathargy w/bouts of hysteria & anxiety which has worsened over the past few weeks. She has felt "warm & Flushed" waking up drenched in sweat at night. Her BM's are inconsistent & fluctuate b/t constipation & Diarrhea.
PMHX: HTN, Hyperlipidimia, Anemia during pregnancy.
Meds: Melatonin 3mg po qhs (bedtime)
FMHX: Both parents HTN, Hyperlipidimia
LABS: HIGH FSH 100 mlU/ml (4.7-21.5) {Menopausal Female 25.8-134.8}
```
Which labs are indicated?
A. Estrogen, Progesterone, TSH, Free T3, Free T4, Anti-TPO, Anti-TG ab's
B. TSH only
C. Lipid panel
D. CMP
```
Case 37 Q2
A. Estrogen, Progesterone, TSH, Free T3, Free T4, Anti-TPO, Anti-TG ab's
48
52 yo F ppc w/irritability & Lathargy w/bouts of hysteria & anxiety which has worsened over the past few weeks. She has felt "warm & Flushed" waking up drenched in sweat at night. Her BM's are inconsistent & fluctuate b/t constipation & Diarrhea.
PMHX: HTN, Hyperlipidimia, Anemia during pregnancy.
Meds: Melatonin 3mg po qhs (bedtime)
FMHX: Both parents HTN, Hyperlipidimia
LABS: HIGH FSH 100 mlU/ml (4.7-21.5) {Menopausal Female 25.8-134.8}
What is the correct workup for Post-menopausal uterine bleed.
A. TVUS, Cervical Cytology, Endometrial bx
B. TVUS, Complete Blood Count
C. Thyroid Panel, Endometrial bx
D. CBC, Cervical Cytology
Case 37 Q3
A. TVUS, Cervical Cytology, Endometrial bx
49
52 yo F ppc w/irritability & Lathargy w/bouts of hysteria & anxiety which has worsened over the past few weeks. She has felt "warm & Flushed" waking up drenched in sweat at night. Her BM's are inconsistent & fluctuate b/t constipation & Diarrhea.
PMHX: HTN, Hyperlipidimia, Anemia during pregnancy.
Meds: Melatonin 3mg po qhs (bedtime)
FMHX: Both parents HTN, Hyperlipidimia
LABS: HIGH FSH 100 mlU/ml (4.7-21.5) {Menopausal Female 25.8-134.8}
```
What Botanical is best indicated for sx of Perimenopause?
A. Arctium Lappa
B. Actaea racemosa
C. Pisidia erythrina
D. Piper methysticum
```
Case 37 Q4
B. Actaea racemosa
50
52 yo F ppc w/irritability & Lathargy w/bouts of hysteria & anxiety which has worsened over the past few weeks. She has felt "warm & Flushed" waking up drenched in sweat at night. Her BM's are inconsistent & fluctuate b/t constipation & Diarrhea.
PMHX: HTN, Hyperlipidimia, Anemia during pregnancy.
Meds: Melatonin 3mg po qhs (bedtime)
FMHX: Both parents HTN, Hyperlipidimia
LABS: HIGH FSH 100 mlU/ml (4.7-21.5) {Menopausal Female 25.8-134.8}
```
Which pharmaceutical is Rx'd to tx menopause?
A. Doxycycline & Celecoxib
B. Amoxycyline & Clonidine
C. Gabapentin & Fluoxetine
D. Clonidine & Gabapentin
```
Case 37 Q5
C. Gabapentin (Pregabalin) & Fluoxetine (SSRI) - both used to decrease severity of sx's.
*Clonidine - Uncommonly rx'd to alleviate hot falshes & for sleep but too many side effects & only rx'd if all else fails.
51
9 yo boy whom mom of 7 says is "spacing out" too often by staring out in to space & won't respond to her & stops talking in the middle of sentences. Grades are slipping & teacher says he may need Ritalin & his sisters says he looks scary when they happen & he "makes funny movements w/his mouth."
PMHX: Febrile seizures yrs ago of 104F in ER
Psychosocial: Few friends, agrees he struggling in school b/c he just doesn't understand some topics like math but is happy most of the time.
MEDS: His mother gave him St. John's wort, B-Vit., Zinc & Fish oil to see if it helped but stopped. A few rounds of antibiotics.
FMHX: Hrt Dz in family
PE: Unremarkable
```
What's your presumptive dx?
A. Migraines
B. Complex Partial Seizures
C. Vasovagal Syncope
D. Panic attacks
```
Case 9 Q1/5
B. Complex Partial Seizures - Seizures are one of the most freq. Neurologic problems in childhood. He has discrete, involuntary events characterized by alteration of facial expressions, impaired consciousness followed by postictal confusion, HA & Fear {Automatism (involuntary chewing & swallowing) are possible}
***HX of febrile Seizure is common***
52
9 yo boy whom mom of 7 says is "spacing out" too often by staring out in to space & won't respond to her & stops talking in the middle of sentences. Grades are slipping & teacher says he may need Ritalin & his sisters says he looks scary when they happen & he "makes funny movements w/his mouth."
PMHX: Febrile seizures yrs ago of 104F in ER
Psychosocial: Few friends, agrees he struggling in school b/c he just doesn't understand some topics like math but is happy most of the time.
MEDS: His mother gave him St. John's wort, B-Vit., Zinc & Fish oil to see if it helped but stopped. A few rounds of antibiotics.
FMHX: Hrt Dz in family
PE: Unremarkable
```
Which dx procedure is indicated to confirm your dx?
A. Electroencephalogram (EEG)
B. ElectroCardiogram (ECG)
C. MRI
D. Computed Tomography (CT)
```
Case 9 Q2/5
A. Electroencephalogram (EEG) - Supports dx of seizures
53
9 yo boy whom mom of 7 says is "spacing out" too often by staring out in to space & won't respond to her & stops talking in the middle of sentences. Grades are slipping & teacher says he may need Ritalin & his sisters says he looks scary when they happen & he "makes funny movements w/his mouth."
PMHX: Febrile seizures yrs ago of 104F in ER
Psychosocial: Few friends, agrees he struggling in school b/c he just doesn't understand some topics like math but is happy most of the time.
MEDS: His mother gave him St. John's wort, B-Vit., Zinc & Fish oil to see if it helped but stopped. A few rounds of antibiotics.
FMHX: Hrt Dz in family
PE: Unremarkable
If EEG is Normal, but continues to have seizures, which dx would you pursue next?
A. Migraines & Diabetes
B. Sleep D/o, Diabetes
C. Migraines, Brain d/o
D. ADD, Day Dreaming
Case 9 Q3/5
C. Migraines, Brain d/o
54
9 yo boy whom mom of 7 says is "spacing out" too often by staring out in to space & won't respond to her & stops talking in the middle of sentences. Grades are slipping & teacher says he may need Ritalin & his sisters says he looks scary when they happen & he "makes funny movements w/his mouth."
PMHX: Febrile seizures yrs ago of 104F in ER
Psychosocial: Few friends, agrees he struggling in school b/c he just doesn't understand some topics like math but is happy most of the time.
MEDS: His mother gave him St. John's wort, B-Vit., Zinc & Fish oil to see if it helped but stopped. A few rounds of antibiotics.
FMHX: Hrt Dz in family
PE: Unremarkable
The mother is interested in trying diet to help control his episodes. Which would you suggest?
A. Low tyramine diet
B. Ketogenic diet
C. Allergy elimination diet
D. Mediterranean diet
Case 9 Q4/5
B. Ketogenic diet
55
9 yo boy whom mom of 7 says is "spacing out" too often by staring out in to space & won't respond to her & stops talking in the middle of sentences. Grades are slipping & teacher says he may need Ritalin & his sisters says he looks scary when they happen & he "makes funny movements w/his mouth."
PMHX: Febrile seizures yrs ago of 104F in ER
Psychosocial: Few friends, agrees he struggling in school b/c he just doesn't understand some topics like math but is happy most of the time.
MEDS: His mother gave him St. John's wort, B-Vit., Zinc & Fish oil to see if it helped but stopped. A few rounds of antibiotics.
FMHX: Hrt Dz in family
PE: Unremarkable
```
Which of the following supplement is most indicated?
A. St. John's wort
B. B vitamins
C. Zinc
D. Fish Oil
```
Case 9 Q5/5
D. Fish Oil - most studied supplement for seizure control, promising in medical resistant epilepsy.
***St. John's wort may interact w/anti-seizure meds***
56
PATIENT: 45-year-old male, 5’10”, 176 lbs
PRESENTATION: The presents to your office complaining of a rash on his feet. He has had the rash on and off for the last four years. He describes the rash as intensely burning and itching, almost to the point where he cannot wear shoes.
MEDICAL HISTORY: Mild hypertension diagnosed two years ago. Asthma as child, which he claims to have outgrown.
PSYCHOSOCIAL: He is happy with his job as manager of a local restaurant and reports being close to his family and friends.
HEALTH HABITS: He eats a standard American diet, with occasional vegetables. SUPPLEMENTS: Occasional Vitamin A, up to 100,000 IU qd
MEDICATIONS: OTC topical antifungal creams and tea tree oil.
ALLERGIES: Pollen
FAMILY HISTORY: Mother has eczema, allergic rhinitis, and asthma. Father has multiple food allergies and hypertension.
VITAL SIGNS: Temperature 97.2°F, blood pressure 138/78 mmHg, pulse 76 bpm, respirations 18/min.
PHYSICAL EXAMINATION: Erythematous, lichenified, papulovesicular lesions noted on dorsal aspect of both feet with thick serous discharge.
PRELIMINARY LAB RESULTS: Scraped skin lesion sent for culture and sensitivity: negative (no growth).
DIAGNOSTIC IMAGING: None
```
What is the most likely dx?
A. Rosacea
B. Atopic dermatitis
C. Tinea Corporis
D. Tinea Capitis
```
Case 31 Q1
B. Atopic dermatitis
57
Atopic dermatitis has a rash w/sx's that often leads to further development of the dz called:
A. The itch/scratch cycle
B. The edematous/Atopic cycle
C. The color/Urea cycle
D. The prostaglandin/inflammation cycle
Case 31 Q2
A. The itch/scratch cycle
58
Atopic dermatitis is assoc. w/which of the following?
A. Food allergies/sensitivity
B. Asthma
C. Allergic Rhinitis
D. All of them
Case 31 Q3
D. All of them
59
Common tx of Atopic dermatitis is:
A. Hydrocortisone
B. Hydrocodone
C. HydroChlorothiazide
D. HydroxyChloroquine
Case 31 Q4
A. Hydrocortisone
60
PATIENT: 19-year-old male, 5’9”, 172 lbs
PRESENTATION: The patient has a chief complaint of ADHD. He was diagnosed with ADHD at 12 years of age and received stimulant medications that seemed to help. He graduated from High School with honors. Since he has been in college, he occasionally takes his medications when he has to study for a test. He reports a recent increase in anxiety and notes that he is not doing well academically.
MEDICAL HISTORY: ADHD. Otherwise non-contributory.
PSYCHOSOCIAL: His old support system (parents and guidance counselors) helped him through high school, but he is lacking such support in college. He admits to partying often and occasionally drinking too much.
HEALTH HABITS: He eats a standard western diet and states that he is not interesting in changing his health habits.
SUPPLEMENTS: He has tried a few supplements for focus, but can’t remember their names. MEDICATIONS: Methylphenidate 20 mg PRN
ALLERGIES: None
FAMILY HISTORY: Non-contributory
VITAL SIGNS: Temperature 98.6 °F (37.0 °C) Blood pressure 120/68 mmHg, pulse 85 bpm, respirations 20/min.
PHYSICAL EXAMINATION: Neurological exam normal. No tremor. Muscle strength 5/5. DTRs 2+ B/L. CN ii-xii within normal limits. Neck is supple with no masses or thyromegaly.
PRELIMINARY LAB RESULTS: None DIAGNOSTIC IMAGING: None
ADHD is considered a neurological development d/o w/core sx's of inattentiveness, ______ , restlessness and impulsivity.
A. Miscibility
B. Sociability
C. Instability
D. Distractibility
Case 5 - Q1
D. Distractibility
61
Pt w/ADHD complains of experiencing anxiety, What do you know about psychostimulants & ADHD?
A. Anxiety is a contraindication for psychostimulants & ADHD
B. Anxiety m/b a side effect of long term use of psychostimulants.
C. psychostimulants are calming
D. psychostimulants are contraindicated for ADHD
Case 5 - Q2
B. Anxiety m/b a side effect of long term use of psychostimulants.
62
College age Pt w/ADHD on psychostimulants ptc describing excessive partying, what is your concern?
A. College age Pt w/ADHD are less likely to be addicted to drugs.
B. College age Pt w/ADHD are More likely to be addicted to drugs.
C. College age Pt w/ADHD have less response to alcohol and tobacco.
D. College age Pt w/ADHD have more response to alcohol and tobacco.
Case 5 - Q4
B. College age Pt w/ADHD are More likely to be addicted to drugs.
63
PATIENT: 35-year-old African American male, 5’9’’ (175.3 cm), 175 Ibs (79.4 kg)
PRESENTATION: The patient presents with chief complaints of fatigue, fever, chill, and night sweats. His appetite is decreased, and he has had muscle aches. His symptoms developed gradually over the past two weeks and have progressively worsened.
MEDICAL HISTORY: He has had a few recurrent streptococcal pharyngitis since he was 10 years old without any complications that he can remember of. He had a bad cold followed by pneumonia at age 19.
PSYCHOSOCIAL: He is doing graduate study in art. He works as an apartment manager and goes to school at night. He loves travelling but denies any recent travel. He does not have pets. He lives in an apartment where he works. He has a girl friend lives in another state.
HEALTH HABITS: He does not eat regularly. He might have one big meal a day and snack the rest of the day. He eats lots of frozen meals for lunch or dinner. He drinks coffee in the morning and late evening, and denies any sleep disturbances. He does not drink alcohol or smoke cigarettes.
SUPPLEMENTS: none
MEDICATIONS: none
ALLERGIES: Penicillin, severe anaphylactic allergic reaction.
FAMILY HISTORY: His father has poorly controlled hypertension. His mother has celiac disease and is doing well on a gluten free diet. He has two older sisters, one is a breast cancer survivor (three years) and the other one has type 1 diabetes.
VITAL SIGNS: Temperature is 101.4 degrees F (38.6 degrees C). Blood pressure is 114/85 mmHg. Respiratory rate is 12 resp/min. Heart rate is 114 bpm.
PHYSICAL EXAMINATION: Patient appears in moderate distress. Oral examination is unremarkable. Chest auscultation reveals clear breath sounds bilaterally, and high-pitched and blowing murmur at the 5th interspace medial to left mid-clavicular line. Subungual hemorrhages bilaterally; scattered petechiae observed on his distal extremities; painless erythematous lesions on his palm and soles.
PRELIMINARY LAB RESULTS: CBC, basic metabolic panel and urinalysis results are pending DIAGNOSTIC IMAGING: Transesophageal echocardiogram and ECG results are pending
Based on his sx's of heart murmur & characteristic peripheral lesions, what other question could you ask to narrow dx?
A. FMHX of Lupus SLE?
B. FMHX of kidney dz
C. Any sick contacts lately?
D. Any dental work recently?
Case 4 - Q1
D. Any dental work recently?
(Subacute infective myocarditis)
-Fever, Petechia, Subungual hemorrhage (Nail bed), Janeway lesions, tachycardia & mitral regurgitation murmur.
64
What organism causes Subacute infective myocarditis?
A. E. coli
B. Pseudomonas aeroginosa
C. Streptococcus viridans
D. Klebsiella Pneumonia
Case 4 - Q2
C. Streptococcus viridans
65
Which lab test result would help indicate Subacute infective myocarditis?
A. Leukocytosis, increased ESR, Decreased CRP
B. Leukocytosis & left shift, increased ESR, increased CRP
C. Leukopenia, increased ESR, Decreased CRP
D. Leukopenia & left shift, increased ESR, increased CRP
Case 4 - Q3
B. Leukocytosis & left shift, increased ESR, increased CRP
66
antibiotic is chosen for Subacute infective myocarditis, which of the following would have the S/E of Liver injury, thrombocytopenia, and pseudomembranous colitis?
A. Amoxicillin
B. Clindamycin
C. Cephalexin
D. Azithromycin
Case 4 - Q4
B. Clindamycin (Indicated for penicillin allergies for streptococci infxns.)
S/E- Inc. ALT, AST, Bilirubin and thrombocytopenia
67
PATIENT: 18-year-old Caucasian female, 5’5” (165 cm), 202 Ibs (91.6 kg)
PRESENTATION: The patient is accompanied by her mother. The patient has multiple health concerns and wonders whether they are all related. She complains of irregular menses since her menarche at age 13. She has painful, heavy bleeding that occurs every 2-3 months and lasts at least 7 days. She is frustrated with her acne and facial hair issues, as well as steadily gaining weight for the last 4 years. Upon further questioning, her mother states that the patient’s voice has been deepening over the last few years.
MEDICAL HISTORY: She has seasonal allergies, especially in the Fall. She has frequent URIs and heartburn. She denies major surgeries.
PSYCHOSOCIAL: The patient is a senior in high school and plans to work for a year before thinking about applying to college. She lives with her parents and helps them at the religious book and gift store that they own. She volunteers in many local organizations. Her mother mentions that the patient has received verbal and emotional abuse from her paternal grandmother regarding her weight.
HEALTH HABITS: She likes hard boiled eggs for breakfast; salad or leftovers for lunch; and scrambled eggs, dinner rolls, and vegetables for dinner. She does not like meat, especially fatty meat. She loves baked goods and sweets. She denies tobacco or illicit drug use.
SUPPLEMENTS: none
MEDICATIONS: none
ALLERGIES: NKDA
FAMILY HISTORY: Her father has depression. Her mother is in good health. Her family has a strong history of Type 2 diabetes. She is the oldest child and has two healthy siblings.
VITAL SIGNS: Temperature is 97.8 degrees F (36.6 degrees C). Blood pressure is 140/85 mmHg. Respiratory rate is 16 resp/min. Heart rate is 76 bpm.
PHYSICAL EXAMINATION: Patient is obese in NAD. Her BMI is 33.6 with centralized weight gain. Examination of her scalp reveals mildly receding hairline. Erythematous papules and comedones are noted on her face, chest and back. Multiple, coarse, dark hairs are noted on her upper lip. No thyromegaly. Lung, heart, abdominal, and pelvic exams are all normal. DTR’s are 2+ in lower extremities bilaterally.
TESTOSTERONE: US VALUE: 100 ng/dL US RANGE: 40-60 ng/dL IU VALUE: 3.47 nmol/L RANGE: 1.4-2.1 nmol/L URINE HcG: An in-office urine HcG test is negative
TEST: DHEA-S US VALUE: >200μg/dL US RANGE: 65-380μg/dL IU VALUE: >5μmol/L IU RANGE: 2-10μmol/L TEST: LH US VALUE: 19mIU/ml US RANGE: 5-20mIU/ml IU VALUE: 19IU/L IU RANGE: 5-20IU/L
TEST: FSH US VALUE: 7mIU/ml US RANGE: 5-20mIU/ml IU VALUE: 7IU/L IU RANGE: 5-20IU/L
DIAGNOSTIC IMAGING: Transvaginal ultrasound reveals multiple 2-9 mm cysts forming a “pearl necklace” sign.
Conditions in DDX?
A. Pregnancy, Hypothyroidism, Anorexia
B. Congenital Adrenal Hyperplasia, Anorexia & Primary dysmenorrhea
C. Polycystic Ovarian dz, Hypothyroidism, Hyperprolactinemia
D. Hypothyroidism, turner s/d, Congenital Adrenal Hyperplasia
Case 8 - Q1
C. Polycystic Ovarian dz, Hypothyroidism, Hyperprolactinemia
68
Criteria for dx of PCOS (2 of 3 must be present)
A. Oligomenorrhea, Hyperandrogenism, Polycystic ovaries
B. Oligomenorrhea, Hyperestrogenism, Polycystic ovaries
C. Polymenorrhea, Hyperandrogenism, Polycystic ovaries
D. Polymenorrhea, Hyperestrogenism, Polycystic ovaries
Case 8 - Q2
A. Oligomenorrhea, Hyperandrogenism, Polycystic ovaries
69
Which medication would be helpful in PCOS with elevated glucose levels, Hyperandrogenism and wt loss?
A. Metformin
B. Rosiglitazone
C. Indulin
D. Glyburide
Case 8 - Q3
A. Metformin
70
Pt w/PCOS shows skin patterns that thickened, hyper pigmented, velvety around neck, axilla, inguinal, areola which is a sigh of ___ and associated with what?
A. Acanthosis nigrans, sign of niacin def.
B. Acanthosis nigrans, sign of insulin resistance
C. Seborrheic keratosis, sign of niacin def.
D. Seborrheic keratosis, sign of insulin resistance
Case 8 - Q4
B. Acanthosis nigrans, sign of insulin resistance
71
PATIENT: 52-year-old male, 5’9”, 210 lbs
PRESENTATION: The patient walks into your office limping. He is wearing flip-plops because shoes hurt too much. He complains of pain and swelling in his right big toe. The pain started 2 days ago and is moderate to severe. He says both wrists are painful as well.
MEDICAL HISTORY: Hypertension, acute gouty arthritis (7 years ago) PSYCHOSOCIAL: He is a basketball coach at a local high school
HEALTH HABITS: He has been steadily gaining weight over the last few years and estimates that he is about 50 pounds overweight. He drinks a six-pack of beer most days.
SUPPLEMENTS: None
MEDICATIONS: Simvastatin 40 mg (taking for seven years), Lisinopril 20 mg (10 years), Hydrochlorothiazide 25 mg (recently added)
ALLERGIES: None
FAMILY HISTORY: Mother and father both have hypertension
VITAL SIGNS: Temperature 98.9°F (37.2°C), Blood pressure 140/86 mmHg, pulse 82 bpm, respiration 16/min
PHYSICAL EXAMINATION: Significant edema, erythema, and tenderness of right great toe. Pain reported with active ROM of wrists B/L. Hands are mildly erythematous and swollen. All other exams non- contributory.
PRELIMINARY LAB RESULTS: Not performed at this visit DIAGNOSTIC IMAGING: Not performed at this visit
What your DDX?
A. Osteoarthritis, Psoriatic arthritis & reactive arthritis
B. Acute Gouty arthritis, Rheumatoid arthritis, Psoriatic arthritis
C. Psoriatic arthritis, Rheumatoid arthritis & Osteoarthritis
D. Rheumatoid arthritis, Psoriatic arthritis, reactive arthritis
Case 18 Q1
B. Acute Gouty arthritis, Rheumatoid arthritis, Psoriatic arthritis
72
Which test is indicated for Acute Gouty arthritis?
A. Uric acid levels
B. ANA
C. Rheumatoid factor
D. Plain x-rays
Case 18 Q2
A. Uric acid levels
73
What are some known causes of Acute Gouty arthritis?
A. Alcohol, dehydration, vit C
B. Alcohol, injury, fasting
C. Stress, increased water intake, vit C
D. Dairy, increased water intake, stress
Case 18 Q3
B. Alcohol, injury, fasting
74
Gout is more common in?
A. Women
B. Men
C. Children
D. Both Men/Women equal
Case 18 Q4
B. Men
75
PATIENT: 38-year-old female, 5’4”, 126 lbs
PRESENTATION: The patient presents to your office with severe right-sided back pain. She describes the pain as 7 out of 10 (10 high) and “odd, as if someone punched me really hard”. She reports no precipitating event outside of light gardening and lifting her child. She complains of being tired.
MEDICAL HISTORY: No significant medical history outside of a left fractured femur when she was 16 years old (rock-climbing incident). This is the first time she can remember having back pain.
PSYCHOSOCIAL: She is married with a 2-years-old and is hoping to become pregnant again.
HEALTH HABITS: She is physical active and runs, cycles, and walks with friends. She eats well with vegetables and protein at each meal. She occasionally drinks alcohol at social occasions but denies use of tobacco and recreational drugs.
SUPPLEMENTS: 2,000mg/day fish oil and a multivitamin with iron. She has a post-exercise routine that includes a powered protein with vitamins and “recovery nutrients”.
MEDICATIONS: None ALLERGIES: Seasonal allergies
FAMILY HISTORY: Father is alive and well. Mother is living and was diagnosed with DM2 a few years ago.
VITAL SIGNS: Temperature 99.8°F (37.7°C), BP 125/75 mmHg, pulse 80 bpm, respirations 14/min
PHYSICAL EXAMINATION: Upon examination the pain is difficult to reproduce, but appears to be focused around T6 and radiates through anterior midaxillary line. Pain worsens with inhalation. Skin is sensitive to palpation over the painful area.
PRELIMINARY LAB RESULTS: None DIAGNOSTIC IMAGING: None
```
Which are your ddx?
A. Rib subluxation
B Ankylosing Spondylitis
C. Fibromyalgia
D. ALL of the above
```
Case 30 - Q1
D. ALL of the above
76
PRESENTATION: The patient presents to your office with severe right-sided back pain. She describes the pain as 7 out of 10 (10 high) and “odd, as if someone punched me really hard”. She reports no precipitating event outside of light gardening and lifting her child. She complains of being tired.
A day later she calls to say she is no having a itchy rash w/vesicles with crusts across her ribs w/flu like sx's and now you're thinking..
A. Herpes zoster
B. Cellulitis
C. Folliculitis
D. Pityriasis rosea
Case 30 - Q2
A. Herpes zoster
77
PRESENTATION: The patient presents to your office with severe right-sided back pain. She describes the pain as 7 out of 10 (10 high) and “odd, as if someone punched me really hard”. She reports no precipitating event outside of light gardening and lifting her child. She complains of being tired. A day later she calls to say she is no having a itchy rash w/vesicles with crusts across her ribs w/flu like sx's and now you're thinking Shingles but you must also r/o:
A. Pemphigus Vulgaris
B. Scleroderma
C. Psoriasis
D. Contact Dermatitis
Case 30 - Q3
D. Contact Dermatitis (esp. poison Ivy) is the m/c thing to r/o w/Shingles.
78
PATIENT: 50-year-old female, 5'6" (165 cm), 105 lbs (47.6 kg), BMI: 16.9
PRESENTATION: The patient presents with anxiety that has been slowly worsening over the past year. She has a difficult time sleeping because her thoughts are racing, and she notices her heart “skipping a beat” at night. She also has mild night sweats and hot flashes that she attributes to going through menopause. She has also noticed increasing diarrhea, which she attributes to her anxiety.
MEDICAL HISTORY: She has always been relatively healthy, but has noticed losing about 15 lbs over the past year without trying.
PSYCHOSOCIAL: She lives with her husband and 17-year-old daughter and has good relationships with both.
HEALTH HABITS: She eats fried eggs and toast for breakfast most of the time, a sandwich or salad for lunch, and meat and vegetables or beans and rice for dinner. Snacks include fruit, nuts, chips and hummus. She has a good appetite and is frequently hungry. She does not drink coffee because it makes her jittery, but enjoys one glass of red wine after dinner most nights. She runs 3-5 miles 4 or 5 days per week for exercise. Energy is high.
SUPPLEMENTS: Fish oil 1 gram per day
MEDICATIONS: none
ALLERGIES: penicillin
FAMILY HISTORY: Both parents are alive and generally well. Her father has hypertension. Her mother has hypothyroidism. Her sister also struggles with anxiety.
VITAL SIGNS: Temperature is 98.9°F (37.4°C), BP is 150/80 mmHg, heart rate is 96 bpm and irregularly irregular, and respiratory rate is 18/min.
PHYSICAL EXAMINATION: Her skin is warm to the touch and slightly diaphoretic. Heart sounds are irregularly irregular. Lungs are clear to auscultation bilaterally. Her abdomen has normal contour with no scars or striae. You note mildly hyperactive bowel sounds. On palpation, the thyroid gland is diffusely enlarged, soft and non-tender with no nodules. No thyroid bruit noted. No exophthalmos noted.
PRELIMINARY LAB RESULTS: Lab testing is pending DIAGNOSTIC IMAGING: Not performed at this visit
What diagnostic procedure is most indicated at this time?
A. Echocardiogram
B. Thyroid U/S
C. Thyroid scintigraphy
D. Resting ECG
Case 26 - Q1
D. Resting ECG
79
PRESENTATION: The patient presents with anxiety that has been slowly worsening over the past year. She has a difficult time sleeping because her thoughts are racing, and she notices her heart “skipping a beat” at night. She also has mild night sweats and hot flashes that she attributes to going through menopause. She has also noticed increasing diarrhea, which she attributes to her anxiety. Her mother has hypothyroidism. Her sister also struggles with anxiety.
VITAL SIGNS: Temperature is 98.9°F (37.4°C), BP is 150/80 mmHg, heart rate is 96 bpm and irregularly irregular, and respiratory rate is 18/min.
PHYSICAL EXAMINATION: Her skin is warm to the touch and slightly diaphoretic. Heart sounds are irregularly irregular. Lungs are clear to auscultation bilaterally. Her abdomen has normal contour with no scars or striae. You note mildly hyperactive bowel sounds. On palpation, the thyroid gland is diffusely enlarged, soft and non-tender with no nodules. No thyroid bruit noted. No exophthalmos noted.
PRELIMINARY LAB RESULTS: Lab testing is pending DIAGNOSTIC IMAGING: Not performed at this visit
Most likely dx is ____ but you also consider _____
A. Gen Anxiety d/o; Pheochromocytoma
B Grave's; Gen Anxiety d/o
C. Menopause; Atrial fib
D. Hashimoto's; Menopause
Case 26 - Q2
B Grave's; Gen Anxiety d/o
80
Pt w/Grave's; Gen Anxiety d/o should be rx'd what?
A. Propylthiouracil & atenolol
B. Warferin & atenolol
C. Lisinopril & digoxin
D. Levothyroxine & atenolol
Case 26 - Q3
A. Propylthiouracil & atenolol
81
Pt w/Grave's & Gen Anxiety d/o, which herb would help w/her primary dx?
A. Melissa off, Leonorus cardiaca, Lycopus verginicus
B. Leonorus cardiaca, Crataegus oxycanthas, Commiphora mukul
C. Melissa off, fucus vesiculosis, Iris versicolor
D. Lycopus verginicus, coleus forskohii, Mentha peperita
Case 26 - Q4
A. Melissa off (Antirhythmic & Antithyroid), Leonorus cardiaca (Antirhythmic Nervine Cardiotonic for A. FIB), Lycopus verginicus (Antithyroid relaxing nervine)
82
PATIENT: A 48-year-old Caucasian male, 5’11” (180.34 cm), 230 lbs (104.33 kg)
PRESENTATION: Patient arrives in a distressed state, complaining of cramping RLQ pain and frequent (5 to 6/day) watery bowel movements. He also notes a “shimmery” oily residue in the toilet following bowel movements. In the last 3 months he has lost 30 pounds.
MEDICAL HISTORY: He has been treated in the past year for “some kind of “itis” ” in his right eye, but doesn’t recall the diagnosis. He says he has the usual aches and pains that most men his age do, but has not sought any treatment. He was being treated for hypertension and high cholesterol, but stopped taking the medication because of dizziness, grogginess and muscle pain.
PSYCHOSOCIAL HISTORY: The patient is a master carpenter and owns his own custom-made cabinet shop. He is married with three children. All children live at home. He appears to be happily married.
HEALTH HABITS: The patient quit smoking 6 months ago. He drinks 1 beer on evenings during the week and 4 beers on weekend days. He describes himself as a “meat and potatoes man” and doesn’t care for vegetables.
SUPPLEMENTS: None
MEDICATIONS: Occasional ibuprofen for joint/muscle aches ALLERGIES: beestings, pollen, NKDA
FAMILY HISTORY: Father died at age 62 from a myocardial infarction. Mother died at age 65 of breast cancer. Maternal grandmother died at age 68 following a stroke. He has no siblings— both died at a very young age in a house fire—he was not at home at the time.
VITAL SIGNS: Temperature is 100.5°F (38.06°C). BP is 160/85. HR is 94bpm. RR is 22/min (shallow).
PHYSICAL EXAMINATION: Abdominal exam reveals diffuse abdominal tenderness, most pronounced in RLQ, and a firm mass palpated in RLQ. Perianal exam reveals skin tags and areas of scarring. No hemorrhoids noted. Integumentary exam reveals multiple small, tender, erythematous nodules on the extensor aspect of both lower legs (Rt x2; Lt x1). Oral exam reveals a shallow, grayish ulceration of the buccal mucosa. MSK exam reveals limited ROM in knees, bilaterally. Spinal ROM WNL. Left MTP joint of 3rd digit swollen, erythematous, and TTP. Neurological exam non-contributory.
PRELIMINARY LAB RESULTS: (Results shown as Test value, (normal range))
```
CBC:
WBC 12,100/ mm3 (5000-10,000/mm3) Neutrophil 71.1% (55-70%) Lymphocyte 15.9% (20-40%) Eosinophil 0.5% (1-4%)
Basophil 8.7% (0.5-1%)
RBC 2.69x106/μL (4.7-6.1x106/μL)
HGB 10.6 g/dL (14-18 g/dL)
HCT 31.6% (42-52%)
MCV 117.6μm (80-95μm)
MCH 39.6pg (27-31pg)
MCHC 33.7% (32-36%)
RDW 14.1% (11-14.5%)
PLT 578x103/mm3 (150x103- 400x103/mm3)
Comp metabolic: WNL
```
Lipid lowering medications such as ____ have the potential for serious adverse rxn's including ____, which is characterized by _____ .
A. Nystatin; Rhabdomyolosis, Muscle pain, weakness, dark urine
B. Nystatin, Hypotension; blurred vision, dizziness, mental status change
C. Atorvastatin; Rhabdomyolosis, Muscle pain, weakness, dark urine
D. Atorvastatin; Hypotension; blurred vision, dizziness, mental status change
Case 63 - Q1
D. Atorvastatin; Hypotension; blurred vision, dizziness, mental status change
83
What does the blood work reveal?
```
CBC:
WBC 12,100/ mm3 (5000-10,000/mm3) Neutrophil 71.1% (55-70%) Lymphocyte 15.9% (20-40%) Eosinophil 0.5% (1-4%)
Basophil 8.7% (0.5-1%)
RBC 2.69x106/μL (4.7-6.1x106/μL)
HGB 10.6 g/dL (14-18 g/dL)
HCT 31.6% (42-52%)
MCV 117.6μm (80-95μm)
MCH 39.6pg (27-31pg)
MCHC 33.7% (32-36%)
RDW 14.1% (11-14.5%)
PLT 578x103/mm3 (150x103- 400x103/mm3)
Comp metabolic: WNL
```
A. Microcytic anemia w/leukocytosis
B. Macrocytic Anemia w/eosinophilia w/left shift
C. Megaloblastic Anemia w/concomitant aplastic anemia
D. Megaloblastic Anemia w/leukocytosis & thrombocytopenia
Case 63 - Q2
D. Megaloblastic Anemia (high MCV) w/leukocytosis (high WBC) & thrombocytopenia (Low platelet levels)
*Megaloblastic Anemia (high MCV) cause by def. of folate or B12
or
pernicious anemia/Addison's dz (A decrease in red blood cells when the body can't absorb enough vitamin B-12)
*Microcytic (low MCV)
84
PATIENT: A 48-year-old Caucasian male, 5’11” (180.34 cm), 230 lbs (104.33 kg)
PRESENTATION: Patient arrives in a distressed state, complaining of cramping RLQ pain and frequent (5 to 6/day) watery bowel movements. He also notes a “shimmery” oily residue in the toilet following bowel movements. In the last 3 months he has lost 30 pounds.
VITAL SIGNS: Temperature is 100.5°F (38.06°C). BP is 160/85. HR is 94bpm. RR is 22/min (shallow).
PHYSICAL EXAMINATION: Abdominal exam reveals diffuse abdominal tenderness, most pronounced in RLQ, and a firm mass palpated in RLQ. Perianal exam reveals skin tags and areas of scarring. No hemorrhoids noted. Integumentary exam reveals multiple small, tender, erythematous nodules on the extensor aspect of both lower legs (Rt x2; Lt x1). Oral exam reveals a shallow, grayish ulceration of the buccal mucosa. MSK exam reveals limited ROM in knees, bilaterally. Spinal ROM WNL. Left MTP joint of 3rd digit swollen, erythematous, and TTP. Neurological exam non-contributory.
```
Which of the following would your possible dx be?
A. Crohn's dz
B. Alcoholism
C. Ankylosing Spondylosis
D. Pyoderma gangrenosum
```
Case 63 - Q3
A. Crohn's dz
85
Which statement is true?
A. Bleeding is more commonly seeing in UC & Obstruction in Crohn's dz
B. Fistulas, abscesses and scarring are assoc w/both UC & Crohn's dz.
C. Perianal dz is more common is UC
D. UC involves the whole GI while Crohn's is the colon
Case 63 - Q4
A. Bleeding is more commonly seeing in UC & Obstruction in Crohn's dz
* B. Fistulas, abscesses and scarring are assoc w/Crohn's dz.only
* C. Perianal dz is more common is Crohn's dz, not UC
* D. Crohn's involves the whole GI while UC is the colon
86
PATIENT: 72-year-old male, 5’11” 190 lbs
PRESENTATION: Patient presents with urination difficulties that started about a year ago. He tells you that the stream isn’t as forceful as it used to be and he has been experiencing discomfort in his pelvic area for the past few weeks.
MEDICAL HISTORY: Hypertension diagnosed 30 years ago and heartburn diagnosed 5 years ago.
PSYCHOSOCIAL: He lives with his wife of 40 years in a retirement condo.
HEALTH HABITS: He eats a standard American diet and eats the same thing most days, but he hasn’t been very hungry for the past few months.
SUPPLEMENTS: None
MEDICATIONS: Propranolol 20 mg qd, Omeprazole 10 mg qd
ALLERGIES: None
FAMILY HISTORY: His father died of ALS at age 60 and his mother died of ovarian cancer at age 76.
VITAL SIGNS: Temperature 98.6°F (37.0°C), BP 142/80 mmHg, HR 70 bpm, RR 14/min
PHYSICAL EXAMINATION: Digital rectal exam reveals an irregularly enlarged and indurated prostate with areas of nodularity. All other exams non-contributory.
PRELIMINARY LAB RESULTS: Pending DIAGNOSTIC IMAGING: None performed at this time
```
What is the most likely dx?
A. BPH
B. Chronic Prostatitis
C. UTI
D. Prostate CA
```
Case 47 - Q1
D. Prostate CA but (A) BPH w/o bx is also likely
*D/t his age, sx's & DRE prostate being hard on palpation
87
PRESENTATION: Patient presents with urination difficulties that started about a year ago. He tells you that the stream isn’t as forceful as it used to be and he has been experiencing discomfort in his pelvic area for the past few weeks.
PHYSICAL EXAMINATION: Digital rectal exam reveals an irregularly enlarged and indurated prostate with areas of nodularity. All other exams non-contributory.
Which of the following test are indicated?
A. tPSA & fPSA
B. Pelvic MRI & Prostatic acid Phosphstase
C. A-Phetoprotein & Bx
D. Urinalysis & culture
Case 47 - Q2
A. tPSA & fPSA (Lower the ratio of fPSA:tPSA the greater the change it is Cancer rather than BPH.
88
With a pt w/Prostate CA, what would be the best recommendation?
A. Reduce animal products & avoid simple carbs
B. Increase Fatty fish to 3 times/wk
C. Eat a handful of pumpkin seeds daily for zinc
D. Hypoallergenic diet
Case 47 - Q3
A. Reduce animal products & avoid simple carbs
89
Pt w/Prostate CA has difficulty having erections, what RX would you recommend?
A. Salmeterol
B. Testosterone
C. Terbinafil
D. Sildenafil
Case 47 - Q4
D. Sildenafil (For erectile dysfxn - used after surgical or radiation tx of prostate CA. ( inhibits PDE-5 = inc. cGMP corpus cavernosum: smooth mm & inc. blood flow)
* Salmeterol: Long acting beta Agonist relaxes bronchial smooth Mm.
* Terbinafil: anti fungal
90
PATIENT: 15-year-old male, 5’11” (180cm), 175 lbs. (79.54kg)
PRESENTATION: This patient is accompanied by his Mother and presents with generalized abdominal pain over the last 24 hours. The pain has gotten worse over the last couple of hours. He reports an episode of vomiting this morning. His Mother reports that he had been complaining of fatigue over the last 4 weeks, but the patient attributes the fatigue to lack of sleep due to frequent nighttime urination.
MEDICAL HISTORY: He is generally healthy, but has exercise-induced asthma.
PSYCHOSOCIAL: He is in the 9th grade and plays on the high school soccer team. He is not sexually active nor does he smoke cigarettes or participate in recreational drug use.
HEALTH HABITS: He eats a vegetarian diet with lots of carbohydrates and sometimes skips breakfast.
SUPPLEMENTS: Multivitamin and 1,000mg of omega 3’s
MEDICATIONS: Albuterol inhaler as needed
ALLERGIES: NKDA, bee venom, grass
FAMILY HISTORY: Father has asthma; Mother has hypothyroidism; Maternal grandmother has HTN and diabetes mellitus type 2; and Paternal grandfather has prostate cancer.
VITAL SIGNS: 98.5°F (36.9°C), BP 118/76, HR 110, RR 24
PHYSICAL EXAMINATION: He has a hard time remembering some basic personal information and seems confused. He is tachycardic. Cardiac auscultation reveals no murmurs or adventitious sounds and his lungs are CTAB. His abdomen has active bowel sounds and is diffusely tender to palpation. His cranial nerves are intact and gait is normal.
PRELIMINARY LAB RESULTS:
Glucose 456 mg/dL (normal US values: 65-100 mg/dL) Sodium 130 mmol/L (normal US values: 135-145 mmol/L) Potassium 4 mmol/L (normal US values: 3.5-5.1 mmol/L) BUN 26 mg/dL (normal US values: 7-20 mg/dL)
What would be your dx and what other things would you be thinking of in your ddx?
A. Keto acidosis, appendicitis & recreational drug overdose
B. Gastroenteritis, Mononucleosis and appendicitis
C. Gluten enteropathy, psychological and diabetic ketoacidosis
D. Gastroenteritis, pancreatitis, and hepatitis
Case 25 - Q1
A. Keto acidosis, appendicitis & recreational drug overdose (*most likely is ketoacidosis d/t acute abd. pain, fatigue and frequent nocturia - Type 1 diabetes freq. presents as acute infection resulting in ketoacidosis)
* Gastroenteritis - vomiting, diarrhea and fever
* Hep A- recent travel & contact w/person w/hep A
* Pancreatitis - alcohol abuse & cholelithiasis
91
PATIENT: 15-year-old male, 5’11” (180cm), 175 lbs. (79.54kg)
PRESENTATION: This patient is accompanied by his Mother and presents with generalized abdominal pain over the last 24 hours. The pain has gotten worse over the last couple of hours. He reports an episode of vomiting this morning. His Mother reports that he had been complaining of fatigue over the last 4 weeks, but the patient attributes the fatigue to lack of sleep due to frequent nighttime urination.
VITAL SIGNS: 98.5°F (36.9°C), BP 118/76, HR 110, RR 24
PHYSICAL EXAMINATION: He has a hard time remembering some basic personal information and seems confused. He is tachycardic. Cardiac auscultation reveals no murmurs or adventitious sounds and his lungs are CTAB. His abdomen has active bowel sounds and is diffusely tender to palpation. His cranial nerves are intact and gait is normal.
PRELIMINARY LAB RESULTS:
Glucose 456 mg/dL (normal US values: 65-100 mg/dL) Sodium 130 mmol/L (normal US values: 135-145 mmol/L) Potassium 4 mmol/L (normal US values: 3.5-5.1 mmol/L) BUN 26 mg/dL (normal US values: 7-20 mg/dL)
```
What dx procedure or test would help you with your ddx?
A. Abd X-ray
B. Urinalysis
C. Abd CT
D. BX of small intestines
```
Case 25 - Q2
B. Urinalysis - mostly shows elevated ketones, proteins & glucose to aid your dx & easy in office test.
*Serologically DKA serum glucose >250, Bicarb <18, blood ph <7.3 & elev. serum ketones.
92
If a pt's asthma is not controlled w/albuterol, what would be your 2nd med to help.
A. Fluticasone
B. Prednisone
C. Montelukast
D. Fluoxetine
Case 25 - Q3
A. Fluticasone - Low dose inhaled corticosteroid is 2nd line when short acting beta agonist (Albuterol) doesn't help.
* B. Oral Corticosteroid (Prednisone) m/b used for Acute exacerbations nut not long term.
* C. Montelukast is a leukotriene inhibiter used when all other low & medium dose inhaled Corticosteroids have been tried.
* D. Fluoxetine is an SSRI for depression.
93
VITAL SIGNS: 98.5°F (36.9°C), BP 118/76, HR 110, RR 24
PHYSICAL EXAMINATION: He has a hard time remembering some basic personal information and seems confused. He is tachycardic. Cardiac auscultation reveals no murmurs or adventitious sounds and his lungs are CTAB. His abdomen has active bowel sounds and is diffusely tender to palpation. His cranial nerves are intact and gait is normal.
MEDICATIONS: Albuterol inhaler as needed
ALLERGIES: NKDA, bee venom, grass
If this pt is stung by bee near your office and you had no epipen, what is the most appropriate tx?
A. 1:1000 IV epinephrine
B. 1:10,000 epinephrine SQ
C. 1:10,000 epinephrine IV
D. Diphenhydramine 50mg IV is 1st line tx
Case 25 - Q4
C. 1:10,000 epinephrine IV - correct concentration
* IM & SQ should always be 10 x's higher @ 1:1000 concentration of epinephrine.
* Diphenhydramine is not 1st line
94
PATIENT: 58-year-old female, 5’2”, 168lbs
PRESENTATION: The patient presents with pain and stiffness in her left arm. The pain is rated at 6-7 out of 10 on the pain scale and is worst at night. She also complains that she has less mobility in that arm than she used to. It is beginning to interfere with work and daily activities, although she is able to compensate somewhat since she is right-handed. Symptoms first began about a year ago.
MEDICAL HISTORY: Hashimoto’s thyroiditis diagnosed 22 years ago.
PSYCHOSOCIAL: The patient is married with 1 grown son. She works as a kindergarten teacher.
HEALTH HABITS: She is gluten-free and tries to include vegetables and protein with most meals. She drinks about 4 glasses of water per day and “knows she should drink more.” She typically has 1 or 2 cups of coffee in the mornings and sometimes has a glass of red wine with dinner. She denies tobacco use.
SUPPLEMENTS: Selenium 200mcg qd, Vitamin D3 2000IU qd, Fish Oil 1000mg bid
MEDICATIONS: Armour Thyroid 60mg qam
ALLERGIES: Sulfa drugs
FAMILY HISTORY: Mother and sister have Hashimoto’s thyroiditis. Father died of Non- Hodgkin Lymphoma at age 64. Her son has celiac disease, diagnosed at age 17.
VITAL SIGNS: Temperature 98.6°F, Blood Pressure 124/78 mmHg, Pulse 82 bpm, Respirations 18/min.
PHYSICAL EXAMS: Reduced active and passive ROM in left shoulder compared to right. Patient reports pain on movement of the affected arm.
PRELIMINARY LAB RESULTS: TSH: 2.19 U/mL (0.5-4.5 U/mL)
DIAGNOSTIC IMAGING: Not performed at this visit
Which ortho test is indicated at this time?
A. Apley's scratch test
B. Soto Hall
C. Apley's compression
D. Yeoman test
Case 19 - Q1
A. Apley's scratch test - (Arm over head) shoulder rotator cuff test (Supraspinatus)
B. Soto Hall - meningitis
C. Apley's compression - Knee meniscus
D. Yeoman test - SI joint lesion
95
PATIENT: 58-year-old female, 5’2”, 168lbs
PRESENTATION: The patient presents with pain and stiffness in her left arm. The pain is rated at 6-7 out of 10 on the pain scale and is worst at night. She also complains that she has less mobility in that arm than she used to. It is beginning to interfere with work and daily activities, although she is able to compensate somewhat since she is right-handed. Symptoms first began about a year ago.
PHYSICAL EXAMS: Reduced active and passive ROM in left shoulder compared to right. Patient reports pain on movement of the affected arm.
```
Which imaging would be most indicated?
A. Plain film radiography
B. MRI
C. U/S
D. All of them
```
Case 19 - Q2
C. U/S for soft tissue problems
96
PATIENT: 58-year-old female, 5’2”, 168lbs
PRESENTATION: The patient presents with pain and stiffness in her left arm. The pain is rated at 6-7 out of 10 on the pain scale and is worst at night. She also complains that she has less mobility in that arm than she used to. It is beginning to interfere with work and daily activities, although she is able to compensate somewhat since she is right-handed. Symptoms first began about a year ago.
PHYSICAL EXAMS: Reduced active and passive ROM in left shoulder compared to right. Patient reports pain on movement of the affected arm.
```
What is the most likely dx?
A. Glenohumeral joint instability
B. Biceps tendonitis
C. Rotator cuff tear
D. Adhesive capsulitis
```
Case 19 - Q3
D. Adhesive capsulitis
97
PATIENT: 58-year-old female, 5’2”, 168lbs
PRESENTATION: The patient presents with pain and stiffness in her left arm. The pain is rated at 6-7 out of 10 on the pain scale and is worst at night. She also complains that she has less mobility in that arm than she used to. It is beginning to interfere with work and daily activities, although she is able to compensate somewhat since she is right-handed. Symptoms first began about a year ago.
MEDICAL HISTORY: Hashimoto’s thyroiditis diagnosed 22 years ago.
FAMILY HISTORY: Mother and sister have Hashimoto’s thyroiditis. Father died of Non- Hodgkin Lymphoma at age 64. Her son has celiac disease, diagnosed at age 17.
VITAL SIGNS: Temperature 98.6°F, Blood Pressure 124/78 mmHg, Pulse 82 bpm, Respirations 18/min.
PHYSICAL EXAMS: Reduced active and passive ROM in left shoulder compared to right. Patient reports pain on movement of the affected arm.
PRELIMINARY LAB RESULTS: TSH: 2.19 U/mL (0.5-4.5 U/mL)
```
What other c/d's are risk factors for this pt?
A. Autoimmune dz
B. Thyroid dz
C. DM
D. All of them
```
Case 19 - Q4
D. All of them - adhesive cap is assoc w/ all dz mentioned
98
PATIENT: A 19-year-old Asian male. 5’10” (177.8 cm), 121 lbs (54.88kg) BMI: 17.4
PRESENTATION: The patient presents at your clinic with complaints of fatigue, malaise and anorexia, worsening for the last 6 months. He also complains about a rather vague upper abdominal discomfort. He is always itchy and often nauseous. He has bouts of dizziness and mentions that his stools are much paler than ever before.
MEDICAL HISTORY: Patient emigrated from Cambodia 15 years ago. His medical history is unremarkable. No major illness or surgery.
PSYCHOSOCIAL HISTORY: Patient is a full time undergraduate student, studying history and art. He wants to become an architect and lives at home with his parents and 3 younger siblings. His time is generally spent on schoolwork. He is not currently sexually active, but is interested in a young woman in one of his classes—he has had tea with her a few times and they have spoken about seeing a movie together.
HEALTH HABITS: Patient smokes clove and tobacco cigarettes. The clove cigarettes were given to him by his aunt to treat his abdominal discomfort. The patient does not drink alcohol— the one time he tried, he suffered from uncomfortable facial flushing. He has coffee rarely and mostly drinks water and green tea or herbal teas. He often skips breakfast and brings his lunch from home—usually leftovers from the previous evening’s dinner. His mother cooks traditional Khmer foods including fish amok, bai sach chrouk (pork and rice), lap khmer (lime-marinated salad with beef) and Khmer noodles. Fish and vegetables are staples. He gets limited physical activity other than walking to and from campus every day.
SUPPLEMENTS: He drinks a variety of herbal teas given to him by his aunt, an herbalist and traditional Cambodian healer.
MEDICATIONS: None ALLERGIES: None known, NKDA
FAMILY HISTORY: Both parents are alive. He knows that both his mother and father are not entirely healthy, but he is the first in his family to see an American doctor, and he does not know what their health problems “translate” into. Both grandparents are deceased, but he does not know how—it was their time, he says.
VITAL SIGNS: Temperature is 99.0°F (37.22°C). BP is 90/75. HR is 77 bpm. RR is 18/min (shallow).
PHYSICAL EXAMINATION: Abdominal exam reveals splenomegaly, hepatomegaly with TTP. Neurological, Cardiac, MSK exams non-contributory. Sensory exam unremarkable. Respiratory exam reveals pleural friction rub. Dermatologic exam reveals multiple, bilateral petechiae and purpura. Icterus of sclera noted.
PRELIMINARY LAB RESULTS: (Results shown as Test value, (normal range))
Urinalysis:
Appearance: turbid, dark amber Leukocytes: Negative (Negative) Nitrite: + (Negative)
Urobilinogen: ++ (Negative)
Protein: Trace (Negative)
pH: 6.5 (4.6-8.0)
Blood: Positive (Negative)
Specific Gravity: 1.040 (1.005-1.030) Ketones: Negative (Negative) Bilirubin: Positive (Negative) Glucose: Negative (Negative)
Underwt BMI is ____ & overwt BMI is ____.
A. <18 & b/t 25-29
B. <25 & b/t 25-29
C. <30 & >35
D. <18 & >35
Case 67 - Q1
A. <18 & b/t 25-29
>30 = obesity
99
PATIENT: A 19-year-old Asian male. 5’10” (177.8 cm), 121 lbs (54.88kg) BMI: 17.4
PRESENTATION: The patient presents at your clinic with complaints of fatigue, malaise and anorexia, worsening for the last 6 months. He also complains about a rather vague upper abdominal discomfort. He is always itchy and often nauseous. He has bouts of dizziness and mentions that his stools are much paler than ever before.
VITAL SIGNS: Temperature is 99.0°F (37.22°C). BP is 90/75. HR is 77 bpm. RR is 18/min (shallow).
PHYSICAL EXAMINATION: Abdominal exam reveals splenomegaly, hepatomegaly with TTP. Neurological, Cardiac, MSK exams non-contributory. Sensory exam unremarkable. Respiratory exam reveals pleural friction rub. Dermatologic exam reveals multiple, bilateral petechiae and purpura. Icterus of sclera noted.
PRELIMINARY LAB RESULTS: (Results shown as Test value, (normal range))
Urinalysis:
Appearance: turbid, dark amber Leukocytes: Negative (Negative) Nitrite: + (Negative)
Urobilinogen: ++ (Negative)
Protein: Trace (Negative)
pH: 6.5 (4.6-8.0)
Blood: Positive (Negative)
Specific Gravity: 1.040 (1.005-1.030) Ketones: Negative (Negative) Bilirubin: Positive (Negative) Glucose: Negative (Negative)
Which labs need to be ordered next after CBC & CMP?
A. GGT, total & direct bilirubin
B. GGT, total & direct bilirubin, coag. studies (PT/PTT)
C. coag. studies (PT/PTT), f/u urinalysis, serum glucose & toxicity for herb
D. Fecal occult blood, stool test for OVA/Parasite
Case 67 - Q2
B. GGT, total & direct bilirubin, coag. studies (PT/PTT)
* B/c of + Oganomegaly, Jaundice & Urobilinogen, liver enzymes & Coag studies are indicated.
* *A CMP includes Albumin, ALT/AST & Alkaline phosphatase.
* **GGT & total & direct bilirubin, coag. studies (PT/PTT) will help evaluate hepatic injury, biliary tract dz, hemolysis or inherited d/o of bilirubin & biliary obstruction or intrahepatic cholestasis.
* ***COag studies are also indicated in pts w/juandice should be done b/c of petechiae & purpura to eval. to eval DIC.
100
PATIENT: A 19-year-old Asian male. 5’10” (177.8 cm), 121 lbs (54.88kg) BMI: 17.4
PRESENTATION: The patient presents at your clinic with complaints of fatigue, malaise and anorexia, worsening for the last 6 months. He also complains about a rather vague upper abdominal discomfort. He is always itchy and often nauseous. He has bouts of dizziness and mentions that his stools are much paler than ever before.
VITAL SIGNS: Temperature is 99.0°F (37.22°C). BP is 90/75. HR is 77 bpm. RR is 18/min (shallow).
PHYSICAL EXAMINATION: Abdominal exam reveals splenomegaly, hepatomegaly with TTP. Neurological, Cardiac, MSK exams non-contributory. Sensory exam unremarkable. Respiratory exam reveals pleural friction rub. Dermatologic exam reveals multiple, bilateral petechiae and purpura. Icterus of sclera noted.
Which ddx can be excluded from hx?
A. Acute Gastroenteritis
B. Peptic ulcer dz
C. Hepatocellular CA
D. Liver Abscess
Case 67 - Q3
A. Acute Gastroenteritis - usually gastric pain, diarrhea, nausea & vomitting caused by bacteria, virus or parasite.
101
PATIENT: A 19-year-old Asian male. 5’10” (177.8 cm), 121 lbs (54.88kg) BMI: 17.4
PRESENTATION: The patient presents at your clinic with complaints of fatigue, malaise and anorexia, worsening for the last 6 months. He also complains about a rather vague upper abdominal discomfort. He is always itchy and often nauseous. He has bouts of dizziness and mentions that his stools are much paler than ever before.
VITAL SIGNS: Temperature is 99.0°F (37.22°C). BP is 90/75. HR is 77 bpm. RR is 18/min (shallow).
PHYSICAL EXAMINATION: Abdominal exam reveals splenomegaly, hepatomegaly with TTP. Neurological, Cardiac, MSK exams non-contributory. Sensory exam unremarkable. Respiratory exam reveals pleural friction rub. Dermatologic exam reveals multiple, bilateral petechiae and purpura. Icterus of sclera noted.
Labs have been completed for the patient. The CBC shows mild anemia along with significant thrombocytopenia (50,000/ mm3; Normal range: 150,000-400,000/mm3). PTT is 105 seconds (Normal: 60-70 seconds). A manual differential reveals schistocytes. Liver enzymes are as follows: • ALT: 98 U/L (Normal: 4-36 U/L) • AST: 195 U/L (Normal: 0-35 U/L) • ALP: 80 U/L (Normal: 30-120 U/L) • GGT: 58 U/L (Normal: 5-27 U/L) • Total Bilirubin: 1.5 mg/dL (Normal: 0.0 to 1.0 mg/dL) • Direct Bilirubin: 1.0 mg/dL (Normal: 0.0 to 0.4 mg/dL) Which of the following tests are indicated for follow up?
Select your answer:
A. Bone marrow biopsy
B. Anti-HBs, Anti–HBc IgG and IgM, HBsAg, and anti-HCV
C. HIV-AIDs testing
D. Stool culture
Case 67 - Q4
Answer (B) Anti-HBs, Anti–HBc IgG and IgM, HBsAg, and anti-HCV.
This patient should be screened for chronic hepatitis using Anti-HBs, Anti–HBc IgG and IgM, HBsAg, and anti-HCV. There is no indication for bone marrow biopsy, the schistocytes, the only reported abnormal hematological finding is likely a result of DIC. HIV-AIDs testing could be considered, although there is no indication that the patient is at high risk for HIV-AIDS and it is not the most indicated test for the patient’s signs and symptoms.
102
Which of the following statements is FALSE regarding tests of liver enzymes?
Select your answer:
A. The AST/ALT ratio tends to be high in alcoholic liver disease
B. ALP has a number of different isozymes—if ALP is increased, the isozyme levels can be determined to differentiate between liver, bone and intestinal diseases
C. GGT is a liver enzyme that is elevated in chronic alcoholism
D. The AST/ALT ratio is only accurate if the AST levels are at least 10 times higher than the ALT levels.
Case 67 - Q5
Answer (D) AST/ALT ratio is only accurate if the AST levels are at least 10 times higher than the ALT levels.
The AST/ALT ratio is only accurate if the AST levels are less than 10 times higher than the ALT levels.
103
PATIENT: 14-year-old male, 5’6’’, 126 lbs
PRESENTATION: Patient presents with multiple skin lesions on his face and upper back
MEDICAL HISTORY: Diagnosed with asthma at age 7
PSYCHOSOCIAL: He lives at home with both parents and his two younger brothers
HEALTH HABITS: He eats most of his meals at home and his mother generally prepares well- balanced meals for the family. He eats fast food often for lunch at school and on weekends.
SUPPLEMENTS: None
MEDICATIONS: Salbutamol prn
ALLERGIES: None known
FAMILY HISTORY: His grandfather has heart disease and his grandmother has psoriasis
VITAL SIGNS: Temperature 98.6°F (37.0°C), BP 110/70 mmHg, heart rate 70 bpm, and respiratory rate 14/min.
PHYSICAL EXAMINATION: Skin exam reveals numerous erythematous papules and both open and closed comedones on the face and back. Facial lesions are primarily across forehead and jawline. Evidence of scarring is present. All other exams non-contributory.
PRELIMINARY LAB RESULTS: None performed at this time DIAGNOSTIC IMAGING: None performed at this time
```
What is most likely dx?
A. Acne rosacea
B. Folliculitis
C. Eczema
D. Acne Vulgaris
```
Case 44 - Q1
D. Acne Vulgaris - Common in teens on face & Back
*A. Acne rosacea - Usually in middle aged women w/telangiectasis & no comedones
104
Which of the meds work by dec. sebum & inflammation?
A. Isotretinoin
B. Clindamycin
C. Salicylic Acid
D. Ciprofloxazine
Case 44 - Q2
A. Isotretinoin - used in acne spec. w/scarring. Synthetic retinoid that reduces sebum production from sebaceous glands.
* Clindamycin & Ciprofloxazine are A/B's
* *Salicylic Acid is for warts
105
Which of the following herbs treats ACNE?
A. Arctium Lappa, Berberis Aquifolium, Rumex crispus, Galium aperine
B.
Case 44 - Q3
A. Arctium Lappa, Berberis Aquifolium, Rumex crispus, (all 3 - alterative & hepatoprotetive actions indicated for inflammatory & skin hormonal issues like acne) Galium aperine (lymphatic used for Acne & chronic skin c/d
106
For Acne, the following recommendations work best
A. Eliminate simple carbs & refined sugars
Case 44 - Q4
A. Eliminate simple carbs & refined sugars
107
PATIENT: 42-year-old female, 5’2”, 147lbs
PRESENTATION: The patient presents with a “bump” on her arm that she would like you to look at. She first noticed it about two years ago. It isn’t painful but she finds it annoying and would like to have it removed. She also reports feeling tired lately. She typically sleeps 6.5 to 7 hours each night.
MEDICAL HISTORY: G3P3. Hyperlipidemia diagnosed at age 33. She reports frequent UTIs, typically 3 to 4 times per year.
PSYCHOSOCIAL: She is married with 3 children. She is a lawyer at a busy firm and often works 10-12 hour days.
HEALTH HABITS: She eats a standard western diet. She eats vegetables at dinner but rarely with other meals. She often skips breakfast and grabs a sandwich or take-out for lunch. She goes to yoga class twice a week. She drinks 3-4 cups of coffee in the morning and occasionally has a glass of wine in social situations. She denies tobacco use.
SUPPLEMENTS: Vitamin D3 2000IU qd, Fish Oil 1000mg bid MEDICATIONS: Atorvastatin 40mg qd
ALLERGIES: None
FAMILY HISTORY: Mother has hypertension. Father is deceased following a myocardial infarction at age 56. Maternal Grandfather has hypertension and Type 2 Diabetes. Paternal Grandmother died of breast cancer at age 67.
VITAL SIGNS: Temperature is 98.6°F, blood pressure is 128/84 mmHg, pulse is 86 bpm, respirations 14/min.
PHYSICAL EXAMS: Patient is in no acute distress. BMI is 26.9. Capillary refill is 2 seconds bilaterally. No cyanosis or deformities of extremities. Singular, raised lesion noted on the upper left arm. It is approximately 3 cm x 4 cm x 2cm, mobile, and non-tender, with rubbery texture and regular margins. The overlying skin moves freely over the lesion. All other exams unremarkable.
PRELIMINARY LAB RESULTS:
Fasting Glucose: 112 mg/dL (60-100 mg/dL)
Total Cholesterol: 198 mg/dL (Optimal: 150-200 mg/dL) LDL-C: 122 mg/dL (Optimal: <100 mg/dL)
HDL-C: 38 mg/dL (>50 mg/dL)
Triglycerides: 186 mg/dL (<150 mg/dL)
DIAGNOSTIC IMAGING: Not performed at this visit.
A. Furuncle
B. Dermatofibroma
C. Epidermoid cyst
D. Lipoma
Case 45 - Q1
D. Lipoma
A. Furuncle - An infection of a hair follicle w/pus
B. Dermatofibroma- firm hyper pigmented nodule on lower legs that "dimple" & are firm.
C. Epidermoid cyst- mobile skin colored nodules w/central punctum
108
What is the most correct thing to do w/a Lipoma?
A. Excision
B. Incision
C. Refer to Dermatologist
D. Shave bx
Case 45 - Q2
A. Excision - if painful or for cosmetic reason
B. Incision - is for furuncles or abscess
C. Refer to Dermatologist - if its too big or not licensed state
D. Shave bx - malignancy
109
Which of the following is correct when removing a lesion from the arm?
A. 6.0 proline suture - removed 1-6 days after
B. 4.0 Nylon suture - removed 7-10 days after
C. 3.0 vicryl suture - removed 1-6 days after
D. 3.0 proline suture - removed 7-14 days after
Case 45 - Q3
B. 4.0 Nylon suture - removed 7-10 days after (For Arm)
* A. 6.0 proline suture - removed 1-6 days after (Face & Neck)
* C. 3.0 vicryl suture - removed 1-6 days after (Not a common combination)
* D. 3.0 proline suture - removed 7-14 days after (trunk, legs, feet & scalp)
110
PATIENT: 42-year-old female, 5’2”, 147lbs
VITAL SIGNS: Temperature is 98.6°F, blood pressure is 128/84 mmHg, pulse is 86 bpm, respirations 14/min.
PHYSICAL EXAMS: Patient is in no acute distress. BMI is 26.9. Capillary refill is 2 seconds bilaterally. No cyanosis or deformities of extremities. Singular, raised lesion noted on the upper left arm. It is approximately 3 cm x 4 cm x 2cm, mobile, and non-tender, with rubbery texture and regular margins. The overlying skin moves freely over the lesion. All other exams unremarkable.
PRELIMINARY LAB RESULTS:
Fasting Glucose: 112 mg/dL (60-100 mg/dL)
Total Cholesterol: 198 mg/dL (Optimal: 150-200 mg/dL) LDL-C: 122 mg/dL (Optimal: <100 mg/dL)
HDL-C: 38 mg/dL (>50 mg/dL)
Triglycerides: 186 mg/dL (<150 mg/dL)
Beside CC, what is your biggest concern w/her?
A. Nutritional def
B. Unexplained Fatigue
C. Metabolic s/d
D. HTN
Case 45 - Q4
C. Metabolic s/d
* three or more of the following five criteria are met:
1. waist circumference over 40 inches (men) or 35 inches (women),
2. blood pressure over 130/85 mmHg,
3. fasting triglyceride (TG) level over 150 mg/dl,
4. fasting high-density lipoprotein (HDL) cholesterol level less than 40 mg/dl (men) or 50 mg/dl (women) and
5. fasting blood sugar over 100 mg/dl.
111
PATIENT: 15-year-old male, 5’8”, 167lbs
PRESENTATION: The patient presents with pain in his lower left leg. The pain began about 7 months ago and seems to come and go.
MEDICAL HISTORY: Unremarkable
PSYCHOSOCIAL: He is a sophomore in High School. He lives with his parents and has two younger sisters. He currently has a girlfriend but denies being sexually active.
HEALTH HABITS: The patient is active in sports and is a member of both the Junior Varsity soccer and Cross-Country teams at his school. He eats a standard western diet, often grabbing fast food while out with friends. He denies tobacco and recreational drug use. He has experimented with alcohol at parties, but does not drink regularly.
SUPPLEMENTS: None
MEDICATIONS: None
ALLERGIES: Pollen
FAMILY HISTORY: Mother has rheumatoid arthritis. Father has hypertension. Maternal Grandmother died of breast cancer at age 62.
VITAL SIGNS: Temperature 98.6°F, Blood Pressure 110/74 mmHg, Pulse 62 bpm, Respirations 14/min.
PHYSICAL EXAMS: Patient is well nourished and well developed and in no acute distress. Palpation of the left lower leg reveals a 4 cm x 6 cm mass inferior to the patella that is tender to palpation.
PRELIMINARY LAB RESULTS: CBC and CMP within normal limits. DIAGNOSTIC IMAGING: Not performed at this visit
```
What is the next appropriate step?
A. Xrays
B. A/B's
C. Cold level laser
D. RICE cold tx
```
Case 17 - Q1
A. Xrays
112
Which c/d is most likely dx & assoc w/Codman Traingle & "sunburst" patter in soft tissue?
A. Osteoblastoma
B. Osteosarcoma
C. Osteomyelitis
D. Spiral fx
Case 17 - Q2
B. Osteosarcoma - Rare primary bone CA- Radiodense/luscent on xray w/ossified soft tissue mass ("sunburst" patter)
*Codman triangle - bx is needed as it can be Ewing sarcoma, Osteomyelitis, chondrosarcoma
113
What would be a risk factor for pt's c/d?
A. Lack of Vit. D
B. Prior fx
C. Prior radiation
D. Team sport
Case 17 - Q3
C. Prior radiation or chemotherapy increases risk of developing
114
Where in the bone does Osteosarcoma usually effect?
A. Trabecular bone
B. Diaphyseal of long bones
C. Metaphyseal of long bones
D. There is no predominant location
Case 17 - Q4
C. Metaphyseal of long bones - usually distal femur & Prox. tibia
115
Osteosarcoma would be treated w/?
A. Plaster cast & immobilization
B. Doxycyxline
C. High dose vit. D
D. Doxorubicin
Case 17 - Q5
D. Doxorubicin
116
PATIENT: 55-year-old male, 5’11’’ 210 lbs
PRESENTATION: Patient presents with difficulty maintaining an adequate erection for the past six months. He is quite distressed about it because he is recently divorced and dating again. He said he no longer gets a morning erection.
MEDICAL HISTORY: Cold sore (HSV) outbreaks occasionally.
PSYCHOSOCIAL: He works as a mortgage broker. He doesn’t engage in any physical activity.
HEALTH HABITS: He eats a standard American diet and eats out 2-3 times per week.
SUPPLEMENTS: None
MEDICATIONS: None
ALLERGIES: None
FAMILY HISTORY: His father died of a myocardial infarction. His mother has hypercholesterolemia for which she is medicated.
VITAL SIGNS: Temperature is 37.5 degrees Celsius, BP is 138/84 mmHg, heart rate is 70 bpm, and respiratory rate is 14/min.
PHYSICAL EXAMINATION: DRE and genital examination were unremarkable. PRELIMINARY LAB RESULTS:
LAB TEST: Fasting glucose US VALUE: 110 mg/dl US RANGE: 65-100 mg/dl IU VALUE: 5.6 mmol/L IU RANGE: 3.61-6.38 mmol/L
LAB TEST: Total Cholesterol US VALUE: 250 mg/dl US RANGE: 130-200 mg/dL IU VALUE: 5.9 mmol/L IU RANGE: 3.9-5.69 mmol/L
LAB TEST: Triglycerides US VALUE: 140 mg/dl US RANGE: 30-150 mg/dl IU VALUE: 1.2 mmol/L IU RANGE: 0.79-1.24 mmol/L
LAB TEST: TSH US VALUE: 3.1 IU/mL US RANGE: 0.5 – 5 IU/mL IU VALUE: 3.1 IU/mL IU RANGE: 0.5 – 5 IU/mL
DIAGNOSTIC IMAGING: None performed at this time
This pt has erectile dysfxn, what is the most likely cause?
A. DM
B. Atherosclerosis
C. Hypothyroidism
D. Cushing's dz
Case 52 - Q1
B. Atherosclerosis
*ETOH, Smoking, DM, Thyroid dz, depression, medication, & surgeries may cause ED
117
Which drug can help treat ED?
A. Sindenafil
B. Metformin
C. Levo
D. Finasteride
Case 52 - Q2
A. Sindenafil - releases nitrous oxide
118
?????
Case 52 - Q3
119
PATIENT: 56-year-old-female, 5’7”, 163lbs
PRESENTATION: The patient presents with concerns of hearing loss and ringing in her ears. She reports that her left ear seems to be primarily affected. She also reports increased dizziness and often feels unsteady when helping patients at work.
MEDICAL HISTORY: Parathyroid adenoma removed 6 years ago. Hypothyroidism diagnosed 5 years ago.
PSYCHOSOCIAL: She is married with four children. She works as a nurse in an assisted living facility.
HEALTH HABITS: She eats a standard western diet. She attends a yoga class once a week. SUPPLEMENTS: Calcium/Magnesium/Vitamin D
MEDICATIONS: Levothyroxine 100mcg qam
ALLERGIES: Aspirin
FAMILY HISTORY: Mother died of breast cancer at age 52. Father has COPD. Sister has hypothyroidism.
VITAL SIGNS: Temperature is 98.6°F, blood pressure is 118/68 mmHg, pulse is 66 bpm, respirations 18/min.
PHYSICAL EXAMS: Patient is in no acute distress. Lung and cardiovascular exams normal. Whispered voice test 1/3 on the left and 3/3 on the right. Weber test lateralizes to the right. Rinne test reveals air conduction>bone conduction bilaterally. Funduscopic exam normal. DTRs 2+ in upper and lower extremities bilaterally.
PRELIMINARY LAB RESULTS: Not performed at this visit DIAGNOSTIC IMAGING: Not performed at this visit
Which of the following is the correct interpretation?
A. Sensorineural Hearing loss on left ear
B. Sensorineural Hearing loss on right ear
C. Conductive hearing loss on left
D. Normal results
Case 20 - Q1
A. Sensorineural Hearing loss on left ear
120
PATIENT: 56-year-old-female, 5’7”, 163lbs
PRESENTATION: The patient presents with concerns of hearing loss and ringing in her ears. She reports that her left ear seems to be primarily affected. She also reports increased dizziness and often feels unsteady when helping patients at work.
PHYSICAL EXAMS: Patient is in no acute distress. Lung and cardiovascular exams normal. Whispered voice test 1/3 on the left and 3/3 on the right. Weber test lateralizes to the right. Rinne test reveals air conduction>bone conduction bilaterally. Funduscopic exam normal. DTRs 2+ in upper and lower extremities bilaterally.
You determine that she has Sensorineural Hearing loss on left ear, what is the next step?
A. Vestibular testing
B. MRI
C. Audiometry
D. CT scan w/o contrast
Case 20 - Q2
C. Audiometry
121
Which of the following would you suspect a growing lesion in the internal auditory canal & is the most likely dx?
Glioblastoma
Acoustic neuroma
osteoma
exostosis
Case 20 - Q3
Acoustic neuroma - AKA Vestibular Schwannoma - MRI would reveal growing lesion in IAC
* Glioblastoma- fast growing tumor in CNS
* osteoma- bone growth in the skull that may cover the tympanic membrane causing hearing loss
122
PATIENT: 56-year-old-female, 5’7”, 163lbs
PRESENTATION: The patient presents with concerns of hearing loss and ringing in her ears. She reports that her left ear seems to be primarily affected. She also reports increased dizziness and often feels unsteady when helping patients at work.
PHYSICAL EXAMS: Patient is in no acute distress. Lung and cardiovascular exams normal. Whispered voice test 1/3 on the left and 3/3 on the right. Weber test lateralizes to the right. Rinne test reveals air conduction>bone conduction bilaterally. Funduscopic exam normal. DTRs 2+ in upper and lower extremities bilaterally.
Which of the following would be likely in this pt?
A. Paraneoplastic s/d
B. Li-Fraumeni s/
C. Neurofibromatosis type 2
D. MEN 1 s/d
Case 20 - Q4
C. Neurofibromatosis type 2 - Autosomal dom. d/o that leads to B/L Acoustic neuroma - AKA "Vestibular Schwannoma"
A. Paraneoplastic s/d - metastasis - nutritional def.
B. Li-Fraumeni s/d - brca, osteosarcoma, acute leukemia, CNS CA, Adrenal cortex CA
D. MEN 1 s/d - tumors in the Ant pit, Parathyroid, Pancreatic islet
123
Which are assoc. w/aspirin allergy?
A. Hearing loss
B. Atopic dermatitis
C. Nasal Polyps
D. Psychosis
Case 20 - Q5
C. Nasal Polyps - Samter's triad (Nasal polyp, aspirin allergy, asthma)
NPLEX 2
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