TEST 33 - QId: 2618

Giant Cell Tumor of Bone

-worsening pain in knee

no chronica conditions
image of bone...
Q = diagnosis?
A = Giant Cell Tumor. (bubbles on bone)

----wrong:
*hyperparathyroid ? bone resorption - thinning bone/cystic degeneration (osteitis fibrosa
cystica)..... + hypercalcemia ss: constipation, fatigue) h/o renal failrue 2/2 hyperparathyroid (cr
increases)
Surgery - Rheumatology/Orthopedics & Sports

QId: 2910
Nonalcoholic Fatty Liver Disease

-hepatic steatosis on image/biopsy

-exclude alcohol use
-exlusion of other causes of fatty liver

ss: mostly no symptoms; metabolic sd (fatty stools); steatohepatitis LFT; Hyperechoic texture on
ultrasound***
AST/ALT ratio <1

tx = diet/exercise..... (bc he's FAT)

case:
abnml LFT
h/o hypercholesterol on statin but stoped statin dt elevated LFT.
Drinks 1-2 glasses wine on weekends.
Alk phos 121; AST 82; ALT 93
exam: mild HEPATOMEGALY***
Q = diagnosis?
A = Nonalcoholic fatty liver disease

----------
wrong:
*Alcoholic liver disease (hepatic steatosis in NAFLD resembles that found in alcohol liver
dz)...but alcohol liver dz has AST >> ALT 2:1 [ moderate alcohol if <15drinks/wk men; <10/wk
for women)
"drink" 12oz beer, 5oz wine, 1.5oz of 80proof shot
Medicine - Gastrointestinal & Nutrition

QId: 3470

1
Narcolepsy (tx = Modafinil)***
-excessive daytime sleepiness, cataplexy*** (emotion triggered loss of muscle tone)....
hypnagogic/hypnopompic hallucinations, sleep paralysis

Tx = sleep hygiene, schedule naps, avoidance of alcohol and drugs that cause drowsiness.

When medications are needed to decrease daytime somnolence, wakefulness-promoting

agents (MODAFINIL) preferred.

case: excessive sleepiness. HEARS voices while falling asleep. "Temporarily frozen" and
unable to move on awakening
Q = appropriate treatment for this pt?
A = Modafinil
Psychiatry - Nervous System

QId: 3670
INFANT HIV (low CD4 lymphocyte count)

rf: mom viral load; breastfeeding by infected mom.

ss:
-fails to thrive; chronic diarrhea***; Lymphadenopathy; pneumocystis pneumonia

case:
18month old infant + resp distress dt pna.
poor wt gain & diarrhea, not improved.
wt 3rd percent. T103F
exam: oral thrush, general LN; wbc 18,000 lymphocytes 45% (chronic)
Endotrach shows pneumocystis jirovecii..
Q = likely present?
A = decreased CD4 lymphcyte count

after 18month old...persistent HIV antibody is confirms infxn. (DNA PCR test)
-----
wrong:
*Abnml chloride = cystic fibrosis..... (won't see pneumocystis pna or general LN)

*Low B cell x-link agammaglobulin = ss: recurrent BACTERIAL sinus-lung infxn; NO lymphoid
tissue, low immunoglobulin

*Adenosine deaminase deficiency = gene defects results in severe combined immunodeficiency

affected infants have profound lymphopenia, recurrent infxns, fails to thrive.

-------
Pediatrics - Infectious Diseases

QId: 4212
62yoM
has severe abdominal pain

2
ss: suddenly felt weak, diaphoretic, had no energy.
Smoker & HTN.

exam: diffusely tender abdomen

CT scan becomes PALE & DROWSY

CT scan shown.
BP 80/50mmHg; Pulse 110/min.
Q = next step management?
A = exploratory abdominal surgery

why: CT scan shows RUPTURED aorta w/blood collection in adventitial layer.

--------wrong:
*HoTN w/abdominal pain & has a CT scan showing enlarged aortic silhouette
has diagnosis of a RUPTURED Abdominal aortic aneurysm

Pt needs IMMEDIATE SURGERY to fix it.

Surgery - General Principles

QId: 4373
Bacillary Angiomatosis

epi:
-bartonella henselae; cat exposure or homelessness (lice); severe immunocompromise
(advanced HIV CD4<100)

ss: vessel cutaneous lesions (papular, nodular, peduncular)

systemic sx: fever, night sweats, fatigue; organ involved rarely (liver, bone, CNS)

dx = lesion BIOPSY
tx = DOXYCYCLINE or erythromycine; antiretrovirus meds

case: 43yoM fever/night sweats, fatigue + SKIN LESIONS.

reddish/purple papules gradually enlarged to large nodules. h/o HIV CD4 <50.
pedunculated lesions on face/limbs.
Q = cause of current systemic illness?
A = Bartonella species
Medicine - Infectious Diseases

QId: 4408
Ischemia oculomotor (CN III) palsy
a/w poor controlled DM
ss: inner nerve eye: DOWN/OUT, diplopia, nml pupil***** response.

Elderly double vision

DM2 poor glycemic control***
exam: ptosis right eye; eye is "down-an-out" position
Adduction, elevation, depression movements impaired.
Q = likely cause of current condition?

3
A = Nerve ISCHEMIA

----wrong:
-nerve conduction, if aneurysm, tumor of CN3. (but cause abnml pupil response MYDRIASIS)
seen***
Medicine - Nervous System

QId: 4473
Acetaminophen, NSAIDs, amiodarone, abx...can potentiate anticoagulant effects of
warfarin....leads to variable dose response...risk bleeding.

Case:
70yoM ss: bruising & bleeding gums.
had afib treated with metoprolol & WARFARIN.

Takes ACETMINOPHEN**** for joint pain.

Q = responsible for pt's bleeding?
A = Acetaminophen

why: CYP450 inhibitors...increase WARFARIN/bleed effect

-acetaminophen, NSAIDs
-abx/antifungals (metro);
-amiodarone, cimetidine, cranberry juice, ginkgo biloba (not ginseng), vit E;
-Omeprazole, thyroid hormone
-SSRIs (fluoxetine)

CYP40 inducers ?warfarin effect

(carbamazepine, phenytoin) GINSENG, st john's wort
-OCP (women); phenobarb; RIFAMPIN (TB)
Medicine - Cardiovascular System

QId: 4603
Severe Pancreatitis

42yoM severe abdominal pain & vomiting.

pain is constant and nagging, localized to upper abdomen, radiates to back.

BP drops to 80/60mm...P incr to 120/min.

Lung: Crackles.

Likely cause of HoTN?

A = Increased vasclar permeability

why: severe pancreatitis

ss: fever/tachycardia/HoTN
-dsypnea, tachypnea & or basilar crackles
-abdominal tenderness or distension
-cullen sign: periumbilical bluish coloration indicates hemoperitoneum

4
-Grey-turner sign: red color around flanks = Retroperitoneal bleed

a/w ?risk severe pancreatitis:

->75age; obese; alcoholism; CRP >150mg
BUN & cr incr
CXR: pulm infiltrates or pleural effusion
CT/MR cholangiopancreatography w/pancreas necrosis

risk: pseudocyst; peripancreas fluid collected, necrotizing pancreatitis, ARDS, renal fails, GI
bleeds.
wrong: -----------
Medicine - Gastrointestinal & Nutrition

QId: 4610
Pressure ulcers (decubitus ulcers)
@sacrum, ischial tuberosities, malleolus, heels, 1st or 5th metatarsal heads.****toes

prolonged pressure over a bony prominence...cause ISCHEMIA necrosis to tissues

rf: impaired mobility, malnutrition, abnml mental status, decreased skin perfusion, reduced
sensation.

tx = repositioning, wound care.

case:
elderly has foot ulcer. 3 months ago had CVA cerebrovascular accident now has hemiparesis
with contractures***
h/o DM, hypercholesterolemia, coronary arty disease.
image of skin. (by toes)
Q = primary cause of skin ulcers?
A = pressure necrosis moa

----wrong:
*arterial insufficiency - arterial ulcers (lack blood supply leads to tissue necrosis....tips of toes
lowest blood flow)

*DM foot ulcers = chronic unnoticed trauma dt peripheral neuropathy and poor wound healing dt
microvascular insufficiency....a/w charcot deformity. MC on soles of feet under metatarsal heads
and at tops of toes.
Surgery - Dermatology

QId: 4781
HELLP syndrome

ss: Preeclampsia, n/v/ RUQ abdominal pain

Serious liver problems: centrilobular necross, hematoma, thrombi of portal capillary system

Liver swelling with distension of hepatic (Glisson) capsule....results in RUQ or epigastric pain.

5
case: 31wks pregnant + RUQ pain, n/v.
BP 160/90***
exam: tenderness at midline & RUQ abdomen; no peritoneal signs.
Hb 9.7; plt 80,000, LFT 120s.
Q = likely casue of upper abdominal pain?
A = distension of liver capsule***

------wrong:
*Acute Fatty Liver of pregnancy (AFLP) : ss: n/v/abdominal pain.....high LFT in 3rd trimester
(AFLP has extrahepatic problems: WBC incr, hypoglycemia

*Peptic ulcer Perforation = RAPID sudden epigastric pain...can get generalized +

peritonitis/abdomin rigid, HoTN***

*Rupture hepatic adenoma = HoTN from blood loss + peritonitis (tenderness & rebound). needs
surgery
Obstetrics & Gynecology - Pregnancy, Childbirth & Puerperium

QId: 4782
Pulmonary edema = life threatening complication of severe preeclampsia
ss: ?systemic vascular resistance, capillary permeability, Pulmonary capillary hydrostatic
pressure, decreased albumin

case:
she develops dyspnea & drop arterial oxy sat 3 hrs later.
exam: bibasilar crackles**** accessory msk for breathing****, pitting edema legs.
Urine output is 60mL.
Q = cause of resp sx?
A = Pulmonary Edema

ss: sudden dyspnea, hypoxia, crackles dt acute pulmonary edema

pre-eclampsia ss: generalized arterial vasospasm leads to increased systemic vasclar
resistance & high cardiac afterload.

Pulm edema dt: decreased renal function, decr serum albumin, endothelium damage leads to
increased capillary permeability***

-----wrong:
*Amniotic fluid emboli - SUDDEN hypoxemic resp failure & HoTN shock. amniotic fluid gets into
mom circulation during labor/delivery.

*Bronchospasm ss: dyspnea & hypoxemia..cause wheezing instead of crackles relieved by

steroids. (bronchospasm not likely w/o Asthma hx
Obstetrics & Gynecology - Pregnancy, Childbirth & Puerperium

QId: 4881
Major Depression

case: older brother passed away 3months ago.

6
"very down" "poor energy and concentration" eating less.; sad lost interst in work.

Q = likely diagnosis?
A = Major depressive disorder

depression following loss of loved one...

(vs nml gief)
SIG E CAPS

Dx = major depression

---wrong:
*Adjustment disorder w/depressed mood = depression ss in response to a stressor. but sx
should not represent nml bereavement and can't be diagnosed when criteria is med for another
disorder like MDD.

*Persistent complex bereavement disorder "Complicated grief" ss: persistent yearning for
decreased & prolonged emotional pain related to loss....then cannot adapt/ has thoughts and
dysfunctional behaviors.
Psychiatry - Psychiatric/Behavioral & Substance Abuse

QId: 11958
1st gen psych meds
2nd gen psych meds = cause less EPS (but wt changes)

Clozapine & Olanzapine...risk metabolic changes

Ziprasidone, aripiprazole, lurasidone = lowest risk of metabolic wt changes.***

case:
*21yoM hearing voices.
"ppl trying to control me thru a chip..." put on haldo...then got msk spasm in neck and
restlessness.
Q = appropriate med for pt?
A = Ziprazidone
Psychiatry - Psychiatric/Behavioral & Substance Abuse
QId: 12004
Leiomyomata uteri

32yoF
Pelvic Pain 2 days...after menstrual period ended.
5 yrs ago had spontaneous abortion treated by D&C. "Feels like labor contractions pains"***
pass occasional CLOTS**

Exam: irregularly enlarged uterus

cervix dilated 5cm w/spherical MASS visible through external os. (= fibroid juts out of cervix;
prolapsing fibroid)

Q = likely diagnosis?
A = Leiomyoma Uteri.

7
expulsion causes labor-like pain (bc cervical dilation by solid mass....preceed by heavy vagina
bleeding)
high BP & pulse dt discomfort and anemia may be present (dt bleeding)

----wrong
*Cystocele (bladder prolapse)
-pelvic pressure, urinary symptoms, or palpable vagina bulge (NOT heavy menses); cervix is
behind cystocele appears nml.
Obstetrics & Gynecology - Female Reproductive System & Breast