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36 yo F in ED with difficulty breathing. SOB for 24 hrs w/ mild CP with deep inspiration and coughing w/o production. No fever. No LE edema, hx of CV problems, or wt loss. No travel. Meds are norgestrel/ethinyl-estradiol. VSS. BMI 32kg/m2. PE: diaphoretic, CV norm, pul, with fine bibasilar rales. Q1: What actions should be taken for this patient? (8) Q2:ABG shows pH 7.45, pO2 90mmHg, pCO2 30mmHg. CXR shows elevated diphragm. EGK sinus tachy. D-dimer 1.4ug/ml FEU, bhCG neg. HR 108, BP 118/70. What action next? (4) Q3: CTPA shows filling defects in R interlobar bulmonary arteries consistent with PE. Pt is alert and conversant. HR 110, BP 114/68, RR 24, O2% 96. What action, if any, should be next? - ANSWER✔✔Q1: D-dimer (with low pretest probability), but if patient were to have a high pretest probability, skip D-dimer go to CTPA. Q2: CTPA (ONLY do a VQ scan if CTPA is contraindicated in pregnancy or renal insufficiency). No treatment initiated in hemodynamically stable patient since there is bleeding risk. If unstable then its ok to treat. Q3: Tx with enoxaparin. If patient is HDS choose anticoagulation therapy (LMWH
UFH b/c they do not require PTT monitoring q 6hrs). If contraindicated, use IVC. If pt is HD unstable (aka systolic BP <90 for >15 min) choose thrombolysis. If contraindicated, emergent embolectomy. Note: those with PE should be treated at least 3 months of outpatient anticoagulation. Warfarin is good after heparin bridge. Other Xa inhibitors can be used. After 3 months, ASA is used. Heme workup later would evaluate for deficiency in antithrombin III, protein S and C, factor V leiden mutation, antiphospholipid antibodies 67 yo F in ED. 1 hr ago, pt started having slurred speech and weakness in L arm and leg. PMHx of 35 pack yr smoking. No current meds. T98.2, BP 180/104, HR
108, RR 19, O2% 98%. PE: anxious, unable to answer questions well, L side facial droop, 4/5 strength on left side, decreased sensation. No abnormal BG. Q1: Single most important step? (2) Q2: CT is unremarkable. What is the most appropriate next step? (5) Q3: 24 hrs after alteplase, the patient facial droop improved speech returned to normal. L arm strength improved but leg strength diminished. L sided sensation decreased. BP 132/78. Next step of mgmt? - ANSWER✔✔Q1: Noncontrast computed tomography of the head. In addition to initial steps, it is good to do an extensive neuro exam, serum glucose evaluation, O2 sat (try to maintain level
94%) Q2:Alteplase and EKG. Thrombolytic should be given within 4.5 hours of symptom onset. EKG evaluates for cardiac ischemia or a. fib. Labs: CBC, platelet count, PT, PTT, BMP. Ok to have permissive HTN in order to ensure brain perfusion. Can use IV labetalol if sys BP is >185. Start antithrombotic (ASA) and anti-lipid (statin) within 48 hrs of stroke Q3: ASA, dysphagia evaluation, Echocardiogram, MRI of the brain, statin. Patient should be admitted. MRI and echocardiogram used to confirm diagnosis of stroke and determine underlying cause of stroke (embolism from cardiac source). CT again to look for hemorrhagic conversion but only in hi risk. Common complication of stroke is development of aspiration PNA due to undetected dysphagia. 63 yo male presents for routine visit, c/o L knee pain. Hx of contact sports (rugby, football). Pain is deep, throbbing medial joint pain worse after active day. Recently avoiding exercise, feels "old and worthless." Stiff in the am for 15 minutes, pain interferes with sleep 3-4 nights/wk. No relief with acetaminophen and partial relief from ibuprofen daily. No hx of CV, peptic ulcer dz, no current meds. HR 72, BP 118/80, RR 12, BMI 32kg/m2. PE: crepitus of L knee with passive movement, decreased flexion on ROM, no knee pain with passive L hip motion. Mild swelling, LE edema. ESR 12.
Q1: What action if any should be taken for patient at this time? (7) Q2: Patient in discomfort. You encourage exercise, ROM and strengthening exercises. Referred to nutritionist. He loses 20lbs BMI 30. Naproxen BID. SxS
Q1: What test will you order at this time? Q2: PFT revealed reduced FEV1 and FEV1/FVC ratio that reverses with bronchodilator therapy. Findings reproduce with methacholine. CXR no abnormalities. CBC elevated eosinophils. After 2 albuterol doses spread 4 hrs apart, pts symptoms return in 4 hrs. Next step? Q3: After 1 wk of therapy systemic glucocorticoids and intermittent SABA pt returns to clinic feeling better. She is to follow up in 3 months for repeat assessment. At f/u she has dyspnea, cough 3x per wk, she takes albuterol with relief. 4 nights in past month symptoms woke her up. Most appropriate mgmt? - ANSWER✔✔Q1:CXR and spirometry Q2: continued SABA, systemic glucocorticoids, avoid triggers, asthma education Q3: continue SABA, add daily inhaled glucocorticoid. 21 yo male with pruritic rash on elbows and forearms from a few weeks ago. 2nd time. No sick contacts, changes in skin care or diet. No PMHx, no current meds. Had months of loose stools. PE: T 97.6, HR 72, BP 109/70, RR 15 Q1: What tests do you order? (6) Q2: Lab studies show WBC, Hgb, platelets wnl. Direct immmunofluorescence microscopy reveals granular IgA deposits at dermal papillae. ELISA for IgA tissue transglutaminase abs is positive. What additional diagnostic testing would you do? Q3: EGD shows scalloped duodenal flds. Bx taken shows absent villi and presence of intraepithelial lymphocytes - ANSWER✔✔Q1: CBC (celiac disease aka gluten sensitive enteropathy is highly associated with iron deficiency), direct immunofluorescence microscopy, ELISA for IgA tissue transglutaminase antibodies Q2: EGD and small bowel biopsy Q3: dapsone and gluten free diet
63 yo woman presents to the clinic with L knee pain for several months. Described as achy (3 out of 10 pain) when climbing stairs and getting up from seated position. She c/o stiffness in knee which worse when she awakens and resolves in 20 mins. PE: VSS, BMI 36kg/m2. L knee with mild joint effusion w/o erythema, + crepitus along joint, ROM decreased 2/2 pain Q1: What test should be ordered for this patient to confirm the diagnosis? (5) Q2: Most appropriate initial steps in mgmt? (5) Q3: Patient returns for follow up after 6 wks of PT, lost 15 lbs, but still has same symptoms. PE: increased joint effusion. Most appropriate pharm tx? - ANSWER✔✔Q1: No investigation. Criteria is based on HPI of persistent pain in 1+ joints that is worse with activity, age >45, morninh stiffness <30 minutes Q2: Weight loss, exercise or fitness training, PT. No pharm therapy as first line treatment Q3: NSAIDs 81 yo femal hospitalized fo CAP for past 12 days. Treated with ceftriaxone and azithromycin originally. Clinical status deteriorated over first 3 days of admission and switched to vanc and pipercillin-tazobactam. Med hx includes type 2 DM and HTN. Other meds include insulin and acetaminophen and ibuprofen for fever. HTN meds held d/t hypotension. HDS, started PT. Day of discharge she spikes fever of 101F. Cr 3.6 from 1.4. Q1: UA shows microscopic hematuria and WBCs with eosinophilia. What actions will you take? Q2:Renal US shows echogenic normal sized kidneys w/o obstruction. All meds stopped, fever resolves, Cr remains elevated, 6 days later Cr is 3.2. How do you manage this patient? Q3: renal bx shows interstitial infiltrate with lymphocytes and eosinophils and localized sites of interstitial fibrosis. Histo dx is AIN. 6 wk course of oral predisone is given. Cr does not recover. GFR 25. Which actions will you ta - ANSWER✔✔Q1: d/c pipercillin-tazobactam (or d/c abx), discontinue ibuprofen
Q2: meningococcal vaccine, HPV 35 yo woman at PCP with fatigue of 3 months and pruritic rash under breasts and inguinal area. Nocturia twice a night, routine exercise. No children. PE: T 98.6, BP 142/78, HR 96, RR 14, BMI 38 ,darkening of skin and back of neck, flat erythematous scaly rash with definite borders. CVPULM normal. Q1: In addition to prescribing nystatin powder for rash, which action will you take next? (9) Q2: Pt not ready for weight loss program. Advised to avoid weight gain and educated on benefits of physical activity. Random glucose 208, total Cholesterol 196, glycosylated hemoglobin 7.2%. What tx is indicated? Q3: 2 yrs later she returns after using metformin, 35 lb weight loss, polydipsia, polyuria, no other symptoms. HR 84, BP 110/80, HgbA1C 11.8%. What interventions would be initiated? - ANSWER✔✔Q1: assess readiness to achieve weight loss, education on benefit of physical activity, measurement of glycosylated hemoglobin Q2: metformin. Dont prescribe anything else. Metformin can bed used as monotherapy as long as HgbA1C is less than 7.5% Q3: basal bolus insulin (detemir, NPH, glargine). Any HgbA1C >9% insulin should be started.
