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  #1  
Old 01-09-2015
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Default Tough Shelf questions ... Can you answer them?

Hey gang ... I had these tough question (IM) shelf 1 ... any help would be appreciated ....

1) 25 yo female ... no temp, pulse is 86/min, and blood pressure is 110/50 mm Hg. Had viral infection and sent home. One week later, she returns
because of continued fatigue and jaundice. Her pulse is 80/min, respirations are 12/min, and blood pressure is 110/64 mm Hg. She has scleral icterus. No heart problems. The liver edge is palpated 1 cm below the right costal margin and is slightly enlarged, smooth, and tender to palpation.

Laboratory studies show:
Hemoglobin Serum 13.2 g/dL
Bilirubin, total Direct 4.2 mg/dL 3.6 mg/dL
Alkaline phosphatase AST 330, ALT 270
LDH 410
It is NOT G
A) Acute hepatitis
B) a Antitrypsin deficiency
C) Biliary atresia
D) Cholangiocarcinoma
E) Choledocholithiasis
F) Gilbert syndrome
G) Glucose 6-phosphate dehydrogenase deficiency
H) Liver abscess
I) Peptic ulcer disease

2) Male, no History of serious illness, Current medications include daily aspirin. He drinks one glass or wine daily, he is oriented to person but not to place or time.

He becomes light-headed on sitting up. His temperature is 38.7C (102), pulse is 120/min, and blood pressure is 84/50 mm Hg while supine. Abdominal examination shows right lower quadrant tenderness with guarding and rebound; there is a suggestion of a mass. The upper and lower extremities are cool and clammy. Additional laboratory studies show:
Leukocyte count 25K
Serum
+ Na 140
Cl 103
HCO3- 19
Urea nitrogen 40
Creatinine 1.6

pH 7.2, PCO2 34 mm, PO2 84 mm

Which of the following serum concentrations is most likely to be increased in this patient?
It is NOT C. I thought F but why would 1 aspirin have such problem
A) Acetone B) Alcohol
C) Ethylene glycol D) Glucose
E) Lactic acid F) Salicylate

3)
Old woman with severe dementia is brought to the physician because of fever, chills, lethargy, and agitation for 2 days. Her temperature 101F. Examination shows tenderness of the lower abdomen and right costovertebral angle. Laboratory studies show:

Leukocyte count 18,000/mm
Segmented neutrophils 65%
Bands 20%
Lymphocytes 15%

Urine
RBC 20/hpf WBC 50 /hpf
Granular casts Positive
Bacteria few

Not "A"
A) Allergic interstitial nephritis
B) Glomerulonephritis
C) Pyelonephritis
D) Retroperitoneal abscess
E) Tubular necrosis

Thanks!
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  #2  
Old 01-09-2015
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I would say:

1) A - fatigue + jaundice + elevated liver enzymes = hepatitis

2) E - the patient is probably in septic shock, thus lowered oxygen delivery to tissues, which in turn causes increased lactic acid ?

3) C - chills, costovertebral angle tenderness, rbc & wbc in urine sounds like pyelonephritis

Quote:
Originally Posted by docholly123 View Post
Hey gang ... I had these tough question (IM) shelf 1 ... any help would be appreciated ....

1) 25 yo female ... no temp, pulse is 86/min, and blood pressure is 110/50 mm Hg. Had viral infection and sent home. One week later, she returns
because of continued fatigue and jaundice. Her pulse is 80/min, respirations are 12/min, and blood pressure is 110/64 mm Hg. She has scleral icterus. No heart problems. The liver edge is palpated 1 cm below the right costal margin and is slightly enlarged, smooth, and tender to palpation.

Laboratory studies show:
Hemoglobin Serum 13.2 g/dL
Bilirubin, total Direct 4.2 mg/dL 3.6 mg/dL
Alkaline phosphatase AST 330, ALT 270
LDH 410
It is NOT G
A) Acute hepatitis
B) a Antitrypsin deficiency
C) Biliary atresia
D) Cholangiocarcinoma
E) Choledocholithiasis
F) Gilbert syndrome
G) Glucose 6-phosphate dehydrogenase deficiency
H) Liver abscess
I) Peptic ulcer disease

2) Male, no History of serious illness, Current medications include daily aspirin. He drinks one glass or wine daily, he is oriented to person but not to place or time.

He becomes light-headed on sitting up. His temperature is 38.7C (102), pulse is 120/min, and blood pressure is 84/50 mm Hg while supine. Abdominal examination shows right lower quadrant tenderness with guarding and rebound; there is a suggestion of a mass. The upper and lower extremities are cool and clammy. Additional laboratory studies show:
Leukocyte count 25K
Serum
+ Na 140
Cl 103
HCO3- 19
Urea nitrogen 40
Creatinine 1.6

pH 7.2, PCO2 34 mm, PO2 84 mm

Which of the following serum concentrations is most likely to be increased in this patient?
It is NOT C. I thought F but why would 1 aspirin have such problem
A) Acetone B) Alcohol
C) Ethylene glycol D) Glucose
E) Lactic acid F) Salicylate

3)
Old woman with severe dementia is brought to the physician because of fever, chills, lethargy, and agitation for 2 days. Her temperature 101F. Examination shows tenderness of the lower abdomen and right costovertebral angle. Laboratory studies show:

Leukocyte count 18,000/mm
Segmented neutrophils 65%
Bands 20%
Lymphocytes 15%

Urine
RBC 20/hpf WBC 50 /hpf
Granular casts Positive
Bacteria few

Not "A"
A) Allergic interstitial nephritis
B) Glomerulonephritis
C) Pyelonephritis
D) Retroperitoneal abscess
E) Tubular necrosis

Thanks!
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docholly123 (01-09-2015)
  #3  
Old 01-10-2015
israaoday's Avatar
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Quote:
Originally Posted by
2) Male, no History of serious illness, Current medications include daily aspirin. He drinks one glass or wine daily, he is oriented to person but not to place or time.

He becomes light-headed on sitting up. His temperature is 38.7C (102), pulse is 120/min, and blood pressure is 84/50 mm Hg while supine. Abdominal examination shows right lower quadrant tenderness with guarding and rebound; there is a suggestion of a mass. The upper and lower extremities are cool and clammy. Additional laboratory studies show:
Leukocyte count 25K
Serum
+ Na 140
Cl 103
HCO3- 19
Urea nitrogen 40
Creatinine 1.6

pH 7.2, PCO2 34 mm, PO2 84 mm

Which of the following serum concentrations is most likely to be increased in this patient?
[B
It is NOT C. I thought F but why would 1 aspirin have such problem [/B]
A) Acetone B) Alcohol
C) Ethylene glycol D) Glucose
E) Lactic acid F) Salicylate
Hey
I agree with lnr4 for questions 1 and 3
but i think the second one the answer is F
the patient has anion gap metabolic acidosis with some respiratory compensations which is caused by salicyllate overdose which is also causing the perforated DU giving the scenario of shock and acute abdomen

Thanks for sharing
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  #4  
Old 01-11-2015
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Quote:
Originally Posted by docholly123 View Post

1) 25 yo female ... no temp, pulse is 86/min, and blood pressure is 110/50 mm Hg. Had viral infection and sent home. One week later, she returns
because of continued fatigue and jaundice. Her pulse is 80/min, respirations are 12/min, and blood pressure is 110/64 mm Hg. She has scleral icterus. No heart problems. The liver edge is palpated 1 cm below the right costal margin and is slightly enlarged, smooth, and tender to palpation.

Laboratory studies show:
Hemoglobin Serum 13.2 g/dL
Bilirubin, total Direct 4.2 mg/dL 3.6 mg/dL
Alkaline phosphatase AST 330, ALT 270
LDH 410
It is NOT G
A) Acute hepatitis
B) a Antitrypsin deficiency
C) Biliary atresia
D) Cholangiocarcinoma
E) Choledocholithiasis
F) Gilbert syndrome
G) Glucose 6-phosphate dehydrogenase deficiency
H) Liver abscess
I) Peptic ulcer disease
I think this is B. Non-specific hepatitis points to alpha antitrypsin.

Quote:
Originally Posted by docholly123 View Post
2) Male, no History of serious illness, Current medications include daily aspirin. He drinks one glass or wine daily, he is oriented to person but not to place or time.

He becomes light-headed on sitting up. His temperature is 38.7C (102), pulse is 120/min, and blood pressure is 84/50 mm Hg while supine. Abdominal examination shows right lower quadrant tenderness with guarding and rebound; there is a suggestion of a mass. The upper and lower extremities are cool and clammy. Additional laboratory studies show:
Leukocyte count 25K
Serum
+ Na 140
Cl 103
HCO3- 19
Urea nitrogen 40
Creatinine 1.6

pH 7.2, PCO2 34 mm, PO2 84 mm

Which of the following serum concentrations is most likely to be increased in this patient?
It is NOT C. I thought F but why would 1 aspirin have such problem
A) Acetone B) Alcohol
C) Ethylene glycol D) Glucose
E) Lactic acid F) Salicylate
This one is a bit tricky. BUN/Crea ratio is elevated which points to pre-renal azotemia, has high anion gap met acidosis and seems to be in septic shock. I think E /lactate is the answer

[QUOTE=docholly123;630106]
3)
Old woman with severe dementia is brought to the physician because of fever, chills, lethargy, and agitation for 2 days. Her temperature 101F. Examination shows tenderness of the lower abdomen and right costovertebral angle. Laboratory studies show:

Leukocyte count 18,000/mm
Segmented neutrophils 65%
Bands 20%
Lymphocytes 15%

Urine
RBC 20/hpf WBC 50 /hpf
Granular casts Positive
Bacteria few

A) Allergic interstitial nephritis
B) Glomerulonephritis
C) Pyelonephritis
D) Retroperitoneal abscess
E) Tubular necrosis
[QUOTE=docholly123;630106]
This is again tricky. But i think granular cast is a sign of tubular necrosis. So E?
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  #5  
Old 01-11-2015
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[QUOTE=coelom;631258]I think this is B. Non-specific hepatitis points to alpha antitrypsin.



This one is a bit tricky. BUN/Crea ratio is elevated which points to pre-renal azotemia, has high anion gap met acidosis and seems to be in septic shock. I think E /lactate is the answer

[QUOTE=docholly123;630106]
3)
Old woman with severe dementia is brought to the physician because of fever, chills, lethargy, and agitation for 2 days. Her temperature 101F. Examination shows tenderness of the lower abdomen and right costovertebral angle. Laboratory studies show:

Leukocyte count 18,000/mm
Segmented neutrophils 65%
Bands 20%
Lymphocytes 15%

Urine
RBC 20/hpf WBC 50 /hpf
Granular casts Positive
Bacteria few

A) Allergic interstitial nephritis
B) Glomerulonephritis
C) Pyelonephritis
D) Retroperitoneal abscess
E) Tubular necrosis
Quote:
Originally Posted by docholly123 View Post
This is again tricky. But i think granular cast is a sign of tubular necrosis. So E?
1. cant be alpha 1 antitrypsin there's no pulmo history or anyother physical findings.
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