6- match the clinical description with the most likely organism:
a- Strep. Pneumoniae
b- Staph. Aureus
c- Strep. Viridans
d- Providentia stuartii
e- Actinomyces israelii
f- Hemophilus ducreyi
g- Neisseria meningitides
h- Listeria monocytogene
1- 30 y/o female with MVP, MR develops fever, anorexia & weight loss after a dental procedure
2- 80 y/o male hospitalized for hip Fx, has foley cath. in place, develops shaking chills, fever & hypotension.
3- young man develops painless, fluctuant, purplish lesion over mandible, after several weeks cutaneous fistula is noted.
4- sickle cell patient presents with high fever, toxicity signs of pneumonia & stiff neck.
Answers:
1- c, 2- d, 3- e, 4-a
7- 65 y/o male with Hx of DM & cardiomyopathy, presents with severe knee pain. On P/E, knee is swollen, red & tender. Knee X-Ray shows linear clcification.
*** Dx is best made by:
A- Serum uric acid
B- Serum calcium
C- Arthrocentesis & identification of birefringent rhomboid crystals
D- Rheumatoid factor
*** Further workup inthis patient should include evaluation for:
A- Renal dis.
B- Hemochromatosis
C- PUD
D- Lyme dis.
Answers are C & B. Acute monoarticular arthritis in association with linear calcification in the cartilage of knee maqkes the Dx of pseudogout which is positive for birefringent crystals in joint fluid. Pseudogout maybe associated with hemochromatosis.
8- 65 y/o woman with a 12 Hx of symmetric polyarthritis, presents with splenomegaly, ulcers on lat. Malleoli, synovitis of wrists, shoulders and knees, and no hepatomegaly.
Lab results : WBC=2500, RF= 1:4096, this patients WBC diff is most likely to show what ?
A- pancytopenia
B- lymphopenia
C- granulocytopenia
D- lymphocytosis
E- basophilia
Answer is C. case of felty's syn. ( RA+ splenomegaly+ leukopenia ), the mech. Of granulocytopenia is poorly understood.
9- A patient with low grade fever & weight loss has poor excursion on the Rt. side of chest with decreased fremitus, flatness to percussion and decreased breath sounds. Trachea is deviated to the Lt. What's the most likely Dx?
A- Pneumothorax
B- Pleural effusion secondary to histoplasmosis
C- Consolidated pneumonia
D- Atelectasis
Answer is B. Physical findings all consistent with pleural effusion, which in large amount can shift trachea to the Lt. in pneumothorax hyperresonance of the affected side is present. Atelectasis on the Rt would shift trachea to the Rt.
10- A patient have an unexpected high value for diffusing capacity, this finding is most consistent with which of the ffg?
A- Anemia
B- Cystic fibrosis
C- Emphysema
D- Intrapulmonary hemorrhage
Answer is D. Decreased diffusing capacity is seen in: primary parenchymal disorder, anemia & removal of lung tissue.
Increased value is seen in : polycythemia, CHF & intrapulmonary hemorrhage.
11- A 65 y/o man is admitted to the hospital with anginal chest pain. His general health has been excellent, although he has had a multinodular goiter for many years. He had a series of thyroid function tests 4 weeks before admission, and the results are :
Serum T4 8.0 µg/dL
Free T4 index 8.0
Serum T3 152 ng/dL
Serum thyrotropin (TSH) 0.7 µU/mL
A MI is ruled out, but chest pain continues. A coronary arteriogram shows a 90% stenosis of the left main coronary artery. A coronary artery bypass graft is done. The patient has an uneventful postoperative course and is discharged on the seventh postoperative day. One month later, he is readmitted in atrial fibrillation with a rapid ventricular response. Repeat thyroid function testing shows the following:
Serum T4 15.0 µg/dL
Free T4 index 15.8
Serum T3 220 ng/dL
Serum TSH <0.01 mU/µL
What is the most likely Dx?
A. Graves' disease
B. Stress-induced hyperthyroidism
C. Iodine-induced hyperthyroidism
D. Silent thyroiditis
Answer is C. The natural history of multinodular goiters is slow growth and gradual decrease in thyrotropin (TSH), reflecting increasing thyroid hormone production. This progression occurs over years to decades, however. Many patients with multinodular goiters have autonomous areas within their thyroid. This patient had normal thyroid function 1 month before admission. However, his serum TSH level was near the lower limits of normal, suggesting the possibility of autonomous thyroid function.
When patients with multinodular goiters are exposed to excess iodine, severe hyperthyroidism may occur. This is known as iodine-induced hyperthyroidism or the Jod-Basedow phenomenon. When iodine supplementation is introduced into areas of iodine deficiency, iodine-induced hyperthyroidism may occur in patients with multinodular goiters. Iodine-induced hyperthyroidism may occur in nonendemic goiter areas as well, often with devastating consequences.
The high iodine content of the dye used for the cardiac catheterization undoubtedly precipitated the hyperthyroidism in this patient. The onset of hyperthyroidism may be delayed for several weeks to months after the iodide exposure.
Although other causes of hyperthyroidism are possible, none is as likely as this scenario. When patients with multinodular goiter must be exposed to excess iodine (for example, during cardiac catheterization, computed tomographic [CT] scan with contrast medium, or amiodarone therapy), premedication with antithyroid drugs (methimazole or propylthiouracil) should be considered.
12- A 43 y/o woman complains of itching that keeps her awake at night. Physical examination is normal, except for the liver, which is felt 7 cm below the right costal margin.The blood count is normal; the results of serum chemistry tests are as follows:
• Creatinine 0.8 mg/dL
• Bilirubin 0.6 mg/dL
• Alanine aminotransferase 78 U/L
• Albumin 4.2 g/dL
• Alkaline phosphatase 450 U/L
Which test would you order next in order to diagnose the underlying disorder?
(A) Serum protein electrophoresis
(B) Anti¬smooth-muscle antibody
(C) Antimitochondrial antibody
(D) Technetium-99m liver-spleen scan
(E) ERCP
Answer is C. This is the classic description of primary biliary cirrhosis. Itching is the most common specific symptom of early primary biliary cirrhosis. Approximately 70% of affected patients have enlarged livers. The best screening test for suspected primary biliary cirrhosis is the antimitochondrial antibody test. It is positive in 95% of affected patients and has a 98% specificity if newer enzyme-linked immunosorbent assay (ELISA) tests are used. Serum protein electrophoresis might show a diffuse increase in immunoglobulins. However, this finding is nonspecific and may be found in many chronic liver diseases. Anti¬smooth-muscle antibody tests are positive in some patients with autoimmune chronic hepatitis. However, the test is nonspecific and not terribly useful. The sulfur colloid technetium liver-spleen scan is useful for detecting portal hypertension and hypersplenism. However, it is not specific and would not be helpful in diagnosing primary biliary cirrhosis. Endoscopic retrograde cholangiopancreatography (ERCP) is typically normal in patients with primary biliary cirrhosis. Its only role in the diagnosis of primary biliary cirrhosis is in the patient who presents with a similar syndrome but who has a negative antimitochondrial antibody test. ERCP would then be performed to look for other causes of disease such as primary sclerosing cholangitis.
a- Strep. Pneumoniae
b- Staph. Aureus
c- Strep. Viridans
d- Providentia stuartii
e- Actinomyces israelii
f- Hemophilus ducreyi
g- Neisseria meningitides
h- Listeria monocytogene
1- 30 y/o female with MVP, MR develops fever, anorexia & weight loss after a dental procedure
2- 80 y/o male hospitalized for hip Fx, has foley cath. in place, develops shaking chills, fever & hypotension.
3- young man develops painless, fluctuant, purplish lesion over mandible, after several weeks cutaneous fistula is noted.
4- sickle cell patient presents with high fever, toxicity signs of pneumonia & stiff neck.
Answers:
1- c, 2- d, 3- e, 4-a
7- 65 y/o male with Hx of DM & cardiomyopathy, presents with severe knee pain. On P/E, knee is swollen, red & tender. Knee X-Ray shows linear clcification.
*** Dx is best made by:
A- Serum uric acid
B- Serum calcium
C- Arthrocentesis & identification of birefringent rhomboid crystals
D- Rheumatoid factor
*** Further workup inthis patient should include evaluation for:
A- Renal dis.
B- Hemochromatosis
C- PUD
D- Lyme dis.
Answers are C & B. Acute monoarticular arthritis in association with linear calcification in the cartilage of knee maqkes the Dx of pseudogout which is positive for birefringent crystals in joint fluid. Pseudogout maybe associated with hemochromatosis.
8- 65 y/o woman with a 12 Hx of symmetric polyarthritis, presents with splenomegaly, ulcers on lat. Malleoli, synovitis of wrists, shoulders and knees, and no hepatomegaly.
Lab results : WBC=2500, RF= 1:4096, this patients WBC diff is most likely to show what ?
A- pancytopenia
B- lymphopenia
C- granulocytopenia
D- lymphocytosis
E- basophilia
Answer is C. case of felty's syn. ( RA+ splenomegaly+ leukopenia ), the mech. Of granulocytopenia is poorly understood.
9- A patient with low grade fever & weight loss has poor excursion on the Rt. side of chest with decreased fremitus, flatness to percussion and decreased breath sounds. Trachea is deviated to the Lt. What's the most likely Dx?
A- Pneumothorax
B- Pleural effusion secondary to histoplasmosis
C- Consolidated pneumonia
D- Atelectasis
Answer is B. Physical findings all consistent with pleural effusion, which in large amount can shift trachea to the Lt. in pneumothorax hyperresonance of the affected side is present. Atelectasis on the Rt would shift trachea to the Rt.
10- A patient have an unexpected high value for diffusing capacity, this finding is most consistent with which of the ffg?
A- Anemia
B- Cystic fibrosis
C- Emphysema
D- Intrapulmonary hemorrhage
Answer is D. Decreased diffusing capacity is seen in: primary parenchymal disorder, anemia & removal of lung tissue.
Increased value is seen in : polycythemia, CHF & intrapulmonary hemorrhage.
11- A 65 y/o man is admitted to the hospital with anginal chest pain. His general health has been excellent, although he has had a multinodular goiter for many years. He had a series of thyroid function tests 4 weeks before admission, and the results are :
Serum T4 8.0 µg/dL
Free T4 index 8.0
Serum T3 152 ng/dL
Serum thyrotropin (TSH) 0.7 µU/mL
A MI is ruled out, but chest pain continues. A coronary arteriogram shows a 90% stenosis of the left main coronary artery. A coronary artery bypass graft is done. The patient has an uneventful postoperative course and is discharged on the seventh postoperative day. One month later, he is readmitted in atrial fibrillation with a rapid ventricular response. Repeat thyroid function testing shows the following:
Serum T4 15.0 µg/dL
Free T4 index 15.8
Serum T3 220 ng/dL
Serum TSH <0.01 mU/µL
What is the most likely Dx?
A. Graves' disease
B. Stress-induced hyperthyroidism
C. Iodine-induced hyperthyroidism
D. Silent thyroiditis
Answer is C. The natural history of multinodular goiters is slow growth and gradual decrease in thyrotropin (TSH), reflecting increasing thyroid hormone production. This progression occurs over years to decades, however. Many patients with multinodular goiters have autonomous areas within their thyroid. This patient had normal thyroid function 1 month before admission. However, his serum TSH level was near the lower limits of normal, suggesting the possibility of autonomous thyroid function.
When patients with multinodular goiters are exposed to excess iodine, severe hyperthyroidism may occur. This is known as iodine-induced hyperthyroidism or the Jod-Basedow phenomenon. When iodine supplementation is introduced into areas of iodine deficiency, iodine-induced hyperthyroidism may occur in patients with multinodular goiters. Iodine-induced hyperthyroidism may occur in nonendemic goiter areas as well, often with devastating consequences.
The high iodine content of the dye used for the cardiac catheterization undoubtedly precipitated the hyperthyroidism in this patient. The onset of hyperthyroidism may be delayed for several weeks to months after the iodide exposure.
Although other causes of hyperthyroidism are possible, none is as likely as this scenario. When patients with multinodular goiter must be exposed to excess iodine (for example, during cardiac catheterization, computed tomographic [CT] scan with contrast medium, or amiodarone therapy), premedication with antithyroid drugs (methimazole or propylthiouracil) should be considered.
12- A 43 y/o woman complains of itching that keeps her awake at night. Physical examination is normal, except for the liver, which is felt 7 cm below the right costal margin.The blood count is normal; the results of serum chemistry tests are as follows:
• Creatinine 0.8 mg/dL
• Bilirubin 0.6 mg/dL
• Alanine aminotransferase 78 U/L
• Albumin 4.2 g/dL
• Alkaline phosphatase 450 U/L
Which test would you order next in order to diagnose the underlying disorder?
(A) Serum protein electrophoresis
(B) Anti¬smooth-muscle antibody
(C) Antimitochondrial antibody
(D) Technetium-99m liver-spleen scan
(E) ERCP
Answer is C. This is the classic description of primary biliary cirrhosis. Itching is the most common specific symptom of early primary biliary cirrhosis. Approximately 70% of affected patients have enlarged livers. The best screening test for suspected primary biliary cirrhosis is the antimitochondrial antibody test. It is positive in 95% of affected patients and has a 98% specificity if newer enzyme-linked immunosorbent assay (ELISA) tests are used. Serum protein electrophoresis might show a diffuse increase in immunoglobulins. However, this finding is nonspecific and may be found in many chronic liver diseases. Anti¬smooth-muscle antibody tests are positive in some patients with autoimmune chronic hepatitis. However, the test is nonspecific and not terribly useful. The sulfur colloid technetium liver-spleen scan is useful for detecting portal hypertension and hypersplenism. However, it is not specific and would not be helpful in diagnosing primary biliary cirrhosis. Endoscopic retrograde cholangiopancreatography (ERCP) is typically normal in patients with primary biliary cirrhosis. Its only role in the diagnosis of primary biliary cirrhosis is in the patient who presents with a similar syndrome but who has a negative antimitochondrial antibody test. ERCP would then be performed to look for other causes of disease such as primary sclerosing cholangitis.