65 yo F had 2 min generalized tonic-clonic seizure that occured when asleep.
PMH: HTN, breast cancer 2 yrs ago s/p lumpectomy, radiation therapy, adjuvant
chemo 1 yr ago. Meds: lisinopril, tamoxifen.Pt is drowsy, not oriented to
person,place,time. BP 160/95. Pulse ox 95%.Exam: right lower face drooping. Eyes
conjugately deviated to left. Briskly withdraws LUE & both LE to noxious stimuli;
there's no movement of RUE. Fingerstick BG 70, serum sodium concentration 130.
CAUSE of seizure? - CORRECT ANSWER-*Brain metastasis* prly from breast cancer
-looks like she got a stroke
strongest predisposing factor for prostate cancer - CORRECT ANSWER-age (old)
32 yo F 6 day f/u for 12 cm lipoma removal from left lateral thigh. For past 2 days,
she had swelling &mild increase in tenderness on and around incision site. Exam
of incision site: bubble-like swelling underneath incision w/o erythema, drainage
or lymphadenopathy. Area is ballotable & fluid wave on palpation.DX? - CORRECT
ANSWER-*Seroma*=pocket of clear serous FLUID -common after surgery
-ballotable means significant effusion
28 yo F G1P1 at 33 wks gestation in active labor. RR 22. Exam: nontender
abdomen. fundal height 36 cm. pelvic ultrasound shows pocket of amniotic fluid
91.5 mm. Underlying cause? - CORRECT ANSWER-*Fetal esophageal atresia* (not
fetal polycystic kidneys)
66 yo Irish American man has SOB on exertion for past 6 months, but now present
when climbing 1 flight of stairs. +Dry cough. Retired 1 yr ago from job in *Stone*
quarry. Exam: finger *Clubbing," end-expiratory crackles. CXR: fibronodular
infiltrate in UPPER LOBES. Dx? - CORRECT ANSWER-*Silicosis*
asbestosis - CORRECT ANSWER--construction & shipyard workers
-20 yrs after initial exposure
,-dyspnea on exertion, cough, chest tightness, wheezing
-chest CT: pulmonary fibrosis
mesothelioma - CORRECT ANSWER-linked to asbestos exposure
-dyspnea, chest pain
-CXR: nodule thickening of pleura and/or obscuring of diaphragm
10 month old girl has 12 hr hx of intermittent colicky pain&vomiting. Dx 1 wk ago
w/otitis media and 10 day course of amoxicillin started at that time. P 168, BP
82/46. Infant is fussy. Observed for 1 hr and d/c home. 12 hrs later, he's again
brought to ED b/c sx have recurred. VS: 99.4F, P 170, RR 42, BP 84/46. Fussy
&Crying. Tympanic membranes are dull but move w/insufflation. Oral exam:
*Swollen gums & erupting teeth.* Skin exam: *1 bruise over right side of
forehead and one on left leg*. Palpable fullness in LUQ. Rectal exam: formed stool
w/mucus that's positive for occult blood. Explanation for condition? - CORRECT
ANSWER-*intussusception*
65 yo F has a 3 month hx of *increasing low back pain*. Had low back pain for
past 3 yrs that's been treated w/NSAIDs and codeine. Now rated as 7/10 in
severity. Pain radiates to both legs, worsens when walking or standing & Relieved
when sitting. 1 YEAR AGO: X ray lumbosacral spine: mild osteoarthritis. Exam: 4/5
mm strength LE, hyporeflexia of knees&ankles b/, unsteady gait b/c of pain. No
other abnormalities. Most appropriate diagnostic study of lumbosacral spine to
order at this time? - CORRECT ANSWER-*MRI*
-prly b/c this pain is worse than the usual pain & neuro sx of hyporeflexia,
decreased mm strength, and unsteady gait
A couple comes to discuss the results of prenatal testing in current pregnancy.
Screening test showed increased risk for having a child w/Down syndrome.
Amniocentesis is suggested for her. Husband asks "When can we schedule the
amniocentesis? I think that we should just get on w/it." Wife responds angrily,
"That's easy for u to say. U haven't been carrying this baby for 4 months & u
haven't felt it move like I have. Appropriate response? - CORRECT ANSWER-"I
, know this is difficult news for both of u. I would like to know what both of u are
thinking now"
3 y.o. boy is at 50th %tile for height&weight. Exam: hemihypertrophy of left side
of body when compared to right. Palpable mass in LLQ. Labs: Hgb 12, Hct 36%,
Urine: SG 1.020, WBC 0-1/hpf, RBC 10-20/hpf. U/S: left kidney mass. Dx? -
CORRECT ANSWER-*Wilms tumor*
-most common RENAL malignancy in kids
-age <5
-*Unilateral, PAINFUL, abdominal mass*
-HTN, hematuria
neuroblastoma - CORRECT ANSWER-most common extracranial solid tumors in
kids
-painLESS abdominal mass
-may have HTN Due to mass compressing renal artery and activating renin-
angiotensin system
-FLUSHING &SWEATING due to catecholamine hypersecretion
-neural crest origin
-involves adrenal medulla, sympathetic chain
-median age <2
-*periorbital ecchymoses(orbital METASTASES)*
-spinal cord compression from epidural invasion("dumbbell tumor")
-opsoclonus-myoclonus syndrome
DX: elevated catecholamine metabolites, small&round blue cells on histology, N-
myc gene amplification
58 year old F has heavy substernal chest pain relieved by nitroglycerin & rest. Pain
occurs w/exertion&accompanied by some SOB&sweating. 6 months ago: CABG.
VSS. ECG: NSR w/*inverted T waves NEW in leads V4-V6.* next step in evaluation
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