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Block 1 part 1
1. 22yo Primi admitted in labor. Pregnancy was complicated by 3 UTIs, the last one at 22 weeks gestation. She’s now taking daily nitrofurantoin. Pt is otherwise healthy. What’s causing the recurrent UTIs?
- Urinary Stasis
2. 4yo boy with 3-day hx of cough, fever, runny nose. No wheezing, vomiting, or diarrhea. 75th %ile for height, and 10th %ile for weight. T 37.5. Cap refill is 2 sec. Exam shows clear rhinorrhea. Breath sounds normal. There is a media tab to view the cardiac exam. Dx?
3. 42yo woman with generalized weakness, lethargy, and double vision for 2 weeks. Chest X-ray shows upper anterior mediastinal mass. Dx?
4. 4mo old brought to ER after an apparent seizure. Pt has vomiting 6 times over the last 2 days, feeding poorly, and sleeping more than usual. Pt is lethargic and afebrile. Anterior fontanel is tense, bilateral retinal hemorrhages. Dx?
- Child abuse
5. 52yo man with excruciating pain/swelling of his great toe since undergoing appendectomy 10 days ago. Celecoxib has provided no relief. Temp is 37.6. Exam shows red/swelling great toe and tender MTP joint. Most appropriate next step?
6. During a sports physical, a healthy 14-yo boy has a BP of 150/90. Previous BP checks have been normal. 6 ft 2 in and weights 180 lb. BMI is 24. Exam is normal otherwise. Most appropriate next step?
- Repeat BP check in 4 weeks
7. 19yo man brought to ER by police after found standing in his neighbor’s living room in the middle of the night. He is conscious but remains mute during questioning. Temp 37C, respirations 18/min, BP 160/95. Exam shows bilateral nystagmus, constricted pupils, hypertonia, and decreased sensation to pinprick. Substance?
8. Officer investigates an outbreak of illness at a picnic. Onset of nausea and vomiting 3 to 4 hours after attending the picnic. All those affected recover without Rx. Egg salad was the vehicle of transmission. What is the factor most commonly contributing to an outbreak of this type?
- Inadequate refrigeration of implicated food
9. 2 days after beginning ACTH therapy for MS, a 47yo woman exhibits bizarre behavior. She is easily angered and thinks the nurses are terrorists. She’s been pulling out her IV and walking down the halls at night. Muscle strength in lower extremities is 2/5. On mental status exam, she is fidgety, labile affect, and is easily distracted. Oriented to person, but not place or time. Most appropriate Rx?
10. 50yo F with 5-year Hx of metastatic breast cancer has SOB for 8 hours. Pulse 116/min, resp 32/min, BP 90/60. End-inspiratory crackles heard at base of both lungs. JVD present. Distant heart sounds. ABG shows: pH 7.50; Pco2 28; Po2 78. XR shows cardiomegaly, ECG shows alternating QRS amplitude patterns. Echo shows paradoximal motion of the interventricular septum and a pericardial effusion. Most appropriate next step?
- Pericardial window.
11. 14 month boy brought in for well-child exam. Mother is worried because he is not yet walking on his own. He will stand for several seconds before falling. He can empty raisins from a cup and tries to eat with a spoon. 25th %ile for length and 30th %ile for weight. Exam shows no abnormalities. Most appropriate next step?
12. Asymptomatic 23yo M in for preemplyoment evaluation. Exam shows normal findings. PPD shows 16 mm of induration & erythema. He has had no previous PPD tests and hasn’t been exposed to anyone with active TB. XR shows no abnormalities. Sputum contains no acid fast bacilli. Most appropriate next step?
- Treat latent TB now
13. Previously healthy 26yo M in ER with SOB for 3 weeks and painful bumps on his legs for 1 week. T 38.2, P 80/min, BP 140/85. Exam shows 2- to 3-cm tender, red nodules on anterior shins. CXR shows bilateral hilar fullness. Which serum abnormalities is most likely in this patient?
- Increased calcium
14. 47yo F with fever, nausea, vomiting, and severe headache for 24 hours. T 39. Exam shows weakness of right upper extremity and nystagmus, optic fundi cannot be visualized. Kernig sign is present. Most appropriate next step in diagnosis?
- CT of head
15. 47yo F brought to ER 30 minutes after a MVC, unrestrained driver. Severe neck pain and mild chest and abdominal pain. P 95/min, Respirations 20/min, and BP 120/80. Exam shows severe tenderness of the cervical spine at C5. Bruise and mild tenderness over lower sternum and upper abdomen. Neuro exam is normal. CXR is normal except for slightly widened mediastinum. Cervical spine XR shows C5 facet fracture. Abdominal XR is normal. Most likely location of the life-threatening cardiovascular injury?
- Thoracic aorta
16. 18yo primi at 37 weeks’ gestation admitted in labor. Regular contractions every 3 minutes. Pregnancy complicated by several episodes of genital herpes, most recent episode 6 weeks ago. No lesions or prodromal symptoms since last episode. Vaginal exam shows no lesions. Membranes are intact. Fetal movement has been appropriate. Cervix 100% effaced, 5cm dilated, vertex at -1 station. Most appropriate next step?
- Amniotomy and vaginal delivery
17. 4yo girl with 5lb weight loss during the last 2 months. No Hx of illness, on no medications, immunizations up to date. 50th %ile for height, 25th %ile for weight. Occasional crackles over right middle lung field. Intradermal testing with PPD, tetanus, and antigens for candida and trichophyton is nonreactive at 72 hours. WBC count is 5100. Nucleic acid hybridization testing of gastric aspirates shows TB. Most likely explanation?
- T lymphocyte dysfunction
18. 27yo F with 5 day history of headache, severe, diffuse abdominal pain, nausea, vomiting. Pain is exacerbated by eating and relieved by vomiting. Vomitus originally had semisolid content with green fluid, and now only contains clear yellow fluid. Hx of Crohn dz treated with prednisone, tapered over the last 2 weeks, mesalamine, and azathioprine. LMP 7 weeks ago. Sex w/ 1 partner, use condoms inconsistently. Temp 38.4, P 120/min, Resp 22/min, BP 90/50. Dry oral mucosa, pale conjunctiva, distended abdomen, diffusely tender and tympanic. Decreased bowel sounds. Pelvic exam is normal. Labs: HCT 31% WBC 15k, amylase 300, lipase 9. Dx?
19. 37yo F with malaise, muscle aches, painful vulvar blisters, vaginal discharge, and dysuria for 3 days. Had sex with new partner 7 days ago. T 38. Exam shows bilateral painful inguinal lymphadenopathy and numerous 1-3 mm vesicles and ulcers on labia majora and minora, perineum, vulva, mons pubis. Next step in diagnosing these lesions?
- Cx for herpes
20. 52yo F with personality change since death of close friend 2 weeks ago. Irritable, less sleep, speaks rapidly, jumping from topic to topic. She’s had past episodes excessive sleeping, decreased energy, and loss of interest, but never thought these symptoms were severe enough to seek medical attention. Mental status exam shows loud, rapid speech, and flight of ideas. She says she is not sad, but rather uplifted by her friend’s death. She hears her friend’s voice and communicates with her. Dx?
- Bipolar d/o
21. 6 hours after CABG, 62yo experiences drop in BP from 120/80 to 100/85. Urine output decreases from 60 to 10 mL/h, and cardiac output decreases from 6 to 3 L/min. Pulmonary artery diastolic pressure has decreased . CXR shows widened mediastinum. Most appropriate next step?
- Surgical exploration of mediastinum
22. Homeless 66yo M with jaundice for 1 week. Eats irregularly, 20lb weight loss, over the past year. 20-year Hx of alcoholism. Icteric sclerae, palmar erythema, and spider angiomata. Serum Mg is 0.8. Serum studies most likely to show?
- Decreased Calcium
23. 24yo F with amenorrhea for 7 days. 8-year Hx of anorexia. Compared to other women her age, she has an increased risk for?