20 Cases note.pdf

8/10/2019 20 Cases note.pdf

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20 Cases note

this note is only a summary for Kaplan USMLE Comprehensive Cases By Dr.Conrad Fischer MD

summarized by Dr Araki USMLE . Sudan

Best way to use this note is to print it and study it along with the Videos , also add your tips

if you dont have 30 hour to watch the Videos , u can read it and google the Mediagood luck

01 - Mitral Stenosis

All MS about this case

young female wt Hx of Rheumatic fever

case 1

m c valvular lesion ? (Mitral stenosis)

case 2m likely risk factor ? ( immigrant)

case 3

what m likely make her seek medical attention ? ( pregnancy) preg increase plasma volume

case 4

witch murmur ? ( rumbling med diastolic murmur) plzz try to hear it

case 5

witch will increase the intensity of murmur ? ( leg rising)

increase (squatting / leg rising / expiration)

decrease (standing /valsalva / inspiration )

no effect with hang grip and amylnitrate

case 6

mechanism of hemoptysis ? ( pulmonary HT)

case 7

m likely found on P Ex ? ( dysphagia) Lt atrium hypertrophy

case 8

what expected to be on Swan Ganz cath ( low : CO . high : Wedge/SVR/PA)

case 9

what auscultatory founding indicate worsening ? ( shortening duration btw the S2 to op snap )

case 10

witch ECG ? ( A fib) irregular irregular rhythm

case 11

m accurate test ( Cardiac Cath) initial Echo

case 12

m likely seen on X ray ? ( straining of Lt heart border Lt mean bronchus pushed up)

case 13

best initial Rx ? ( Furosemide)

case 14

same case developed palpitation , best initial Rx ( ECG show A fib ) ? ( Digoxin )

if not there BB or CCB

case 15

pt get worse what Next ? ( Balloon vavuloplasty)


2/25

02 - Coagulation Disorders

case 1

young female wt epistaxis ( pic show petechiae on the lower limb )

first test to do ? ( platelet count)

case 2

same pt , only evil on lab was platelet count 17,000 , m likely to be found ? ( Purpura) on pic

case 3

with drug can induce that ( Amoxicillin)

penicillin / sulfa drug / rifampin / allopurinol / quinidin / lamotrigin

case ( Hemolysis / thrombocytopenia / AIN / SJS / TEN )

case 4

NS in management ? ( Steroid)

case 5

m likely be found ? ( Megakaryocytes) on pic

case 6

m likely diagnosis ? ( I T P )case 7

same pt treated and come after 2 month with melena

most effective NS ? ( IV IG ) for the bleeding on GI or Brain

case 8

new case wt epistaxis and petechiae , 2 day after starting a new drug , normal platelet , PTT high

m likely diagnosis ? ( VW D)

case 9

most likely precipitate this ? ( Aspirin)

case 10

best initial test ( Bleeding Time)case 11

same case BT prolonged , best NS to confirm diagnosis ( factor VIII antigen) just anther name for VW

case 12

BN Rx ? ( Desmopressin DDAVP)

case 13

new case , 8 y fall and presented after 2 week wt swallowing warm knee (there is a pic)

m likely diagnosis ( Hemophilia A) more common the H B

case 14

initial test ? ( PTT)

case 15same pt has prolonged PTT NS ? ( Mixing study)

case 16

m accurate test ? ( factor VIII level)

case17

why the bleeding is delayed ? ( primary plug is with pletelet) so it go away soon

case 18

NZ Rx ? ( factor VIII ) if mild Desmopressin DDAVP

case 19

new case 48 y female come wt fever , flank pain , hypotesive , tachycardic , +iv heam occult blood ,

Hematuria , prolonged PT/PTT

what expected on lap ? ( low pletelet) m likely DIC

case 20

m accurate test ? ( D-dimer) or fibrin split product

case 21


3/25

same pt platelet r low , NS ? ( FFP and platelet )

case 22

old man wt Hx of igA nephropathy have rise Cr and oozes Blood on central line , lap normal

m likely diagnoses ? ( Acquired storage pool disorder) from uremia

case 23

NS Rx ? (Desmopressin DDAVP) then dialysis

case 24

truck driver presented wt sudden SOB , u start hem on Heparin/Warfarin after 3 day platelet dropDiagnosis ? ( Heparin induce thrombocytopenia )

case 25

Rx NS ? ( switch to argatroban) it is direct acting thrombin inhibitor

case 26

m accurate test ? ( platelet factor 4 antibodies)

case 27

9 y boy wt fatigue , diarrhea , Cr 2.8 / BUN 34 ,HTC 29% , platelet low , normal PT/PTT , ( pic show

Jaundice )

m likely diagnosis ? ( HUS)

case 28

m likely etiology ( Shigella) m c E coli O157,H7 not on the answer

case 29

what the mechanism ? ( decrease ADAMTS 13)

case 30

m likely to be found ? ( normal PT/PTT)

case 31

Rx NS ? ( FFP Plasma exchange) if mild no Rx

case 32

what drug can cause this ? ( Clopidogrel) also Ticlopopidin


4/25

03 Sarcoidosis

case 1

African American wt SOB for weeks , misdiagnose with asthma , and she have fatigue , wt loss

m likely diagnosis ? ( Sarcoidosis )

case 2

m likely finding ? ( skin lesion)

bilateral facial palsy only on Lyme and sarcoidosis

case 3

m likely found on this pt ? ( lupus pernio ) on pic , it is mc skin finding do biopsy , Rx steroid

case 4

lung auscultation finding ? ( fine rales/crepitation/crackles ) on media , sign for consolidation

case 5

another media ? (fine rales/crepitation/crackles )

case 6

video show facial palsy ? ( VII CN) , not like stork , on sarcoidosis both upper and lower half of the face

affectedcase 7

if it involve the heart , what u expect to see ? ( 3ed degree heart block ) effect conduction

case 8

many ECG ? ( chose the one show 3ed degree heart block )

case 9

many CXR ? (chose the one show bilateral Hilar adenopathy )

case 10

m likely seen on LAP ? ( high ACE level) more common than high Ca

case 11

m accurate test ? ( LN biopsy)case 12

m likely seen on biopsy ? ( non-caseating Granuloma) with pic

case 13

Rx ? ( steroid)

case 14

drug should be avoided ? ( Interferon) bcoz it make granuloma

TNF make granuloma and TNF inhibiter open it (bad for TB coz it is infection , but for sarcoidosis not bad )

case 15

pic show reddish brown lesion on legs ? ( erythema nodosum) use to determine who is getting worse

case 16m likely prognosis ? ( spontaneous resolution in 80%)

case 17

mechanism of hyperCa ? ( increase Vit D synthesis by macrophages )

case 18

strongest indication of treatment ? ( Uveitis) , yes it is not the bilateral hilar adenopathy o_O


5/25

04 Graves Disease

case 1

young female wt palpitation , sweting , weight loss , anxiety , BP 144/90 , Puls 112

m likely diagnosis ? ( Hyperthyroidism)

case 2

m likely ass wt this finding , pic of Exophthalmoses ? ( Graves D) mucopolysacharide deposit behind eye

can cause corneal ulcer bcoz it cant closed

case 3

m c finding ? ( pretibial myxedema) only wt graves D

case 4

new case , he toke the last one and add , pt has thyroid tenderness

what is m likely diagnosis ? ( subacute thyroditis) dont confuse it wt SILENT thyroiditis ()

case 5

back to graves D ,expected on thyroid profile ? ( TSH low , T4 ^ , RAIU ) if all ^ it is TSH producing

tumor

case 6ECG ? ( chose the one show Afib) dont be fowled wt ECG show Multi Focal AT

case 7

first case young female wt palpitation , sweting , weight loss , anxiety , BP 144/90 , Puls 112

m accurate diagnostic test ? ( RAIU)

case 8

best initial therapy ? ( Propylthiouracil PTU) or methemazol

case 9

m c SE of that drug ? ( neutripenia) both drug can cause it

case 10

ECG show rapid A fib , Rx ? ( Propranolol)case 11

new case 1 y wt pic of ( cretinism ) , mother have Hypothyroidism but not adherent to medication

mechanism of feature on this pt ? ( T4 essential for CNS growth)

brain/uterus/gonads , dose not depend on T4 for metabolic rate

case 12

new case , 48 female wt thyroid nodule

NS ? ( TSH / T4) if normal Biopsy , if high RAUI

case 13

biopsy show follicular adenoma , NS ? ( Excisional biopsy) have malignant potential

case 14new case , old female , 1.5 nodule on the neck , TSH/T4 normal , FNA show medullary Ca

NS ? ( plasma and urine catecholamine) ass wt MEN so plzz exclude Pheocromocytoma first

if u Operate without that , u may be Kill pt ( hypertensive crisis ) o_O

case 15

new case old female Dx wt Hypothyroidism , she have HT , DM , hyperlipidemea , u start Levothyroxine

m dangerous complication ? ( M I) suddenly increase metabolic rate


6/25

05 - Myasthenia Gravis

case 1

young man , wt double vision get worse through day , cant finish his meals

m likely diagnosis ? (Myasthenia Gravis) m c affect ocular muscle and masseters muscle ( eating TV )

case 2

m likely found ? ( Ptosis) on pic

case 3

best initial test ? ( Acetylcholine receptor antibody) it is not tensilon (edrophonium) test

case 4

m accurate test ? ( Electromyogram)

case 5

best initial therapy ? ( Pyridostigmin) acetylcholine esterase inhibiter

SE , salivation , lacrimation , Diarrhea

case 6

drug wore the condition ? ( Aminoglycoside / Gentamicin)case 7

same case worse , unable to walk (Myasthenia crisis )

m likely cause of death ? ( Respiratory failure) Myasthenia Gravis spare the heart

case 8

best initial Rx ? ( IV IG) or plasmaphesesis , dont combine them

MG/GB/good paster/TTP : plasmapheresis

case 9

new case young man wt MG manage wt pyridostigmin , maximam doses , he decrease response to

medication

most important imaging study ? ( Chest CT) if pt under 60 remove thymusMIBG for occult pheochromocytoma

case 10

CXR ? ( chose the one show ant mediastinal mass)

case 11

same case but he chanre age is 75

what to do ? ( Prednisone)


7/25

06 Meningitis

case1

42 y man wt fever , headache , neck stiffness , photophobiam likely diagnosis ? ( Meningitis)

naeglaria fowelri

case 2

NS ? ( Lumber Puncture) if there is focal/sever confusion do CT ( any delay to LP give Ax )

case 3

pic of papillodema , what to do next ? ( Cetriaxon/Vancomycin ) there is a delay to LP

case 4

where u but the needle on LP ? ( Subarachnoid space) under Dura and above Pia

case 5

new case pt has meningitis and focal , u give Ax prior to LP , now gram stain is ve , u suspect bacterialbcoz there is high neutrophil on LP

witch of the following u can use to detect the etiology ? ( bacterial antigen detection by latex

agglutination)

sensitive like gram stain, but not specific

case 6

new case CSF show 2,700 WBCs , wt 90% neutrophil best Rx ? ( Cetriaxon/Vancomycin/Steroid )

case 7

m accurate test ? ( CSF Culter)

case 8

m likely organism ? ( pneunococcus) on pic ( G+ve diplococcic )case 9

what the indication of intrathecal Ax ? ( Ommaya reservoir infection / intraventricular cath)

case 10

m effective thereby for old / alcoholic / COPD / pt on steroid ? ( Add Ampicillin) for Lsteria

case 11

pt has Gram+ve cocci on cluster ( staph ) m likely to have this bug ? (ventriculoperitoneal shunt /

neurosurgury)

case 12

pt wt meningitis had ventriculoperitoneal shunt 1week ago Rx ? ( Ceftriaxon/Vancomycin)

case 13

pt wt meningitis , HIV and CD 4 45 ? ( Voriconazole ) it is Cryptococcus 1stline Ampho B

Voriconazole . SE : transient ocular problem

case 14

military recruit living in barracks come wt meningitis , Rx ? ( Ceftriaxon/Vancomycin) N,meningitides

m c risk factor for N,meningitides inf ( Asplenia )

case 15

same pt witch rash u expect ? ( chose the one show petechiae) on pic

case 16

same case the pt has girl friend she on OCP , what Next ? ( Ciprofloxacin) Rifambin also but it is relative

contraindication with OCP


8/25

07 Atherosclerosis

case 1

52 y old man come wt chest pain off and on fore the past week , wt and wtout exertion , pain is behindsternum , crushing /squeezing pain , he has HT , DM , hyperlipidemea

m c risk factor ? ( HT) worst risk factor ( DM)

case 2

witch of the following exclude CAD ? ( chest wall tenderness) - 95% NPV enough for CK

also change wt positing or breathing

case 3

NS ? ( E C G)

case 4

he show u ECG ? ( Normal)

case 5back to case , what next ? ( stress test) Hx of chest pain and ECG normal

case 6

Now if ECG ( show slight t wave and ST depression on V 4/5/6 ) , what Nx ? ( stress echo ) or stress

thallium

u cant read the ECG if there Baseline abnormality

case 7

if stress test show ischemia what next ? ( Aspirin)

case 8

new case , 44 female wt intermitting chest pain for month no risk factor , ECG wt ST elevation . C Enz -ve

what m likely be found on angiogram ? ( abnormality only when give ergonovine) induce coronaryspasm

menstruating female can't have CAD period , so think prinzmetal angina

case 9

new case CAD pt on sildenafil , HCZ , statin , buproprion , fluoxetin , he should start Aspirine , Nitrate , BB

wetch side effect is expected ? ( Hypotension) sildenafil + Nitrate = DEATH

case 10

new case wt typical chest pain and ECG show anterior MI ? ( chose ECG shoe ST elevation on V234)

case 11

initial step in management ? ( Aspirin)

case 12

m likely found on gross pathology autopsy ( chose the pic show white fibrosis btw myocardium of

ventricle)

case 13

new case , old pt has HT , DM , Hyperlipidemea , LDL 60

m likely useful for pt ? ( ACE inhibitor) bcoz he DM+HT

case 14

68 y pt come to ED wt typical chest pain for an hour , ECG show anterior MI wt ST elevation

m likely to detect in this pt ? ( Myoglobin) Troponin/CK-MB take 4 - 6 hour

case 15

Aspirin what Nx ? ( Angioplasty) greatest mortality benefit for ST elevation

case 16

strongest indication of thrombolytic ? ( ST elevation or new Lt BBB within 12 hour)

case 17

same pt , after 5 day return wt chest pain , what Nx ? ( CK-MB) for reinfarction bcoz it normalized on 2-3


9/25

day

Troponin stay high for 2 weeks

case 18

m c cause of erectile dysfunction on postMI pt ? ( Anxiety) , yes ,far more than BB

case 19

new case 68 pt wt typical chest pain fore 1 hour , aspirin is given and there is an ECG show ST depression

on V345

best next step ? ( Enoxaparin) , dont panic it is Heparincase 20

pt is planned to Cath , best next step ? ( Tirofiban) or abciximab or eptifibatide it is glycoprotein IIb/IIIa

inhipeter

or u can use clopedogril

08 - Multiple Myeloma

case 1

57 old woman wt pain in Rt flank , she feel pop and pain ass wt coughing and roll over her bed , she has Hx

of vertebral compress fracture

m likely diagnosis ? ( M M)

case 2

m likely found on CXR ? ( chose the one show multiple lytic lesion) don't be fowled by vertebral

compress fracture

case 3

next best diagnostic test ? ( serum protein electrophoresis) M spik wt IgG (mean one type)

case 4image of electrophoresis ? ( chose one have tow spik on albumin and on gama range)

spike on first and last (M shape) , Monoclonal spik

WARNING , M spike dose not mean IgM

case 5

m likely be found on preph smear ? ( chose the one show rouleaux formation) RBCs stuck to each

other

case 6

m accyrate test ? ( BM biopsy) 30 % plasma cell diagnostic as a single finding

when u combine it wt lytic lesion and monoclonal spik u only need 10 % to diagnose MM

case 7

Technetium bone scan done what u expect ? ( normal ) MM only lytic activity , B scan only detect plastic

activity

case 8

same pt no SOB/confusion/visual disturbance , how u explain absence of hypervescusity ? ( never - IgG is

small)

case 9

best initial Rx ? ( Steroid / Thalidomide)

case 10

her disease controled wt Rx , what next ? ( autologous stem cell trans )

case 11

m c cause of death in MM ? ( infection)


10/25

09 Diabetes

case 1

58 y man come for routine exam , he has HT , obese , smokingappropriate screening test ? ( Diabetes screening )

case 2

appropriate type of screening test ? ( 2 fasting Glucose above 126) or (RBG ^200 wt Symptom) or

(OGTT)

case 3

Fasting B G is 180 and 170 , m likely etiology ? ( decrease number of receptor) = preph insulin resistant

( type 2 )

case 4

best initial Rx ? ( Metformin) but first trial of life style modification , 25% controled Diet / exercise

Metformin : ( only block gluconeugenisis ) no weight gain , no hypoglycemiacase 5

if despite weight loss and metformin , FBG stay 150 , what adverse effect expected ? ( lactic acidosis)

alpha glucosidase inhibiter ( acrabose / meglitol) : Diarrhea ,flatus

sulphonylureas and natiglenide : hypoglycemia sulphonylureas : can give SIADH

Glitazones ( rosiglitazone / pioglitazone ) : exacerbation of CHF and fluid overload

case 6

contraindication to metformin ? ( Renal insufficiency) metformin accumulate

case 7

witch the best drug to control HT in this pt ? ( ACE inh) protect the Kidney , best for HT/DM

case 8

target BP on Diabetic pt ? ( 130/80 mmHg) v H/Y

case 9

LDL 134 , what Nx ? (Statin) lower mortality , treat DM like CAD , so LDL ^100 get Rx

case 10

m c SE of statin ? ( ^transaminase ) ^liver enz , and YES it is NOT myositis

case 11

what u do to monitor compliance ? ( Hg A1C)

case 12

on PE his BP 135/87 mmHg , all LAP is normal , most appropriate action ? ( Microalbumin level)

case 13

on PE his BP 135/87 mmHg , BUN 18 and creatinine 1 despite ACE inh the creatinine 2.2witch of the following lesion is present ? ( Kimmelstiel Wilson ) it is unique lesion for Diabetic

nephropathy

look to biopsy pic of this

case 14

60 y man with uncontrolled DM for 10 y , he show u many endoscopy pic

witch m likely found ? ( chose the one show extra blood vessels/neuvascularization) see some pics

plz

case 15

A 25 y G2Pa women in he 2ed trimester present pr prenatal checkup ,

witch test should be done to this pt ? ( Oral GTT)case 16

he show u a big ulcer in a foot and ask about etiology ? ( Neuropathy)

case 17


11/25

60 y man with uncontrolled DM for 15 y , present with GI disturbance bloating , constipation ,

witch of the following is the best initial management to this pt ? ( Erythromycin) it is Gastroparesis

also u can use Metachlopramid

case 18

65 yrs man present with weakness , fatigue , confusion . Na 135 mEq/L , K 4.6 mEq/L Cl 100 mEq/L

bicarbonate 12 mEq/L glucose 450 , Which physical finding ? ( Mucormycosis)

case 19

Best initial treatment for pt ? ( Amphotericin)case 20

Most common adverse effect of treatment ? ( metabolic acidosis)

case 21

Pt placed on Amphotericin Bmost important next step ? ( surgical debridement)

case 22

48 yrs woman with sever type 2 DM maintained on glargine , aspart present with headache and fever .

glucose 270 mg/dl , bicarbonate 20mE/L . CT of head was done

Most likely diagnosis ? ( malignant otitis media)

case 23

Organism is responsible ? ( pseudomonas)

case 24

Best therapy ? ( Piperacillin / Tazobactam)

case 25

30 yrs woman with type 1 DM . experience lightheadness and headache . her glucose show :

8am 248 , 12noon 150 , 6pm 120 , 10pm 140 her HbA1c 6.5%

the mechanism ? ( increase epinephrine and glucagon)

case 26

23 yrs history of type 1 DM present with weakness , lightheadness , dyspnea and confusion . PR =125

BP= 92/62 RR=32 Blood glucose = 300

witch Led to this problem ? ( infection)

case 27

Physical examination finding ? ( kussmaul's breathing)

case 28

Lab value indication of severity ? ( serum bicarbonate)

case 29

Best initial therapy ? ( bolus of normal salin)

case 30

Mechanism of hyperkalemia ? ( increase entry of hydrogen ions to the cell)

case 31

Respiratory effect similar to ? ( carbon monoxide)

case 32Most likely to be found ? ( metabolic acidosis + hyperkalemia)

case 33

Relation among electrolytes ? ( increase glucose , decrease sodium)

case 34

Explain of blood pressure ? ( osmotic dieresis)

case 35

Pt present with DKA glucose = 450 in past half hour the glucose dropped to 100 . she switched to 5%

dextrose in half NS , Adverse effect of therapy ? ( seizures)

case 36

Mechanism of adverse effect ? ( shift of water into cells)


12/25

10 Pneumonia

case 1

67 y male with productive couph , fever , he has Hx of COPD , HT , smoking , Puls 105 , BP 105/70 , RR

32

m likely organism , show u pic with G+ve cocci ? ( Strep)

case 2

Next step in management ? ( Pulse Oxemetry) , NOT CXR (not predict severity), pt may die from

Hypoxia if sever,

then give Abx , then pneumovac and Stop Smoking on discharge

case 3

Next step ? ( IV Ceftriaxon / Azithromycin) , for out pt Macrolide , Quinolones ( not Cipro )

admission according to severity ( ch pain , SOB , Hypotension , Confusion , Hyponatremia )

case 4new case , 27 y male , with recurrent episodes of sinus and pulmonary inf witch required hospitalization

He has normal LN and Tonsil , Normal count of B and T cell , normal urine analysis

M likely diagnosis ? ( Common variable immunodeficiency )

case 5

m accurate test ? ( Serum protein electrophoresis SPEP)

case 6

witch best Rx ? ( I V I G)

case 7

pt has recent viral infection , witch organism does predispose to ? ( Staph)

case 854y male alcoholic has pneumonia , what m c organism ? ( Strep pneumonia) o_O , YEP NOT Klepseilla

, it is ass with Alcoholic but not the m c

Hospital accuared/Ventilator (G-ve rode) : E coli , enterobacter , Citrobacter, Morganella , pseudomonas ,

Serratia

Legionella with old / immunodeficint , ass with GI and CNS , S/S

case 9

new case 82 y female , in home lyinf flat secondary to immobility , she has dehydration and alter mantal

status m she developed a new fever and ^^^RR , CXR done

witch m likely location of the pneumonia ? ( Rt upper lobe ) if setting upright , aspiration to Rt lower lobe

case 10m c organism ? ( Anaerobes)

case 11

67 y male with productive couph , fever , he has Hx of COPD , HT , smoking , Puls 98 , BP 120/80 , RR 14

m likely be found , he play weird sound ? ( Egophony) try to hear it

case 12

Treatment of choice ? ( Azethromycin)

case 13

24 y female with her husband go to Dominican Republic in honeymoon , 2 day later both developed couph

with CXR show resolving infiltration despite Abx , m likely organism ? ( Strongyloides )

case 14

same case , show pic of Strongyloides , SO plzz see a pic of this organism @

case 15

Rx ? ( Ivermectine)

case 16


13/25


14/25

11 CHF

case 1

68 y female presented to ER with SOB for last few h , when she lies flat SOB increase , she need 3 pillows

to sleep , on PE : RR 28 , Puls 112 , ^JVD , peripheral edema and rales to he apices

m likely diagnosis ? ( Pulmonary edema)

case 2

next best step ? ( Oxygen) NOT Echo , NOT CXR

case 3

witch expected in this pt , murmurs' ? ( S3 gallop) listen to that plz

case 4

witch expected CXR in this pt ? ( chose the one show vascular congestion/pulm edema)

case 5witch make the biggest different in acute management ? ( E C G)

Arrhythmia can change it ( Cardioversion )

case 6

ECG m likely is this pt ? ( chose the one show Atrial flutter ) ass with decompensated CHF

case 7

m likely show on Cath ? ( ^ wedge/Rt A pressure . low COP . ^ SVR)

case 8

best initial Rx ? ( Furosemide) preload reduction

case 9

mechanism of the benefit of Morphine in pulmonary edema ? ( Dilate pulmonary vein) I know u thought itis for pain . but they r not in pain SMARTY

case 10

mechanism of effect of Nitroglycerin ? ( Arterial dilation greater than venous ) bcoz vein r larger than

artery the relative dilation more in veins . So open up venous capacitance vessels will make Blood go

backward from the heart

case 11

witch would Nesiritide be a substitute for? ( Nitrates) synthetic ANP

case 12

new case 56 y man with Hx of COPD , MI , HT , presents to ER with sever SOB , PE show rales and some

peripheral edema , CXR is unreadable ?best initial diagnostic test ? ( Brain Natriuretic Peptide BNP)

case 13

pt has ^BNP , what is the most accurate test for Ejection fraction ? ( MUGA) Nuclear Venticulography

case 14

witch drug lower Mortality ? ( ACE inhibitors )

case 15

64 y woman presents to ED for dyspnea on examination S3 , jugular venous distention edema , orthopnea

are found oxygen , furosemide ,nitrates and morphine are given . still dyspneic BP 114/80

next step ? ( Dobutamine)

case 16

The pt is ready for discharge . placed on enalapril and metoprolol .

which is most likely to decrease his mortality ? ( Spironolactone)

case 17

64 y woman with CHF . she has dilated cardiomyopathy of unclear etiology .her injection fraction has


15/25

dropped to less than 15% despite medical therapy her BP remain stable at 115/75 . which medication will

provide with increased mortality benefit ? ( Carvedilol)

case 18

Which is the most common cause of death in these pts ( ventricular tachycardia)

case 19

Person with CHF has persistent S.O.B despite the use of diuretics , digoxin , Spironolactone ,ramipril and

metoprolol ECG show an injection fraction of 16% .

which most likely benefit this pt ? ( biventricular pacemaker)case 20

Which is the most dangerous cardiac lesion in pregnant woman ? ( Eisenmenger's syndrome)

case 21

48 y male with dyspnea , ranal failure and edema . his ECG shows a speckled septum .

the most likely diagnosis is ? ( amyloid)

case 22

58 y man has a history of CHF secondary to alcoholism progressed to dilated cardiomyopathy with injection

fraction of 22% . what is the only difference in management between this pt and one with CHF secondary to

CAD ( coronary artery bypass graft)

case 23

17 y male with murmur gets worse with the valsalva maneuver and improves with squatting which is

common presentation ? ( S.O.B) m c in HOCM . it is NOT sudden death

case 24

The location is this patient's murmur best heard ? ( lower left sternal border)

case 25

Which will improve this murmur ? ( Handgrip)

case 26

The pt has two episodes of syncope .

which have the greatest mortality benefit ( Implantable cardioverter defibrillator (AICD))

case 27

72 y man with PMH of COPD , MI , gout and type II DM present with dry cough . he's on enalapril ,

furosemide , allopurinol and ipratropium . on ECG has injection fraction of 34%

the best next step ? ( switch enalapril to losartan)

case 28

The pt still symptomatic . he has potassium of 6.0 mEq/L the best next step ( Hydralazine & nitrates)

Case 29

His enalapril was changed to Hydralazine and nitrates the hyperkalemia corrects . he developed throbbing

headache . the most likely cause is ( nitrates)


16/25

12 - Macrocytic Anemia

case 1

68 y female present with slow fatigue for month , and SOB for last week , Bp 114/70 mmhg , puls 107 ,

there is mild decrease sensation in her LL , on LAP HCR 28% , Hg 9.2 , MCV 118

m likely diagnosis ? (Vit B12 deficiency)

case 2

witch physical finding most likely be found ? ( Vitiligo) B 12 DA associated with autoimmune condition like

:

Vitiligo / Addison D / pernicious anemia / Hashimoto thyroiditis

case 3

initial diagnostic test ? ( peripheral blood smear)case 4

witch m likely found , show u many peripheral smear ? ( chose the one show Hypersegmented

neutrophil )

case 5

confirmatory test ? ( Methylmalonic acid level MMA) specific for B12 deficiency

case 6

m likely found in LAP (retic,LDH,Bilirubin) ? ( low retic , ^ LDH , ^ Bilirubin )

case 7

what is mechanism of Hyperbilirubinemia ? ( RBCs destruction in BM)

case 8m likely found , show u many peripheral smear ? NO Hypersegmented neutrophil ( Macro ovalocyte)

case 9

m likely found , show many pic of tong ? ( chose the one show Atrophic glossitis ) smooth tongue

case 10

m likely cause of this pt Disease ? ( Pernicious anemia)

case 11

what u will do to confirm the etiology in this pt ? ( Anti intrinsic factor antibody)

case 12

most serious complication for B12 replacement ? ( Hypkalemia)

case 13

m c neurological abnormality ass with this disease ? ( peripheral neuropathy)


17/25

13 Inflammatory Bowl Disease IBD

case 1

24 y female presented with Diarrhea , sometime with Blood , and weight loss , Stool culture , ova and

parasite and C.diff toxin all normal , what is the m likely diagnosis ? ( I B D)

case 2

witch skin lesion m likely present in this pt ? ( Erythema Nodosum) reddish tender lesion in the ant leg

it indicate the activity of the disease

case 3

witch m likely found in this pt , show u a lot of pic ? ( Pyoderma Gangrenosum)

case 4

he show u endoscopy pic ? ( Uveitis/Iritis )case 5

m accurate diagnostic test for the ocular finding ? ( Slit Lamp)

case 6

what is the Rx for the ocular finding ? ( Steroid)

case 7

new case 24 y female presented with Diarrhea , sometime with Blood , and weight loss , Stool culture , ova

and parasite and C.diff toxin all normal , now present with Jaundice , dark urine , itching , on PE abdomen

is not tender LAP show AST 12 , ALT 18 and alkaline phosphate 110 , m likely diagnosis ? ( sclerosing

cholangitis )

case 8what is the worst complication for the sclerosing cholangitis ? ( Cholangiocarcinoma )

case 9

m accurate test sclerosing cholangitis ? ( E R C P) it NOT biopsy

case 10

most consistent with UC ? ( ANCA +ve and ASCA -ve ) reverse it for CD

case 11

he show u many pic of colonoscopy , witch most likely found ? ( Cobblestoning pattern)

case 12

witch the greatest point of different of UC vs CD ? ( Rectum involvement ) CD spare the Rectum

case 13

initial Rx for maintenance ? ( MESALAMINE)

case 14

pt now present with urinary frequency and burning , she had noticed a foul small to her urine and also a

dark colore witch m likely diagnosis ? ( Rectovesicular fistula)

case 15

witch of the following must be don before start Rx for fistula ? ( P D D)

infeximab open Granulomas and flare TB

if PDD is +ve give INH with infleximab

case 16

disease not controlled with Mesalamin and Budesonide , witch to add ? ( Azathioprine )

case 17disease not controlled with Mesalamin / Budesonide / 6-Mercaptopurine , pt had persistent disease in

perianal areaWhat to do ? ( Ciprofloxacin / Metronidazol)


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14 Systemic Lupus Erythematosus SLE

case 126 y female presented with joint pain , pain is bilateral in several joint with swollen , it does not change

through the day , she feel tired and have a skin lesion

m likely diagnosis ? ( S L E)

case 2

best initial test ? ( A N A ) Anti Nuclear Antibody

case 3

m specific test ? ( Anti dsDNA antibody )

Anti Histone antibody is ass with Drug induce Lupus ( spare Brain & Kidney )

case 4

he show u pic of facial rash ? ( Malar Rash)case 5

he show u pic of palm of the hand with white last 2 finger ? ( Ryanauds phenomenon)

case 6

he show u 5 hand x ray , m likely found in this pt ( normal hand x ray) SLE it is not deforming to joint

case 7

pt had a CBC , m likely found ? ( Pancytopenia)

case 8

he show u blood smears ? ( chose the one show Spherocytes)

case 9

a mother with SLE gives birth , the baby +ve for anti Ro antibody , he show u ECG ? ( 3ed degree AVblock)

case 10

32 y female G3P0020 , come in her 12thweek and concern about spontaneous abortion , she has +ve

VDRL , -ve FTA and elevated aPTT ? ( Antiphospholibid syndrome)

case 11

what expected in this pt ? ( D V T)

case 12

26 y female presented with joint pain , pain is bilateral in several joint with swollen , it does not change

through the day , she feel tired and have a skin lesion , 5 y after diagnosis her complement low , anti ds

DNA ab elevated , and on Urine analysis ( ^proteinuria , ^hematuria , red cell cast )

m accurate diagnostic test ? ( Renal biopsy)

case 13

he show u biopsy pic ? ( Membranous Glomerulonephritis) ass with SLE

case 14

Rx to this pt nephropathy ? ( Prednison / Mycophenolate)

case 15

pt present afebrile with pleuritic pain and hemoptysis , CBC normal , CXR show bilateral infiltration

m likely diagnosis ? ( Alveolar Hemorrhage)

case 16

witch determine disease activity ? ( decrease complement level)

case 17he show u pics of fundoscopy ? ( chose the one show central retinal vein occlusion )

case 18

36 y female with SLE presented with speech impairment and right facial dropp for the past 2 h , on PE her


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eyes deviate to the left and there is a murmur , LAP show normal complement .

best initial test ? ( Echo) there is 2 cause for stroke in SLE ( Libman sacks vegetation / Lupus

anticoagulant )

case 19

witch murmur m likely found in this pt ? ( pansystolic ) MR m c valvular lesion ass with Lupus

case 20

5 health care worker with +PDD , and all started on INH , he developed bilateral joint pain in hands and

feet's , rash , with pleuritic painwhy he is the only one get S/S ? ( decrease acetylation rate) drug induce Lupus

case 21

next step ? ( stop the drug)

15 RA

case 1

32 y women with pain and stiffness in her joins for the past 7 week , she also c/o fatigue , malaise Wight

loss

m likely diagnosis ? ( R A)

case 2

m likely found on X ray ? ( chose the one show PIP , MCP , wrist involvement) RA spare DIP

case 3

m reliable way to differentiate RA from Hx ? ( condition improve with use) AM stiffness less than 1 hour

case 4

witch procedure consider dangerous to this pt ? ( endotracheal intubation )if cervical spine involved , there is a risk for atlantoaxial subluxation ( C1 - C2 )

case 5

he show u hand pic , witch with RA? ( chose the one show , ulner deviation , swan neck deformity )

case 6

hand X ray in RA pt , ask about it ? ( panuus formation) take a look in x ray plzz

case 7

new case pt present with rapidly swelling , warm , tender knee and fever , arthrocentesis is done

show u slide , and ask about m likely found in pt ? ( chose the one show staph or strep) septic artharitis

case 8

Bach to RA case , routine blood test on this pt will show ? typical case for anemia of chronic disease( normal MCV and platelet low ion TIBC high ferritin )

case 9

m specific test for RA ? ( anti CCP antibodies) Cyclick Citrulinated Peotide it is sensitive and specific .

case 10

after 12 week on NSAID , wrist splint and phesical therapy , pt still worsen S/S and findind on x ray

what u will do ? ( Methotrexate)

answer DMARDS if fail therapy or abnormal x ray

case 11

he show u many x ray , and ask about one with RA ? ( chose same as case 3)

case 12

what u should do before give hydrochloroquine ? ( Ophthalmologec exam) it cause retinal toxicity

case 13

pt on pain , immobility , and deformity progressed despite the use of NSAID , methotrexate , abatacept and

anakinra


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what next ? ( Adalimumab) TNF inhibiter

DO NOT forget to test PDD first , it can reactivate TB

16 - Multiple Sclerosis

case 1

32 y caucasian woman presented with muscular weakness for the last 2 days , she had visual disturbance

twice in the past resolve with Steroid

m likely diagnosis ? ( M S)

case 2

m c presentation of this disease ? ( Visual deficit ) optic neuritis , No cognitive disturbance with MS

case 3

m likely physical finding ? ( Spasticity)

case 4

best initial test ? ( M R I) NOT LP , LP looking for oligoclonal band in 3% of pt not diagnosed by MRI

case 5m likely be found , show pic of many MRI ? ( chose the one show multiple white lesion)

case 6

witch of the following m likely found on ocular exam ? (chose the one show optic nerve pallor) optic

neuritis

case 7

what the following show , he play a video ? ( internuclear opthalmoplegia ) o_O , goolge it

case 8

what the following show , he play a video ? ( afferent papillary defect)Marcus Gunn pupil , YouTube it

case 9m accurate diagnostic test ( M R I) YEP it is best initial and m accurate

case 10

best initial Rx ? ( Steriod)

case 11

witch Rx delay progression ? ( Beta interferon) only for MS (one disease drug) , alpha interferon for viral

hepatitis

case 12

witch Rx delay progression , no beta interferon in choices ? ( Mitoxantrone)

case 13

witch Rx delay progression , no beta interferon and no Mitixantrone in choices ? ( Natalizumab )and Glateramer also delay progression in MS

case 14

pt developed progressive multifocal leukoencephalopathy (PML), witch drug to stop ? (Natalizumab)

caused by JC virus , on MRI : multiple white matter lesion with no mass effect no edema no ring enhancing

case 15

mechanism of action for Natalizumab ? ( alpha 4 integrin inhibitor)

case 16

pt has Spasticity , witch drug u use ? ( Baclfen)

case 17

pt has sever fatigue , witch drug to use ? ( Amantadine) not known how it work

case 18

ethical Q about the right of competent pt to refuse Rx

case 19

pt develops incontinence , bladder palpable to the umbilicus , m likely diagnosis ? ( Atonic bladder)


21/25

MS can be ass with atonic bladder or urge incontinence

case 20

how to treat atonic bladder ? ( Bethanechol)

Oxybutynin Tolterodine , for urge incontinence

case 21

MS pt in sever pain not respond to Rx , u decide to give Opiates in high dose that make her sleepy ,

confuse

what should u do ? ( continue the medication and add Pemoline)

17 Acromegaly

case 1

a 44 y man present with daytime somnolence and deep voice , his wife is complaining that he has a new

unpleasant distinct smell , and show u pic of pt face , m likely diagnosis ? ( Acromegaly)

case 2

next best step in management ? ( IGF 1 level) insulinlike growth factor

case 3

what is the mechanism of daytime somnolence ? ( Sleep Apnea ) coz ^soft tissue of the neck

case 4

he show u many mouth pics , witch m likely ass with this pt ? ( Wide space teeth)

case 5

another many coloscopy pics witch ass with this pt ? ( chose the one show Colonic Polyps)

case 6

pt develop erectile dysfunction , m likely etiology ? ( ^ Prolactin) GH cosecrision with prolactin

prolactin inhibit GTRH from hypothalamus

case 7

on PE pt has bilateral thenar eminence wasting is noted , etiology ? ( ^ protein synthesis)

case 8

best initial Rx ? ( Surgury) NOT medication like prolactinoma

case 9

A 16 y old boy present with shor stature , his GH and IGF-1 low ?

whitch should the pt tested for ? ( T4 / TSH) Thyroxin is necessary for normal release of GH

case 10A 52 y man present with indistinct abnormal facial features with high GH

m accurate diagnostic test ? ( Glucose suppression test) normal response is decrease GH

case 11

A 48 y man undergoes transsphenoidal surgery , his BP 150/90 nnHg

witch is the prognosis in term of blood pressure ? ( improvement BP over time)

case 12

a 44 y man present with daytime somnolence and deep voice , his wife is complaining that he has a new

unpleasant distinct smell , he undergoes transsphenoidal surgery

witch of the following complication will occur most Rapidly ? ( Hyper Na) loss of ADH

NB : m c cause of death is cardiac complication ( DCM / ACS ) from DM & HT


22/25


23/25

52 yrs man present to ED with headache blurry vision , S.O.B and palpation. BP 220/140 mmgh

Next step ? ( IV labetolol)

case 19

Which drug has greatest risk of depression ? ( reserpine)

19 - Infectious Endocarditis

case 1

48 man come to ER with Fever , murmur for the last 3 week on exam he show u a pic ( IV drug mark on

hand )

m likely diagnosis ? ( Infective endocarditis)

case 2

best initial test ? ( Blood Culture) have 95% sens , o_O , yes it is not Echo

case 3

m likely found in this pt , he show u pic of fundoscopy ? ( chose the one show Roth spot)

case 4

he show u pic of finger with red line on the nail , what is it ? ( splinter hemorrhage)case 5

again some leg pic ? ( chose the one show jeneway lesion )

eruthema nodusum wt : sarcoidosis/syphlis/preg/strep inf

case 6

another pic of eyes ? ( chose the one show subconjectiva peticheia)

case 7

witch murmur m likely found ? ( Mitral regurg) on media

case 8

witch murmure will increase with respiration ( Tricusped regurg) all Rt heart murmure

it us mc Valve affected on IV drug abuser

case 9

bet area to hear M regurg murmure ? ( Apex)

case 10

CXR with multiple round region on the Rt side ( multiple little abscess ) from septic emboli , witch V lesion

m likely found ? ( T regurg)

case 11

Blood culture pending , next step ? ( start antibiotic )

case 12

best empiric therapy ? ( Vancomycin / Gentamicin)

case 13

after start Abx , he developed redness and flushing at the neck line , next step ? ( decrease the rate of

infusion ) Red man syndrome ass with rapid infusion of first does Vanco

case 14

m likely be found on LAP ? ( low complement level)

case 15

68 y old female present have fever and murmur , culture grow strep bovis

next step ? ( Colonoscopy) s.bovis asso with colon CA

# rifampin is added for pt with prosthetic valve for good penetration

case 16

stat Q ask about sensitivity ? ( it is easy one )

case 17another stat Q about PPV ? ( also easy one )

case 18

54 y male has progressive aortic stenosis , he went valve replacement 2 week ago , he now present with


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fever 102 F , blood culture grow staph aureus , he is on Vanco and Genta

next step ? ( Transesophageal echo TEE) with prothsetic valve do NOT go with TTE

case 19

TEE is don he has freely mobile vegetation , blood culture grow sensitive staph aureus

he is on Vanco and Genta , what next ? ( change Vanco to Nafcillin) it is Sensitive

case 2035 y homless , alcoholic in Seattle present to ED with fever and murmure , blood culture is nivetive , Echo

show vegetation , he is diagnosed with PCR

what is the m likely organism ? ( Bartonella) when u see alcoholic + homeless + culture negative

case 21

pt has Hx of AS and about to going for colonoscopy

witch of the following indicated ? ( no prophylaxis required) Non for GI procedure

case 22

pt with AR going to have prostate biopsy

witch of the following indicated ? ( no prophylaxis needed) also NON for GU procedure

case 23

pt had prosthetic valve going for dental fillings

witch of the following indicated ? ( no prophylaxis needed) dental filling dose not cause significant

bleeding

case 24

pt with unrepared cyanotic heart disease going for tonsillectomy

witch of the following indicated ? ( oral Amoxicillin before)

20 Hemochromatosis

case 1

50 y man wt fatigue , joint pain , skin darkening , erectile dysfunction

m likely diagnosis ? ( Hemochromatosis)

case 2

site of the defect ? ( Duodenum) over absorption of iron in Duodenum ()another cause is chronic blood transfusion , but less common

case 3

mood of inheritance ? (auto recessive) 25 % - can skip generation in male and female

case 4

u tap the joint and show u pic , wich present ? ( +ve birefringent / rhomboid shape crystal )

Ca pyrophosphate ( psudogout )

case 5

most likely be found ? ( D M) bronze diabetes , iron build up on pancreas

case 6

test most likely to show abnormality ? ( Echocardiogram) restrictive cardiomypathycase 7

m c cause of death ? ( Cirrhosis) it is not HEART FAILURE

also hemochromatosis m c cause of Hepatoma

case 8


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hear sound , witch associated with hemochromatosis ? ( chose S4) I know it hard , just practice it

case 9

witch u will use on liver biopsy ? ( Prussian blue)

case 10

bet initial test ? ( iron study) ^iron low TIBC

case 11m accurate diagnostic test ? ( HFE gen and MRI) dont panic . there is no liver biopsy

that test may replace liver biopsy soon

case 12

what will be found on cardiac cath ? ( decrease COP increase PCWP)

case 13

m likely found on iron study ? ( ^ iron - ^ ferritin low TIBC) exactly the opposite of ID anemia

case 14

witch organism this pt at risk of ? ( Vibrio vulnificus) also Yersinea and Legonela

case 15

mechanism of erectile dysfunction ? ( iron deposit on pituitary) cause low LH/FSH

case 16

treatment of choice ? ( phlebotomy)

I hope it help u

GOOD LUCK

Dr . Araki . Sudan

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