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155 Cards in this Set
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21 yo African American male in ER with 6 week history of progressive SOB and cough. Wheezes at night has to sit up to relieve his chest discomfort. Chest CT shows a mediastinal mass compressing the trachea. Serum levels of alpha-fetoprotein and beta-HCG are elevated. Most likely Dx?
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21 yo African American male in ER with 6 week history of progressive SOB and cough. Wheezes at night has to sit up to relieve his chest discomfort. Chest CT shows a mediastinal mass compressing the trachea. Serum levels of alpha-fetoprotein and beta-HCG are elevated. Most likely Dx? --- Mixed germ cell tumor. Anterior mediastinal mass includes 4 T - Thymoma, Teratoma, Thyroid neoplasm, and Terrible Lymphoma. Teratoma (has Fat or Calcium - tooth) has Other Germ cell tumors. Serum hormone levels may be helpful in differentiating Seminomatous Germ cell tumors from NonSeminomatous variants. Serum B-HCG can be Elevated in 33 perc of pt with Seminoma, althought AFP is always normal. NonSeminomatous forms of Germ cell tumors include Yolk Sac Tumor, Choriocarcinoma, and Embryonal Carcinoma. A mixture of different cell types is also possible and referred to as Mixed germ cell tumor. NonSeminomatous Germ cell tumor (Elevated AFP), with a considerable amount also having an Elevated B-HCG.
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What are types of Anterior Mediastinal mass?
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What are types of Anterior Mediastinal mass? Anterior Mediastinal mass - 4T - 1 Thymoma, 2 Teratoma (and other Germ cell tumors), 3 Thyroid Neoplasm, and 4 Terrible Lymphoma. Seminomas - Elevated B-HCG. NonSeminomatous (Yolk Sac Tumor, Choriocarcinoma, and Embryonal Carcinoma) Germ Cell tumors - Elevated AFP, and Elevated B-HCG
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Seminoma Lx?
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Seminoma Lx? Elevated B-HCG
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What are NonSeminomatous tumor? Lx?
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What are NonSeminomatous tumor? Lx? NonSeminomatous (Yolk Sac Tumor, Choriocarcinoma, and Embryonal Carcinoma) Germ Cell tumors. Elevated AFP, and B-HCG.
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25 yo African American man with nocturia over past several months. Wake to urinate 2 to 3 times per night despite restricting his fluid intake. PMH - Recurrent otitis media in childhood and hepatitis A infection two years ago. Sexually active with one partner and does not use condoms. Brother died of a "blood disease" at age 10. Man's hematocrit is 49 perc. Nocturia is most likely?
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25 yo African American man with nocturia over past several months. Wake to urinate 2 to 3 times per night despite restricting his fluid intake. PMH - Recurrent otitis media in childhood and hepatitis A infection two years ago. Sexually active with one partner and does not use condoms. Brother died of a "blood disease" at age 10. Man's hematocrit is 49 perc. Nocturia is most likely? ---- Hyposthenuria (Impairment in kidney ability to concentrate urine) in sickle cell anemia and sickle cell trait.
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What is eczema?
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What is eczema? Inflammatory condition of skin with itching and exudation of serous matter
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49 yo woman with Strange, Itchy Rash on her left areola for last month. Tried applying various lotions and creams, but did not help. Eczematous plaque on left nipple. Biopsy shows large cells surrounded by halo-like areas invading epidermis. Most likely Dx?
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49 yo woman with Strange, Itchy Rash on her left areola for last month. Tried applying various lotions and creams, but did not help. Eczematous plaque on left nipple. Biopsy shows large cells surrounded by halo-like areas invading epidermis. Most likely Dx? --- Adenocarcinoma. Paget Disease of breast suspected in pt with no history of skin disease who presents with eczematous rash near nipple that does not improve with topic treatments. Majority of pt with Paget disease have underlying Breast Adenocarcinoma. Large cells surrounded by clear halo (cancer cells retracted from adjacent keratinocytes).
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Order the following stages of therapies (Adjuvant, Consolidation, Induction, Maintenance, Neoadjuvant, Salvage).
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Order the following stages of therapies (Adjuvant, Consolidation, Induction, Maintenance, Neoadjuvant, Salvage). --- 1 Neoadjuvant, 2 Induction and Adjuvant, 3 Consolidation, 4 Maintenance, 5 Salvage. Induction - Standard therapy. Consolidation - reduce tumor burden. Maintenance - kill an residual tumor cell and keep pt in remission. Salvage - given after Standard therapy fails.
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19 yo male presents for checkup. Long distance cyclist and has been achieving outstanding results recently. Bp 153 over 98 and HR 62. Mild Gynecomastia. Liver span is 8 cm. HCT 59 perc. Most likely explanation for high hematocrit?
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19 yo male presents for checkup. Long distance cyclist and has been achieving outstanding results recently. Bp 153 over 98 and HR 62. Mild Gynecomastia. Liver span is 8 cm. HCT 59 perc. Most likely explanation for high hematocrit? --- Steroid drug abuse. Hematocrit level is frequently elevated in illegal doping either with androgens, autologous blood transfusion, or erythropoietin abuse. Androgens has other side effects (Gynecomastia, Decreased testicular size, Hepatotoxicity, psychological disturbance, dislipidemia, increased coagulation. Erythopoietin has not side effect.
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What is MEN1? Inheritance?
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What is MEN1? Inheritance? MEN I (3 Ps) - Pituitary, Parathyroid, Pancreas. Inheritance - Autosomal Dominant. Pancreas and GIT has 1 Gastrinoma, 2 Insulinoma, 3 VIPoma, and 4 Glucagonoma. Pituitary tumor - Prolactinoma, GH secreting, Non Hormone secreting, ACTH secreting
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What is MEN2a?
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What is MEN2a? MEN IIa (1M,2Ps) - Medullary Thyroid Ca, Pheochromocytoma, Parathyroid
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What is MEN2b?
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What is MEN2b? MEN IIb (2Ms,1P) - Medullary Thyroid Ca, Marfanoid habitus/mucosal neuroma, Pheochromocytoma
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What is Warfarin? Food and supplement interaction?
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What is Warfarin? Food and supplement interaction? Warfarin is Vitamin K Antagonist used for Anticoagulation in numerous clinical settings. Decrease Warfarin activity - Food Rich in vitamin K (Dark Green vegetables). Increase Warfarin activity - Alcohol, Vitamin E, Garlic, Ginkgo Biloba, Ginseng, St John wort, and several antibiotics.
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Hemolytic anemia, Venous Thrombosis, Anemia. Dx?
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Hemolytic anemia, Venous Thrombosis, Anemia. Dx? PNH. Diminished Hematopoiesis (Anemia)
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What is Cobalamin?
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What is Cobalamin? Vitamin B12
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What is enoxaparin?
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What is enoxaparin? Enoxaparin is Low molecular weight Heparin.
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What is the most common cause of nutritional deficiency in Alcoholic?
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What is the most common cause of nutritional deficiency in Alcoholic? Folate deficiency (megaloblastic anemia within 5 to 10 weeks - folate in body is limited)
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What is Thiamine deficiency disease association?
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What is Thiamine deficiency disease association? Wernicke Encephalopathy
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What is the most common cause of iron deficiency anemia in an adult male or a post-menopausal woman? Lx?
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What is the most common cause of iron deficiency anemia in an adult male or a post-menopausal woman? Lx? Chronic GI blood loss. Lx - Initial - Fecal Occult blood test.
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What is Panendoscopy?
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What is Panendoscopy? Triple Endoscopy is 1 Esophagoscopy, 2 Bronchoscopy, 3 Laryngoscopy.
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Alcoholic smoker with palpable cervical lymph node. Next step?
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Alcoholic smoker with palpable cervical lymph node. Next step? Suspect squamous cell carcinoma of mucosa of head and neck in alcoholic smoker with palpable cervical lymph node. Next step - Panendoscopy
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64 yo woman presents with Irritating sore throat for 3 months. She smokes 1 pack of cigarettes daily for past 29 years, and continues to smoke. Jailed twice for driving under influence of alcohol and went to Alcohol Rehabilitation last year. Complete hysterectomy several years ago for symptomatic fibroids. 1.5 cm right cervical lymph node. Biopsy of lymph node reveals metastatic squamous cell carcinoma. Best next step in management?
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64 yo woman presents with Irritating sore throat for 3 months. She smokes 1 pack of cigarettes daily for past 29 years, and continues to smoke. Jailed twice for driving under influence of alcohol and went to Alcohol Rehabilitation last year. Complete hysterectomy several years ago for symptomatic fibroids. 1.5 cm right cervical lymph node. Biopsy of lymph node reveals metastatic squamous cell carcinoma. Best next step in management? --- Suspect squamous cell carcinoma of mucosa of head and neck in alcoholic smoker with palpable cervical lymph node. Next step - Panendoscopy
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19 yo man with Funny color stool. First it was black and almost sticky. Yesterday, it became maroon. Today, some bright red blood. Stool is positive for occult blood. Hematocrit of 29 perc and hemoglobin concentratio of 9.6. Colonoscopy reveals hundreds of colonic polyps, which are identified as adenomatous polyps with biopsy. Appropriate recommendation?
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19 yo man with Funny color stool. First it was black and almost sticky. Yesterday, it became maroon. Today, some bright red blood. Stool is positive for occult blood. Hematocrit of 29 perc and hemoglobin concentratio of 9.6. Colonoscopy reveals hundreds of colonic polyps, which are identified as adenomatous polyps with biopsy. Appropriate recommendation? --- Pt needs Elective Procto-colectomy. Familial colonic polyposis has 100 perc risk of cancer, if not treated appropriately with a proctocolectomy at the time of diagnosis. Autosomal dominant disease caused b mutation in adenomatous polyposis coli (APC) gene.
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23 yo man in ER with severe abdominal pain. Suffered from nausea and vomiting for several hours. His brother had a similar problem requiring surgery. Temp 101.8 F, HR 102. Tenderness in right upper quadrant exacerbated by deep inspiration. Liver span is 7 cm. His spleen is palpated 2 cm below the left costal margin. Most likely diagnosis?
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23 yo man in ER with severe abdominal pain. Suffered from nausea and vomiting for several hours. His brother had a similar problem requiring surgery. Temp 101.8 F, HR 102. Tenderness in right upper quadrant exacerbated by deep inspiration. Liver span is 7 cm. His spleen is palpated 2 cm below the left costal margin. Most likely diagnosis? --- Hereditary spherocytosis. Autosomal dominant disorder of spectrin that leads to Increased RBC membrane fragility. Positive Family history, Splenomegaly, Sphereocytosis, and can cause Cholecystitis due to pigmented gallstones (calcium bilirubinate). Tx. Folate supplementation and splenectomy.
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What does chronic hemolysis cause?
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What does chronic hemolysis cause? Jaundice and Pigmented (calcium bilirubinate) gallstones leading to Acute cholecystitis.
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What disease is Fascinating disease because it can spread to unimaginable places?
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What disease is Fascinating disease because it can spread to unimaginable places? Malignant Melanoma - can go to most unimaginable places, lie dormant for 15-25 years, then recur in surprising ways, even if primary tumor was resected.
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Metastatic mass that is bleeding in the brain. Dx?
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Metastatic mass that is bleeding in the brain. Dx? Malignant melanoma
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What tumors have not been reported to metastasize to brain?
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What tumors have not been reported to metastasize to brain? 1 Non-melanomatous skin cancer, 2 Oropharyngeal cancer, 3 Esophageal carcinoma, 4 Prostate cancer.
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Elderly with anemia, renal failure, and hypercalcemia. Dx?
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Elderly with anemia, renal failure, and hypercalcemia. Dx? Multiple myeloma
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67 yo man with one month history of progressive fatigue and exertional dyspnea. Enlarged, non-tender axillary lymph nodes bilaterally. Abdomen is soft and non-tender and the liver span is 10 cm. Hemoglobin 7.8, MCV 90, MCHC 33, Reticulocytes 7 perc, WBC count 22k, Platelet 200k. Most likely to improve this pt symptoms?
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67 yo man with one month history of progressive fatigue and exertional dyspnea. Enlarged, non-tender axillary lymph nodes bilaterally. Abdomen is soft and non-tender and the liver span is 10 cm. Hemoglobin 7.8, MCV 90, MCHC 33, Reticulocytes 7 perc, WBC count 22k, Platelet 200k. Most likely to improve this pt symptoms? ---- Prednisone. Enlarged lymph nodes suggest NHL or CLL may be underlying cause. Hemolytic anemia in setting of malignant lymphoproliferative disorder is often a warm autoimmune hemolytic anemia.
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Hemolytic anemia with malignant lymphoproliferative disorder. Dx?
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Hemolytic anemia with malignant lymphoproliferative disorder. Dx? Warm autoimmune hemolytic anemia.
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38 yo male recently emigrated from Asia comes to clinic complaining of two-month history of exertional SOB and easy fatigability. Been taking isoniazid for latent tuberculosis over last five months. Due to religious beliefs, he began practicing veganism five months ago. Physical examination reveals severe pallor and areas of depigmentation on his arms suggestive of vitiligo. Hemoglobin 4.5, MCV 110, WBC 4500, Platelet 145k. Most likely diagnosis?
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38 yo male recently emigrated from Asia comes to clinic complaining of two-month history of exertional SOB and easy fatigability. Been taking isoniazid for latent tuberculosis over last five months. Due to religious beliefs, he began practicing veganism five months ago. Physical examination reveals severe pallor and areas of depigmentation on his arms suggestive of vitiligo. Hemoglobin 4.5, MCV 110, WBC 4500, Platelet 145k. Most likely diagnosis? --- Pernicious anemia.
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What are some autoimmune disease?
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What are some autoimmune disease? Vitiligo, Pernicious anemia, Autoimmune Thyroid disease.
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Smudge cells. Dx?
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Smudge cells. Dx? CLL
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What is the most common type of leukemia in western countries?
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What is the most common type of leukemia in western countries? CLL. Lymphocytosis is classical signature mark. Most cells have an over-matured look because of hypercondensed nuclear chromatin material. Smudge cells are highly characteristic. Other signs include Lymphadenopathy and splenomegaly. As disease advances, anemia and thrombocytopenia are seen.
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Leukocytosis with a left shift and marked splenomegaly. Dx?
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Leukocytosis with a left shift and marked splenomegaly. Dx? CML. Leukocytosis with Left shift (more myelomonocytes, neutrophils, etc), basophilia and marked splenomegaly.
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What is glossitis?
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What is glossitis? Shiny tongue.
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What is the most common cause of vitamin B12 deficiency? What risk is asso?
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What is the most common cause of vitamin B12 deficiency? What risk is asso? Pernicious anemia is most common cause of vitamin B12 deficiency and is associated with at least double the risk of gastric cancer as compared to general population.
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What does Pernicious anemia leads to? How?
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What does Pernicious anemia leads to? How? Pernicious Anemia leads to vitamin B12 deficiency in two ways. 1 Anti-Intrinsic factor antibodies Decrease the amount of functional intrinsic factor available to facilitate B12 absorption. 2 Pt develops Chronic Atrophic Gastritis with Decreased production of Intrinsic Factor by Gastric Parietal Cells. Atrophic Gastritis Increases the risk of Intestinal-type gastric cancer and Gastric Carcinoid tumors by 2-3 times over the general population. Thus, pt with Pernicious Anemia need to be monitored for development of gastric cancer (Periodic stool testing for the presence of blood).
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What is the most important prognostic factor for breast cancer?
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What is the most important prognostic factor for breast cancer? TNM Staging (T - Tumor size and chest wall involvement and skin change, N - Lymph node involvement, M - Distal Metastasis). Stage 4 disease have worst prognosis. Tumor burden is the Single most important Prognostic consideration in Treatment of pt with breast cancer.
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Breast cancer. Good prognostic features?
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Breast cancer. Good prognostic features? ER+ and PR+.
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ER+ and PR+ prognostic significance for Breast cancer?
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ER+ and PR+ prognostic significance for Breast cancer? Good prognostic
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Breast cancer. Worse prognostic feature?
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Breast cancer. Worse prognostic feature? Overexpression of Her-2_neu Oncogen.
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What breast cancer histological feature has prognostic significant?
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What breast cancer histological feature has prognostic significant? Poorly differentiated tumors have worst prognosis.
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58 yo nurse with node-positive metastatic breast cancer comes to office for her monthly follow-up visit. Tumor is estrogen receptor (ER) and progesterone receptor (PR) positive, and her whole body bone scan is positive for metastatic disease. She is being treated with systemic chemotheray and hormonal therapy (Tamoxifen). She feels weak with vague muscle, joint, and bone pains. Physical exam reveals a hard, well-defined dominant mass in left breast. Calcium 11.3. Best next step in management of her hypercalcemia?
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58 yo nurse with node-positive metastatic breast cancer comes to office for her monthly follow-up visit. Tumor is estrogen receptor (ER) and progesterone receptor (PR) positive, and her whole body bone scan is positive for metastatic disease. She is being treated with systemic chemotheray and hormonal therapy (Tamoxifen). She feels weak with vague muscle, joint, and bone pains. Physical exam reveals a hard, well-defined dominant mass in left breast. Calcium 11.3. Best next step in management of her hypercalcemia? --- Bisphosphonates (Zoledronic acid therapy) are DOC for Mild to Moderate Hypercalcemia due to malignancy. Bisphosphonates may prevents skeletal complications (Reduce bone pain, fracture risk), and perhaps improve survival in pt with multiple myeloma or breast cancer. IV fluid and Furosemide are used in Hypercalcemic Crisis. Breast cancer has osteolytic metastases with local release of cytokines and tumor secretion of parathyroid hormone-related protein (PTHrP).
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What is Lynch syndrome?
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What is Lynch syndrome? Lynch syndrome is aka Hereditary Non-Polyposis Colorectal Cancer (HNPCC). Amsterdam Criteria - 1 At Least 3 relatives with Colorectal cancer, One of whom must be a First degree relative of other two, 2 Involvement of Two or More Generations, 3 At Least One case diagnosed before age 50, 4 Familial Adenomatous Polyposis has been Excluded. HNPCC is divided into two subgroups - 1 Hereditary site specific Colon cancer (Lynch syndrome 1), 2 Cancer family syndrome (Lynch syndrome 2). Lynch syndrome 2 is Distinctly associated with High Risk of Extracolonic tumors, Most common of which is Endometrial Carcinoma.
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What is the cause of Pancytopenia in SLE?
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What is the cause of Pancytopenia in SLE? Pancytopenia (Decreased RBC, WBC, and Platelets) is common in pt with SLE. It occurs due to formation of autoantibodies against blood cells, a form of type 2 hypersensitivity reaction. Warm antibodies to RBC.
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What is ineffective hematopoiesis?
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What is ineffective hematopoiesis? Ineffective hematopoiesis is blood cell breakdown in bone marrow before release into circulation. Thalassemias and Myelodysplastic syndrome are examples.
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Hypercoagulable state and Thrombocytopenia developed days after anticoagulation therapy was initiated. Dx?
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Hypercoagulable state and Thrombocytopenia developed days after anticoagulation therapy was initiated. Dx? HIT due to unfractionated heparin. In HIT, heparin-induced release of platelet factor 4 (PF4) from platelet granules spurs the formation of immungenic heparin-PF4 complexes. IgG antibodies directed against heparin-PF4 complexes cause platelet activation, endothelial cell activation, and abnormal generation of intravascular thrombin without the usual stimulus of subendothelial collagen exposure.
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What is Danaparoid?
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What is Danaparoid? Danaparoid is a Heparinoid anticoagulant with anti-factor Xa activity. Effective in treating HIT, but not available in US.
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What is Trastuzumab? Tx for? AE?
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What is Trastuzumab? Tx for? AE? Trastuzumab is aka Herceptin, commonly used to treat breast cancer that is HER2 positive. Benefit both in adjuvant situations as well as in case of Metastatic disease. AE - Cardiotoxity. Echocardiogram is recommended before starting treatment to get baseline ejection fraction
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What is Naproxen med class?
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What is Naproxen med class? Naproxen is NSAID. It can cause gastric ulcer.
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63 yo male complains of easy fatigability. Hypertension treated with lisinopril. Over last two months, he has had right knee pain due to osteoarthritis and he has been taking naproxen for pain relief. His right knee is mildly deformed due to bony overgrowth, but it is not tender or swollen. Hemoglobin 8.6, MCV 72, Platelet 145k, ESR 15. What do you expect with Serum Iron, Serum Ferritin, TIBC, Transferrin Saturation?
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63 yo male complains of easy fatigability. Hypertension treated with lisinopril. Over last two months, he has had right knee pain due to osteoarthritis and he has been taking naproxen for pain relief. His right knee is mildly deformed due to bony overgrowth, but it is not tender or swollen. Hemoglobin 8.6, MCV 72, Platelet 145k, ESR 15. What do you expect with Serum Iron, Serum Ferritin, TIBC, Transferrin Saturation? --- Iron Deficiency due to Naproxen (NSAID) use causing Peptic ulcer or Gastritis. Serum Iron - Low, Serum Ferritin - Low, TIBC - High, Transferrin Saturation (Iron per TIBC) - Low
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45 yo Asian man with easy fatigability. Gastrectomy for a non-healing gastric ulcer. Shiny tongue and pale palmar creases. Blood hemoglobin level is 7.5 and WBC count is 3800. His condition involves which pathophysiologic mechanisms?
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45 yo Asian man with easy fatigability. Gastrectomy for a non-healing gastric ulcer. Shiny tongue and pale palmar creases. Blood hemoglobin level is 7.5 and WBC count is 3800. His condition involves which pathophysiologic mechanisms? --- Impaired DNA synthesis. Vitamin B12 deficiency is common after a Total or Partial Gastrectomy. Vitamin B12 is a necessary cofactor in pathway leading to Purine synthesis. B12 deficiency Decreases DNA synthesis and Erythropoiesis, leading to a megaloblastic anemia.
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How is B12 absorbed? What causes B12 deficiency?
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How is B12 absorbed? What causes B12 deficiency? --- 1 Gastric derived Intrinsic factor binds to vitamin B12 in stomach and facilitates its absorption in Ileum. If a significant portion of stomach has been removed (partial or total gastrectomy), sufficient Intrinsic Factor will not be produced and B12 absorption will be Severely limited. Other common causes of B12 deficiency - 1 Pernicious anemia, 2 Gastritis, 3 Intestinal Disorders preventing absorption, and 4 Elderly age. B12 deficiency presents as Megaloblastic, Macrocytic anemia with glossitis and neurologic changes. B12 is a necessary cofactor in pathway leading to Purine synthesis. B12 deficiency Decreases DNA synthesis and Erythropoiesis, leading to a Megaloblastic anemia.
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RBC memebrane instability. What hematological disorder?
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RBC memebrane instability. What hematological disorder? Hereditary spherocytosis
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Impaired Hemoglobin synthesis. What hematological disorder?
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Impaired Hemoglobin synthesis. What hematological disorder? 1 Iron Deficiency anemia, 2 Hemoglobinopathies (Sickle cell anemia, alpha and beta Thalassemia)
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Impaired Glutathione synthesis. What hematological disorder?
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Impaired Glutathione synthesis. What hematological disorder? Hemolytic anemia of Glucose-6-Phosphate Dehydrogenase deficiency
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Mechanical injury of RBC. Cause?
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Mechanical injury of RBC. Cause? Artificial heart valves. Schistocytes.
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Immune-mediated hemolysis. Cause?
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Immune-mediated hemolysis. Cause? IgG autoantibodies attach to RBC membrane and promote their removal from circulation in spleen.
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What can occur if more than one unit of pRBC is transfused over 24 hours?
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What can occur if more than one unit of pRBC is transfused over 24 hours? Develop Elevated plasma levels of Citrate (a substance added to stored blood). Citrate chelates Calcium and Magnesium, and may Reduce their plasma levels, causing Paresthesias.
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What is dorsum of hand?
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What is dorsum of hand? Back side or Dorsal side of hand. Opposite is Palmer side or ventral side.
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79 yo woman with Intermittent skin rash over last several months. Diet-controlled diabetes and right knee osteoarthritis treated with acetaminophen. Several dark purle ecchymotic areas over dorsum of both arms. Liver span is 8 cm. Hematocrit 47 perc, Fibrinogen 350, PT 10, INR 1, PTT 25. Most likely cause of pt complaint?
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79 yo woman with Intermittent skin rash over last several months. Diet-controlled diabetes and right knee osteoarthritis treated with acetaminophen. Several dark purle ecchymotic areas over dorsum of both arms. Liver span is 8 cm. Hematocrit 47 perc, Fibrinogen 350, PT 10, INR 1, PTT 25. Most likely cause of pt complaint? --- Perivascular Connective Tissue Atrophy. Senile purpura has ecchymoses that occur on elderly pt extensor surfaces due to perivascular connective tissue atrophy. Unsightly, but not dangerous and does not require further workup.
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When does poor platelet adhesion occurs?
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When does poor platelet adhesion occurs? 1 Anti-platelet medication (Aspirin, Clopidogrel, and Eptifibatide) or 2 Von Willebrand disease. 3 Renal failure can also cause platelet dysfunction.
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Vitamin K deficiency effect on PT and PTT?
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Vitamin K deficiency effect on PT and PTT? Vitamin K deficiency will Deplete the levels of vitamin K-dependent clotting factors - Factors 2, 7, 9, and 10. They are used in Intrinsic and Extrinsic coagulation cascades. Thus, vitamin K deficiency results in Increased PT (INR) and PTT.
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25 yo G3P0 white female in her 6th week of gestation comes to antenatal clinic. Mild nausea. Two first trimester miscarriages. Taking folic acid and iron supplementation. VDRL positive, Hematocrit 33 perc, Platelet 88k, PT 10, PTT 46. Urine analysis does not show any blood or protein. Most appropriate next step in management?
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25 yo G3P0 white female in her 6th week of gestation comes to antenatal clinic. Mild nausea. Two first trimester miscarriages. Taking folic acid and iron supplementation. VDRL positive, Hematocrit 33 perc, Platelet 88k, PT 10, PTT 46. Urine analysis does not show any blood or protein. Most appropriate next step in management? --- Low Molecular Weight Heparin. Antiphospholipid antibody syndrome (APS) is associated with false positive VDRL, prolonged PTT and Thrombocytopenia. APS promote arterial and venous thromboses and a resultant tendency toward spontaneous abortions. Prophylaxis with low dose aspirin and LMWH are recommended to avoid pregnancy loss.
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What is Pagophagia?
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What is Pagophagia? Pica for Ice.
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Pica. Dx?
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Pica. Dx? Iron Deficiency anemia
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What is Oral leukoplakia?
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What is Oral leukoplakia? Oral leukoplakia is precancerous white patch or plaque on oral mucosa.
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80 yo female with fatigue. Lives alone and is suffering from severe bilateral knee osteoarthritis, which significantly limits her mobility. Hypertension. Takes hydrochlorothiazide and over-the-counter pain killers. Bp 146 over 92. Conjunctival pallor. Both knees are deformed due to bony overgorwth, but there is no significant effusion or erythema. Extension of both knees is limited. Most likely cause of pallor?
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80 yo female with fatigue. Lives alone and is suffering from severe bilateral knee osteoarthritis, which significantly limits her mobility. Hypertension. Takes hydrochlorothiazide and over-the-counter pain killers. Bp 146 over 92. Conjunctival pallor. Both knees are deformed due to bony overgorwth, but there is no significant effusion or erythema. Extension of both knees is limited. Most likely cause of pallor? --- Iron Deficiency anemia. NSAIDs are a common cause of iron deficiency anemia often through chronic low grade blood loss per gastrointestinal tract. Many pt may not appreciate the potentially harmful side effects of NSAIDs since they are so readily available over-the-counter. Use Iron studies and Hemo occult stool testing to confirm diagnosis.
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Does osteoarthritis cause Anemia of chronic disease?
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Does osteoarthritis cause Anemia of chronic disease? No, Osteoarthitis does not cause Anemia of Chronic disease. Rheumatoid arthritis does.
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What does retinal vein engorgement shows?
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What does retinal vein engorgement shows? Hyperviscosity in Waldenstrom Macroglobulinemia. IgM spike (causes hyperviscosity in blood) on SPEP. Plasma cell neoplasm
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What are major signs of Waldenstrom Macroglobulinemia?
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What are major signs of Waldenstrom Macroglobulinemia? 1 Increased size of Spleen_Liver_SomeLymphNodes, 2 Tiredness - usually due to anemia (too few RBC), 3 Tendency to bleed and Bruise easily, 4 Night sweats, 5 Headache and dizziness, 6 Various visual problems, 7 Pain and numbness in extremitites due to predominantly demyelinating sensorimotor neuropathy.
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What shows hyperviscosity?
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What shows hyperviscosity? Retinal vein engorgement in Waldenstrom Macroglobulinemia. Due to too much IgM
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How does Tumor Lysis syndrome cause changes in Calcium, Phosphate, Potassium, and Uric Acid?
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How does Tumor Lysis syndrome cause changes in Calcium, Phosphate, Potassium, and Uric Acid? --- Tumor Lysis syndrome cause changes in Calcium - Decrease, Phosphate - Increase, Potassium - Increase, and Uric Acid - Increase. Tumor lysis syndrome causes HyperPhophatemia, hypoCalcemia, HyperKalemia, and HyperUricemia.
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What disease do you see Tumor Lysis Syndrome?
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What disease do you see Tumor Lysis Syndrome? Associated with Tumor with high cell turnovers. Poorly differentiated lymphomas (Burkitt Lymphoma), Leukemias (mostly ALL, and less frequently AML). Allopurinol reduced acute urate nphopathy to a large extend, possibility of tumor lysis syndrome remains. TLS can lead to fatal arrhythmias, acute renal failure, and even sudden death.
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35 yo Caucasian male diagnosed with ulcerative colitis involving left and right colon eight years ago comes for routine follow up. Complains of occasional crampy abdominal pains and infrequent diarrhea. He is maintained on daily 5-aminosalicylic acid. He had an exacerbation of colitis six months ago which was treated with oral steroids and antibiotics. He smokes one pack per day. His family history is negative for inflammatory bowel disease and cancer. On physical examination, he has mild tenderness in the left lower abdominal quadrant. He asks about his risks of colon cancer and appropriate surveillance if applicable. What is the best response?
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35 yo Caucasian male diagnosed with ulcerative colitis involving left and right colon eight years ago comes for routine follow up. Complains of occasional crampy abdominal pains and infrequent diarrhea. He is maintained on daily 5-aminosalicylic acid. He had an exacerbation of colitis six months ago which was treated with oral steroids and antibiotics. He smokes one pack per day. His family history is negative for inflammatory bowel disease and cancer. On physical examination, he has mild tenderness in the left lower abdominal quadrant. He asks about his risks of colon cancer and appropriate surveillance if applicable. What is the best response? ---- Offer colonoscopy Now and then every year. Ulcerative colitis at an increased risk for development of colorectal cancer. Most guidelines state that pt should begin colonoscopy surveillance 8 years after diagnosis, possibly longer if only the left colon is involved. Once a surveillance program is started, colonoscopy should be repeated every 1-2 years to assess for development of colonic dysplasia.
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What is ulcerative colitis increased risk of developing? When to start screening?
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What is ulcerative colitis increased risk of developing? When to start screening? --- Ulcerative colitis is an increased risk for development of colorectal cancer. Most guidelines state that pt should begin colonoscopy surveillance 8 years after diagnosis, possibly longer if only the left colon is involved. Once a surveillance program is started, colonoscopy should be repeated every 1-2 years to assess for development of colonic dysplasia.
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For ulcerative colitis, what is screening plan? What involvement is less severe and longer screening period?
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For ulcerative colitis, what is screening plan? What involvement is less severe and longer screening period? --- Ulcerative colitis should begin colonoscopy surveillance 8 years after diagnosis, possibly longer if only the left colon is involved. Once a surveillance program is started, colonoscopy should be repeated every 1-2 years to assess for development of colonic dysplasia. Colonic dysplasia on biopsies is highly associated with progression to adenocarcinoma. It require a Total colectomy if dysplasia is identified.
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For ulcerative colitis, dysplasia is found on biopsy. Next Step?
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For ulcerative colitis, dysplasia is found on biopsy. Next Step? Total colectomy
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45 yo previously healthy male is brought to ER because of headaches and confusion for 2 days. Temp 100.2 F, Bp 140 over 86, Pulse 96. Mild icterus. Hemoglobin 8.4, Platelet 80k, Leukocyte 5500, BUN 30, Creatinine 2.2, Serum Calcium 10, Blood glucose 98. Peripheral blood smear shows many fragmented RBC. PT is normal. Next step?
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45 yo previously healthy male is brought to ER because of headaches and confusion for 2 days. Temp 100.2 F, Bp 140 over 86, Pulse 96. Mild icterus. Hemoglobin 8.4, Platelet 80k, Leukocyte 5500, BUN 30, Creatinine 2.2, Serum Calcium 10, Blood glucose 98. Peripheral blood smear shows many fragmented RBC. PT is normal. Next step? --- Plasma Exchange. Unexplained hemolytic anemia and Thrombocytopenia in pt with Renal Failure and Neurologic symptoms should raise strong suspicions for TTP-HUS. Fragmented cells in peripheral smear suggests Microangiopathic Hemolytic Anemia (MAHA), a characteristic finding in TTP-HUS.
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What is vom Willebrand factor cleaving protease?
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What is vom Willebrand factor cleaving protease? ADAMTS-13. Defective ADAMTS-13 is cause of von Willebrand factor multimers and platelet aggregation in TTP-HUS. Plasmapheresis repletes ADAMTS-13.
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Unexplained Hemolytic Anemia, Thrombocytopenia, Renal Failure, and Neurologic symptoms. Dx?
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Unexplained Hemolytic Anemia, Thrombocytopenia, Renal Failure, and Neurologic symptoms. Dx? TTP-HUS. ART (Anemia, Renal failure, Thrombocytopenia). FAT RN (Fever, Anemia, Thrombocytopenia, Renal failure, Neurological symptoms).
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What is transfusion indication for healthy? CAD and CHF?
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What is transfusion indication for healthy? CAD and CHF? Transfusion is indicated at Hemoglobin Less than 7-8 for Healthy. Hemoglobin Less than 10 for CAD and CHF.
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What does Cryoprecipitate contains?
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What does Cryoprecipitate contains? Fibrinogen.
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Fibrinogen replacement. Tx?
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Fibrinogen replacement. Tx? Cryoprecipitate
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55 yo woman comes with complaints of episodes of night sweats and fever, for the last 6 weeks. She has lost 20 lb and does not feel like eating anything. Her brother was recently diagnosed with polycythemia vera. Pallor and Splenomegaly. WBC 66k, Hemoglobin 8.7, Hematocrit 30 perc, Platelet 610k. Leukocyte distribution on differential smear - Promyelocyte 1 perc, Myelocyte 8 perc, Metamyelocyte 15 perc, Bands 35 perc, Segmented neutrophils 25 perc, Lymphocytes 14 perc, MOnocytes 2 perc. What is expected in this pt?
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55 yo woman comes with complaints of episodes of night sweats and fever, for the last 6 weeks. She has lost 20 lb and does not feel like eating anything. Her brother was recently diagnosed with polycythemia vera. Pallor and Splenomegaly. WBC 66k, Hemoglobin 8.7, Hematocrit 30 perc, Platelet 610k. Leukocyte distribution on differential smear - Promyelocyte 1 perc, Myelocyte 8 perc, Metamyelocyte 15 perc, Bands 35 perc, Segmented neutrophils 25 perc, Lymphocytes 14 perc, MOnocytes 2 perc. What is expected in this pt? ---- Decreased Leukocyte Alkaline Phosphatase. CML - Leukocytosis, Anemia, Increased number of Mature Granulocytic forms (Segmented Neutrophils and Band forms) on peripheral blood film. Mostly seen after age of 50 and resents with fatigue, malaise, low-grade fever, anorexia, weight loss and bone pains. Bone Marrow biopsy - Hypercellularity with Prominent Granulocytic Hyperplasia. LAP Low. Philadelphia chromosome.
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Low LAP with Leukocytosis. Dx?
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Low LAP with Leukocytosis. Dx? CML - Leukocytosis, Anemia, Increased number of Mature Granulocytic forms (Segmented Neutrophils and Band forms) on peripheral blood film. Mostly seen after age of 50 and resents with fatigue, malaise, low-grade fever, anorexia, weight loss and bone pains. Bone Marrow biopsy - Hypercellularity with Prominent Granulocytic Hyperplasia. LAP Low. Philadelphia chromosome.
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What diseases has Low LAP score?
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What diseases has Low LAP score? 1 CML, 2 Hypophosphatemia, 3 PNH.
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Increased bone marrow iron. Dx?
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Increased bone marrow iron. Dx? 1 Hemachromatosis, 2 Anemia of Chronic disease, 3 Sideroblastosis
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Absence of measurable erythropoietin in urine. Dx?
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Absence of measurable erythropoietin in urine. Dx? Polycythemia vera
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Auer Rods. Dx?
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Auer Rods. Dx? AML
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Tartrate resistant acid phosphatase. Dx?
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Tartrate resistant acid phosphatase. Dx? Hairy cell leukemia.
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55 yo Caucasian male hospitalized after a massive hemorrhage from duodenal ulcer. Hemorrhage was stopped with endoscopic manipulation. Two liters of Ringer lactate was infused, and two units of pRBC ordered. Ten minutes after transfusion of packed RBC had been started, pt was complaining of tremor and feeling Chilly. Temp 103 F. Transfusion was stopped, and acetaminophen was given. Direct antiglobulin test and plasma free hemoglobin level are negative. Urinalysis is normal. Reaction abated three hours after transfusion had started. What action could have prevented the reaction described?
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55 yo Caucasian male hospitalized after a massive hemorrhage from duodenal ulcer. Hemorrhage was stopped with endoscopic manipulation. Two liters of Ringer lactate was infused, and two units of pRBC ordered. Ten minutes after transfusion of packed RBC had been started, pt was complaining of tremor and feeling Chilly. Temp 103 F. Transfusion was stopped, and acetaminophen was given. Direct antiglobulin test and plasma free hemoglobin level are negative. Urinalysis is normal. Reaction abated three hours after transfusion had started. What action could have prevented the reaction described? --- Washing cells (wash donor leukocyte). Febrile reaction is a common transfusion reaction that is caused by antibodies in pt plasma reacting with donor leukocytes. Leukocyte depletion techniques, like Cell Washing, decrease the probability of febrile, nonhemolytic transfusion reaction.
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62 yo Caucasia man with occasioal ear pain and a lump in his neck. Hypertension treated with hydrochlorothiazide and diabetes mellitus treated wtih metformin. Smokes two packs of cigarettes per day and consumes alcohol occasionally. Hard, non-tender submandibular mass that is 3 cm in diameter. Liver span is 8 cm. Most likely cause of complaint?
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62 yo Caucasia man with occasioal ear pain and a lump in his neck. Hypertension treated with hydrochlorothiazide and diabetes mellitus treated wtih metformin. Smokes two packs of cigarettes per day and consumes alcohol occasionally. Hard, non-tender submandibular mass that is 3 cm in diameter. Liver span is 8 cm. Most likely cause of complaint? --- Squamous cell carcinoma. Firm, solitary lymph nodes are highly suspicious for lymph node metastases, particularly in older pts with significant smoking history. Non-tender, solitary nodes in head and neck are concerning for squamous cell carcinoma.
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62 yo male, firm solitary submandibular lymph node, smoking. Dx?
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62 yo male, firm solitary submandibular lymph node, smoking. Dx? Squamous cell carcinoma (sCa++mous carcinoma)
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What is most common cause of folic acid deficiency? other cause?
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What is most common cause of folic acid deficiency? other cause? 1 Nutritional due to poor diet and_or Alcoholism. Other cause - 2 Drugs Impairs absorption of folic acid in small intestine (Anti-epileptic - Phenytoin, Primidone, and Phenobarbital), or 2 Drugs antagonize folic acid physiologic effects (Inhibit dihydrofolate reductase - Trimethoprim, Methotrexate. Methotrexate requires Folinic acid - Leucovorin to reverse effect)
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What is classical triad of glucagonoma? Lx?
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What is classical triad of glucagonoma? Lx? 1 Hyperglycemia, 2 Necrotizing migratory erythema (ex erythematous scaly plaques on face), 3 Diarrhea. Lx - Confirmed - Elevated levels of Fasting glucose, and Serum Glucagon. CT scan.
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39 yo woman complains of double vision. Feels Weak all Over, especially end of the day. Same complaints 8 months ago that persisted for several weeks, but she did not see a doctor because no insurance. Mother has rheumatoid arthritis, and brother has type 1 diabetes mellitus. She has diplopia and mild ptosis. Electromyography and repetitive nerve stimulation reveals a decremental response in compound action potentials. Her acetylcholine receptor antibody test is positive. What test should be ordered?
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39 yo woman complains of double vision. Feels Weak all Over, especially end of the day. Same complaints 8 months ago that persisted for several weeks, but she did not see a doctor because no insurance. Mother has rheumatoid arthritis, and brother has type 1 diabetes mellitus. She has diplopia and mild ptosis. Electromyography and repetitive nerve stimulation reveals a decremental response in compound action potentials. Her acetylcholine receptor antibody test is positive. What test should be ordered? --- CT scan of chest to look for Thymoma. All newly-diagnosed myasthenia gravis should have CT chest to look for Thymoma.
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What is Myasthenia Gravis? Px? Lx? Tx?
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What is Myasthenia Gravis? Px? Lx? Tx? --- Myasathenia Gravis can affect muscles anywhere in body. Most common symptoms relate to weakness of muscles that lift up the lid (Ptosis) or Move the eyes (Double Vision). SOB or Difficulty swallowing may be very serious. MG does not produce Pain or Numbness. Lx - MA - 1 Electromyogram (EMG) and 2 Acetylcholine receptor antibody test. Lx - 3 CT chest for Thymoma. Tx - Thymectomy.
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Ptosis and Double vision. Dx?
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Ptosis and Double vision. Dx? Myasthenia Gravis. Weakness of muscles that lift up the lid (Ptosis) or Move the eyes (Double Vision). SOB or Difficulty swallowing may be very serious. MG does not produce Pain or Numbness.
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Electromyogram with repetitive nerve stimulation shows a decremental response in compound action potentials. Dx?
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Electromyogram with repetitive nerve stimulation shows a decremental response in compound action potentials. Dx? --- Myasthenia Gravis. Lx - MA - 1 Electromyogram (EMG) and 2 Acetylcholine receptor antibody test. Lx - 3 CT chest for Thymoma. Tx - Thymectomy.
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Acetylcholine receptor antibody test. Dx?
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Acetylcholine receptor antibody test. Dx? --- Myasthenia Gravis. Most common symptoms relate to weakness of muscles that lift up the lid (Ptosis) or Move the eyes (Double Vision). SOB or Difficulty swallowing may be very serious. MG does not produce Pain or Numbness. Lx - MA - 1 Electromyogram (EMG) and 2 Acetylcholine receptor antibody test. Lx - 3 CT chest for Thymoma. Tx - Thymectomy.
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What is most common cause of Myasthenia Gravis?
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What is most common cause of Myasthenia Gravis? Thymoma. Most common symptoms relate to weakness of muscles that lift up the lid (Ptosis) or Move the eyes (Double Vision). SOB or Difficulty swallowing may be very serious. MG does not produce Pain or Numbness. Lx - MA - 1 Electromyogram (EMG) and 2 Acetylcholine receptor antibody test. Lx - 3 CT chest for Thymoma. Tx - Thymectomy.
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Anti-Jo antibodies and Anti-RNP antibodies. Dx?
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Anti-Jo antibodies and Anti-RNP antibodies. Dx? Polymyositis and Mixed Connective Tissue disease.
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48 yo white female undergoing a routine work-up 9 months after radical mastectomy due to right-sided breast cancer. Full of energy. Chest radiograph reveals an isolated pulmonary nodule, 2 cm in diameter, in middle lobe of right lung. CT confirms that the lesion is solitary with poorly defined margins, but completely within lung parenchyma. Bone scan is negative. CT abdomen and pelvis is normal. Transthoracic biopsy demonstrates adenocarcinoma with positive estrogen receptors (ER) and no HER-2_neu overexpression. Best management strategy?
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48 yo white female undergoing a routine work-up 9 months after radical mastectomy due to right-sided breast cancer. Full of energy. Chest radiograph reveals an isolated pulmonary nodule, 2 cm in diameter, in middle lobe of right lung. CT confirms that the lesion is solitary with poorly defined margins, but completely within lung parenchyma. Bone scan is negative. CT abdomen and pelvis is normal. Transthoracic biopsy demonstrates adenocarcinoma with positive estrogen receptors (ER) and no HER-2_neu overexpression. Best management strategy? --- Surgery. Local therapy (Resection of metastases, Local irradiation) is rarely curative in pt with metastatic breast cancer, but it can be tried in pts with a resectable solitary metastatic focus without signs of systemic involvement.
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52 yo female is being evaluated for areas of microcalcifications in Right upper quadrant of right breast detected on a routine screening mammogram. Hypertension and kidney stones. Smokes one pack of cigarettes per day and consumes 1-2 cans of beer daily. Core needle biopsy of area is consistent with invasive ductal carcinoma. She undergoes breast-conserving surgery that reveals 2.1 cm adenocarcinoma with clear margins. Which patholoic markers has most impact on future management of this pt?
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52 yo female is being evaluated for areas of microcalcifications in Right upper quadrant of right breast detected on a routine screening mammogram. Hypertension and kidney stones. Smokes one pack of cigarettes per day and consumes 1-2 cans of beer daily. Core needle biopsy of area is consistent with invasive ductal carcinoma. She undergoes breast-conserving surgery that reveals 2.1 cm adenocarcinoma with clear margins. Which patholoic markers has most impact on future management of this pt? --- Oncogene amplification by FISH. Pt had breast conserving surgery she will likely need radiation therapy, and adjuvant chemotherapy will likely eb needed as well given the size of tumor. Important factor for both prognosis and treatment is presence of overexpression in HER2 oncogene. The level of HER2 expression can be determined either by Fluorescent in Situ hybridization (FISH) or ImmunoHistochemical (IHC) staining. HER2 overexpression allows one to treat with Trastuzumab. (Herceptin). They have more positive response to Anthracyclines.
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How is HER2 oncogene overexpression detected?
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How is HER2 oncogene overexpression detected? 1 FISH (Fluorescent in situ Hybridization), 2 ImmunoHistochemical Staining (IHS)
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What does Breast cancer with S-phase fraction by flow cytometry means?
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What does Breast cancer with S-phase fraction by flow cytometry means? Higher level of proliferation and poor prognosis.
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What is the most common type of intracranial brain tumors?
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What is the most common type of intracranial brain tumors? Metastatic brain tumor. Metastatic lesions are usually seen at Grey-White matter junction. Brain metastasis is frequently seen in Non Small cell lung carcinoma (NSCLC)
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65 yo Hispanic male in ER after having one seizure episode. Non-Small cell lung carcinoma, which was diagnosed two years ago and treated surgically. CT scan of brain with contrast now shows a solitary cortical mass in right hemisphere of brain at gray-white matter junction. Started on Phenytoin. Most appropriate management?
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65 yo Hispanic male in ER after having one seizure episode. Non-Small cell lung carcinoma, which was diagnosed two years ago and treated surgically. CT scan of brain with contrast now shows a solitary cortical mass in right hemisphere of brain at gray-white matter junction. Started on Phenytoin. Most appropriate management? --- Surgical Resection of Mass. Surgical resection followed by whole brain radiation is standard practice in management of Solitary brain metastasis with Stable Extracranial disease. Multiple brain metastases are best treated wtih palliative whole brain radiation.
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Solitary metastatic brain tumor with Stable extracranial disease. Next Step?
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Solitary metastatic brain tumor with Stable extracranial disease. Next Step? --- Surgical Resection of Mass. Surgical resection followed by whole brain radiation is standard practice in management of Solitary brain metastasis with Stable Extracranial disease. Multiple brain metastases are best treated wtih palliative whole brain radiation.
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64 yo male had undergone an emergency colonic resection following an extensive ischemic colitis. Surgery was uneventful. On piperacillin and tazobactam for past five days. NOP for past five days. Significant alcoholic history. On postoperative day six, he developed bleeding from the venipuncture site. Hb 11.5, MCV 88, Platelet 160k, Leukocyte 7500, PT 20 sec (INR = 1.9), PTT 45 sec. Most likely cause of his condition?
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64 yo male had undergone an emergency colonic resection following an extensive ischemic colitis. Surgery was uneventful. On piperacillin and tazobactam for past five days. NOP for past five days. Significant alcoholic history. On postoperative day six, he developed bleeding from the venipuncture site. Hb 11.5, MCV 88, Platelet 160k, Leukocyte 7500, PT 20 sec (INR = 1.9), PTT 45 sec. Most likely cause of his condition? --- Vitamin K deficiency. Vitamin K Deficiency is seen in pt who has been kept NPO for a prolonged period of time and receiving broad-spectrum antibiotics. Labs show Prolongation of PT followed by prolonged PTT. PT is elevated more than PTT. Similar presentation of Vitamin K deficiency in newborn who had not received prophylactic vitamin K (home born) for the prevention of hemorrhagic disease of newborn.
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Post operative, NPO five days, Antibiotics five days, Venipuncture site bleeding. Dx?
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Post operative, NPO five days, Antibiotics five days, Venipuncture site bleeding. Dx? --- Vitamin K Deficiency. Vitamin K from 2 sources - 1 Exogenous from food (absorb in small intestine), 2 Exogenous from bacterial production of vitamin K in intestine. 3 Vitamin K storage (30 days in normal liver). Sick person becomes deficient in 7-10 days. Vitamin K deficiency leads to a fall in plasma levels of all prothrombin complex proteins (factor 2, 7, 9, 10, and Protein C and S). Prolonged PT, followed by prolonged PTT. Tx - 1 Vitamin K takes 8-10 hours, 2 FFP in acute hemorrhage.
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54 yo male with chronic cough and recent bloody sputum. Smoke 2 packs of cigarettes daily for 22 years, but quit last month. Other symptoms are weight loss, anorexia, constipation, increased thirst, and easy fatigability. He thinks he is depressed because his wife died 4 months ago and Life never Felt the same After that. Slim man who appears pals. A little irritable and SOB. Sodium 144, Potassium 4.3, Calcium 12.9, BUN 28, CXR Hilar mass in left lung. Biopsy of mass would most likely reveal?
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54 yo male with chronic cough and recent bloody sputum. Smoke 2 packs of cigarettes daily for 22 years, but quit last month. Other symptoms are weight loss, anorexia, constipation, increased thirst, and easy fatigability. He thinks he is depressed because his wife died 4 months ago and Life never Felt the same After that. Slim man who appears pals. A little irritable and SOB. Sodium 144, Potassium 4.3, Calcium 12.9, BUN 28, CXR Hilar mass in left lung. Biopsy of mass would most likely reveal? --- Squamous cell carcinoma of lung. SquamousCC - sCa++mous. Smoking history, Hypercalcemia, Hilar Mass. Hypercalcemia from PTHrP - Increase calcium resorption from bone.
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Hypercalcemia, Hilar mass, smoking. Dx?
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Hypercalcemia, Hilar mass, smoking. Dx? Squamous cell carcinoma. sCa++mous. Hypercalcemia from PTHrP - Increase calcium resorption from bone.
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lung cancer, paraneoplastic syndromes. Dx?
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lung cancer, paraneoplastic syndromes. Dx? Small cell carcinoma of lung. ACTH production and SIADH
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75 yo male who underwent surgery for prostate cancer six months ago presents to ER with worsening back pain for past 2-3 days. Fallen three times since yesterday due to Imbalance. Muscle power in his lower extremities is 4 out of 5 bilaterally, with mild spasticity and brisk deep tendon reflexes. Rectal sphincter tone is weak. Point tenderness over midline L5 and S1 region. Most appropriate next step in management?
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75 yo male who underwent surgery for prostate cancer six months ago presents to ER with worsening back pain for past 2-3 days. Fallen three times since yesterday due to Imbalance. Muscle power in his lower extremities is 4 out of 5 bilaterally, with mild spasticity and brisk deep tendon reflexes. Rectal sphincter tone is weak. Point tenderness over midline L5 and S1 region. Most appropriate next step in management? --- Dexamethasone (reduce swelling and preserve neurologic function). Compression of thecal sac should be suspected in any pt with a history of cancer or fever who presents with back pain and neurologic symptoms, particularly loss of bowel or bladder function. An MRI is most commonly used to confirm the diagnosis, but Glucocorticoid treatment should be started while awaiting test results in order to decrease the risk of permanent neurologic damage.
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Point tenderness over spine processes of L5 and S1. Dx?
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Point tenderness over spine processes of L5 and S1. Dx? Spinal Cord Compression.
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34 yo white man with easy fatigability, difficulty concentrating, insomnia, and occasional muscle pain. Right hand clumsiness and some memory loss. Drinks one to two can sof beer on weekends. Extensor weakness of right hand. Hemoglobin 8.5, MCV 81, Creatinine 2.1. most important in revealing the cause of pt condition?
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34 yo white man with easy fatigability, difficulty concentrating, insomnia, and occasional muscle pain. Right hand clumsiness and some memory loss. Drinks one to two can sof beer on weekends. Extensor weakness of right hand. Hemoglobin 8.5, MCV 81, Creatinine 2.1. most important in revealing the cause of pt condition? --- Occupational history. Neurologic abnormalities, Renal disease, and Anemia with Low-Normal MCV suggest Lead Poisoning.
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Extensor weakness. What does it suggest?
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Extensor weakness. What does it suggest? Peripheral neuropathy.
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Occuption - solder, paint, car radiators, batteries, pigments, smelting, and refining. Dx?
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Occuption - solder, paint, car radiators, batteries, pigments, smelting, and refining. Dx? Lead poisoning. solder, paint, car radiators, batteries, pigments, lead glazes, smelting, and refining.
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GI complaint, poor concentration, and anemia. Dx?
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GI complaint, poor concentration, and anemia. Dx? Lead poisoning. Tx - exposure reduction and Lead chelator (EDTA).
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What are the steps to breaking bad news?
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What are the steps to breaking bad news? --- 1 Environment - make sure pt is in a quiet, private and comfortable environment. 2 Gauge knowledge - Ask pt how much he knows, or what he thinks he might have. This will give you an idea of what his expectations are. What do you think of your symptoms? 3 Interest - Ask pt How much he wants to know. How much would you like to know about your condition?. 4 Warning shot - Give him a warning shot. Unfortunately, the situation is more serious than what I earlier thought. 5 Tell Bad news - Break the news if he want you to. The results show that you have advanced lung cancer. 6 Give Prognosis - Future. Give his prognosis, but always keep him aware of all the options available to make his life as comfortable as possible. 7 Explain - Try to explain everything as clearly and simple as possible.
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How to break bad news?
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How to break bad news? --- SPIKES, STEP 1: S—SETTING UP the Interview, STEP 2: P—Assessing the Patient's PERCEPTION, STEP 3: I—Obtaining the Patient's INVITATION, STEP 4: K—Giving KNOWLEDGE and Information to the Patient, STEP 5: E—Addressing the Patient's EMOTIONS with Empathic Responses, STEP 6: S—STRATEGY and SUMMARY
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62 yo woman complains of recurrent cough productive of yellow sputum. She was seen several weeks ago for similar complaints and was effectively treated with a course of azithromycin. Today she expresses frustration that she seems to keep getting sick with the same infection. On review of systems pt also reports recent-onset back pain for which she has been taking acetaminophen. Her past medical history is otherwise insignificant. She has never smoked cigarettes and drinks alcohol only on rare social occasions. Physical examination reveals conjunctival pallor, a few scattered rales in lungs bilaterally, and tenderness over the lumbar vertebrae. Hemoglobin 8.4, Leukocyte count 5500, BUN 34, Creatinine 2.0, Calcium 10.9, Albumin 3.8, Total protein 9.5. Pt is at increased risk for recurrent infections because of which of the following abnormalities?
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62 yo woman complains of recurrent cough productive of yellow sputum. She was seen several weeks ago for similar complaints and was effectively treated with a course of azithromycin. Today she expresses frustration that she seems to keep getting sick with the same infection. On review of systems pt also reports recent-onset back pain for which she has been taking acetaminophen. Her past medical history is otherwise insignificant. She has never smoked cigarettes and drinks alcohol only on rare social occasions. Physical examination reveals conjunctival pallor, a few scattered rales in lungs bilaterally, and tenderness over the lumbar vertebrae. Hemoglobin 8.4, Leukocyte count 5500, BUN 34, Creatinine 2.0, Calcium 10.9, Albumin 3.8, Total protein 9.5. Pt is at increased risk for recurrent infections because of which of the following abnormalities? --- Inability to produce effective antibodies. Multiple Myeloma is a hematologic malignancy marked by a monoclonal proliferation of plasma cells. The classic tetrad of multiple myeloma signs and symptoms can be remembered using mnemonic CRAB - Calcium (HyperCalcemia), Renal impairment, Anemia, and Bones (Bone pain, lytic lesions, fractures). IgG antibodies, or Paraproteins, produced by myeloma cells can collect in glomeruli, causing renal failure, or Myeloma kidney. Paraprotein gap (More than 4. Normal is 3-4).
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Multiple Myeloma tetrad?
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Multiple Myeloma tetrad? CRAB - Calcium (HyperCalcemia), Renal impairment, Anemia, and Bones (Bone pain, lytic lesions, fractures). IgG antibodies, or Paraproteins, produced by myeloma cells can collect in glomeruli, causing renal failure, or Myeloma kidney. Paraprotein gap (More than 4. Normal is 3-4).
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Complement deficiencies cannot effectively opsonize pathogens. Recurrent infection with what?
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Complement deficiencies cannot effectively opsonize pathogens. Recurrent infection with what? Encapsulated bacteria.
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What does Deficiency of any component of terminal membrane attack complex (MAC) causes? Recurrent infection with what?
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What does Deficiency of any component of terminal membrane attack complex (MAC) causes? Recurrent infection with what? --- Bacterial lysis defect. Neisseria infection frequent.
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What is Cladribine tx for? AE?
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What is Cladribine tx for? AE? Cladribine (2-ChloroDeoxyAdenosine, 2-CdA) is toxic to bone marrow. Tx Hairy Cell Leukemia. AE - CNS and Kidney damage.
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What is 2-CdA? Tx for? AE?
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What is 2-CdA? Tx for? AE? --- Cladribine (2-ChloroDeoxyAdenosine, 2-CdA) is toxic to bone marrow. Tx Hairy Cell Leukemia. AE - CNS and Kidney damage.
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What is 2-ChloroDeoxyAdenosine? Tx for? AE?
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What is 2-ChloroDeoxyAdenosine? Tx for? AE? --- Cladribine (2-ChloroDeoxyAdenosine, 2-CdA) is toxic to bone marrow. Tx Hairy Cell Leukemia. AE - CNS and Kidney damage.
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What is the Lx finding for Alpha-Thalassemia minor and Beta-Thalassemia minor?
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What is the Lx finding for Alpha-Thalassemia minor and Beta-Thalassemia minor? --- Alpha-Thalassemia minor (Normal Hemoglobin Electrophoresis) and Beta-Thalassemia minor (Elevated Hemoglobin A2 on Electrophoresis)
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What to monitor for TTP plasmapheresis effectiveness?
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What to monitor for TTP plasmapheresis effectiveness? Rates of recovery (usually defined as normalization of platelet count and LDH level) are High if therapy is given promptly.
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Fragmented RBC. Suspect Dx?
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Fragmented RBC. Suspect Dx? TTP-HUS
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56 yo man with fatigue and occasional palpitations. 20 year history of diabetes mellitus and takes daily insulin therapy. He receives hemodialysis three times a week for end-stage renal disease. He was recently started on erythropoietin therapy for anemia (his pretreatemetn hemoglobin was 8.0). Pale conjunctiva. Hemoglobin 9.2, MCV 77, MCHC 30, WBC 7000, Platelets 150k, Hemoglobin A1c 7.5, ESR 15. What is likely to be helpful in improving symptoms?
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56 yo man with fatigue and occasional palpitations. 20 year history of diabetes mellitus and takes daily insulin therapy. He receives hemodialysis three times a week for end-stage renal disease. He was recently started on erythropoietin therapy for anemia (his pretreatemetn hemoglobin was 8.0). Pale conjunctiva. Hemoglobin 9.2, MCV 77, MCHC 30, WBC 7000, Platelets 150k, Hemoglobin A1c 7.5, ESR 15. What is likely to be helpful in improving symptoms? --- Iron supplementation. Anemia of chronic kidney disease is due to erythropoietin deficiency. One must be careful to ensure adequate iron stores prior to erythropoietin replacement because the erythropoietin-induced surge in RBC production can precipitate an iron-deficient state.
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60 yo HIspanic laboratory technician presents with increasing fatigue and generalized weakness for the last 2 months. He also has chronic pain in the lower back and legs when he walks. He has been smoking 2-3 packs of cigarettes daily for 30 years, and drinks alcohol almost daily. His mother has diabetes, while his father died of a stroke. Physical examination reveals pallor. There is mild hepatomegaly. Hemoglobin 9.8, MCV 85, Platelet 226k, Leukocyte 6500, BUN 28, Serum Creatinine 2.1, Calcium 11.2, Alkaline phosphatase 110, AST 58, ALT 25. ESR 100. Best next step in management?
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60 yo HIspanic laboratory technician presents with increasing fatigue and generalized weakness for the last 2 months. He also has chronic pain in the lower back and legs when he walks. He has been smoking 2-3 packs of cigarettes daily for 30 years, and drinks alcohol almost daily. His mother has diabetes, while his father died of a stroke. Physical examination reveals pallor. There is mild hepatomegaly. Hemoglobin 9.8, MCV 85, Platelet 226k, Leukocyte 6500, BUN 28, Serum Creatinine 2.1, Calcium 11.2, Alkaline phosphatase 110, AST 58, ALT 25. ESR 100. Best next step in management? --- Serum Immunoelectrophoresis - Abnormal M-spike due to IgG antibody by abnormal plasma cells - Multiple Myeloma.
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ANA and Anti-Smith antibody titers. Dx?
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ANA and Anti-Smith antibody titers. Dx? Autoimmune disease - SLE, and other autoimmune diseae.
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Cancer, moderate hypercalcemia. Tx?
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Cancer, moderate hypercalcemia. Tx? Bisphosphonates
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27 yo African American woman presents to ER complaining of unilateral leg swelling, pleuritic chest pain and SOB. She reports a rash on her face that worsens in the sun, two previous miscarriages, and complains of recent painful swelling in both knees. CT angiogram confirms a pulmonary embolus. Most like laboratory abnormality?
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27 yo African American woman presents to ER complaining of unilateral leg swelling, pleuritic chest pain and SOB. She reports a rash on her face that worsens in the sun, two previous miscarriages, and complains of recent painful swelling in both knees. CT angiogram confirms a pulmonary embolus. Most like laboratory abnormality? --- Prolonged PTT. Acute Venous Thromboembolic (VTE) disease (DVT and PE) and classic symptoms of Systemic lupus erythematosus (SLE). In pt with SLE and VTE, Lupus Anticoagulant, or Anti-Phospholipid Antibody Syndrome must be suspected. Lx - MA - Russel Viper Venom test
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DVT, SLE. Suspect?
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DVT, SLE. Suspect? Lupus Anticoagulant, or Anti-Phospholipid antibody. Prolonged PTT. Lx - MA - Russel Viper Venom test.
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African American female, rash on her face that worsens in sun. Dx?
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African American female, rash on her face that worsens in sun. Dx? SLE
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What is Warfarin? Function?
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What is Warfarin? Function? Warfarin is Anticoagulant agent. It Inhibite synthesis of vitamin K-dependent factors - 2, 7, 9, and 10 (Prothrombin), Protein C and S. Warfarin Decreases circulating concentrations of factors 2, 7, 9, 10, Protein C and S. It can cause a false positive test for Protein S deficiency.
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How does Heparin work?
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How does Heparin work? Activates AntiThrombin 3
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How does Aspirin work?
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How does Aspirin work? AntiPlatelet agent that functions by inhibiting Cyclooxygenase-1, thereby inhibiting Thromboxane A2 synthesis.
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How does Clopidogrel work?
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How does Clopidogrel work? Antiplatelet agent that prevents platelet activation by blocking platelet surface ADP receptors.
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Newly diagnosed diabetes, hepatomegaly, and arthropathy. Dx?
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Newly diagnosed diabetes, hepatomegaly, and arthropathy. Dx? Hemochromatosis.
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40 yo male comes to office because of progressive knee and shoulder pain, which he describes as 5 out of 10 in intensity and started 6 months ago. He has no other medical problems, except for newly diagnosed diabetes. He admits to Chain Smoking for All His Life and drinks 1-2 bottles of beer a night. He is in a monogamous relationship. His mother died of Blood Cancer when he was 3 yo. His father has diabetes mellitus. Temp 98.6 F, Bp 134 over 86. Slightly swollen and tender knee joints. Mild hepatomegaly is present on abdominal examination. What is the best next step in management?
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40 yo male comes to office because of progressive knee and shoulder pain, which he describes as 5 out of 10 in intensity and started 6 months ago. He has no other medical problems, except for newly diagnosed diabetes. He admits to Chain Smoking for All His Life and drinks 1-2 bottles of beer a night. He is in a monogamous relationship. His mother died of Blood Cancer when he was 3 yo. His father has diabetes mellitus. Temp 98.6 F, Bp 134 over 86. Slightly swollen and tender knee joints. Mild hepatomegaly is present on abdominal examination. What is the best next step in management? ---- Serum Iron Studies. Suspect Hemochromatosis (Autosomal Recessive) in a pt with New-Onset Diabetes, Arthropathy, and Hepatomegaly. Iron deposition in tissue - damage organs - Liver (Risk of Hepatocellular carcinoma), Pancreas, Heart, and Pituitary. Iron studies shows - Increased levels of Serum Iron, Ferritin, and Transferrin Saturation. Liver biopsy - Confirm diagnosis.
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55 yo woman comes with complaints of episodes of night sweats and fever, for last 6 weeks. She has lost 20 lb and does not feel like eating anything. Her brother was recently diagnosed with polycythemia vera. Physical examination reveals pallor and splenomegaly. WBC 66k, Hemoglobin 8.7, Hematocrit 30 perc, Platelets 610k. Leukocyte distribution on differtial smear - Promyelocyte 1p, Myelocyte 8p, Metamyelocyte 15p, Bands 35p, Segmented neutrophils 25p, Lymphocytes 14p, Monocytes 2p. What is expected in this pt?
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55 yo woman comes with complaints of episodes of night sweats and fever, for last 6 weeks. She has lost 20 lb and does not feel like eating anything. Her brother was recently diagnosed with polycythemia vera. Physical examination reveals pallor and splenomegaly. WBC 66k, Hemoglobin 8.7, Hematocrit 30 perc, Platelets 610k. Leukocyte distribution on differtial smear - Promyelocyte 1p, Myelocyte 8p, Metamyelocyte 15p, Bands 35p, Segmented neutrophils 25p, Lymphocytes 14p, Monocytes 2p. What is expected in this pt? --- CML - Decreased LAP. CML - Leukocytosis, Anemia, and Increased number of Mature granulocytic forms (Segmented Neutrophils and Band forms on peripheral blood film). The disease is mostly seen after the age of 50 and presents with fatigue, malaise, low-grade fever, anorexia, weight loss and bone pains. Night sweats and fever associated with increased metabolism due to granulocytic cell turn over may occur.
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Leukocytosis, Anemia, and Increased number of mature granulocytic forms. Dx?
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Leukocytosis, Anemia, and Increased number of mature granulocytic forms. Dx? CML
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Macrocytosis, Vitiligo. Dx?
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Macrocytosis, Vitiligo. Dx? Pernicious Anemia
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What is telangiectasia?
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What is telangiectasia? Chronic dilatation of capillaries and other small blood vessels.
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27 yo man in ER with unremitting nose bleeding. He reports having a similar bleeding episode one year ago that was stopped in ER. He works as a computer programmer and has a sedentary lifestyle. He drinks alcohol on social occasions but does not smoke or use illicit substances. ON physical examination, there are several ruby-colored papules on his lips that blanch partially with pressure. Digital clubbing is also present. His abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. Hematocrit 60 p, WBC 8000, Platelets 180k. What is most likely responsible for increased hematocrit?
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27 yo man in ER with unremitting nose bleeding. He reports having a similar bleeding episode one year ago that was stopped in ER. He works as a computer programmer and has a sedentary lifestyle. He drinks alcohol on social occasions but does not smoke or use illicit substances. ON physical examination, there are several ruby-colored papules on his lips that blanch partially with pressure. Digital clubbing is also present. His abdomen is soft and non-tender. The liver span is 8 cm and the spleen is not palpable. Hematocrit 60 p, WBC 8000, Platelets 180k. What is most likely responsible for increased hematocrit? --- Arteriovenous shunting. Hereditary telangiectasia (Osler-Weber-Rendu syndrome) can develop pulmonary AVM (AV malformations) associated with hemoptysis and right-to-left shunt physiology. Autosomal Dominant. This diagnosis must be entertained in this pt with recurrent nose bleeds and oral lesions.
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What is osler Weber Rendu syndrome?
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What is osler Weber Rendu syndrome? Aka Hereditary telangiectasia. Autosomal dominant disorder. It has Diffuse telangiectasias, recurrent epistaxis, and widespread AV malformations (AVM). AVM tend to occur in mucous membranes, skin, and GIT, but may also be present in Liver, Brain, and Lung. AVM in lungs can shunt blood from right to left side of heart, causing chronic hypoxemia and a reactive polycythemia. Pulmonary AVM can also present as massive, sometimes fatal, hemoptysis.
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What is Ruby-colored papules on the lips that blanch partially with pressure?
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What is Ruby-colored papules on the lips that blanch partially with pressure? Telangiectasia
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