Icr Test 1

Front 1

AST 100 IU/L; ALT 150 IU/L; alkaline phosphatase, 120 IU/L; total bilirubin, 1.0 mg/dl; serum iron/transferrin saturation 70%; serum antimitochondrial antibody negative; serum
alpha-fetoprotein normal

Back 1

Hemochromatosis

Front 2

AST 50 IU/L; ALT 60 IU/L; alkaline phosphatase, 450 IU/L; total bilirubin, 1.0 mg/dl; serum iron/transferrin saturation 20%; serum antimitochondrial antibody positive 1:160 titer;
serum alpha-fetoprotein normal.

Back 2

Primary biliary cirrhosis

Front 3

AST, 1,200 IU/L; ALT, 1,500 IU/L; alkaline phosphatase, 120 IU/L; total bilirubin, 5.0 mg/dl; direct bilirubin, 4.3 mg/dl; serum iron/transferrin saturation 25%; serum
antimitochondrial antibody negative

Back 3

Acute viral hepatitis

Front 4

AST, 80 IU/L; ALT 100 IU/L; alkaline phosphatase, 150 IU/L; total bilirubin, 2.0 mg/dl; direct bilirubin, 2.0 mg/dl; serum alpha-fetoprotein markedly elevated.

Back 4

Primary hepatocellular carcinoma (hepatoma)

Front 5

AST, 120 IU/L; ALT, 60 IU/L; alkaline phosphatase, 120 IU/L; total bilirubin, 2.0 mg/dl; direct bilirubin 1.3 mg/dl; serum iron/transferrin saturation 40%; serum antimitochondrial
antibody negative; serum alpha-fetoprotein slightly elevated.

Back 5

Alcoholic hepatitis

Front 6

Serum osmolality 290 mOsm/kg; potassium, 3.5 mEq/L; chloride, 89 mEq/L; bicarbonate, 24 mEq/L; BUN, 10 mg/dl; creatinine, 0.6 mg/dl; urine osmolality, 500 mOsm/kg; sodium, 30 mEq/L. BP 130/70 supine and upright; jugular venous pressure 6 cm of water; pedal edema absent.

Back 6

Pseudohyponatremia (i.e., severe hypertriglyceridemia)

Front 7

Serum osmolality 260 mOsm/kg; potassium, 3.5 mEq/L; chloride, 89 mEq/L; bicarbonate, 24 mEq/L; BUN, 8 mg/dl; creatinine, 0.6 mg/dl; urine osmolality, 320 mOsm/kg; sodium, 44 mEq/L. BP 140/80 supine and upright; jugular venous pressure 6 cm of water; pedal edema absent.

Back 7

Syndrome of inappropriate antidiuresis (SIAD)

Front 8

Serum osmolality 260 mOsm/kg; potassium, 3.5 mEq/L; chloride, 83 mEq/L; bicarbonate, 30 mEq/L; BUN, 30 mg/dl; creatinine, 1.1 mg/dl; urine osmolality, 330 mOsm/kg; sodium, 40 mEq/L. BP 110/60 supine; 90/50 standing; jugular venous pressure < 5 cm of water; pedal edema present.

Back 8

Intravascular volume depletion due to diuretic use/abuse

Front 9

Serum osmolality 260 mOsm/kg; potassium, 3.5 mEq/L; chloride, 89 mEq/L; bicarbonate, 24 mEq/L; BUN, 30 mg/dl; creatinine, 1.1 mg/dl; urine osmolality, 750 mOsm/kg; sodium, 5 mEq/L. BP 110/60 supine and upright; jugular venous pressure 9 cm of water; pedal edema present.

Back 9

Congestive heart failure

Front 10

Serum osmolality 260 mOsm/kg; potassium, 3.5 mEq/L; chloride, 95 mEq/L; bicarbonate, 18 mEq/L; BUN, 30 mg/dl; creatinine, 1.1 mg/dl; urine osmolality, 850 mOsm/kg; sodium, 5 mEq/L. BP 100/60 supine and 85/50 standing; jugular venous pressure < 5 cm of water; pedal edema absent.

Back 10

Intravascular volume depletion due to severe diarrhea

Front 11

HIV patients:
CD4 count > 500/mm3

Back 11

Generalized lymphadenopathy and aseptic meningitis

Front 12

HIV patients:
CD4 count 200-400/ mm3

Back 12

Recurrent yeast (Candida) vaginitis

Front 13

Risk in HIV patients:
CD4 count 50-200/ mm3:

Back 13

Pneumocystis carinii pneumonia

Front 14

Risk for HIV patients:
CD4 count < 50/ mm3

Back 14

Cytomegaloviral (CMV) retinitis

Front 15

BUN 40 mg/dl, creatinine 1.3 mg/dl; jugular venous pressure, < 5 cm of water; BP 100/60 supine, 80/50 upright; urine sediment with rare epithelial cells, 0-1 WBC’s and 0-1 RBC’s per HPF.

Back 15

Pre-renal azotemia due to intravascular volume depletion from upper GI bleeding

Front 16

BUN 30 mg/dl; creatinine 3.0 mg/dl; jugular venous pressure, 6 cm of water; BP 140/90 supine and upright; urine sediment with abundant epithelial cells, 2-5 WBC’s, and 0-1 RBC’s per HPF.

Back 16

Obstructive uropathy due to prostatic hypertrophy

Front 17

BUN 30 mg/dl; creatinine 1.3 mg/dl; jugular venous pressure, 9 cm of water; BP 110/80 supine and upright; urine sediment with rare epithelial cells, 0-2 WBC’s, and 0-1 RBC’s per HPF.

Back 17

Pre-renal azotemia due to congestive heart failure

Front 18

BUN 80 mg/dl; creatinine, 7.8 mg/dl; jugular venous pressure, 7-8 cm of water; BP 150/100 supine and upright; urine sediment with rare epithelial cells, 0-2 WBC’s, and TNTC RBC’s with RBC casts.

Back 18

Intrinsic renal failure due to rapidly progressive glomerulonephritis (RPGN)

Front 19

BUN 80 mg/dl; creatinine, 7.8 mg/dl; jugular venous pressure, 7-8 cm of water; BP 170/110 supine and upright; urine sediment with abundant epithelial cells, TNTC WBC’s with WBC casts,and 5-10 RBC’s per HPF.

Back 19

Intrinsic renal failure due to papillary necrosis

Front 20

Harsh grade IV/VI systolic crescendo-decrescendo murmur peaking late in systole and radiating to both carotids; carotid pulse upstroke delayed and sustained; S4 audible at apex; murmur is louder upon squatting and softer upon standing.

Back 20

Valvular aortic stenosis

Front 21

Blowing holosystolic grade III/VI murmur best heard at apex, radiating to left axilla; carotid pulse upstroke normal; S3 audible at apex.

Back 21

Mitral regurgitation (insufficiency)

Front 22

Rumbling, low pitched grade II/VI diastolic murmur only audible over apex in left lateral position; carotid pulse upstroke normal; no S3 or S4 but S1 loud.

Back 22

Mitral stenosis

Front 23

grade IV/VI systolic crescendo-decrescendo murmur peaking late in systole and radiating faintly to the base of the neck; carotid pulse upstroke normal; S4 audible at apex; murmur is louder upon standing and softer with squatting.

Back 23

Hypertrophic cardiomyopathy with subvalvular aortic outflow tract obstructionHarsh

Front 24

Soft decrescendo diastolic murmur Grade II/VI audible in left 3rd intercostal space just to the left of the sternum, only when the patient sits and leans forward; S3 audible at apex, which is displaced to left anterior axillary line.

Back 24

Aortic insufficiency (regurgitation)

Front 25

Sharp pain accentuated by inspiration in the left 5th intercostal region, accompanied by tachypnea. Arterial blood gas reveals pH 7.46, pCO2 30 mmHg, pO2 65 mmHg (room air). EKG shows sinus tachycardia; chest x-ray reveals patchy atelectasis in the left mid-lung field.

Back 25

Acute pulmonary embolism

Front 26

Severe "tearing" sensation radiating to the interscapular region of mid-back; patient writhes continually in discomfort. Arterial blood gas reveals pH 7.40, pCO2 40 mmHg, pO2 90 mmHg (room air). EKG shows sinus tachycardia; chest x-ray reveals slight widening of the mediastinum.

Back 26

Acute dissection of the ascending thoracic aorta

Front 27

Substernal burning sensation accompanied by nausea and diaphoresis. Arterial blood gas reveals pH 7.40, pCO2 40 mmHg, pO2 90 mmHg (room air). EKG shows sinus tachycardia and 2 mm ST segment depression in leads II, III, and aVF; chest x-ray is normal.

Back 27

Acute coronary syndrome (Myocardial infarction vs. unstable angina)

Front 28

Dull ache localized to left 5th intercostal region, unchanged with inspiration; no associated respiratory symptoms. Chest pain is accentuated by palpation of the left 5th rib and intercostal region. Arterial blood gas reveals pH 7.40, pCO2 40 mmHg, pO2 90 mmHg (room air). EKG and chest x-ray are normal.

Back 28

Musculoskeletal chest wall pain

Front 29

Substernal burning sensation without associated nausea and diaphoresis. Arterial blood gas reveals pH 7.40, pCO2 40 mmHg, pO2 90 mmHg (room air). EKG and chest x-ray are normal.

Back 29

Gastroesophageal reflux (GERD)

Front 30

Gradually progressive dysphagia for solid foods but not for liquids; no weight loss; longstanding GERD symptoms in a non-smoker, non-alcoholic 60 year old male. Barium swallow demonstrates smooth narrowing of the mid-thoracic esophagus.

Back 30

Benign peptic stricture of the esophagus

Front 31

Gradually progressive dysphagia for solid foods but not for liquids; 10 pound weight loss; no prior history of GERD in a 50 pack year-smoking, alcoholic 60 year old male. Barium swallow demonstrates irregular narrowing of the mid-thoracic esophagus.

Back 31

Squamous cell carcinoma of the esophagus

Front 32

Gradually progressive dysphagia for solids in a 60 year old woman with longstanding severe heartburn at night and following meals; gradual 10 pound weight loss. Associated medical history of severe hypertension controlled with ACE inhibitor; taut and thickened skin of digits and face. Barium swallow demonstrates decreased esophageal motility and "wide open" gastroesophageal reflux.

Back 32

Scleroderma (progressive systemic sclerosis)

Front 33

Gradually progressive dysphagia for both solids and liquids in a 60 year old woman with no prior history of heartburn; 10 pound weight loss. Barium swallow demonstrates sharply tapered distal esophagus and marked dilatation of proximal esophagus.

Back 33

Achalasia

Front 34

Gradually progressive dysphagia for liquids, with associated choking and nasal regurgitation in a 60 year old man with no prior history of heartburn; no weight loss. Barium swallow demonstrates nasal regurgitation but no apparent luminal narrowing of the esophagus or decreased esophageal motility.

Back 34

Myasthenia gravis

Front 35

30 year old male Tech Sergeant with non-productive nocturnal cough for three months, without hemoptysis, weight loss, dyspnea, or wheezing; three weeks of treatment with an antihistamine-decongestant have produced no relief. Sinus CT scan reveals no evidence of sinusitis.

Back 35

Spirometry pre- and post-methacholine challenge

Front 36

30 year old male Petty Officer with non-productive nocturnal cough for three months, without hemoptysis, weight loss, dyspnea, or wheezing; history of frequent heartburn following meals; no other significant past medical history. Sinus CT scan reveals no evidence of sinusitis, and three weeks of treatment with an antihistamine-decongestant have produced no relief.

Back 36

Empiric treatment with H2 blockers or proton pump inhibitor (omeprazole)

Front 37

55 year old female Colonel with chronic cough productive of copious amounts of thick yellowish-green sputum for the past three weeks; no history of smoking; positive history of recurrent pneumonia in childhood. No associated dyspnea, fever, chills, or chest pain. Sinus CT reveals no evidence of sinusitis, and antihistamine-decongestant medication produces no relief of symptoms.

Back 37

Chest x-ray plus empiric treatment with broad spectrum oral antibiotic, with follow-up scheduled within one week

Front 38

40 year old non-smoking female Lieutenant Commander with one week history of cough producing yellowish thick sputum intermittently streaked with blood. No associated dyspnea, fever, chills, or chest pain. Sinus CT scan reveals no evidence of sinusitis, and chest x-ray is normal.

Back 38

Empiric treatment with decongestant and anti-tussive, with follow-up scheduled in one week.

Front 39

50 year old male Navy Captain with one week history of cough producing yellowish thick sputum intermittently streaked with blood. No associated dyspnea, fever,chills, or chest pain. Patient has a 40 pack year history of cigarette smoking. Sinus CT scan reveals no evidence of sinusitis, and chest x-ray is normal. Treatment?

Back 39

Empiric treatment with broad spectrum oral antibiotic and anti-tussive, with fiberoptic bronchoscopy scheduled within one week.

Front 40

Sudden onset of dyspnea at rest six hours earlier; history of arthroscopic knee surgery one week earlier. Physical exam: temperature 98 degrees F; BP 110/80 supine and upright; pulse 100; respirations 20; no wheezing or crackles on lung auscultation; normal S1 and loud P2 component of S2 on cardiac auscultation. Arterial blood gas (room air): pH 7.46; pCO2 30 mmHg; pO2 74 mmHg. Chest x-ray: patchy atelectasis right lower lobe, superior segments. EKG: sinus tachycardia.

Back 40

Acute pulmonary embolism

Front 41

Gradual onset of air hunger three hours earlier; sensation of "not being able to draw in enough air" described, with no difficulty on expiration. Intermittent similar symptoms over the past five years. Physical exam: temperature 98 degrees F; BP 110/80 supine and upright; pulse 90; respirations 20; no wheezing or crackles on lung auscultation; normal S1 and S2 on cardiac auscultation. Arterial blood gas (room air): pH 7.46; pCO2 30 mmHg; pO2 98 mmHg. Chest x-ray: normal. EKG:
normal.

Back 41

Primary hyperventilation syndrome

Front 42

Patient brought in after loosing consciousness. Gradual onset of labored breathing at rest, worsened with light exercise, beginning three hours earlier, accompanied by nausea and diaphoresis. Denies any chest pain; has not had similar symptoms in the past. Physical exam: temperature 98 degrees F; BP 110/80 supine and upright; pulse 48; respirations 20; basilar crackles on lung auscultation; S4, S1, and S2 plus grade II/VI blowing holosystolic murmur over apex on cardiac auscultation. Arterial blood gas (room air): pH 7.46; pCO2 30 mmHg; pO2 74 mmHg. Chest x-ray: cephalization of blood flow and bilateral perihilar vascular fullness. EKG: sinus bradycardia, with inverted T waves in leads II, III, and aVF.

Back 42

Acute coronary syndrome (myocardial infarction vs. unstable angina)

Front 43

Sudden onset of difficult inspiration at rest and with exercise, accompanied by chest tightness and "inability to draw in enough air", over a one day period. Symptoms began after choking on link sausage at breakfast. Physical exam: temperature 98 degrees F; BP 110/80 supine and upright; pulse 100; respirations 20; diffuse inspiratory wheezing on auscultation of the central chest, but no expiratory wheezing or inspiratory crackles; normal but distant S1 and S2 on cardiac auscultation. Arterial blood gas (room air): pH 7.33; pCO2 50 mmHg; pO2 74 mmHg. Chest x-ray: elevated diaphragms bilaterally, consistent with poor inspiratory
effort. EKG: sinus tachycardia.

Back 43

Foreign body obstruction of upper airway

Front 44

Gradual onset of labored breathing at rest and with exercise over a three day period, accompanied by exacerbation of chronic productive cough, now with thick yellowish-green sputum. He has a 50 pack year history of cigarette smoking, and had symptoms of an upper respiratory tract infection for several days prior to onset of the current symptoms. Physical exam: temperature 98 degrees F; BP 110/80 supine and upright; pulse 100; respirations 20; diffuse low-pitched rhonchi and faint low-pitched expiratory wheezing on lung auscultation; distant S1 and S2 on cardiac auscultation. Arterial blood gas (room air): pH 7.33; pCO2 50 mmHg; pO2
65 mmHg. Chest x-ray: flattened diaphragms bilaterally. EKG: sinus tachycardia.

Back 44

Chronic obstructive pulmonary disease exacerbation

Front 45

Patient looses consciousness. Now conscious but disoriented and confused by voice commands; moves all extremities and has brisk and symmetric deep tendon reflexes. Oral mucosal lacerations are present, and there is evidence of urinary incontinence. Continuous EKG monitoring shows sinus tachycardia. Treatment?

Back 45

Head CT scan and electroencephalogram (EEG)

Front 46

A man looses consciousness. Now he is alert and oriented, and cooperative to voice commands; moves all extremities and has brisk and symmetric deep tendon reflexes. There are no oral mucosal lacerations, and no evidence of urinary incontinence. Loss of consciousness occurred while he was playing basketball; he denies any lightheadedness, nausea, or visual changes and witnesses confirm that the loss of consciousness was abrupt, and lasted for about 30 seconds. EKG monitoring shows sinus rhythm and a prolonged QT interval. Treatment?

Back 46

Cardiac catheterization, with electrophysiologic studies

Front 47

Alert and oriented, and cooperative to voice commands; moves all extremities and has brisk and symmetric deep tendon reflexes. There are no oral mucosal lacerations, and no evidence of urinary incontinence. He had never previously had an episode of loss of consciousness. Prior to loss of consciousness, he recalls feeling warm, nauseated, and breaking out in a cold sweat after standing in line for a prolonged time at a stadium ticket window. Witnesses report that he collapsed, had several rhythmic jerks of the right arm, and regained consciousness within 10 seconds of falling. These witnesses report that he was alert immediately upon regaining consciousness. EKG monitoring shows sinus bradycardia (rate 54) and a normal QT interval. Treatment?

Back 47

No additional workup

Front 48

Patient looses consciousness. Now is alert and oriented, and cooperative to voice commands; moves all extremities and has brisk and symmetric deep tendon reflexes. There are no oral mucosal lacerations, and no evidence of urinary incontinence. He recalls no faintness or nausea prior to abruptly "blacking out" while playing basketball. Bystanders report that he was motionless after collapsing, and was unconscious for approximately 30 seconds. He was fully alert upon regaining consciousness. EKG monitoring
shows sinus bradycardia (rate 54) and a normal QT interval.
Treatment?

Back 48

Echocardiogram

Front 49

A man looses consciousness. Now he is alert and oriented, and cooperative to voice commands; moves all extremities and has brisk and symmetric deep tendon reflexes. There are no oral mucosal lacerations, and no evidence of urinary incontinence. He has had five previous identical episodes over the past three months, in each case related to prolonged standing. None have occurred during strenuous exertion. Prior to loss of consciousness, he recalls feeling warm, nauseated, and breaking out in a cold sweat. Witnesses report that he collapsed, had several rhythmic jerks of the right arm, and regained consciousness within 10 seconds of falling. These witnesses report
that he was alert immediately upon regaining consciousness. EKG monitoring shows sinus bradycardia (rate 54) and a normal QT interval.
Treatment?

Back 49

Tilt table testing, assessing response to physical and pharmacologic stressors

Front 50

Hemoglobin 10 gm/dl; hematocrit, 30.1%; MCV 70; platelet count, 450,000/mm3; peripheral blood smear reveals poikilocytosis, anisocytosis, and variable microcytosis. Reticulocyte count 1%. Serum ferritin < 5 ng/ml; serum iron: transferrin saturation 10%.

Back 50

Iron deficiency anemia

Front 51

Hemoglobin 10 gm/dl; hematocrit, 30.1%; MCV 65; platelet count 290,000/mm3; peripheral blood smear reveals abundant target cells and rather uniform microcytosis. Reticulocyte count 6%. Serum ferritin 110 ng/ml; serum iron: transferrin saturation 25%.

Back 51

Alpha or beta thalassemia minor

Front 52

Hemoglobin 10 gm/dl; hematocrit, 30.1%; MCV 85; platelet count 600,000/mm3; peripheral blood smear reveals normal RBC morphology. Reticulocyte count 1%. Serum ferritin > 1,000 ng/ml; serum iron: transferrin saturation 40%.

Back 52

Anemia of chronic inflammation

Front 53

Hemoglobin 6 gm/dl; hematocrit, 19%; MCV 100; platelet count 5,000/mm3; peripheral blood smear reveals abundant schistocytes and rare platelets. Reticulocyte count 10%. Serum ferritin 245 ng/ml; serum iron:transferrin saturation 16%.

Back 53

Microangiopathic hemolytic anemia

Front 54

Hemoglobin 8 gm/dl; hematocrit 25%; MCV 110; platelet count 245,000/mm3; peripheral blood smear reveals macrocytosis and poikilocytosis. Reticulocyte count 1%. Serum ferritin 245 ng/ml; serum iron:transferrin saturation 18%.

Back 54

Pernicious anemia

Front 55

ABG: pH 7.29, pCO2 30 mmHg, calculated bicarbonate, 14 mEq/L. Serum electrolytes: sodium, 140 mEq/L, potassium 4.4 mEq/L, chloride 114 mEq/L, bicarbonate, 14 mEq/L

Back 55

Non-anion gap metabolic acidosis

Front 56

ABG: pH 7.37, pCO2 50 mmHg, calculated bicarbonate 28 mEq/L. Serum electrolytes: sodium 140 mEq/L, potassium 4.4 mEq/L, chloride 100 mEq/L, bicarbonate 28 mEq/L

Back 56

Chronic respiratory acidosis

Front 57

ABG: pH 7.22, pCO2 45 mmHg, calculated bicarbonate 18 mEq/L. Serum electrolytes: sodium 140 mEq/L, potassium 4.4 mEq/L, chloride 104 mEq/L, bicarbonate 18 mEq/L

Back 57

Respiratory acidosis + wide anion gap metabolic acidosis

Front 58

ABG: pH 7.42, pCO2 30 mmHg, calculated bicarbonate 19 mEq/L. Serum electrolytes: sodium 140 mEq/L, potassium 4.4 mEq/L, chloride 110 mEq/L, bicarbonate 18 mEq/L

Back 58

Chronic respiratory alkalosis

Front 59

ABG: pH 7.48, pCO2 30 mmHg, calculated bicarbonate 22 mEq/L. Serum electrolytes: sodium 140 mEq/L, potassium 4.4 mEq/L, chloride 100 mEq/L, bicarbonate 28 mEq/L

Back 59

Laboratory error; ABG and electrolyte data are incompatible