Test your might!

[Depakote]

In the same vein as Allo's Name that Pathogen thread, let's get some good review going here. Anything on Step I is fair game.

A 37 year old male presents with a BP of 80/?. PT and PTT are elevated. Fibrinogen and Platelet count are decreased. D-Dimers are present. Peripheral blood smear reveals schistocytes as well as the following pathologic abnormality:

What is this patient's acute illness?
What is this patient's underlying illness?
Is there a specific abnormality associated with the underlying illness?
What must be done to treat this patient's underlying illness as not to aggravate the acute disease?

---

Members don't see this ad.

 

[SomeDoc]

Maybe also add some I.V. Cl-

Edit: just normotonic saline should be sufficient. Should take care of the Cl- loss. Excess Na should be expected to be renally excreted, but watch for hypernatremia given Cl:Na loss ratio.

 

[mlw47]

The wife shows up, surprised and disappointed her husband is not dead yet, seems the guy is abusive and an all round dick.

The suspicion of deliberate poisoning plus the diahrrea makes me think of arsenic or selenium. Selenosis mimicks radiation poisoning (thanks House, M.D.!) so I'll go with arsenic.

Arsenic interferes with mit. ox. phos. and is associated with seizures.
It also produces hyperpigmentation/hyperkeratosis and a predilection for squamous cell CA. How does his skin look?

 

[Slide]

The suspicion of deliberate poisoning plus the diahrrea makes me think of arsenic or selenium. Selenosis mimicks radiation poisoning (thanks House, M.D.!) so I'll go with arsenic.

Arsenic interferes with mit. ox. phos. and is associated with seizures.
It also produces hyperpigmentation/hyperkeratosis and a predilection for squamous cell CA. How does his skin look?

What would also lead me to thinking it was arsenic poisoning was the garlic breath; arsenic sometimes makes the patient's breath garlic-like.

 

[FutureInternist]

The wife shows up, surprised and disappointed her husband is not dead yet, seems the guy is abusive and an all round dick.

If I had read this before I would have guessed some sort of poisoning as well

White Phosphorous poisoning? (I googled the crap out of this one)

Wait a sec.....We can "google"....Just watch me answer every single Q correctly from now on

What would also lead me to thinking it was arsenic poisoning was the garlic breath; arsenic sometimes makes the patient's breath garlic-like.

I didn't guess arsenic until after reading this...Can't believe I forgot this. I just saw Italian food, figured they served garlic bread & had seafood.

 

[Redrox]

Arsenic interferes with mit. ox. phos.

The classic triad for arsenic poisoning according to FA and various Christy novels is "rice water" stools, vomiting, and garlic breath.

Any guesses as to which enzyme of metabolism is most affected? Or a treatment?

 

[Slide]

The classic triad for arsenic poisoning according to FA and various Christy novels is "rice water" stools, vomiting, and garlic breath.

Any guesses as to which enzyme of metabolism is most affected? Or a treatment?

Inhibits pyruvate dehydrogenase by acting as a competitive inhibitor of phosphate, thereby effectively turning off the glycolytic link to the TCA cycle. Treatment would be dimercaprol (BAL).

 

[obieards]

A 24-year-old male presents to the clinic complaining of being tired all the time and an accompanying sore throat. He has a temperature of 37.3 and his liver and spleen are palpable. Results of a blood workup show the presence of atypical lymphocytes and a positive Monospot test for heterophile antibodies. The patient also mentions a painless lesion on his penis. Which of the following is your next best move?

A. Perform cryotherapy on the lesion
B. Administer penicillin
C. Perform a Tzanck smear of the lesion; if positive, treat with acyclovir
D. Run a VDRL; if positive, treat with penicillin
E. Run a FTA; if positive, treat with penicillin
F. None of the above

 

[BoneNibbler]

A 24-year-old male presents to the clinic complaining of being tired all the time and an accompanying sore throat. He has a temperature of 37.3 and his liver and spleen are palpable. Results of a blood workup show the presence of atypical lymphocytes and a positive Monospot test for heterophile antibodies. The patient also mentions a painless lesion on his penis. Which of the following is your next best move?

A. Perform cryotherapy on the lesion
B. Administer penicillin
C. Perform a Tzanck smear of the lesion; if positive, treat with acyclovir
D. Run a VDRL; if positive, treat with penicillin
E. Run a FTA; if positive, treat with penicillin
F. None of the above

#1 Stop buying hookers for him!

then..F
do a vdrl, if positive, confirm with FTA then treat w PenG

 

[obieards]

Well done, BoneNibbler!

 

[Depakote]

An 8 year old male is receiving chemotherapy for T-Cell Lymphoblastic Lymphoma. 3 days into therapy, the patient complains of severe pain at the base of his great toe. Physical exam notes erythema of the joint. Aspiration of the joint yields crystals that are yellow when parallel to polarized light and blue when perpendicular to polarized light on microscopic examination.

What is the diagnosis?
Why does this patient have this condition?
Is there a medication that could have prevented it? How does that medication work?

 

[Teee]

Well done, BoneNibbler!

not to be nitpicky, but would we really wait for all the tests before prescribing penicillin? i think we were taught to treat while confirming, i might be wrong... but a painless lesion, what else could it be?

 

[Teee]

An 8 year old male is receiving chemotherapy for T-Cell Lymphoblastic Lymphoma. 3 days into therapy, the patient complains of severe pain at the base of his great toe. Physical exam notes erythema of the joint. Aspiration of the joint yields crystals that are yellow when parallel to polarized light and blue when perpendicular to polarized light on microscopic examination.

What is the diagnosis?
Why does this patient have this condition?
Is there a medication that could have prevented it? How does that medication work?

gout?
tumor lysis syndrome from chemotherapy
alluporinol
don't know

 

[mlw47]

A mother and her 7 months old present to you because he has been missing developmental milestones. The mother comments to you that the his diapers are especially foul smelling. Blood work shows a normocytic anemia with acanthocytosis, and very low serum cholesterol and triglyceride levels. A pilocarpine sweat test is normal.

What is it and what's the pathophysiology?
What's the inheritence?

 

[Slide]

A mother and her 7 months old present to you because he has been missing developmental milestones. The mother comments to you that the his diapers are especially foul smelling. Blood work shows a normocytic anemia with acanthocytosis, and very low serum cholesterol and triglyceride levels. A pilocarpine sweat test is normal.

What is it and what's the pathophysiology?
What's the inheritence?

Hmm, given that the kid has foul stools, acanthocytes, and low cholesterol/trg levels, I'm gonna go with some sort of abetalipoproteinemia, probably AR due to its at-birth onset of symptoms.

The defect in making Apo-B proteins makes it difficult for the body to process fats because without Apo-B, chylomicrons and VLDL cannot deliver fats and cholesterols to the liver and other cells in the body. As a result, low cholesterol and TRG levels will result, and the lack of these substances will likely result in CNS defects and failure to develop properly because you need them for a ton of things. Intestinal cells will probably look very distended and fatty due to all of the fat stuck in it. I don't know why the pilocarpine sweat test is ordered (maybe to rule out CF? I dunno).

 

[mlw47]

Hmm, given that the kid has foul stools, acanthocytes, and low cholesterol/trg levels, I'm gonna go with some sort of abetalipoproteinemia, probably AR due to its at-birth onset of symptoms.

The defect in making Apo-B proteins makes it difficult for the body to process fats because without Apo-B, chylomicrons and VLDL cannot deliver fats and cholesterols to the liver and other cells in the body. As a result, low cholesterol and TRG levels will result, and the lack of these substances will likely result in CNS defects and failure to develop properly because you need them for a ton of things. Intestinal cells will probably look very distended and fatty due to all of the fat stuck in it. I don't know why the pilocarpine sweat test is ordered (maybe to rule out CF? I dunno).

I wrote the question, and I added the line about the sweat test just to make it absolutely clear that it wasn't CF; otherwise I thought that it sounded similar enough within reason to be CF.

 

[ENThopeful]

gout?
tumor lysis syndrome from chemotherapy
alluporinol
don't know

Off the top of my head,

the prophylaxis is allopurinol, that inhibits xanthine oxidase in the purine degredation/recycling pathway. you wouldnt give probenecid because its not an excretion problem but a production problem..

 

[ENThopeful]

Hmm, given that the kid has foul stools, acanthocytes, and low cholesterol/trg levels, I'm gonna go with some sort of abetalipoproteinemia, probably AR due to its at-birth onset of symptoms.

The defect in making Apo-B proteins makes it difficult for the body to process fats because without Apo-B, chylomicrons and VLDL cannot deliver fats and cholesterols to the liver and other cells in the body. As a result, low cholesterol and TRG levels will result, and the lack of these substances will likely result in CNS defects and failure to develop properly because you need them for a ton of things. Intestinal cells will probably look very distended and fatty due to all of the fat stuck in it. I don't know why the pilocarpine sweat test is ordered (maybe to rule out CF? I dunno).

follow up question! what causes fatty liver and abetalipoproteinemia in children? this isn't an a genetic disease

 

[Depakote]

gout?
tumor lysis syndrome from chemotherapy
alluporinol
don't know

Off the top of my head,

the prophylaxis is allopurinol, that inhibits xanthine oxidase in the purine degredation/recycling pathway. you wouldnt give probenecid because its not an excretion problem but a production problem..

sounds good, guys

 

[neil100]

A mother just delivered a baby which was complicated by ischemia and hemorrhage. A CT scan of the head shows signs of hemorrhage near the sella tursica.
1) what's the dx?
2) what should you give this patient immediately so that the head hemorrhage doesn't cause adverse affects? (After controlling the hypovolemia)
3) What is the TPR, Cardiac output, and LVEDV during her episode of hypovolemic shock compared to normal?
4) What will happen to her Resistance to Venous return and Right Atrial Pressure when she receives a blood transfusion?
5) After the mother's condition subsides, the baby starts to develop cyanosis and respiratory distress. What is this condition called? Give the pathology.
6) What could have prevented this baby's condition?
7) What is the baby's lung compliance, RV, and FEV1/FVC ration during her condition compared to normal?
8) What cells in the affected organ produce a substance which can treat the baby's condition? What is the additional role of these cells?

 

[cgscribe]

Wow, that question is hardcore. For boards, all you need to know is 1. hahaha.

 

[mlw47]

A mother just delivered a baby which was complicated by ischemia and hemorrhage. A CT scan of the head shows signs of hemorrhage near the sella tursica.
1) what's the dx?
2) what should you give this patient immediately so that the head hemorrhage doesn't cause adverse affects? (After controlling the hypovolemia)
3) What is the TPR, Cardiac output, and LVEDV during her episode of hypovolemic shock compared to normal?
4) What will happen to her Resistance to Venous return and Right Atrial Pressure when she receives a blood transfusion?
5) After the mother's condition subsides, the baby starts to develop cyanosis and respiratory distress. What is this condition called? Give the pathology.
6) What could have prevented this baby's condition?
7) What is the baby's lung compliance, RV, and FEV1/FVC ration during her condition compared to normal?
8) What cells in the affected organ produce a substance which can treat the baby's condition? What is the additional role of these cells?

To be clear, the initial patient is the mother? The second sentence of your stem is a bit ambiguous.

Also, the cyanosis in the baby could be from a multitude of things. Perhaps you should add whether the baby was full term or not, or if the baby has any abnormal heart sounds/physical findings... I can tell from the other questions what you might have in mind, but it's a bit too open ended.

 

[neil100]

To be clear, the initial patient is the mother? The second sentence of your stem is a bit ambiguous.

Also, the cyanosis in the baby could be from a multitude of things. Perhaps you should add whether the baby was full term or not, or if the baby has any abnormal heart sounds/physical findings... I can tell from the other questions what you might have in mind, but it's a bit too open ended.

Yeah the patient is the mother.yup.
the baby's question starts at #5.

Also, I think covered that by saying respiratory distress. But, yeah there aren't any abnormal sounds on auscultation. What you have in mind is probably correct, I am sure.

 

[FutureInternist]

Don't feel like thinking too much right now, so here's an easy one

26 year old black female walks into your office.

1) Dx
2) Tests to verify
3) Reason behind the abnormal levels (high or low) being abnormal.

 

[mlw47]

Don't feel like thinking too much right now, so here's an easy one

26 year old black female walks into your office.

1) Dx
2) Tests to verify
3) Reason behind the abnormal levels (high or low) being abnormal.

A fairly accurate site, at least for the medical stuff on the boards:

http://www.agraphia.net/zac-fact-10-bigot-your-way-to-success/

 

[Depakote]

A fairly accurate site, at least for the medical stuff on the boards:

http://www.agraphia.net/zac-fact-10-bigot-your-way-to-success/

So, she's pregnant and has sickle cell.

B-HCG and CBC/Peripheral Blood Smear + Hemoglobin Electrophoresis

Embryonic/Syncytiotrophoblast production of B-HCG

Valine substitution for glutamate causes HbS, the abnormal HbS polymerizes and sickles in low oxygen tension. HbS can't pass through small blood vessels leading to microinfarction of the spleen, bones and other capillaries. At 26, she'd have a functionally absent spleen and be predisposed to Salmonella osteomyelitis and pneumococcus infections.

 

[FutureInternist]

So, she's pregnant and has sickle cell.

B-HCG and CBC/Peripheral Blood Smear + Hemoglobin Electrophoresis

Embryonic/Syncytiotrophoblast production of B-HCG

Valine substitution for glutamate causes HbS, the abnormal HbS polymerizes and sickles in low oxygen tension. HbS can't pass through small blood vessels leading to microinfarction of the spleen, bones and other capillaries. At 26, she'd have a functionally absent spleen and be predisposed to Salmonella osteomyelitis and pneumococcus infections.

Good stuff, Depakote.
I guess I should have thrown in maybe one more thing to tip the balance towards what I was thinking i.e. Sarcoidosis.
Elevated ACE levels & vit D
Increased vit D d/t MQs --> Inc INF-gamma --> inc alpha-1-hydroxylase --> inc Vit D

As one of my preceptors once said "Medicine, the only place you can be a total racist & get away with it"

 

[Depakote]

Good stuff, Depakote.
I guess I should have thrown in maybe one more thing to tip the balance towards what I was thinking i.e. Sarcoidosis.
Elevated ACE levels & vit D
Increased vit D d/t MQs --> Inc INF-gamma --> inc alpha-1-hydroxylase --> inc Vit D

As one of my preceptors once said "Medicine, the only place you can be a total racist & get away with it"

I knew I forgot one...

 

[Depakote]

Here's a mean one for you:

A 20 year old man presents with a chief complaint of "I have swine flu." A detailed history indicates that he had a sore throat, malaise, rhinnorhea for the past 5 days. He denies myalgia or chills.

Vitals:
Temp: 37.0
Resp Rate: 12
BP: 106/76
Pulse: 76

Physical examination demonstrates a mildly erythematous pharynx. A swab is taken.

Culture on blood agar shows the following:

What is the diagnosis?
What is your treatment for this patient?

 

[neil100]

Here's a mean one for you:

A 20 year old man presents with a chief complaint of "I have swine flu." A detailed history indicates that he had a sore throat, malaise, rhinnorhea for the past 5 days. He denies myalgia or chills.

Vitals:
Temp: 37.0
Resp Rate: 12
BP: 106/76
Pulse: 76

Physical examination demonstrates a mildly erythematous pharynx. A swab is taken.

Culture on blood agar shows the following:

What is the diagnosis?
What is your treatment for this patient?

Is it as easy as I think it is?
I see hemolysis on blood agar. So,
Bacterial pharyngitis by strep. pyogenes
Penicillin or one of its classes

 

[Depakote]

Is it as easy as I think it is?
I see hemolysis on blood agar. So,
Bacterial pharyngitis by strep. pyogenes
Penicillin or one of its classes

not as easy as you'd think.

What type of hemolysis is it?

 

[Mortal_Lessons]

not as easy as you'd think.

What type of hemolysis is it?

The green color suggests alpha hemolysis, indicating either strep viridans or strep pneumoniae. Perhaps this patient has a viral URI and you've cultured normal flora.

 

[Depakote]

The green color suggests alpha hemolysis, indicating either strep viridans or strep pneumoniae. Perhaps this patient has a viral URI and you've cultured normal flora.

bingo.

 

[Slide]

bingo.

This vignette seems awfully familiar.....

 

[Depakote]

This vignette seems awfully familiar.....

I posted something pretty similar in the "identify that pathogen" thread in allo...

but I couldn't resist the call of swine flu.

 

[neil100]

bingo.

You know I noticed that temperature and the thing about mild pharynx. So, i'd thought it might be viral. But then I saw hemolysis and assumed beta-hemolysis. But, that's a good vignette man. I guess you had to know type of hemolysis. I learned something. Cool.

 

[obieards]

Which of the following DOES NOT describe someone infected by a paramyxovirus? (Choose wisely; more than one answer is possible )

A newborn male with microcephaly, patent ductus arteriosus, cataracts, and deafness.

A 5 month-old male from a day care center who presents in February with wheezing, necrotizing bronchiolitis, peribronchial infiltration, and interstitial pneumonitis.

A 2-yo male who presents in April with a harsh, brassy, bark-like cough

A 12-yo female with high fever, chills, myalgia, pharyngitis and rhinorrhea.

A 15-yo female with seizures, myoclonus, dementia, and ataxia; when she was a toddler she presented to your clinic with a maculopapular rash and Koplik spots.

A 16-yo male with testicular pain and swelling, abdominal pain that radiates to his back, and upwardly-displaced ears.

 

[Depakote]

A newborn male with microcephaly, patent ductus arteriosus, cataracts, and deafness.- Congenital Rubella (not paramyxo... I forget what, though)

A 5 month-old male from a day care center who presents in February with wheezing, necrotizing bronchiolitis, peribronchial infiltration, and interstitial pneumonitis.- RSV (paramyxovirus)

A 2-yo male who presents in April with a harsh, brassy, bark-like cough- pretussus? (not viral)

A 12-yo female with high fever, chills, myalgia, pharyngitis and rhinorrhea. Influenza (orthomyxovirus)

A 15-yo female with seizures, myoclonus, dementia, and ataxia; when she was a toddler she presented to your clinic with a maculopapular rash and Koplik spots. measles (paramyxo)

A 16-yo male with testicular pain and swelling, abdominal pain that radiates to his back, and upwardly-displaced ears.
Mumps (paramyxovirus)

 

[ENThopeful]

A 2-yo male who presents in April with a harsh, brassy, bark-like cough- pretussus? (not viral)

Parainfluenza i believe, croup.


whats with the upwardly displaced ears?

 

[Depakote]

Parainfluenza i believe, croup.


whats with the upwardly displaced ears?

I assumed that was the markedly swollen parotid glands mechanically displacing the ears.

edit: I think you're right about the parainfluenza.

 

[ENThopeful]

I assumed that was the markedly swollen parotid glands mechanically displacing the ears.

Good call

 

[obieards]

Parainfluenza i believe, croup.

Now, pray tell, what would you look for in a radiograph?

 

[obieards]

A newborn male with microcephaly, patent ductus arteriosus, cataracts, and deafness.- Congenital Rubella (not paramyxo... I forget what, though)

In the words of Bluto "The Wise", "TOGA! TOGA! TOGA!"

A 5 month-old male from a day care center who presents in February with wheezing, necrotizing bronchiolitis, peribronchial infiltration, and interstitial pneumonitis.- RSV (paramyxovirus)

Spot on!

A 12-yo female with high fever, chills, myalgia, pharyngitis and rhinorrhea. Influenza (orthomyxovirus)

Very good, oh experienced medical padawan

A 15-yo female with seizures, myoclonus, dementia, and ataxia; when she was a toddler she presented to your clinic with a maculopapular rash and Koplik spots. measles (paramyxo)

So....this 15-yo is currently presenting with what condition?

 

[Depakote]

I
So....this 15-yo is currently presenting with what condition?

subacute sclrerosing panencephalitis... I just saw koplick spots and skipped the rest.

 

[ENThopeful]

Now, pray tell, what would you look for in a radiograph?

steeple sign! laryngotracheobronchitis (hope i didn't butcher that) on frontal xray

 

[obieards]

subacute sclrerosing panencephalitis... I just saw koplick spots and skipped the rest.

What if I left out the fact that she had both Koplik spots and a maculopapular rash when she was a toddler--would you have still gone with SSPE?

 

[obieards]

steeple sign! laryngotracheobronchitis (hope i didn't butcher that) on frontal xray

Clearly we have a winner in the steeplechase

 

[Depakote]

What if I left out the fact that she had both Koplik spots and a maculopapular rash when she was a toddler--would you have still gone with SSPE?

So I have a 15-yo female with seizures, myoclonus, dementia, and ataxia. No significant medical history?

I guess I'd include the following on my differential:
CJD (or other prion disease)
Rabies
Cerebellar Tumor

 

[Depakote]

You are performing a pediatric health screening and you see a 8 year old female patient. The patient is shown to have mild allopecia and a subtle tremor. You check liver enzymes and find ALT and AST are elevated. The patient's mother indicates that she has no allergies and is only taking one prescription "to help her with school", they had tried another drug but that one didn't work. No over the counter medications have been used and the patient is up to date on all vaccinations. Vitals are within normal limits and the patient appears cognitively intact.

What is the cause of the allopecia, tremor, liver enzyme elevation, and the patients academic difficulty?
If there are multiple pathologies at work. Explain.

 

[Captopril]

I'm considering skipping UWorld and just studying this thread instead.

 

[obieards]

So I have a 15-yo female with seizures, myoclonus, dementia, and ataxia. No significant medical history?

I guess I'd include the following on my differential:
CJD (or other prion disease)
Rabies
Cerebellar Tumor

I would probably put Rabies #1 because of likelihood. As for the other two, vCJD would be more likely than CJD because vCJD has an earlier onset--but it's usually around 30 yrs of age. More likely than vCJD would be an astrocytoma, I imagine.