[Medicalstudyzone.com] Internal Medicine 4 - Answers v1 [wide]
Question 1: Seborrheic Dermatitis
A 42-year-old man presents with greasy, diffuse scaling of the scalp and variable itching for a year.
Yellowish-red scaling papules are present along the hairline and behind the ears, but there is no hair loss.
Most likely diagnosis: Seborrheic dermatitis, a chronic inflammatory skin disease in regions with sebaceous glands.
Presentation:
Adults: Yellowish-red, scaly patches on the scalp, forehead, around the ears, nasolabial folds, and chest.
Infants: "Cradle cap," diaper rash, yellow scaling on the scalp.
Severe cases can occur in immunosuppressed patients.
Treatment:
Zinc pyrithione or selenium sulfide shampoo for the scalp.
Topical antifungals like ketoconazole.
Topical corticosteroids for severe cases to reduce inflammation and pruritus.
Incorrect Answers:
Exfoliative dermatitis: Generalized, diffuse erythema and scaling with desquamation involving large areas of the body; often associated with pre-existing skin disorders, cancer, or certain medications.
Lichen simplex chronicus: Localized region of skin thickening (lichenification) from repetitive rubbing or itching.
Pediculosis capitis: Infestation of the scalp and hair by Pediculus humanus capitis (human louse), causing severe pruritus; treated with permethrin, pyrethrins, ivermectin, or malathion lotions.
Psoriasis: Erythematous plaques with silvery scales typically on extensor surfaces (knees, elbows); scalp involvement is less common.
Question 2: Tinea Cruris and Autoinfection
A 24-year-old man presents with a recurrent red, scaly rash in the groin after a 6-week course of topical clotrimazole.
Examination shows an erythematous, excoriated rash over the groin and a similar rash on the instep of the left foot.
KOH preparation of skin scraping shows hyphae.
Most likely cause: Autoinfection from untreated tinea pedis (athlete's foot).
Tinea (dermatophytosis):
Cutaneous fungal infection with organisms like Microsporum, Trichophyton, and Epidermophyton.
Characterized by branching septated hyphae on KOH preparation.
Tinea cruris (groin) treated with clotrimazole, but tinea pedis (foot) was not treated.
Untreated tinea pedis served as a source for autoinfection, leading to recurrent tinea cruris.
Treatment:
Treat both the groin and left foot simultaneously with clotrimazole.
Incorrect Answers:
Clotrimazole resistance: Possible but uncommon; the patient's initial tinea cruris responded to clotrimazole.
Impaired cellular or humoral immunity: Immunocompromised patients are at increased risk for disseminated dermatophytosis, but autoinfection is more likely in this scenario.
Reinfection from sexual partner: Less likely given the patient's untreated tinea pedis source; dermatophytes spread through contact with infected skin.
Question 3: Supraspinatus Tendon Injury
A 30-year-old man has recurrent aching right shoulder pain initiated by overhead reaching.
Pain is also present at night in bed and is most prominent in the deltoid muscle area.
Pain is elicited by abduction of the shoulder against resistance.
Most likely site of the underlying condition: Supraspinatus tendon.
Supraspinatus Tendon:
The most common location of rotator cuff injury.
The muscle lies within the supraspinous fossa along the superior portion of the scapula.
Its tendon inserts on the greater tuberosity of the humerus.
Contributes to initiation of arm abduction before the deltoid muscle.
Injury:
May occur from degeneration, impingement, or trauma.
Evaluated through abduction of the shoulder against resistance.
Incorrect Answers:
Biceps tendon: Injury results in weakness of elbow flexion and forearm supination; the biceps brachii inserts at the radial tuberosity.
Cervical nerve root: Injury results in neurologic symptoms like weakness, numbness, and paresthesia along a specific dermatome and myotome; not aggravated by shoulder abduction.
Deltoid muscle: Not commonly injured and less common than supraspinatus tendon injury; contributes to abduction of the shoulder after the first 15 degrees.
Proximal humerus: Injury such as a surgical neck fracture can lead to axillary nerve injury, resulting in dysfunction of the deltoid muscle and loss of sensation over the proximal lateral arm.
Question 4: Renal Artery Stenosis
A 72-year-old woman presents with high blood pressure (210/114 mm Hg) despite a 20-year history of well-controlled hypertension with a thiazide diuretic.
Funduscopic examination shows arteriovenous nicking, and a right carotid bruit is heard.
Laboratory studies are within normal limits.
Most likely cause: Renal artery stenosis, a cause of secondary hypertension.
Renal Artery Stenosis:
Abnormal stimulation of the juxtaglomerular apparatus due to stenosis of the renal artery leads to insufficient afferent blood flow.
Excessive production of renin and angiotensin occurs.
Secondary hypertension should be considered in new-onset or treatment-resistant hypertension.
Two main causes: fibromuscular dysplasia and atherosclerosis.
Younger patients: fibromuscular dysplasia is more common.
Older patients: atherosclerosis is more common.
Diagnosis:
Renal artery Doppler ultrasonography or magnetic resonance angiography.
Treatment:
Angioplasty or stenting of the stenosed renal artery to improve flow.
ACE inhibitors can be considered for unilateral stenosis but can lead to acute end-stage kidney disease in bilateral renal artery stenosis.
Incorrect Answers:
Acute glomerulonephritis: Nephritic syndrome can result in hypertension, although less likely given the patient's risk factors for atherosclerosis.
Acute porphyria: Presents with abdominal pain, polyneuropathy, psychological symptoms, and port wine-colored urine, not resistant hypertension.
Coarctation of the aorta: Presents in childhood with differential blood pressure between upper and lower extremities; associated with bicuspid aortic valve and gonadal dysgenesis 45,X (Turner syndrome).
Cushing syndrome: Results from increased cortisol levels and presents with hypertension, moon facies, abdominal striae, osteoporosis, hyperglycemia, and amenorrhea.
Hyperaldosteronism: Presents with hypertension and metabolic derangements, including hypokalemia and metabolic alkalosis.
Primary hyperparathyroidism: May present with hypercalcemia and hypophosphatemia with symptoms such as constipation, renal stones, psychiatric disturbances, and osseous lytic lesions.
Hyperthyroidism: Typically presents with heat intolerance, weight loss, diarrhea, hyperreflexia, palpitations, and myopathy.
Pheochromocytoma: Results in episodic hypertension with associated palpitations, diaphoresis, headache, and pallor.
Question 5: Hospice Care for Lung Carcinoma
A 57-year-old woman with stage IV non-small cell lung carcinoma is admitted for shortness of breath and fever (39°C/102.2°F), diagnosed with postobstructive pneumonia, and treated with IV antibiotics.
She wishes to discontinue chemotherapy and requests no resuscitation if she has a cardiac arrest.
In addition to advance directives and durable power of attorney, the most appropriate recommendation is discharge home with home hospice care.
Hospice Care:
Indicated for patients with a life expectancy of less than six months in the setting of a terminal diagnosis.
Focuses on palliation of a patient's symptoms with attention to providing comfort, rather than aggressive treatment.
Incorrect Answers:
Discharge home with physical and occupational therapy: Indicated for rehabilitation to improve physical abilities and return to daily life and work activities.
Discharge home with visiting nurse services and discharge to a skilled nursing care facility: Indicated for patients needing nursing care for medications and hygiene, not primarily focused on palliation and comfort.
Remain in the hospital: Would not allow the patient to receive palliative care in the comfort of her own home.
Question 6: Debridement of Pressure Ulcer
An 87-year-old resident of a skilled nursing care facility presents with a lesion on his left leg for 3 weeks.
He has been confined to bed for 3 years due to left hemiplegia after a cerebral infarction.
Examination shows a 5 x 7-cm, grade 3 pressure ulcer over the left greater trochanter with an overlying eschar and a small rim of erythema.
Most appropriate next step: Debridement of the ulcer.
Pressure Ulcer Management:
Debridement is necessary for decubitus ulcers with necrotic tissue.
Grade 3 pressure ulcer is characterized by full-thickness tissue loss with visible subcutaneous fat.
Overlying eschar and rim of erythema are present.
Followed by:
Application of wet-to-dry dressings.
Pressure offloading.
Consistent wound cleaning.
Incorrect Answers:
Use of an air bed: Can be utilized to limit pressure to dependent body regions, but only as adjunct management of an existing ulcer with necrosis; serves as a preventive measure.
Application of wet-to-dry dressings and silver sulfadiazine cream with a sterile dressing: Therapeutic interventions used for tissue regrowth and cleanliness, but not sufficient alone for a decubitus ulcer with necrosis.
Skin grafts: Treatment choices for patients with clean stage 3 or 4 ulcers that do not respond to optimal medical interventions or when the patient's quality of life would improve from rapid wound closure.
Question 7: Hypertension and Renal Failure Risk
A 42-year-old woman with hypertension, treated with hydrochlorothiazide and lisinopril, presents for follow-up.
Her blood pressure remains elevated (160/98 mm Hg), and she asks how to decrease her risk for renal failure.
Most appropriate recommendation: Increasing the dose of lisinopril.
Lisinopril (ACE Inhibitor):
Inhibits angiotensin-converting enzyme, reducing angiotensin II and aldosterone production.
Reduces blood pressure through multiple mechanisms.
Decreases glomerular filtration pressure by causing relative efferent arteriole dilatation.
Chronic hypertension contributes to end-stage kidney disease.
Increased lisinopril reduces intraglomerular pressure, decreasing damage to glomerular capillaries and reducing the risk for end-stage kidney disease.
Incorrect Answers:
Protein-restricted diet: Reduces progression of nephropathy in chronic end-stage kidney disease, especially in diabetic nephropathy, but lisinopril provides more benefit for hypertension-related kidney disease.
24-Hour urine collection for protein concentration: Utilized for evaluation of nephrotic syndrome and albuminuria for diabetic nephropathy. The patient's nephropathy is likely from chronic hypertension.
Switching from hydrochlorothiazide to furosemide: These agents do not demonstrate reno-protective properties and are both diuretics. Furosemide is typically used in the management of hypervolemia.
No further measures are indicated at this time: The patient's blood pressure remains increased and she would benefit from an increased lisinopril dose to improve her blood pressure and reduce her risk for end-stage kidney disease.
Question 8: Wide-QRS Tachyarrhythmia
A 55-year-old man is admitted to the hospital in a coma after a sudden collapse with a history of recent coronary bypass operation.
ECG shows wide QRS complexes (QRS 160 ms) with a ventricular rate of 170/min and an atrial rate of 110/min.
Most appropriate initial step: Direct current countershock.
Direct Current Countershock:
Delivery of electrical energy for the treatment of cardiac arrhythmias (synchronized cardioversion and non-synchronized defibrillation).
The patient presents with wide-QRS tachyarrhythmia and altered mental status.
The differential for wide-QRS tachyarrhythmias includes ventricular tachycardia (monomorphic or polymorphic), antidromic atrioventricular reentrant tachycardia in Wolff-Parkinson-White syndrome, or supraventricular tachycardia with aberrant conduction.
Indications include tachyarrhythmias presenting with no pulse, hypotension, end-organ failure, or altered mental status.
Incorrect Answers:
Administration of digitalis: Indicated for atrial fibrillation or heart failure.
Administration of verapamil: Primarily used for treatment of supraventricular tachyarrhythmias.
Carotid sinus massage: Increases vagal output, not indicated for wide-complex tachycardia.
External pacing: Used for treatment of refractory or unstable bradycardia.
Question 9: Pancreatic Pseudocyst
A 32-year-old woman presents with recurrent nausea, vomiting, and epigastric abdominal pain radiating to her back for 8 hours.
She has had two similar episodes in the past 2 months.
CT scan of the abdomen demonstrates a pseudocyst in the pancreatic parenchyma.
Most appropriate next step in diagnosis: Endoscopic retrograde cholangiopancreatography (ERCP).
Pancreatic Pseudocysts:
A potential complication of acute pancreatitis.
Granulation tissue lined collections of simple fluid in the pancreatic parenchyma or peripancreatic region.
Can lead to persistent elevation of serum pancreatic enzymes and recurrent epigastric abdominal pain.
Intervention is indicated if:
Pseudocysts are larger than 5 cm or are symptomatic.
First-line intervention for drainage:
Endoscopic approach: transpapillary or cystogastrostomy/cystoduodenostomy to create drainage pathways between the cyst and gastrointestinal tract.
Incorrect Answers:
HIDA scan: Used for the diagnosis of acute cholecystitis.
Esophagogastroduodenoscopy: Not sufficient for definitive diagnosis and therapeutic intervention of pseudocyst; drainage is required.
Mesenteric angiography: Indicated for evaluation of mesenteric vessels in mesenteric ischemia or gastrointestinal bleed.
Percutaneous transhepatic cholangiography: Indicated for visualization of the biliary tree if ERCP is unsuccessful.
Question 10: Celiac Disease and Malabsorption
A 27-year-old man presents with fatigue and loose stools over 3 months, with a 6.8-kg (15-lb) weight loss despite a good appetite.
He has a childhood history of diarrhea that resolved in early adolescence.
72-hour test of stool for fecal fat shows 12 g/d (N=2-6), and D-xylose absorption test shows a serum D-xylose concentration of 4 mg/dl (N=25-40) 2 hours after administration.
Most likely underlying cause: Villous atrophy in the small bowel is a characteristic finding of celiac disease.
Celiac Disease:
Gluten-sensitive enteropathy mediated by immune intolerance of gliadin, commonly found in wheat products.
Results in inflammatory infiltration of the proximal small bowel, leading to intraepithelial lymphocytosis, villous atrophy, and crypt hyperplasia.
Malabsorption of substances in the proximal small bowel ensues, presenting as chronic diarrhea, steatorrhea, and nutritional deficiencies.
Abnormal small bowel absorption:
Results in abnormal serum D-xylose and fecal fat tests.
Reduced serum D-xylose indicates reduced small bowel mucosal surface area for absorption.
Increased fecal fat indicates intestinal malabsorption of lipids.
Incorrect Answers:
Bacterial overgrowth in the small bowel: Occurs in the setting of impaired intestinal peristalsis, leading to intestinal malabsorption, diarrhea, bloating, and chronic abdominal pain; diagnosed through the hydrogen breath test.
Exocrine pancreatic insufficiency: Results in insufficient pancreatic enzyme production and secretion, leading to inadequate digestion of macromolecules and resultant malnutrition, with diarrhea and steatorrhea.
Failure of bile acid excretion and reabsorption: Leads to steatorrhea due to impaired fat digestion and absorption; bile acids are absorbed in the terminal ileum, and absorption can be impaired by Crohn disease.
Lactase deficiency: Results in dietary intolerance to lactose, causing abdominal cramping, bloating, and diarrhea after dairy ingestion.
Question 11: Autonomous T4 Production
A 77-year-old woman presents with palpitations for 2 days and a 4.5-kg (10-lb) weight loss over 6 months.
Examination shows nontender enlargement of the left lobe of the thyroid gland. TSH less than 0.05 µU/ml and thyroxine {T4) concentration of 30 µg/dl.A 131I study shows a single area of increased uptake in the left lobe of the thyroid gland and suppressed uptake elsewhere in the gland.
Most likely mechanism: Autonomous T4 production is the most likely mechanism for the patient's hyperthyroidism.
Autonomous T4 Production:
Low TSH and increased T4 indicate primary hyperthyroidism originating within the thyroid gland.
Nontender left thyroid lobe enlargement with a single "hot" nodule on radioactive iodine uptake scan suggests a toxic adenoma, autonomously producing thyroxine.
Incorrect Answers:
Autoimmune destruction of thyroid cells: Occurs in Hashimoto's thyroiditis and typically presents with diffusely decreased 1-131 uptake on an RAIU scan.
Focal granulomatous inflammation: Refers to subacute {de Quervain) thyroiditis, which presents with tender thyroid enlargement and flu-like symptoms.
Parafollicular cell cytokine overproduction: Refers to the production of calcitonin by the parafollicular cells, typically not affecting thyroid hormone production except in advanced medullary thyroid cancer.
Production of thyroid-stimulating immunoglobulin: Occurs in Graves disease and results in diffuse 1-131 uptake without a focal nodule.
Question 12: Diverticulitis
A 72-year-old nursing home resident presents with abdominal pain and bloody stools for 3 days.
History includes dementia (Alzheimer type) and long-standing constipation treated with psyllium and docusate.
Examination shows left lower quadrant tenderness and distention; rectal examination shows blood and no masses.
Most likely diagnosis: Diverticulitis.
Diverticulitis:
A common cause of left lower quadrant abdominal pain and tenderness in adults.
Presents with fever, nausea, and vomiting.
Results from inflammation and infection involving pre-existing diverticula.
Symptoms: Hematochezia (secondary to diverticular bleeding) can be present.
Complications:
Perforation leading to peritonitis, abscess formation, bowel obstruction, and fistula formation.
Treatment:
Bowel rest, symptomatic control, and antibiotics covering enteric flora.
Incorrect Answers:
Campylobacteriosis, Salmonellosis, Shigellosis: These are causes of bloody diarrhea following certain exposures. This patient exhibits focal left lower quadrant pain without diarrhea, making acute bacterial infection less likely.
Celiac disease: Is a chronic inflammatory condition mostly affecting the proximal small bowel in response to gluten ingestion. This results in chronic diarrhea, bloating, weight loss, and malnutrition.
C/ostridium difficile colitis is an opportunistic infection that most commonly occurs after the use of antibiotics because of the effect on the patient's colonic microbiota. It typically presents with abdominal pain and severe watery diarrhea, with the risk for complications such as fulminant colitis and toxic megacolon.
Colon cancer: Is a cause of hematochezia, although it would not be expected to present acutely with fever.
Diverticulosis: Indicates the presence of colonic diverticula, which do not produce abdominal pain outside of episodes of diverticulitis, but can result in diverticular bleeding, which is one of the most common causes of painless hematochezia.
Irritable bowel syndrome: Presents with intermittent abdominal pain that is relieved by bowel movements and associated alterations in bowel habits with intermittent episodes of diarrhea and/or constipation.
Ischemic colitis: Refers to inadequate blood supply to the colon, which can lead to bowel wall necrosis, loss of immune barriers, and bowel perforation.
Ulcerative colitis: Is a type of inflammatory bowel disease that results in mucosal and submucosal ulceration and inflammation that progresses retrograde along the colon from the rectum. This typically presents with chronic bloody diarrhea, tenesmus, and abdominal pain.
Question 13: Pneumothorax After Scuba Diving
A 27-year-old man presents with sudden onset of shortness of breath after rapid ascent during scuba diving.
He reports midchest pain upon ascent and shortness of breath by the time he reached the surface.
Examination shows decreased breath sounds and hyperresonance to percussion on the left.
Most appropriate next step: Chest x-ray is indicated for the evaluation of nontension pneumothorax.
Decompression Sickness:
Occurs when dissolved gases precipitate out of solution in the body or expand due to rapid decrease in ambient pressure.
Increases the risk for air emboli, arthropathy, tympanic membrane rupture, and pneumothoraces.
Evaluation for Pneumothorax:
Chest x-ray is indicated.
Depending on the size of the pneumothorax, the patient may require thoracostomy.
Incorrect Answers:
Measurement of serum D-dimer concentration: Recommended for evaluation of patients with low pretest probability of deep venous thrombosis (DVT) or pulmonary em bolus.
ECG: Indicated for evaluation of cardiac arrhythmias and acute coronary syndromes. The patient presents with midchest pain, which is likely secondary to his left-sided pneumothorax, not myocardial ischemia/infarction.
Echocardiography: Entails ultrasound evaluation of the heart, allowing for visualization of pericardia! pathology and cardiac morphology, motion, ejection fraction, and valvular function. Lung ultrasound, not cardiac, is useful in the evaluation of pneumothorax.
CT scan of the thorax: Can be performed to evaluate for a variety of thoracic pathology, both acute and chronic.
Question 14: Hypercarbia in COPD Exacerbation
A 62-year-old man with a history of chronic obstructive pulmonary disease (COPD) presents with acute shortness of breath and decreased level of consciousness.
He is drowsy and awakens only to loud voices or painful stimuli.
The most likely underlying cause of decreased consciousness: Hypercarbia.
COPD Exacerbation:
Characterized by decreased lung function from chronic bronchitis and/or emphysema, resulting in airflow obstruction on expiration.
Administration of 100% oxygen by face mask can theoretically depress respiratory drive and worsen ventilation/perfusion mismatch.
Depressed ventilation can result in acute hypercarbia, leading to decreased level of consciousness.
Incorrect Answers:
Hypoxemia: Unlikely to account for decreased consciousness, as he received 100% oxygen.
Metabolic acidosis: Typically followed by increased ventilation via respiratory compensation.
Oxygen toxicity: Can manifest with primarily neurotoxic symptoms such as vision and hearing changes, dizziness, nausea, altered mental status, and convulsions.
Respiratory alkalosis: Occurs in the setting of hyperventilation; the patient has inadequate ventilation and hypercarbia.
Question 15: Diabetic Nephropathy
A 47-year-old woman with type 2 diabetes mellitus (DM) presents for follow-up; her father died of end-stage renal disease secondary to type 2 DM.
Urine protein 1+ and hemoglobin A1c is 7.3% Blood Pressure 130/82 mm Hg.
Most likely measure to slow progression of diabetic nephropathy: Addition of lisinopril (ACE inhibitor).
Diabetic Nephropathy:
Results from nonenzymatic glycosylation of the glomerular basement membrane and efferent arterioles.
Increased glomerular filtration rate (GFR) can cause progressive hyperfiltration injury.
Presents as microalbuminuria, progressing to macroalbuminuria, then end-stage kidney disease.
ACE Inhibitor Mechanism:
Decreases angiotensin II production, causing relative efferent arteriole dilatation.
Reduces hyperfiltration injury and slows the progression of nephropathy.
Incorrect Answers:
Calorie-reduced diet: May improve glucose control, but lisinopril more directly affects progression of diabetic nephropathy.
Dietary protein restriction: Shows evidence for slowing progression but is less effective than ACE inhibitor therapy.
Maintenance of A1c < 6% and switching to insulin: Improves management of type 2 DM, slowing microvascular complications, but ACE inhibitor is more effective.
Question 16: Atrial Septal Defect
A 20-year-old woman comes for a routine health maintenance examination with a split fixed S2 with a grade 2/6systolic murmur is heard at the third intercostal space, with no other abnormalities.
Most Likely Diagnosis : Atrial Septal Defect is a defect in the Interatrial Septum.
The most common type is Ostium Secundum defect, although ostium primum defects are commonly associated with Trisomy 21.
Atrial Septal Defect:
results in a left to right shunt with abnormal flow of blood from the left atrium to the right atrium, resulting in relative volume overload of the right atrium and ventricle.
This increased stroke volume of the right ventricle results in delayed closure of the pulmonic valve, which presents as a fixed split S2 and low grade physiologic ejection murmur on cardiac auscultation.
If the atrial septal defect remains uncorrected, it can result in the development of Eisenmenger's syndrome.
Incorrect Answers:
Aortic Insufficiency presents with an Early Diastolic Decrescendo mumur best heard in the right second intercostal space and is most commonly associated with Endocarditis, Rheumatic Fever and Aortic Root Dilation.
Mitral Insufficiency presents with a Holosystolic Murmur best heard in the left fourth or fifth intercostal space along the midclavicular line and radiates to the left axilla and is commonly associated with Mitral Valve Prolapse and Prior Myocardial Infarction.
Patent Ductus Arteriosus is a Continuous Machine-like Mumur best heard in the left second intercostal space and radiates to the clavicle.
Pulmonic Insufficiency presents with a Diastolic Murmur best heard in the left second intercostal space.
Tetralogy of Fallot consists of Pulmonic Infundibular Stenosis, Overriding Aorta, Ventricular Septal Defect and Right Ventricular Hypertrophy, resulting in a Right to Left Shunt with cyanosis first noted in Infancy.
Tricuspid Insufficiency demonstrates a holosystolic murmur best heard in the lower left sternal border.
Question 17: Aortic Dissection
A 52 year old woman is in the ER states that she has had tearing pain starting in the base of her neck that radiates to her back. Temperature is ; Blood pressure is 190/110. Pulse is 96/min. Chest X ray shows a widened mediastinum.
Most appropriate step in the management is Labetalol.
Labetalol Use: Is a first line antihypertensive medication that is used in lowering blood pressure given presentation associated with Aortic Dissection.
The patient is presenting with symptoms of neck pain leading to back, chest X ray showing widened mediastinum leading to Aortic Dissection.
*The CT Angiography of the thoracic aorta is indicated to further delineate whether the patient is giving Type A or B Aortic Dissection.Hypertension in the setting of blood pressure being .
MOA of Labetalol: It targets both and making it a great choice.
Incorrect Answers:
Morphine is indicated for the treatment of acute pain that the patient demonstrates.
The use of Nitroglycerin in the presentation of this case is not appropriate, however it can be appropriate in the use of aortic dissection accompanies with a beta blocker to tachycardia issues.
Using Phenylephrine will only worsen the blood pressure readings and it will stimulate the adrenoreceptors.
Sodium Nitroprusside is a vasodilator that can be for the emergency treatment of Hypertension. Labetalol is a better choice for this case.
Question 18: Hypercalcemia
A 62 year old man is admitted to the hospital for lethargy, weakness, confusion, and constipation for 3 days.
He has recent history of the diagnosis of inoperable squamous cell carcinoma of the lung. Examination shows decreased skin trugor and An ECG shows a short QT interval. Given Intravenous administration of 0.9% Saline most appropriate pharmacotherapy is Pamidronate.
Pamidronate Use: A bisphosphonate indicated for the treatment of hypercalcemia through the inhibition of osteoclasts in the body.
The patient symptoms include those of acute hypercalcemia that results from a short QT interval and significant dehydration.
The common causes for hypercalcemia are hyperparathyroidism and various malignancies. Parathyroid Hormone Peptide (PTHrP) produced in patients induces osteoclast activity leading to Hypercalcemia.
Treatment with Isotonic Fluid and Bisphosphonate Administration for First Line Therapy.
Incorrect Answers:
Allopurinol(Choice A) inhibits xanthine oxidase, decreasing production of uric acid, and is commonly used as preventative therapy for gout.
Cisplatin (Choice B) is a platinum chemotherapeutic agent that cross-links DNA and is used in the treatment of various malignancies.
Cryoprecipitate (Choice C) contains fibrinogen, Factors VIII and XIII, and von Willebrand factor. It is commonly used for treatment of coagulopathic states with diminished levels of fibrinogen and factor VIII.
Demeclocycline (Choice D) is a member of the tetracycline family that serves as an anti-diuretic hormone antagonist used in the treatment of refractory SIADH.
Doxycycline (Choice E) is also a member of the tetracycline family and is a bacteriostatic antibiotic used for a variety of bacterial infections
Fresh Frozen Plasma (Choice F) contains numerous coagulation factors and is used for the treatment of urgent anticoagulation reversal and hypocoagulable states.
Heparin (Choice G) binds anti thrombin III and inhibits thrombin and factor Xa. Commonly associated for the treatment for pulmonary embolism and acute coronary syndrome.
Hydroxyurea is sued int he treatment for sicker cell disease. Induction of increased fetal production occurs.
Tamoxifen is selective estrogen receptor modulator used in the treatment of Breast Cancer.
Question 19: Erythropoietin Supplementation
A 52 year old man comes to the physician for fatigue for 4 months. He has had Hyptertension and a 2 year history of CHronic Renal Problems. His serum creatinine concentrations have ranged between 2.5 and 3.5 . Supplementation with erythropoietin is to most likely have prevented the hematologic findings.
Erythropoietin. Hormone produced by the kidney interstitial cells that goes up to the bone marrow due to the increase to Hypoxia. This leads to subsequent normocytic, nonhemolytic Anemia.
Administration of erythropoietin helps stimulate marrow that can event the development of Normocytic Anemia.
INCORRECT ANSWERS:****
Felic Acid Supplementation can be supplements for increased risk for folic deficiencies such as Hemolytic Anemia.
Iron( Choice C) Supplementation is indicated for Iorn Deficieny and is characterized by Microcytic Mean Corpuscular Volume
Vitamin B12(cyanocobalamin) supplementation is utilized for the treatment for Megaloblastic Anemia or for preventive supplement.
Question 20 : Survival Over Time
This questions is asking which group had the poorest 1 year survival rate. The answer seems to be Group B at Year 3-4.
The most significant decline in the survival rates that occurs are at this point of the graph.
*All other times do not show a significant decrease in survival
Question 21
An MRI of the lumbosacral Spine is used for evaluation of acute onset deterioration from the cauda equina syndrome. With prostate cancer on hand, the need to investigate with lumbosacral spine is a great next step due to metastatic causes.
Radionuclide Bone Scanner uses technetium in or to evaluate Osteoblasts osseous metastases in the breast and the prostate most commonly.
EMG can be used to differentiate myopathic or neuropathic causes of extremity weakness but wouldn't be used for acute weakness.
Lumbar punctures is uses to evaluate CSF Fluid in evaluation such as Meningitis or other CNS diseases.
CT if the HEAD is used best since this is an MRI question for acute evaluation.
Question 22
This question is focused on what would be abnormal for ParaNeoPlastic Hypertrophic Osteoarthropathy (Digit Clubbing). The answer is X ray of the Chest due to having an indication of the presence of primary lung carcinoma.
Serum Creatinine Concentration can use creatinine concentrations to test for any presence of kidney failure disease.
Serum Ferritin can test anemia, increased serum is signs of Hemochromatosis.
*Serum Protein Electrophoresis used for the testing of Hemoglobinopathies test.
*X ray in the abdomen is used less often for any primary malignancy signs or indication and to test for smaller obstructions
Question 23
*Patient Presents with HeartBurn for months and some difficulty in swallowing solids. Ranitidine was ineffective so next set in the management should be upper endoscopy for evaluating the esophagus due to the reflux.
*Adding Metoclopramide to the list would not be a great choice due to 02 receptor antagonist that increases gastric contractility and motility.
*Adding esomeprazole is not needed or switching back and forth to famotidine not needed here due to the ineffective usage of the last medication.
*No further pharmacological testing is ok here since the previous medication was ineffective.
Question 24
*With kidney disease and