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A 53-year-old man presents to the endocrinology clinic after his primary care physician documented new-onset diabetes mellitus poorly responding to oral antidiabetics with an HbA1C of 9.3%. The patient reports adhering to a strict diet but despite this feels like he has gained much weight in the past 3 months. He also reports significant lower extremity weakness and fatigue recently. His physical exam is notable for a blood pressure of 174/89 mmHg, significant abdominal obesity, proximal muscle weakness, and fat collection at the base of neck. After a series of tests, the physician diagnoses Cushing's disease and decides to start the patient on metyrapone therapy. What would you expect to increase after the initiation of therapy? +
A 28-year-old woman recently found to have a positive PPD was started on INH prophylaxis. Six months later, the patient returns to the infectious disease clinic with a small wound on the sole of her foot. She claims she does not remember how she got the wound, and explains that she feels like she has been losing feeling in her feet. She reports having difficulty walking and often losing her shoes without even noticing a difference. She also reports feeling tired and extremely irritable recently. Serum levels of which of the following would you expect to be decreased in this patient? +
A 65-year old man comes to the outpatient gastroenterology clinic for a routine check-up. He was admitted and treated 2 months ago for community acquired pneumonia. He has no complaint today and his vitals are within normal limit. His laboratory investigations are also normal except for a positive Clostridium difficile toxin assay.
What is the best next step to take in the management of this patient? +
A 90-year-old man with a past medical history of hypothyroidism, mild hypertension and rheumatoid arthritis is brought to the outpatient clinic by his son because of a progressively worsening memory loss noticed two weeks ago. His wife died of breast cancer a month ago. His medications are simvastatin, hydrochlorothiazide and L-thyroxine. He claims to be regular on his medications. He denies any history of fever, headache, or trauma. On speaking with the patient, he complains of fatigue, loss of appetite, a 5-kg weight loss and an intense feeling of guilt for the past two weeks. He was also concerned about when he would regain his lost memory. Mini-mental state examination was difficult to assess due to his numerous “I don’t know” answers. A neurologic examination is notable for impaired short-term recall, but motor and sensory functioning are intact with no ataxia and a negative Romberg’s sign. CT scan of the head shows mild cerebral atrophy and cerebral angiography was unremarkable.
Which of the following is the diagnosis in this patient? +
An 87-year-old man with a past medical history of hypothyroidism, mild hypertension and osteoarthritis is brought to the outpatient clinic by his son because of “increasing forgetfulness” for the past two years and it has been progressively getting worse. His medications are simvastatin, hydrochlorothiazide and L-thyroxine. He claims to be regular on his medications. He denies any history of fever, headache, or trauma. Mini-mental state examination (MMSE) reveals a score of 21/30. A neurologic examination is notable for impaired short-term recall, but motor and sensory functioning are intact with no ataxia and a negative Romberg’s sign. CT scan of the head shows mild cerebral atrophy.
Which of the following is an example of a reversible cause of this patient’s diagnosis? +
A 25 year old male patient, previously healthy, is brought to the emergency department after a motor vehicle collision. The patient suffered extensive abdominal trauma and requires splenectomy and pancreatectomy. During post-operative care in the intensive care unit (ICU), the patient is started on intravenous hyperalimentation fluids. On day 10 of hyperalimentation, he develops fever and endophthalmitis. Blood cultures are taken immediately and empirical antimicrobial therapy is initiated. Which of the following organisms is most likely to responsible for this patient's condition? +
A 78-year-old man with a past medical history of hypertension, hypercholesterolemia and diabetes is brought to the ED with an acute onset of impaired speech, right-sided hemiplegia, and right-sided facial palsy. He suddenly noticed that he was unable to hold his cutlery immediately he sat down at his daughter’s wedding rehearsal dinner nearly 2 hours ago. No history of trauma. He is on hydrochlorothiazide, lisinopril and pravastatin. His vitals reveals a blood pressure of 138/89 mmHg, heart rate of 85 beats per minute, respiratory rate of 16 breaths per minute, and he is saturating at 98%, while breathing room air. Examination reveals an elderly man, conscious and alert, not in any obvious painful distress. Lungs and cardiac were auscultations are unremarkable. Abdomen was non-tender, non-distended and without any hepatosplenomegaly. Neurological examination confirms the presenting complaints above. You suspect a slowly evolving stroke.
What is the best next step to take to confirm your diagnosis in the patient? +
A 64-year-old woman with a past medical history of hypertension, osteoarthritis, and diabetes is brought to the ED with an acute onset of impaired speech, right-sided hemiplegia, and right-sided facial palsy. She also complains of headache and dizziness. She suddenly noticed that she was unable to use her right arm and leg 2 hours ago. No history of trauma. She is on hydrochlorothiazide, lisinopril and pravastatin. Her vitals reveals a temperature of 38.5 degrees Celsius, blood pressure of 192/115 mmHg, heart rate of 105 beats per minute, respiratory rate of 12 breaths per minute, and she is saturating at 92%, while breathing room air. Examination reveals an elderly woman, conscious and alert, not in any obvious painful distress. Lungs and cardiac were auscultations are unremarkable. Abdomen was non-tender, non-distended and without any hepatosplenomegaly. Neurological examination confirms the presenting complaints above. An immediate non-contrast CT of the brain done ruled out hemorrhage in the brain. There is no contraindication to the use of thrombolytics in this patient, and intravenous recombinant TPA (alteplase) is being strongly considered.
What is the next best step to take in the management of this patient? +
A 66-year-old woman with a past medical history of hypertension, osteoarthritis, and depression is brought to the ED with an acute onset of impaired speech, right-sided hemiplegia, and right-sided facial palsy. She suddenly noticed that she was unable to use her right arm and leg 2 hours ago. There is history of a prior stroke 2 months ago. She also complains of headache and dizziness. No history of trauma. She is on hydrochlorothiazide, lisinopril, pravastatin, and warfarin. For the past two months, her diet has been restricted to vegetables and an herbal tea which helps with her depression. Her vitals reveals a temperature of 38.5 degree Celsius, blood pressure of 200/112 mmHg, heart rate of 105 beats per minute, respiratory rate of 12 breaths per minute, and she is saturating at 92%, while breathing room air. Examination reveals an elderly woman, conscious and alert, not in any obvious painful distress. Lungs and cardiac were auscultations are unremarkable. Abdomen was non-tender, non-distended and without any hepatosplenomegaly. Neurological examination confirms the presenting complaints above. An immediate non-contrast CT of the brain done ruled out hemorrhage in the brain. You are strongly considering the use of intravenous recombinant TPA (alteplase) in this patient.
What is the next step in the management of this patient? +
A 55 year- old male comes to ED after 2 days of experiencing a chest pain. He mentions the attack as a dull pain started 15 min before arriving to ED all over his chest that radiates to the left shoulder and arm, and he was released the next day after being prescribed some medications. Today he comes with the same presentations, with EKG is as before normal. After the resolve of his attack, you ordered a stress test, which turn abnormal and show a reversible ischemia. Which of the following is the best next step in his further management? +
A 63-year-old obese man with history of hypertension treated with thiazide diuretics complains of rapidly progressive pain in his big toe. The pain began in the morning and has become much worse in the last 6 hours. On physical exam, the toe is erythematous, swollen and tender to palpation. The patient reports two similar prior episodes that were less painful and resolved spontaneously. Synovial analysis reveals strongly birefringent needle-shaped crystals on polarized light microscopy. Deposition of which of the following most likely explains the symptoms in the patient? +
A 62-year-old woman known to have osteoarthritis is hospitalized for pneumonia for which she receives an intravenous course of antibiotics. On her third day of hospitalization, she reports improvement in her respiratory status but complains of a new onset of knee pain that started in the morning and progressively worsened throughout the day. The knee is red, swollen and tender upon palpation. Her temperature is 37 °C (98.6 °F), blood pressure is 120/70 mmHg and heart rate of 70/min. Analysis of the synovial fluid reveals deposition of rhomboid crystals. Which other features characterizes the crystals deposited in this patient’s joint? +
A 33 year old male patient known to have diabetes mellitus type 1 on insulin presents to the ER for severe vomiting and abdominal pain. His symptoms started in the afternoon shortly following a lunch meeting his company organized. When he was asked about what he ate throughout this day, he answers that he didn’t eat anything except some egg salad. Upon physical exam, the patient looks pale, his skin and mouth mucosa are dry and the upper abdomen is tender. Vital signs are: temperature of 37 degree Celsius, blood pressure of 100/60 mmHg and heart rate of 100 bpm. Blood results reveal a sodium level of 132 mEq/L. What are the most possible values of spot urine sodium and BUN/creatinine ratio respectively that are expected in this patient’s conditions? +
A 70 year old male patient is hospitalized for pneumonia requiring an IV course of antibiotics. On the third day of hospitalization, the patient reports less dyspnea and shows overall clinical improvement. His vital signs are: temperature of 37.2 degrees celsius, blood pressure of 120/68 mmHg and heart rate of 70 bpm. The patient has a previous history of myocardial infarction and hypertension. His medications include aspirin, statin and ACE inhibitors. His electrolytes ordered in the morning show the following results: <br>
Sodium: 139 mEq/L <br>
Potassium: 5.5 mEq/L <br>
Calcium: 10 mg/dl <br>
Phosphorus: 3.9 mg/dl <br>
Magnesium: 1.68 mg/dl <br> <br>
Which of the following is a first step in the management of the patient? +
A pregnant woman known to have classic galactokinase deficiency is worried she will not be able to breastfeed her baby because she has been on a strict galactose free diet since her birth. The physician comforts her and tells her that she will be having normal breast milk for lactation. The ability of the mammary glands to synthesize milk in the absence of dietary galactose in this patient is due to the activity of which of the following enzymes? +
Elevated levels of galactose are detected in a newborn screening test and prompt further investigation for a galactose metabolism disorder. An erythrocyte enzyme assay that monitors the accumulation of products of the galactose metabolic pathway following the addition of a radiolabeled substrate is carried out. The enzyme assay confirms the diagnosis of a galactose metabolism disorder that leads to mental retardation, failure to thrive, and jaundice if galactose is not eliminated from the diet. Which of the following is most likely the result of the enzyme assay in this patient? +
A 40-year-old woman presents for complaints of recurrent episodes of abdominal pain, bloating and diarrhea. She reports that the symptoms started several months ago and have been getting progressively worse, and seem to be related to the consumption of dairy products. Acquired deficiency of which of the following explains the symptoms of the patient? +
A 28 year old African-American male presented to the emergency department with complaints of lethargy and vomiting for the past one day. He is a known type 1 diabetes mellitus patient. He had a gastrointestinal disturbance before two days following which he restricted his food intake and skipped his insulin doses. He also played soccer with his friends last evening. Physical examination revealed a confused, dehydrated, tachypneic male with vital signs like heart rate of 120 beats/min, blood pressure of 98/58 mmHg, respiratory rate of 35/minute and oral temperature of 37.2 C. A rapid finger glucose test revealed plasma glucose of 638 mg/dL, thus confirming diabetic ketoacidosis. He was started on 0.9% normal saline while waiting for his lab results, which revealed a high anion gap metabolic acidosis with serum potassium below 5.3 mEq/L. He was admitted in the intensive care unit and started on a continuous infusion of intravenous regular insulin, isotonic 0.9% normal saline and potassium. Repeat blood tests after four hours revealed the following<br>
<br>
Serum sodium: 135 mEq/L<br>
Serum potassium: 5.4 mEq/L<br>
Serum chloride: 97 mEq/L<br>
Serum bicarbonate: 20 mEq/L<br>
Serum BUN: 22 mg/dL<br>
Serum creatinine: 1.2 mg/dL<br>
Blood glucose: 180 mg/dL<br>
Blood pH: 7.20<br>
PaCO2: 30 mmHg<br>
<br>
What will be the next line of management in this patient? +
A 28 year old African-American male presented to the emergency department with complaints of lethargy and vomiting for the past one day. He is a known type 1 diabetes mellitus patient. He had a gastrointestinal disturbance before two days following which he restricted his food intake and skipped his insulin doses. He also played soccer with his friends last evening. Physical examination revealed a confused, dehydrated, tachypneic male with vital signs like heart rate of 120 beats/min, blood pressure of 98/58 mmHg, respiratory rate of 35/minute and oral temperature of 37.2 C. A rapid finger glucose test revealed plasma glucose of 638 mg/dL, thus confirming diabetic ketoacidosis. He was started on 0.9% normal saline while waiting for his lab results, which revealed a high anion gap metabolic acidosis with serum potassium below 5.3 mEq/L. He was admitted in the intensive care unit and started on a continuous infusion of intravenous regular insulin, isotonic 0.9% normal saline and potassium. He was continuously monitored with hourly blood glucose and fourth hourly basic chemistry profile, pH and plasma osmolality until he clinically became stable. The most recent lab tests revealed the following<br>
<br>
Serum sodium: 138 mEq/L<br>
Serum potassium: 4.5 mEq/L<br>
Serum chloride: 106 mEq/L<br>
Serum bicarbonate: 24 mEq/L<br>
Serum BUN: 20 mg/dL<br>
Serum creatinine: 1.2 mg/dL<br>
Blood glucose: 180 mg/dL<br>
Blood pH: 7.38<br>
PaCO2: 36 mmHg<br>
<br>
He feels hungry now. What will be the next line of management in this patient? +
A 71 year old man is brought to the ER following an acute episode of abdominal and back pain. He also complains of nausea accompanying his abdominal pain. He is a known hypertensive and hypercholesterolemia patient for the past 15 years who is on regular treatment. He was diagnosed with an abdominal aortic aneurysm during routine ultrasound screening of his abdomen before 6 years. He is a known smoker for the past 20 years smoking half pack a day and denies taking alcohol or illicit drugs. On physical examination, he looks diaphoretic and his abdomen is diffusely mildly tender. Patient is relatively obese and thus no mass is palpated. His vitals are found to be blood pressure of 80/50 mmHg, pulse rate of 118/minute, respiratory rate of 18/minute and temperature of 36.4 C. Suspecting a rupture of his abdominal aortic aneurysm, the next best step in management of this patient is? +