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32 y/o F who is 36 weeks pregnant p/w persistent itching. Began on palms and soles 5 days ago and has progressed proximally. Diphenhydramine has offered minimal relief. No complications with pregnancy so far. Labs: T bili: 3.3, Elevated bile acids, Alk Phos: 500. What should be done next?
Deliver the fetus
74 y/o M pw new onset eruption on trunk and extremities. Rash started out as "whelps" but became tense blisters which ruptured with minor trauma. Lesions are very itchy. PE: urticarial plaques with intact and ruptured superficial blisters on abdomen, back, thighs and upper arms. No lesions noted on genitals or oral mucosa. Skin biopsy: Subepidermal blistering with numerous eosinophils, linear band of IgG and C3 at basement membrane on direct immunofluorescence
Bullous pemphigoid. (Might have been pemphigus vulgaris if mucosal lesions were found)
What are possible etiologies of hyperthyroidism?
- Graves disease
- Hyperfunctioning adenoma
- Multinodule Goiter
- Subacute thyroiditis
What is the first step in workup for presumed hyperthyroidism?
24 hour radioiodine uptake and scan
- Diffusely increased uptake - Graves Disease
- Focal areas of uptake - Adenoma/Multinodular
- Overall decreased uptake - Subacute thyroiditis (hyperthyroid phase)
32 y/o F pw chronic facial rash. Red rash on cheeks, nose and forehead for last year w flushing and redness with occasional small pimples. Rash worsened with sun exposure and hot drinks. Also noted dryness and stinging in her eyes, unsure if related though. PE: Malar cheeks, nasal sidewalls, and forehead - mild erythema with prominent telangiectasias; few pustules.
48 y/o F w/ ho type I DM pw several months of fatigue. ROS: positive for dyspepsia and lower extremity paresthesias. PE: reduced vibration sense in lower extremities. Labs; HCT: 28% Hb: 9%.
48 y/o F complains of pruritis and fatigue for last 6 months. Not related to any triggers, gradual onset. Has been otherwise feeling well. ROS: occasional arthralgias, dry mouth and dry eyes. Exam: Hepatomegaly, no splenomegaly. Diffuse patchy areas of hyperpigmentation as well as linear areas of excoriation from scratching. AST: 58 ALT: 81. Alk Phos: 858. T Bili: 2.0 GGT: 82
Primary Biliary Cirrhosis
An obese 73 y/o F pw painful right eye. Pain came on suddenly as she was preparing dinner and was accompanied by blurred vision, nausea, and one episode of vomiting. PE: extremely tender right eye with a hazy cornea and a partially dilated and fixed pupil. Left eye is normal
Closed angle glaucoma
55 y/o F falls in shower and hurts right shoulder. Shows up in ED with arm held close to body but forearm is rotated outward as if she were going to shake hands. PE: Shoulder looks square compared with rounded unhurt opposite side, numbness noted in small area of her shoulder over deltoid muscle
Anterior dislocation of shoulder
What is the most common primary glomerular disease?
What is the biopsy finding of IgA nephropathy?
Deposition of IgA in mesangium
35 y/o M w no PMH pw severe chest pain. Pain is worse with ingestion of cold or hot liquids. No history of weight loss and no oral lesions. PE: negative. Cardiac workup is negative.
What is the most useful test to confirm diagnosis of GERD?
24 hour pH monitoring
Pt appears in ED at 3 AM appearing intoxicated. Bystander witnessed bizarre behavior and called 911. Refuses to answer questions and seems combative. Creatinine: 1.5. BUN: 25. U/A reveals envelope/needle shaped crystals
Ethylene glycol ingestion
58 y/o F pw persistent vulvar itching and a burning sensation "down there" for last two months. Underwent menopasuse at age 51. Sexually active w 3 male partners, slight pain in vaginal introitus after intercourse, but denies bleeding. Pelvic exam: 1 cm, white flat, glistening plaque on the right vulvar region, with thin skin and evidence of erythema with excoriations on right labia majora.
18 y/o M pw vomiting. Competing for a wrestling championship so has been vomiting a lot recently. Vomits after each meal instinctively now and has been feeling letharrgic. PE: Vitals: 37C, BP 90/60, HR: 80, RR 8. Dry mucous membranes, mild bilateral parotid gland tenderness, multiple dental erosions, bruises on dorsum of hand. pH: 7.50, Na: 145, K 4, Cl: 93, HCO3: 30 What type of acid base disorder does he have?
Hypochloremic metabolic alkalosis
32 y/o G2P0 p for prenatal checkup. LMP - 10 weeks ago. Prior to this - had regular 28 day cycles. Has been actively trying to get pregnant for last year. Sx: abdominal distention, breast tenderness, nausea. Denies vaginal bleeding or discharge. Ultrasound: fails to reveal intrauterine pregnancy. Serum HCG: 0.5. Repeat testing 1 week later - unchanged. Sx have not improved though
What are some examples of TCA drugs?
Amitriptyline, desipramine, imipramine
Interventions for COPD that alter natural history of condition?
- 1. Discontinuation of smoking
- 2. Oxygen therapy
32 y/o F brought to ED by husband. Suddenly developed right back pain approx 3 hours. Pain is sharp in nature, radiates towards groin, and "comes and goes" When the pain is most severe, she is unable to catch her breath. Denies any fevers, chills or prior episodes. She does not complain of urinary urgency and frequency but denies dysuria or hematuria. Her last BM was yesterdsay and was normal. She is tossing and turning on stretcher. PE: Decreased bowel sounds diffusely with mild right sided abdominal pain. Severe CVA tenderness on right side
76 y/o F with significant visual loss in left eye and now in right eye over last 2 years. At most recent exam, separation of neurosensory retina from retinal pigment epithelium in right eye. Left eye shows neovascularization from choroidal vessels.
Age related macular degeneration (leading cause of blindness in elderly)
What should be ruled out in an elderly patient with thrombocytopenia?
38 y/o F w PMH of SLE, recurrent DVT, 4 prior miscarriages in first trimester and thrombocytopenia. On exam, pt has violaceous, netlike discoloration of lower extremities.
Antiphospolipid antibody syndrome