MsMMaM & MWM

Questions
1 . A 6 1 -y e a r -o ld m a l e p re s e n ts t o y o u r o ffi c e w i th th e c h ie f c o m p la in t o f " c o u g h in g u p b lo o d " f o r th e p a s t 3 we e k s . H e re p o r t s a t le a s t f i v e t o s ix e p is o d e s e v e ry 2 t o 3 d a y s o f c o u g h in g o f b ri g h t r e d b l o o d , a p p ro xi m a te ly 1 to 2 ta b l e s p o o n s e a c h ti m e . T h e p a t ie n t d e n ie s a n y c he s t p a in , fe v e r s , c h il ls , w e i g h t lo s s , o r r e c e n t tr a v e l. H e h a s h a d a p e rs is t e n t p ro d u c ti v e c o u g h (c l e a r s p u t u m ) fo r th e p a s t m o n t h a n d re p o r ts m i ld d y s p n e a d u ri n g th is ti m e . P M H is s i g n i fi c an t f o r C O P D d i a g n o s e d 5 y e a r s a g o a n d H T N . H e h a s a 3 0 p a c k -y e a r s m o k in g h i s to ry a n d c u r re n tly s m o k e s 1 p a c k p e r d a y . O n a u s c u lta t io n o f h is lu n g s , y o u n o t e e n d -e xp ir a t o r y w h e e z i n g a n d a p ro lo n g e d e x p i ra to r y p h a s e . R o u ti n e l a b o r a to ry v a lu e s a re a l l n o r m a l . C X R re v e a ls ty p i c a l c h a n g e s s e e n i n C O P D (fl a tte n e d d ia p h ra g m s , h y p e ri n fla t io n ) w i th o u t a n y l o c a li z i n g a b n o rm a l iti e s . W h a t i s th e a p p ro p ria t e m a n a g e m e n t o f th is p a ti e n t? 2 . A 6 7 -y e a r -o ld m a l e p re s e n ts t o t h e E D w i th L L Q p a in t h a t b e g a n a fe w h o u rs a g o . H e c o m p la i n s o f n a u s e a a n d l o o s e s to o l s . H is P M H is s ig n i fi c an t f o r C HF . H e re p o r t s o n e e p i s o d e o f b lo o d in h is s to o l s a fe w m o n t h s a g o . V it a l s i g n s a re a s f o l lo w s : te m p e r a t u re = 1 0 1 . 1 , B P = 1 3 0 /7 6 , p u l s e = 7 0 . O n p h y s ic a l e x a m i n a t io n , h e h a s g u a r d i n g a n d te n d e rn e s s t o p a lp a t io n i n t h e L L Q . H i s e x a m i n a ti o n is o th e r wi s e u n re m a rk a b le . H is s t o o l i s n e g a ti v e f o r o c c ul t b l o o d . L a b o ra to r y t e s ts r e v e a l a l e u k o c y te c o u n t o f 1 6 ,0 0 0 c e ll s / L . P l a in a n d u p r ig h t a b d o m in a l fi lm s a re n o rm a l. W h a t i s t h e d ia g n o s is ? W h a t t e s ts w o u ld y o u o rd e r? W h a t is t h e n e xt s t e p in m a n a g in g t h i s p a t ie n t? 3 . A 6 4 -y e a r -o ld fe ma l e wi t h a h i s t o r y o f H T N p re s e n ts to th e E D w it h a c hi e f c o m p l a i n t o f l e f t s id e d c h e s t p a i n th a t b e g a n 4 to 5 h o u rs a g o . S h e h a s a h i s to r y o f p e rio d ic e p is o d e s o f c h e s t p a in f o r w h i c h s h e ta k e s s u b lin g u a l n i t ro g l y c e ri n , b u t to d a y 's e p i s o d e h a s b e e n m o r e s e v e re , h a s la s te d l o n g e r, a n d is n o t r e l ie v e d b y n i t ro g ly c er in . S h e d e n ie s n a u s e a /v o m i ti n g , a n y ra d ia t io n o f th e p a i n , o r d i a p h o re s i s . T e m p e ra tu re = 9 7 . 8 , B P = 1 3 6 /7 6 , H R = 8 0 , R R = 2 0 . S h e s e e m s u n c o m fo r ta b le b u t p h y s i c a l e x am in a ti o n i s o th e rw i s e u n r e m a rk a b le . W h a t is t h e d ia g n o s is ? H o w s h o u l d h e r c h e s t p a in b e e v al u a te d ? W h a t is th e n e xt s t e p i n m a n a g e m e n t? 4 . A 6 4 -y e a r -o ld m a l e c o m e s t o y o u r o f fic e wi t h c o m p l a i n t o f a s u d d e n l o s s o f v i s i o n , wh i c h h e l ik e n s to " a c u r ta i n c o m i n g d o wn o v e r m y e y e s ," t h a t o c c u rr e d 2 d a y s b e fo re a n d la s t e d 3 0 m i n u te s . N o w h e h a s n o v is u a l c o m p la in t s . M e d i c a l h is t o ry is s i g n if ic a n t fo r H T N a n d D M . H e d e n i e s h e a d a c h e , l o s s o f c o n s c io u s n e s s , d ip lo p ia , o c u la r p a i n , a t a x i a , a n d v e r ti g o . N e u r o l o g i c e xa m i n a ti o n is n o rm a l. W h a t is t h e n e x t s te p in m a n a g i n g th i s p a ti e n t ? 5 . A 5 8 -y e a r -o ld m a l e p re s e n ts t o y o u r o ffi c e w i th we a k n e s s in h i s le g s a n d a h i s to ry o f f re q u e n t f a ll s o v e r th e p a s t f e w m o n th s . H e a l s o c o m p la in s o f fa t ig u e a t th e e n d o f th e d a y . He d o e s n o t d r in k a l c o h o l o r s m o k e , a n d h is m e d ic a l h i s t o r y i s s ig n if ic a n t fo r g a s t ri c c arc i n o m a fo r w h i c h h e u n d e r we n t g a s tr e c to m y 2 y e a rs a g o . O n p h y s ic a l e x a m i n a tio n , h e is f o u n d to h a v e i n c re a s e d d e e p te n d o n re f le x e s a n d mi l d w e a k n e s s o f h is lo w e r e xt r e m i ti e s , a lo n g wi t h d im i n i s h e d v i b ra t o r y s e n s e in h i s to e s. H is e xa m in a t io n i s o t h e rw is e u n re m a rk a b le . W h a t i s th e l ik e l y d ia g n o s is a n d w h a t i s t h e a p p ro p ri a t e n e x t s te p in m a n a g i n g th is p a t i e n t ? 6 . A 3 7 -y e a r -o ld fe ma l e p r e s e n t s to y o u r o ff ic e c o m p l a i n i n g o f we a k n e s s , e s p e c i a l ly w it h a c ti v i ti e s t h a t r e q u i r e m u s c u l a r fo rc e , s uc h a s c li m b i n g s t a i rs . H e r s ym p to m s h a v e d e v e lo p e d

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g ra d u a ll y o v e r t h e p a s t y e a r o r t wo , a n d s h e h a s l a r g e l y ig n o r e d th e m . S h e r e p o rts a r e c e n t w e i g h t g a in o f 2 5 l b o v e r t h e p a s t y e ar a n d h a s b e e n f e e l in g m e la n c h o l y f o r t h e p a s t fe w months. S he also has had back pain for the P.488

p a s t s e v e ra l mo n t h s . H e r m e d ic a l h i s to ry is s ig n if i c a n t f o r m il d H T N , fo r w h ic h s h e t a k e s m e to p r o lo l , a n d D M t h a t re q u ir e s in s u l in t h e r a p y . S h e ta k e s n o o t h e r m e d ic a t io n s . Ph y s ic a l e xa m i n a ti o n re v e a l s m i ld o b e s it y , w i th f a t d e p o s iti o n m a in l y a r o u n d th e t ru n k a n d th e p o s te r io r n e c k . Y o u n o te s o m e fa c ia l h a i r a n d s c a t te re d p u r p l e s t ri a e o n t h e a b d o m e n . R a d io g ra p h s re v e a l a c o m p r e s s e d fr a c t u re a t t h e le v e l o f T 1 1 . V i ta l s i g n s a r e a s fo l lo w s : B P = 1 4 0 /8 5 , p u lse = 7 0 . W h a t i s th e l ik e l y d ia g n o s i s ? W h a t i s th e a p p r o p ria te n e xt s t e p i n m a n a g i n g t h is p a ti e n t? 7 . A 5 6 -y e a r -o ld m a l e wi t h a h is to r y o f c ig a re t t e s m o k i n g a n d h y p e rc h o le s t e ro le m ia is b ro u g h t t o th e E D wi t h s e v e re , c ru s h i n g c h e s t p a in t h a t h a s l a s te d f o r 9 0 m i n u te s . H e s t a te s t h a t h e f e l t il l a l l d a y a n d t h e n s ta r t e d e x p e ri e n c in g p a i n i n h i s j a w, wh ic h p r o g r e s s e d to c he s t p a i n w it h r a d ia t io n t o th e l e f t a r m wi t h n a u s e a . Vi ta l s ig n s a re a s f o ll o w s : te m p e r a t u re = 9 7 .4 , H R = 1 0 0 , B P = 1 5 0 / 9 0 , R R = 2 2 , p u ls e o x i m e t r y = 9 8 % o n r o o m a i r . A n E C G re v e a ls s i g n i fi c a n t S T e le v a t io n s i n V 1 to V 4 . T h e re a r e S T s e g m e n t d e p r e s s io n s in le a d s I I, I II , a n d a V F . W h a t is t h e n e x t s te p i n m a n a g in g th i s p a tie n t ? 8 . A 3 4 -y e a r -o ld fe ma l e p r e s e n t s to th e E D w i th a 2 - d a y h is to r y o f n a u s e a a n d v om it in g a n d d if fu s e a b d o m in a l p a i n . S h e re p o rts m il d d ia r rh e a . S h e h a s n o t b e e n a b le t o k e e p a n y fo o d d o w n o v e r th e p a s t 3 6 h o u rs s e c o n d a r y to s e v e re v o mi t in g . H e r P MH i s u n r e m a rk a b le . V i ta l s ig n s a r e a s f o l lo ws : t e m p e ra tu r e = 9 9 . 1 , R R = 1 2 , p u ls e = 1 1 0 . H e r B P is 1 3 4 / 8 6 w h e n l y i n g d o w n , 1 1 2 / 7 0 w h e n s t a n d i n g . A b d o m in a l e xa m i n a t i o n re v ea ls m i ld d i ffu s e t e n d e rn e s s w i th h y p e ra c ti v e b o w e l s o u n d s . H e r a b d o m e n , s o ft, a n d th e re i s n o g u a rd i n g o r r e b o u n d t e n d e rn e s s . S t o o l is n e g a t i v e f o r o c c u l t b l o o d . S h e h a s p o o r s k i n tu r g o r a n d d r y mu c ou s m e m b ra n e s . L a b o ra to r y t e s ts r e v e a l th e fo l lo w in g : W BC = 7 . 6 , H g b = 1 1 .8 , H c t = 3 4 .5 , N a

+ +

= 140, K = 3.2,

C l = 9 5 , H C O 3 = 3 7 , B U N = 4 0 , C r = 1 .5 . A B G s a r e o b t a i n e d a n d r e v e a l th e fo ll o w i n g : p H = 7 .5 2 , P a C O 2 = 4 6 , P a O 2 = 8 4 . W h a t i s th e a c i d -b a s e d i s o rd e r i n th i s p a ti e n t ? W h a t i s th e a p p ro p ria te m a n a g e m e n t o f th is p a tie n t ? 9 . A 6 4 -y e a r -o ld m a l e p re s e n ts t o y o u r o ffi c e f o r a p h y s ic a l e x a m in a ti o n . H i s P MH i s s i g n ifi c a n t f o r H T N , fo r wh ic h h e ta k e s m e to p ro l o l. H is s to o l is p o s i ti v e fo r o c c u lt b lo o d . O n e x a m i n a ti o n , t h e re a re n o p a l p a b le m a s s e s in th e a b d o m e n , n o t e n d e rn e s s , a n d b o w e l s o u n d s a re n o rm a l. H e d e n i e s a n y c h a n g e i n b o w e l h a b it s. T h e re m a i n d e r o f h i s p h y s ic a l e xa m i n a tio n is u n r e m a rk a b le . W h a t i s t h e a p p ro p r ia te n e xt s te p in m a n a g i n g t h i s p a ti e n t? 1 0 . A 5 5 - y e a r- o l d m a le p r e s e n ts to th e E D a ft e r v o m it i n g s e v e r a l h u n d re d m ill il i te rs o f b lo o d . H i s s t o o l wa s a d a rk c o lo r. H is P MH is s ig n if ic a n t fo r C A D a n d H T N . M e d i c a ti o n s in c l u d e a n A C E i n h ib i t o r, a - b l o c k e r, a n d a d a il y a s p i ri n ta b le t. H e r e p o rts h a v i n g h a d " h e a rt b u r n " fo r

s e v e ra l y e a rs b u t n o p ri o r e p i s o d e s o f h e m a te m e s is o r m e l e n a . A n a s o g a s t ric tu b e p l a c e d in t h e E D re v e a l e d b lo o d y a s p i ra te . Vi t a l s i g n s a re a s fo ll o w s : R R = 2 0 , B P = 9 0 / 5 5 , p u l s e = 1 0 5 . H e h a s a 2 5 -m m H g o r th o s ta tic d e c re a s e in B P . H i s p h y s ic al e x a m in a ti o n is u n re m a r k abl e . L a b o ra to r y t e s ts r e v e a l a h e m o g lo b i n o f 7 . 3 a n d h e m a to c ri t o f 2 2 .0 . L F T r e s u lt s a re n o rm a l . W h a t is t h e n e xt s t e p in m a n a g in g t h is p a ti e n t ?

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1 1 . A 7 4 - y e a r- o l d m a le p r e s e n ts to th e E D wi t h we a k n e s s i n h i s ri g h t a rm , a s we ll a s s l u rr e d s p e e c h t h a t s t a r te d s u d d e n l y t h a t m o rn in g d u ri n g b r e a k fa s t (6 h o u rs b e fo re e n t e rin g t h e E D ). P M H i s s i g n i fi c a n t fo r M I 1 0 y e a rs a g o , H T N , a n d B P H . H e d e n i e s c h e s t p a in , d i z z i n e s s , v e rt ig o , a t a x i a , a n d a h i s to ry o f a rr h y t h m i a . H i s w if e d e n ie s th a t h e h a s h a d a n y h i s t o r y o f T IA s i n th e p a s t . V i ta l s ig n s a re a s fo l lo ws : t e m p e ra tu re = 9 7 . 5 , R R = 1 8 , B P = 1 5 2 /9 0 , p u l s e = 8 4 . O x y g e n s a tu r a ti o n is 9 8 % o n ro o m a ir . P h y s ic a l e x a m i n a ti o n re v e a l s a rig h t fa c i a l d ro o p , a n d m u s c l e s t re n g th i s d im in i s h e d in th e ri g h t a rm (2 /5 s t re n g t h ) a n d rig h t l e g ( 3 / 5 s t re n g t h ) . P a ti e n t h a s d e c re a s e d s e n s a t io n t o li g h t to u c h a n d p i n p r ic k i n th e r ig h t a rm b u t n o rm a l s e n s a ti o n in h is r ig h t le g . W h a t is t h e a p p ro p ri a t e n e x t s te p i n m a n a g i n g th i s p a t i e n t ? 1 2 . A 7 3 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e wi t h a c o m p la in t o f l o w e r a b d o m i n a l p a i n th a t b e g a n 2 w e e k s a g o . Sh e h a s b e e n h a v in g m o re fre q u e n t b o w e l m o v em e n ts a n d h a s h a d e p is o d e s o f l o o s e s to o ls . H e r P M H is s ig n i fic a n t fo r H T N a n d h y p e rc h o l e s te r o l e m i a . S h e h a s m i ld L L Q p a i n o n a b d o m in a l e xa m i n a tio n , a n d P.489

b o w e l s o u n d s a r e n o rm a l. H e r s t o o l i s n e g a t iv e fo r o c c u l t b l o o d . S h e is a fe b r il e , W B C c o u n t i s 7 .2 , h e m o g lo b in is 1 2 . 1 , a n d h e m a to c ri t i s 3 6 .8 . W h a t is th e l ik e l y d i a g n o s is a n d th e a p p ro p ria te m a n a g e m e n t o f th is p a tie n t ? 1 3 . A 2 4 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e fo r a ro u t in e e x a m in a ti o n . S h e re p o rt s a h is t o r y o f h e a v y m e n s t ru a l b l e e d in g s in c e m e n a rc h e . O n f u rt h e r q u e s ti o n i n g , s h e s ta t e s th a t s h e h a s e p is o d e s o f e p i s t a x i s a b o u t o n c e e v er y 2 w e e k s o r s o a n d h a s a t e n d e n c y to b r u i s e e a s i l y . H e r p h y s ic a l e x a m i n a t io n i s u n re m a rk a b le . C B C re s u l ts a re a s fo ll o w s : H b = 7 .9 g / d L , H c t = 2 3 .9 % , M C V = 6 9 . P la t e l e t c o u n t is 2 3 0 ,0 0 0 / L . W h a t is t h e li k e l y d ia g n o s i s ? W h a t te s t s w o u ld y o u o r d e r ? 1 4 . A 2 5 - y e a r- o l d f e m a le p r e s e n t s t o th e E D a ft e r a n e p is o d e o f n u m b n e s s i n h e r l e ft le g t h a t l a s t e d f o r s e v e r a l h o u r s . S h e h a s n o o th e r c o m p la i n ts . O n fu r t h e r q u e s t io n in g , s h e r e m e m b e rs a n e p is o d e o f t ra n s ie n t u n i la te ra l l o s s o f v is io n 2 y e a r s a g o , wh i c h re s o l v ed a n d n e v e r re c u rr e d . V ita l s i g n s a r e a s fo ll o w s : te m p e ra t u re = 9 7 . 4 , R R = 1 8 , B P = 1 2 8 /8 4 , p u ls e = 7 6 . O n e xa m i n a ti o n , s h e h a s d i m i n i s h e d s e n s a ti o n i n h e r l e ft le g , w h ic h s h e d e s c r i b e s a s " n u m b ." H e r s tr e n g th is n o rm a l, a n d h e r e xa m i n a tio n is o th e rw i s e u n re m a rk a b l e . S h e ta k e s b ir th c o n t ro l p ill s b u t n o o th e r m e d ic a t io n s . W h a t is t h e li k e l y d i a g n o s is a n d t h e a p p r o p r ia t e in it ia l wo rk u p f o r th is p a t ie n t? 1 5 . A 5 9 - y e a r- o l d f e m a le p re s e n ts t o t h e o f fi c e b e c a u s e s h e i s " s i c k a n d ti re d " o f th i s c o u g h s h e h a s h a d fo r 5 y e a rs , a n d i t is g e tt in g wo rs e . T h e c o u g h is o fte n p r o d u c t i v e o f w a t e r y m u c u s . S h e i s a ls o b e c o m i n g m o r e a n d m o r e s h o r t o f b re a th a n d c a n n o t c l im b a f li g h t o f s t a irs w it h o u t ta k in g a re s t . S h e d e n ie s c h e s t p a in , p a ro xy s m a l n o c tu rn a l d y s p n e a , fe v e r s , c h il ls , a n d w e i g h t lo s s . P M H i s s i g n i f ic a n t fo r H T N a n d a 3 5 p a c k - y e a r h i s to ry o f c ig a re tt e s m o k in g . V i ta l s ig n s a r e a s f o l lo ws : t e m p e ra tu r e = 9 9 . 0 , H R = 7 5 , R R = 2 1 , B P = 1 5 8 / 8 2 . P h y s ic a l e xa m i n a ti o n re v e a l s a n o b e s e w o ma n in n o a c u te d is tre s s . O n lu n g a u s c ul t a ti o n , t h e re a r e c o a rs e b r e a t h s o u n d s b ila te ra l l y b u t n o w h e e z es o r c ra c k le s . C h e s t r a d i o g r a p h i s s i g n i fi c a n t f o r p ro m i n e n t lu n g m a rk in g s a t t h e b a s e s . W h a t is c a u s in g th is wo m a n 's c o u g h a n d S O B ?

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1 6 . A 5 6 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e f o r a r o u t in e h e a l t h e v a l u a tio n . H e r e p o rts th a t h e is h e a lt h y , a n d h i s p h y s ic a l e x a m i n a t i o n is u n re m a rk a b l e . H o w e v e r, l a b o ra to r y te s t s r e v e a l a P S A l e v e l o f 5 .8 n g /m L . D R E is n o rm a l , w it h n o p a lp a b l e n o d u le o r i r re g u la ri ty in t h e p ro s ta te . W h a t is th e a p p ro p ri a te m a n a g e m e n t o f t h i s p a ti e n t? 1 7 . A 6 7 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e w it h c o m p l a i n t o f r ig h t h i p p a i n f o r t h e la s t w e e k . H e d e n i e s a n y h is t o ry o f f a l ls o r i n j u r y . T h e p a i n c a m e o n s u d d e n l y a s h e w a s g e tt in g u p f ro m a c h a i r. P r io r t o th i s e p i s o d e , h e d e n i e s a n y h is to ry o f h i p p a i n . P MH i s s i g n i fi c an t fo r H T N , d i a b e te s , a n d h y p o th y ro i d is m . H e s t a rt e d u s i n g a c a n e a fe w d a y s a g o b u t d u e to i n c re a s in g p a i n is n o w i n a w h e e l c h a ir . O n p h y s ic a l e xa m i n a ti o n , h e h a s s e v e re p a in wi t h a n y a tt e m p te d m o t i o n o f th e r i g h t h i p jo in t. P u ls e s a re p a lp a b l e b il a t e ra l ly , a n d n e u ro l o g ic e xa m i n a ti o n is n o rm a l. R a d io g r a p h s o f th e ri g h t h i p a re o b t a in e d , a n d s how a d i s p la c e d f ra c tu re o f t h e r ig h t fe m o ra l n e c k . I n a d d i ti o n t o o b ta in in g a n o rt h o p a e d ic s u r g e r y r e fe rr a l , w h a t i s th e a p p r o p r ia t e n e xt s te p in m a n a g i n g t h i s p a ti e n t? 1 8 . A 3 8 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e wi t h c h i e f c o m p l a i n t o f fa t ig u e f o r t h e p a s t 5 t o 6 m o n t h s . He r fa t ig u e h a s a l s o a f fe c te d h e r p e rfo rm a n c e a t wo rk , wh e r e s he h a s d i ff ic u lt y c o n c e n t ra t i n g . S h e f e e ls m o r e ti re d t h a n u s u a l a ft e r w o r k a n d h a s d i ffi c u l ty p l a y i n g w i th h e r c h il d re n in t h e e v e n i n g . S h e d i d n o t h a v e a n y o f t h e s e s y m p t o m s u n ti l 6 m o n t h s a g o . P M H i s i n s i g n ifi c a n t . T h e p a ti e n t s m o k e s fi v e t o s i x c i g a re t te s a d a y a n d d ri n k s a l c o h o l s o c i a ll y . S h e t a k e s b i rth c o n t ro l p il ls . P h y s ic a l e x a m i n a t io n i s n o r m a l . W h a t i s t h e a p p ro p r ia te n e xt s t e p in m a n a g in g t h i s p a t ie n t? 1 9 . A 4 5 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e w i th a 2 -d a y h i s to ry o f a c o u g h a n d fe v e r. S h e s ta te s t h a t s h e h a s fe l t tir e d fo r t h e p a s t c o u p le o f we e k s b u t is o t h e rw i s e v a g u e . P MH is u n r e m a rk a b le . O n p h y s i c a l e xa m i n a tio n , s h e a p p e a rs il l a n d h a s a p e rs i s te n t c o u g h p r o d u c ti ve o f p u r u l e n t s p u tu m . S h e h a s ra le s i n h e r r ig h t p o s t e ri o r c h e s t . B P = 1 2 6 /7 4 , p u l s e = 8 0 , R R = 8 , te m p e r a tu re = 1 0 2 .2 . W BC c o u n t is 1 4 , 0 0 0 /m m . Y o u o b ta in a C X R , wh i c h re v eal s c o n s o li d a ti o n in t h e ri g h t l o we r P.490
3

l o b e a n d a 2 .3 -c m ro u n d o p a c i ty i n t h e l e f t l o we r l o b e . W h a t is t h e a p p ro p r i a te m a n a g e m e n t o f t h is p a t ie n t? 2 0 . A 7 5 - y e a r- o l d f e m a le wi t h a h i s t o r y o f tw o MI s p re s en ts to th e E D a f te r f a i n t in g . S h e re p o rt s f a tig u e a n d d y s p n e a f o r 2 m o n t h s . S h e d e n i e s c h e s t p a i n , S O B , o r o r th o p n e a . A 1 2 l e a d E C G r e v e a ls a b ra d y c a r d i a wi t h a v e n tric u la r ra t e o f 3 5 b p m . Y o u d e t e c t d e f i n it e , r e g u l a r P w a v e s a n d Q R S c o m p le x e s , b u t n o ti c e th a t t h e re is n o r e la ti o n s h i p b e tw e e n th e P w a v e s a n d t h e Q R S c o m p l e x e s . W h a t ty p e o f b r a d y a rr h y t h m i a is th is , a n d h o w s h o u ld i t b e m a n a g e d ? 2 1 . A 4 0 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e w it h a c o m p la in t o f e p ig a s t ric a b d o m in a l p a in fo r t h e p a s t 5 to 6 m o n th s . Th e p a in is n o t r e l a t e d to m e a ls a n d is in te rm i tt e n t . H e h a s tri e d o v er t h e -c o u n te r a n t a c i d s w it h m in im a l re l ie f o f p a in . H e d e n ie s a n y re c e n t we i g h t l o s s . H e is a n o n s m o k e r a n d d o e s n o t a b u s e a lc o h o l. H is P M H is s ig n if ic a n t f o r H T N , wh i c h is c o n t ro l l e d w it h m e to p ro lo l . H e d o e s n o t t a k e a n y o t h e r m e d ic a t io n s . Ph y s ic a l e x a m in a ti o n i s u n r e m a rk a b le . H o w w o u l d y o u tre a t t h i s p a ti e n t?

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2 2 . A 3 2 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e wi t h a h i s to ry o f d ia rr h e a a n d i n t e rm itt e n t a b d o m in a l c r a m p in g w i th f la t u s . S h e r e p o rt s h a v i n g d i a rrh e a v e r y fr e q u e n tl y o n a n d o ff fo r s e v e ra l y e a rs , b u t h e r s y m p to m s h a v e b e e n w o r s e fo r th e p a s t 3 w e e k s . Sh e a l s o h a s c o n s tip a t io n e v e ry o n c e in a wh i le . Sh e h a s n o a p p a r e n t m e d i c a l p ro b l e ms . H e r p h y s ic a l e xa m i n a ti o n re v e a l s m i ld L L Q te n d e rn e s s w i th o u t g u a rd in g o r re b o u n d . A s t o o l te s t fo r o c c u l t b lo o d i s n e g a ti v e . S h e i s a c o l le g e s t u d e n t a n d i s s t u d y i n g f o r h e r m id te rm e x a m in a ti o n s . W h a t i s th e l ik e l y d ia g n o s is a n d h o w w o u l d y o u m a n a g e t h is p a ti e n t ? 2 3 . A 6 5 - y e a r- o l d f e m a le wi t h a h i s t o r y o f D M, H T N , a n d a la rg e a n te ri o r w a l l M I 5 y e a rs a g o p re s e n ts to th e E D c o m p la in in g o f p ro g re s s iv e SO B . V i ta l s i g n s a r e : te m p e ra tu r e = 9 8 .7 , H R = 8 8 , R R = 1 9 , B P = 1 6 0 /8 5 , o xy g e n s at u ra t io n = 9 0 % o n r o o m a ir. S h e s e e m s s ho rt o f b re a th o n e xa m i n a ti o n b u t is a b le to s p e a k i n fu ll s e n te n c e s . T h e re a re b i b a s il a r c r a c k le s w i th s c a t t e re d e xp ir a t o ry wh e e z e s . T h e r e is a ls o 2 + p it ti n g e d e m a o f th e l o w e r e x tr e m it ie s . A n E C G re v ea ls l e f t v e n tri c u la r h y p e rt ro p h y (L V H ) , w it h Q wa v e s a n d T w a v e i n v ers io n s in V 1 t o V 4 a n d d if f u s e n o n s p e c if ic S T s e g m e n t a b n o rm a li ti e s . A C X R s ho w s c a rd io m e g a ly a n d c o n s id e ra b l e c o n g e s t io n o f th e p u l m o n a ry v a s c u la tu r e . W h a t i s t h e m o s t l ik e l y d i a g n o s is , a n d w h a t i s th e a p p ro p ria te a p p r o a c h t o t re a tm e n t ? 2 4 . A 5 6 - y e a r- o l d m a le p r e s e n ts to th e E D wi t h c o m p l a i n t o f c h e s t p a i n fo r t h e p a s t 3 h o u rs . H e h a s n e v e r e xp e r i e n c e d th i s p a i n b e fo r e , a n d it s t a r te d s u d d e n l y w h il e h e w a s e a t i n g d i n n e r. H e d e s c ri b e s th e p a in a s " g rip p i n g " a n d ra d i a tin g in to h is n e c k . P h y s ic a l e x a m i n a t io n i s n o rm a l . E C G s h o ws a 1 -m m S T s e g m e n t d e p re s s io n in le a d s V 4 to V 6 . P M H is s i g n i fi c a n t f o r D M a n d H T N . Me d i c a ti o n s i n c lu d e in s u l in a n d a s te p i n m a n a g in g th is p a t i e n t ? 2 5 . A 1 9 - y e a r- o l d f e m a le i s b ro u g h t to th e E D re lu c t a n tly b y h e r m o th e r b e c a u s e o f n a u s e a , v o m i ti n g , f e v e r, a n d fl a n k p a in . P MH i s o t h e rw i s e n e g a ti v e. H e r o n l y m e d ic a ti o n is o ra l c o n t ra c e p t i v e s . Vi t a l s i g n s a re : te m p e r a tu re = 1 0 3 . 5 , B P = 1 1 5 / 6 0 , p u ls e = 1 1 0 , R R = 2 0 . L u n g s a re c l e a r t o a u s c u l ta ti o n b i la te r a l ly . Bo t h h e a r t ra te a n d r h y th m a r e re g u l a r, w it h o u t m u rm u rs . T h e p a ti e n t a p p e a rs il l b u t is a l e rt a n d o r i e n t e d . Sh e h a s t e n d e rn e s s a t th e ri g h t c o s t o v e rt e b ra l a n g l e . W ha t is t h e a p p ro p ri a t e n e x t s te p i n m a n a g i n g t h is p a ti e n t? 2 6 . A 6 5 - y e a r- o l d f e m a le i s b ro u g h t to th e E D wi th a d e p re s s e d le v el o f c o n s c io u s n e s s . S h e w a s a t a we d d i n g re c e p t io n , h a d fi n is h e d d a n c in g w it h h e r h u s b a n d , a n d w a s r e t u rn i n g to h e r t a b le w h e n s h e s u d d e n ly c o l la p s e d a n d lo s t c on s c io u s n e s s . S h e s o o n re g a in e d c o n s c i o u s nes s , b u t h e r s p e e c h w a s n o t n o r m a l a n d s he h a d a n e p i s o d e o f v o m it in g . Sh e h a d a s e v e re h e a d a c h e a n d c o u ld n o t m o v e h e r rig h t a rm a n d le g . S h e s o o n e n te re d a s t u p o r o u s s t a t e a n d w a s r u s h e d t o t h e E D . S h e h a s a h is to ry o f H T N b u t n o o t h e r m e d i c al p ro b l e m s . A c c or d i n g to h e r h u s b a n d , s h e ta k e s m e to p ro l o l f o r h e r H T N , a s w e ll a s a d a il y a s p i r in . In t h e E D , h e r v i ta l s ig n s a r e a s f o l lo ws : t e m p e r a tu r e = 9 9 .4 , R R = 2 4 , B P = 1 6 5 /9 8 , p u ls e = 9 8 . O n e x a m in a t io n , t h e p a ti e n t i s l e th a rg i c a n d h e r s p e e c h i s s lu rr e d . S h e c a n n o t m o v e h e r P.491 - b l o c k e r fo r th e H T N . W h a t is t h e a p p ro p ri a te n e x t

ri g h t a r m o r le g . S e n s a tio n is s o m e w h a t d im in i s he d in h e r ri g h t a rm b u t i s n o rm a l in h e r rig h t l e g . W h a t a r e th e n e x t s te p s i n m a n a g i n g th is p a ti e n t?

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2 7 . A 7 1 - y e a r- o l d f e m a le p r e s e n t s t o th e E D w i th a 2 -d a y h is to r y o f s e v e re a b d o m in a l p a in . H e r s y m p to m s w e re m il d a t f irs t , b e c o m i n g s e v e re in t h e n e xt 6 to 1 0 h o u rs . H e r P M H i s s i g n ifi c a n t f o r C A D a n d H T N . H e r s t o o l i s p o s it iv e fo r b lo o d . S h e i s a f e b r il e . H e r a b d o m i n a l e x a m in a ti o n re v e a ls v e r y m i ld te n d e rn e s s i n th e m id - a b d o m e n . L a b o ra t o ry s tu d ie s a re n o rm a l. W h a t is t h e a p p ro p ria te n e x t s te p i n e v a l u a ti o n ? 2 8 . A 4 3 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e w it h a 3 - d a y h is to ry o f c h e s t p a in , wh i c h i s m o s t ly c e n tr a l ly lo c a t e d a n d ra d i a te s t o t h e r ig h t s i d e o f h i s n e c k . T h e p a i n wo rs e n s wi t h d e e p b re a th in g a n d im p ro v e s wh e n h e s i ts u p . H e d e n i e s n a u s e a , v om i tin g , s w e a t in g , a n d S O B . He h a d a n u p p e r re s p ir a to ry in fe c ti o n a b o u t 2 -w e e k s a g o w h i c h r e s o l v e d w it h o u t tr e a t m e n t. P M H i s s ig n i fic a n t fo r h y p e rl ip i d e m ia . H e ta k e s lo v a s ta t i n . H e s m o k es h a lf a p a c k o f c ig a r e tt e s a d a y . V it a l s i g n s a re : t e m p e ra tu r e = 9 9 . 4 , B P = 1 2 5 / 8 0 , p u ls e = 8 4 . P h y s ic a l e x a m in a ti o n is s ig n i fic a n t f o r a fr ic ti o n ru b o v e r th e le f t s te rn a l b o rd e r h e a r d b e s t wh e n h e l e a n s f o r wa rd . A 1 2 -le a d E C G s h o w s S T e l e v a ti o n in l e a d s I, I I, I II , a V L , V 2 , V 3 , V 4 , V 5 , a n d V 6 . W h a t is t h e d ia g n o s is ? H o w w o u l d y o u m a n a g e th i s p a t i e n t ? 2 9 . A 2 5 - y e a r- o l d m a le p r e s e n ts to y o u r o f fic e wi t h c o mp l a in t o f c h e s t p a in a n d S O B th a t s ta rte d la s t e v e n i n g . H i s c h e s t p a i n i s o n t h e r ig h t s i d e o f t h e c he s t a n d i s s t a b b in g i n q u a li ty , a n d th e p a i n i n c re a s e s w i th i n s p ir a ti o n . H e is s h o rt o f b r e a t h e v e n a t re s t. H e d e n i e s a n y p ri o r s u c h e p is o d e s . H e d e n ie s a n y t ra u m a t ic e v ent o r o v er e x e r t io n . P M H i s n e g a t i v e . H e h a s a f i ve p a c k - p e r-y e a r s m o k in g h i s to r y . H e d o e s n o t ta k e a n y m e d ic a t io n s . T e m p e ra t u re = 9 8 .2 , B P = 1 3 0 /8 0 , H R = 1 1 5 , R R = 2 2 . P u ls e o x i m e t r y s h o ws 8 4 % o x y g e n s a tu ra tio n o n ro o m a i r. He is 6 '2 " a n d 1 7 5 lb , a n d h e a p p e a rs h e a l th y . P h y s ic a l e x a m i n a ti o n re v e a l s d e c re a s e d b re a th s o u n d s o n t h e ri g h t s i d e . E xa m i n a ti o n is o t h e r wi s e u n re m a r k a b l e . W h a t is t h e a p p r o p r ia t e n e xt s te p i n m a n a g in g th is p a t i e n t ? 3 0 . A 5 3 - y e a r- o l d m a le w it h n o s ig n i fic a n t m e d ic a l h i s t o r y c o m e s t o y ou r o f fic e . H e i s d o i n g w e l l , e x c e p t f o r s o m e e x e rt io n a l d y s p n e a o v e r t h e p a s t f e w m o n t h s . H e h a s n o h is t o ry o f h e a r t d is e a s e . H e o c c a s i o n a ll y fe e l s s o m e p a lp i t a ti o n s , w h i c h a re n o t b o t h e rs o m e to h i m . O n p h y s ic a l e x a m in a ti o n , y o u n o te a n i rr e g u la rl y irr e g u la r h e a rt rh y t h m . Y o u o b t a i n a n E C G , w h i c h c o n f irm s th e i r re g u la rl y i rr e g u la r a r rh y th m i a . T h e p h y s ic a l e xa m i n a tio n is o t h e rw i s e n o r m a l . W h a t is t h e d i a g n o s i s ? W h a t is t h e n e xt s t e p i n e v a l u a t in g th i s p a t ie n t? D e s c r i b e th e m a n a g e m e n t o f t h is p a t ie n t . 3 1 . A 7 3 - y e a r- o l d m a le w it h H T N p re s en ts t o t h e o f fi c e wi t h a 3 -m o n t h h is to ry o f c h e s t p a in i n d u c e d b y l i fti n g w e i g h ts , s h o v e l in g s n o w, a n d ru n n i n g o n a t re a d m i ll . V it a l s ig n s a re a s f o l lo ws : t e m p e ra tu r e = 9 8 . 3 , H R = 8 5 , R R = 1 7 , B P = 1 6 5 /8 5 . P h y s i c a l e xa m i n a t io n re v e a ls a 4 /6 c r e s c e n d o - d e c re s c e n d o m u rm u r h e a rd a t t h e ri g h t u p p e r s t e r n a l b o rd e r wi t h ra d ia tio n to t h e c a ro t id a rt e ri e s , we a k a n d d e l a y e d c a ro t id p u l s es , a n d a n S 4 g a l lo p . E C G re v ea ls L V H . W h a t v a lv u la r d is e a s e i s p r e s e n t , a n d w h a t is t h e a p p ro p ri a te a p p ro a c h to tr e a t m e n t? 3 2 . A 5 2 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e c om p la i n in g o f l e f t k ne e p a i n f o r t h e p a s t 2 to 3 m o n th s . S h e d e n i e s a n y h is to ry o f i n j u r y . P M H i s s i g n i fi c a n t fo r h y p e rc h o l e s te ro l e m i a fo r w h i c h s h e t a k e s lo v a s ta tin . S h e d e n i e s a n y r e c e n t c h a n g e s in a c t i v it y l e v e l. S h e d e s c r ib e s h e r p a in a s p ri m a r il y " a ro u n d a n d u n d e r m y k ne e c a p . " S h e p o in ts to h e r p a te l la a n d th e a n te ri o r a s p e c t o f h e r k n e e a s t h e s i te o f h e r p a i n . S h e e s p e c i a ll y h a s d if fi c ul t y c li m b i n g a n d d e s c e n d in g s ta i rs . H e r l e ft k n e e s we l ls o n o c c a s io n . O n e x a m i n a t io n , s h e h a s a m il d e f fu s i o n

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a n d n o e r y t h e m a . S h e h a s fu l l r a n g e o f m o t io n w i th o u t p a in . S h e h a s n o te n d e rn e s s a l o n g m e d i a l o r l a te ra l jo in t l i n e s . H e r k n e e is l ig a m e n to u s l y s ta b l e . W h a t is a p p r o p ria te n e xt s t e p i n t h e m a n a g e m e n t o f th is p a ti e n t? 3 3 . A 5 7 - y e a r- o l d m a le h a d a f a s ti n g p la s m a g lu c o s e l e v e l o f 1 6 0 m g /d L 1 m o n t h a g o . T o d a y , h is f a s t in g g lu c o s e l e v e l is 1 4 0 m g / d L . H e h a s a h is to ry o f H T N t h a t i s c on tr o ll e d w i th a n A C E i n h i b i to r. H e h a s n o o th e r m e d ic a l p r o b le m s . H e is 5 ' 1 1 " a n d w e ig h s 2 1 5 lb . H i s d e c e a s e d f a t h e r h a d D M , b u t th e f a m i ly h is to r y i s o t h e rw is e P.492

n o n c o n t ri b u to r y . T h i s p a t ie n t is a s y m p to m a ti c , a n d h is p h y s i c a l e xa m i n a tio n is u n re m a rk a b l e . H o w w o u l d y o u m a n a g e th i s p a ti e n t ? 3 4 . A 3 6 - y e a r- o l d A fr ic a n - A m e ric a n f e m a l e p r e s e n ts t o y o u r o ff ic e wi t h a 4 - m o n t h h is to r y o f d r y c o u g h , S O B , a n d fa ti g u e . S h e h a s a 1 0 p a c k -p e r-y e a r s m o k i n g h i s t o r y . V i ta l s ig n s a r e : t e m p e r a tu re = 9 8 . 2 , B P = 1 3 2 / 7 9 , H R = 7 4 , R R = 1 6 . P u ls e o xi m e t ry s h o w s 9 6 % O 2 s a tu ra t i o n o n ro o m a ir a n d 1 0 0 % O 2 s a tu ra t io n wi t h s u p p le m e n t a l O 2 a t 2 L / m i n v i a n a s a l c a n u la . F u r th e r h is t o r y re v e a l s s l ig h tl y b lu rr e d v is i o n o v e r th e p a s t fe w m o n th s , a s w e l l a s o c c a s i o n a l p a i n a n d s we ll i n g in t h e k n e e s a n d a n k l e s . E xa m i n a t io n re v e a ls c ra c k le s b il a te r a ll y i n t h e l o w e r lu n g f ie ld s . H e a rt e x a m i n a ti o n s h o w s r e g u la r ra te a n d r h y t h m , w i th n o m u rm u rs . S h e h a s a m i ld e ff u s i o n in h e r le ft k n e e b u t h a s f u l l r a n g e o f m o ti o n o f b o th k n e e s a n d a n k l e s . S h e h a s t wo t e n d e r e r y t h e m a to u s n o d u le s o n h e r l e f t l e g m e a s u r i n g a p p ro xi m a t e ly 3 3 c m . C X R s h o w s b ila t e ra l h il a r a d e n o p a th y . W h a t is t h e a p p ro p ri a te n e x t s te p i n th e m a n a g e m e n t o f th is p a t ie n t? 3 5 . A 6 8 - y e a r- o l d m a le is b ro u g h t t o th e E D b y h is w i fe b e c a u s e o f h e a d a c h e , n a u s e a , a n d f a t i g u e . P MH is s ig n i fi c a n t f o r s m a ll c e l l c a r c in o m a o f th e l u n g d i a g n o s e d a p p ro x im a te l y 2 y e a r s a g o . H e a ls o h a s a h i s t o r y o f T IA ( 6 y e a rs a g o ) a n d m i ld C HF . V i ta l s ig n s a r e a s f o l lo ws : t e m p e r a tu re = 9 9 . 8 , R R = 1 8 , B P = 1 4 0 / 8 8 , p u ls e = 7 6 . O n e xa m i n a t i o n , h e is a w a k e b u t s o m e wh a t l e t h a r g i c . P h ys ic a l e xa m i n a tio n is u n re m a rk a b l e . L a b o ra t o r y te s t s re v e a l th e f o l lo wi n g : W B C = 8 . 3 , H c t a n d H g b = 1 0 .2 /3 0 .7 , g lu c os e = 1 0 6 , s e r u m N a + = 1 2 1 m E q /L , K + = 4 .3 , B U N / C r = 7 . 0 /0 .4 . W h a t i s t h e li k e ly d i a g n o s is ? H o w wo u l d y ou m a n a g e th is p a ti e n t? 3 6 . A 2 0 - y e a r- o l d m a le p r e s e n ts fo r a ro u t in e p h y s ic a l e v a lu a t io n f o r c o l le g e f o o tb a ll . A re q u ir e d u ri n a ly s is re v e a l s m a c r o s c o p i c b lo o d i n h i s u ri n e . T h i s is r e p e a te d a n d r e m a i n s p o s i ti v e . Mi c r o s c o p ic e xa m in a t io n i s p o s it i v e f o r d e fo rm e d R B Cs a n d R B C c a s ts . H e is w i th o u t c o m p la i n t s a n d r e p o rts th a t h e i s i n ver y g o o d h e a l t h . W h e re in t h e re n a l /g e n it o u ri n a r y s y s t e m i s th e e ti o lo g y o f t h i s h e m a tu ri a ? 3 7 . A 3 1 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e c om p la i n in g o f p a in f u l jo in t s fo r th e p a s t 4 t o 5 m o n th s , a ffe c t in g h e r wr is t s , a n k l e s , a n d k n e e s . S h e a ls o re p o rt s s e v era l o u tb r e a k s o f a ra sh o v e r h e r f a c e o v e r th e p a s t f e w m o n th s . V it a l s ig n s a r e a s f o l lo w s : t e m p e ra tu re = 9 9 . 2 , R R = 2 0 , B P = 1 4 5 /8 3 , p u l s e = 7 8 . P h y s ic a l e x a m in a ti o n re v e a l s t h re e u lc e rs in h e r m o u t h a n d m i ld s we ll i n g o f th e le ft w ri s t a n d a n k l e . S h e h a s 1 + p i tt i n g e d e m a i n h e r l o we r e xt r e m it ie s b ila t e ra ll y . E x a m i n a t io n is o th e rw i s e u n r e m a rk a b le . C B C r e v e a ls a W B C c ou n t o f 2 ,3 0 0 /m m , H g b = 1 2 .2 , H c t = 3 7 , p la te le ts = 8 2 ,0 0 0 /m m . W h a t i s th e l ik e l y d i a g n o s is ? W h a t is th e a p p ro p ria te n e x t s te p i n m a n a g in g th i s p a ti e n t ?
3 3

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3 8 . A 6 2 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e a c c o m p a n i e d b y h is wi f e . H e c o m p l a i n s o f a t re m o r in h is h a n d s th a t d is a p p e a rs wh e n h e u s e s h i s h a n d s f o r wr i ti n g o r h a n d li n g u te n s i ls . H i s w if e th in k s h e s t a re s o f te n a n d d o e s n o t s h o w a s m u c h e m o t io n a s b e f o r e . H e i s s lo we r in m o v i n g a b o u t th a n b e fo re . O n e xa m i n a t i o n y ou n o te a m i ld r e s ti n g t re m o r a n d a fix e d e xp re s s io n o n h is f a c e . N e u ro l o g i c e x a m i n a t io n is n o r m a l . W h a t i s t h e d ia g n o s i s ? H o w w o u ld y o u m a n a g e th is p a ti e n t? 3 9 . A 2 4 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e h a v i n g h a d c r a m p i n g a b d o m i n a l p a i n fo r th e p a s t 2 m o n t h s . H e r e p o rts h a v in g lo w - v o lu m e d i a rrh e a o n a n d o ff f o r t h e p a s t 1 to 2 y e a rs . H e a ls o r e p o rt s o c c a s io n a l p a in in th e r e c t a l re g i o n w i th d e f e c a ti o n . He d e n ie s a n y m e d i c a l p ro b le m s a n d t a k e s n o m e d i c a t io n s . Hi s p h y s i c al e xa m i n a tio n re v eal s m il d te n d e rn e s s i n t h e R L Q w i th n o rm a l b o we l s o u n d s . T h e r e i s a s m a l l fi s s u r e i n th e a n a l r e g i o n wi t h s u rro u n d in g e ry th e m a . H is s to o l is n e g a t i v e f o r o c c u l t b l o o d . V it a l s i g n s a re a s f o l lo ws : te m p e ra t u re = 9 8 .7 , R R = 1 5 , B P = 1 2 2 / 7 8 , p u l s e = 6 5 . L a b o ra t o r y te s t re s u l ts (C B C , e le c tro ly t e s ) a re wi t h in n o r ma l li m it s . H o w w o u l d y o u f u rt h e r e v a l u a t e th is p a ti e n t? 4 0 . A 5 8 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e w it h c o m p l a i n t o f l e ft h a n d n u m b n e s s a n d t in g l in g f o r th e p a s t 3 m o n t h s . H e d e n ie s a n y h is t o ry o f i n j u r y . H e wo rk s a s a t ru c k d ri v e r . P M H i s s ig n i fic a n t fo r mi ld H T N . T h e n u m b n e s s i n v o lv e s a l l f in g e rs a n d o c c a s io n a l l y e x te n d s u p h is f o r e a r m t o h is e l b o w . H e d e n i e s a n y w e a k n e s s . E xa m i n a t io n r e v e a ls n o rm a l s e n s a t io n t h r o u g h o u t b il a t e r a l u p p e r e xt re m i ti e s . S t r e n g th te s ti n g is n o r m a l . W h a t i s t h e n e x t a p p ro p ria te s te p i n e v a l u a ti n g th is p a ti e n t? P.493

4 1 . Y o u a r e a h o s p i ta li s t c a l le d to e v a l u a te a 7 4 -y e a r - o ld fe ma l e w i th d e m e n ti a fo r S O B a n d i n c re a s in g o x y g e n re q u i re m e n ts . Th e p a tie n t w a s a d m i tte d to t h e h o s p i ta l 4 d a y s a g o wi t h d e h y d ra ti o n . S h e h a s n o t b e e n o u t o f b e d s i n c e b e in g h o s p it a l i z ed b e c a u s e o f h e r g e n e ra l i z ed w e a k n e s s . S h e d e n i e s c h e s t p a i n o r a n y o th e r s y m p to m s . T e mp e r a t u re = 9 9 . 4 , B P = 1 1 6 / 7 4 , p u ls e = 1 1 2 , R R = 2 6 , o x y g e n s a t u ra ti o n = 9 1 % o n 5 L o f o x y g e n v ia n a s a l c a n u l a . S h e is m o d e r a t e l y ta c h y p n e i c . P h y s ic a l e x a m i n a ti o n o f h e a r t a n d l u n g s i s n o rm a l . W h a t is t h e li k e ly d ia g n o s is i n th i s p a t ie n t? W h a t i s t h e a p p r o p r ia te n e xt s te p i n m a n a g e m e n t? 4 2 . A 6 3 - y e a r- o l d m a le c o ll a p s e s s u d d e n l y w h i l e p l a y i n g b a s k e tb a ll . W h e n t h e e m e rg e n c y m e d i c a l t e c h n i c ia n s a r ri v e , t h e y f in d t h e m a n p u ls e l e s s a n d n o t b re a th in g . A f t e r ta k i n g o v er C P R , th e e m e r g e n c y m e d i c a l t e c h n i c i a n s d e li v e r a 2 0 0 -jo u l e s h o c k to h i s c h e s t a n d h e c o n v e rt s to a s i n u s r h y t h m . Th e re c o r d e d rh y t h m s tr ip s h o w s a w id e - c o m p le x t a c h y c a r d ia ( ra t e , a p p ro x im a t e l y 1 7 5 b p m ) th a t i s c h a ra c te r is ti c al l y u n r e s p o n s i v e to c a ro t id s i n u s m a s s a g e . W h ic h a rr h y t h m i a d e s c ri b e d a b o v e in d u c e d h is c a rd ia c a rr e s t? H o w wo u l d y o u m a n a g e t h is p a t ie n t? 4 3 . A 3 8 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e wi t h p a in in h e r w ri s ts , a n k le s , a n d k n e e s b ila t e ra ll y . S h e r e p o rt s n o t ic in g n u m b n e s s a n d s tif f n e s s in h e r h a n d s a b o u t 1 y e a r a g o , m o s tl y i n c o l d w e a th e r. T h is s t iff n e s s g r a d u a l ly s p re a d t o h e r w ri s ts , k n e e s , a n d a n k le s , w i th l e s s e r i n v o l v e m e n t o f h e r s h o u ld e r s . T h e s ti ff n e s s a n d p a i n a r e w o r s e in th e m o rn i n g b u t im p ro v e a s t h e d a y we a r s o n . S y m p to m s h a v e g ra d u a ll y w o rs e n e d . S o m e d a y s s he c a n n o t g o o u t s i d e h e r

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h o u s e b e c a u s e o f t h e p a in . S h e d e n i e s a h is to ry o f r a s h o r p h o t o s e n s i ti v i ty . S h e o f t e n fe e ls t ir e d a n d " wo rn o u t ." M e d ic a l h i s t o r y i s s ig n i fi c a n t f o r H T N , fo r w h i c h s h e t a k e s h y d r o c h lo ro th ia z id e . O n e x a m in a ti o n , h e r m e ta c arp a l j o i n ts a n d w ri s t s a r e s wo l le n a n d te n d e r, a s a re h e r k n e e s a n d a n k l e s b i la te ra l ly . H e r e x a m i n a t io n i s o th e r w is e u n re m a r k ab le . W h a t i s t h e li k e l y d i a g n o s i s ? W ha t is th e a p p ro p ri a te n e x t s t e p in m a n a g e m e n t o f th is p a t i e n t? 4 4 . A 6 0 - y e a r- o l d f e m a le p r e s e n t s t o th e E D w i th a c o m p l a i n t o f R U Q a b d o m in a l p a in t h a t b e g a n s e v e ra l h o u rs a g o . S h e f e l t fi n e b e f o re th i s e p is o d e . H e r P M H is s ig n i f ic a n t f o r H T N a n d o s te o a rth ri ti s . O n p h y s i c a l e x a m in a ti o n , s h e a p p e a r s il l a n d h a s m il d R U Q a b d o m in a l t e n d e r n e s s . Ic te ru s i s n o te d a s w e l l, b u t h e r e x a m in a ti o n i s o th e r wi s e u n re m a r k a b le . Vi t a l s ig n s a r e a s f o l lo ws : t e m p e ra tu r e = 1 0 2 . 1 , R R = 1 6 , B P = 1 4 5 / 9 0 , p u ls e = 7 8 . L a b o ra to r y t e s ts re v e a l a m il d e l e v a ti o n in A L T a n d A S T l e v els , d ir e c t b il i ru b in 4 . 5 , a n d W B C c o u n t 1 6 ,8 0 0 . W h a t is t h e n e xt s t e p i n m a n a g in g t h is p a ti e n t? 4 5 . A 5 7 - y e a r- o l d C a u c a s i a n fe m a l e p re s en ts t o th e E D c om p la in in g o f in c re a s i n g S O B fo r t h e p a s t w e e k . S h e h a s a h e a v y c ig a re t te s m o k i n g h is to ry a n d wa s re c e n t l y d i a g n o s e d w it h C O P D . O n e xa m i n a t i o n , h e r b r e a t h i n g is l a b o re d , a n d s h e h a s d i f fu s e wh e e z i n g . C X R re v ea l s fl a tt e n e d d ia p h r a g m s a n d a n e n l a rg e d re t ro s te rn a l s p a c e. S p ir o m e t ry r e s u lt s s h o w th a t F E V 1 i s 4 0 % o f p re d ic te d v a lu e a n d th a t F E V 1 / F V C is 5 5 % o f p re d ic te d v a l u e . S h e w i l l b e a d m i t te d t o y our t e a m 's c a re , a n d y o u n e e d to w ri t e th e a d m is s i o n o r d e r s . W h a t a r e t h e a p p r o p r ia t e n e xt s t e p s in m anagem ent? 4 6 . A 6 4 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e w it h l e ft k n e e p a in . H e d o e s n o t re c al l h i s h is t o r y we l l b u t d o e s s ta te t h a t t h e p a i n is w o r s e w h e n h e re t u rn s f ro m w a lk in g t o th e s to re fo r g ro c e r ie s . H e d e s c ri b e s t h e p a in a s a d u l l a c h e th a t h a s b e e n p r e s e n t fo r t h e p a s t s e v e ra l m o n t h s , m a y b e l o n g e r. He r e c a ll s b e i n g in a m o to r v e h i c l e a c c i d e n t 3 t o 4 y e a r s a g o w h e n h e b a n g e d h is le f t k n e e a g a in s t t h e d a s h b o a r d . H e h a d n o f ra c tu re s a t th e tim e a n d th e " b ru i s i n g w e n t a w a y " a f t e r a w h i le . H e d e s c ri b e s s om e p a i n i n h is ri g h t k n e e a s we l l, b u t i t i s m il d a n d d o e s n o t b o th e r h im t h a t m u c h . O n p h y s ic a l e x a m i n a t io n , h e h a s a s m a l l e ff u s i o n in h is le ft k n e e ( n o e f fu s io n i n th e r ig h t k n e e ) . H e h a s m il d c re p i tu s i n b o th k n e e s , b u t n o e r y th e m a o r w a r m t h . S tre n g t h is n o rm a l, a n d e xa m i n a ti o n d o e s n o t i n d i c a te a n y l ig a m e n to u s i n s ta b il i ty . W h a t is t h e li k e ly d i a g n o s is ? W h a t is t h e a p p ro p ri a t e m a n a g e m e n t o f t h is p a t ie n t? 4 7 . A 3 4 - y e a r- o l d m a le is b ro u g h t t o th e E D b y E MS a f t e r b e in g fo u n d u n c o n s c i o u s i n h is a p a rtm e n t b y h is b r o th e r. I t i s u n k n o w n wh e t h e r h e s u f fe r e d a n y t ra u m a , b u t th e re a re n o s i g n s o f in ju r y o n e x a m in a t io n . Th e p a ti e n t c a n n o t b e a r o u s e d i n th e P.494

E D b u t d o e s re s p o n d to p a in . V it a l s i g n s a re a s fo l lo w s : te m p e r a tu re = 1 0 0 .8 , R R = 3 4 , B P = 1 5 6 /9 8 , p u l s e = 1 0 4 . P u p ils a re ro u n d a n d re a c t iv e t o li g h t b i la t e ra ll y . A c c o rd in g t o h is b ro th e r, t h is p a t ie n t h a s n o k n o wn me d i c a l p r o b le m s . L a b o r a t o ry t e s t s re v e a l th e fo l lo w in g : W B C = 8 . 4 , H g b = 0 .3 , H c t = 3 0 .9 , Na
+ + -

= 4 2 , K = 4 . 1 , C l = 1 0 4 , H C O 3 = 1 1 , B U N = 1 5 , C r = 0 .9 , g l u c o s e

= 1 1 4 . A B Gs a re o b ta i n e d a n d r e v e a l t h e fo l l o w i n g : p H = 7 . 1 8 , P a C O 2 = 2 3 , P a O 2 = 9 6 . W h a t is t h e a c i d - b a s e d i s o rd e r? W h a t is t h e a p p ro p ri a t e m a n a g e m e n t o f th is p a t ie n t? 4 8 . A 5 3 - y e a r- o l d f e m a le u n d e r we n t a n u n e v e n tf u l t o ta l h i p re p la c e m e n t 2 h o u rs a g o . I n t h e re c o v e ry ro o m , s h e e x p e ri e n c e s a s u d d e n o n s e t o f S O B , n a u s e a , p a l p i ta tio n s , a n d c h e s t p a i n .

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P M H i s s i g n i fi c a n t fo r H T N a n d h y p e rth y ro id is m. S h e is d ia p h o r e ti c a n d a g i ta t e d . T e m p e r a tu re = 1 0 2 . 4 , B P = 1 5 5 /8 8 , p u l s e = 1 3 4 . O x y g e n s a tu r a t io n a t ro o m a ir = 9 6 % . P h y s ic a l e xa m i n a tio n re v e a ls c ra c k l e s in b i l a te r a l l o w e r lo b e s . C a r d ia c e xa m i n a ti o n re v ea ls a re g u l a r rh y th m w i th n o m u rm u rs . Sh e d e n ie s a n y r a d i a ti n g c om p o n e n t t o h e r c he s t p a i n . T h e p a ti e n t i s a l e r t a n d o ri e n t e d . W h a t a re th e a p p r o p r i a te n e x t s t e p s i n t h e m a n a g e m e n t o f th is p a t ie n t? 4 9 . A 6 1 - y e a r- o l d m a le w h o h a s b e e n y o u r p a tie n t f o r s e v e r a l y e a rs p r e s e n ts to y ou r o f fi c e wi t h a c o m p l a i n t o f t wo e p is o d e s o f b lo o d y u ri n e o v e r t h e p a s t 2 4 h o u r s . H e d e n ie s a n y p a i n . P MH i s s ig n i fic a n t fo r h y p e rl ip i d e m ia , H T N , d ia b e t e s , g l a u c o m a , a n d o s te o a rth rit i s . H e h a s s m o k e d o n e p a c k o f c i g a re t te s p e r d a y f o r th e p a s t 3 5 to 4 0 y e a rs . P h y s ic a l e xa m i n a ti o n is n o rm a l. U r in a l y s i s s h o w s g ro s s h e m a tu ri a wi t h o u t p ro te in u r i a , p y u ri a , o r R B C c a s t s . W h a t is t h e a p p ro p ria te n e x t s te p i n m a n a g in g th i s p a ti e n t ? 5 0 . A 5 7 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e w it h a 2 - w e e k h is to ry o f c o u g h . H e d e n ie s f e v e rs o r c h il ls . A n in c re a s e d a m o u n t o f c le a r s pu tu m i s a s s o c i a t e d wi t h th e c o u g h . H e t y p i c a ll y h a s a v e ry m il d c o u g h d a il y , b u t o v e r th e p a s t 2 w e e k s t h is h a s s ig n i fi c a n tl y w o r s e n e d . H e h a s e x p e ri e n c e d c h e s t d is c o m f o rt d u e to e xc e s s i v e c o u g h in g a n d s o m e ti m e s f e e ls s h o rt o f b re a th . P M H is n e g a tiv e a n d h e ta k e s n o m e d ic a ti o n s . H e s m o k e s o n e p a c k o f c ig a re tt e s p e r d a y a n d h a s a 3 0 t o 3 5 p a c k -y e a r h i s t o r y . T e mp e r a t u re i s 9 9 . 1 . A u s c u lt a t io n o f l u n g s re v e a l s c le a r a ir wa y e n t ry . C X R s h o w s m il d o v er e x p a n s i o n o f th e l u n g s w i th o u t i n f il tra t e s . W h a t is th e li k e ly d i a g n o s is a n d h o w w o u ld y o u a p p ro a c h t h is p ro b le m ? 5 1 . A 3 2 - y e a r- o l d A fr ic a n - A m e ric a n m a le , wh o re c e n t l y mo v e d t o th e a re a , p r e s e n ts t o y o u r o ff ic e f o r t h e fi rs t t im e f o r a r o u t in e c h e c k up . P M H i s s ig n i f ic an t fo r t y p e II D M . H e i s 5 ' 9 " a n d w e i g h s 2 1 5 l b . T h e o n l y m e d i c a tio n h e ta k e s i s m e tf o rm in . H e s m o k e s h a lf a p a c k o f c i g a re tte s a d a y ; d o e s n o t d r in k a lc o h o l ; a n d e xe rc i s es s p o ra d i c a l l y , a p p ro xi m a te l y o n c e e v e ry 2 w e e k s . H i s m o t h e r d ie d a t th e a g e o f 6 2 d u e to a n M I. H is f a t h e r is 7 3 y ea rs o f a g e a n d i s h e a l th y . P h y s i c a l e x a m i n a t io n i s n o r ma l . V it a l s i g n s a re : B P = 1 4 5 / 9 5 , p u l s e = 7 3 , R R = 1 9 , te mp e r a t u re = 9 8 .2 . D e s c ri b e th e a p p r o p ria te n e x t s te p s i n th e m a n a g e m e n t o f t h i s p a t ie n t . 5 2 . T h e p a ti e n t i n th e p re v i o u s q u e s t io n re t u rn s to y o u r o f fi c e in 6 w e e k s fo r a re p e a t e v a l u a t io n . He h a s n o c o m p la in ts . H e s ta te s th a t h e h a s b e e n wa lk in g b ri s k l y f o r 3 0 m in u t e s f o u r t im e s a w e e k , h a s lo s t 1 0 l b ., a n d h a s b e e n e a t in g a h e a l th i e r d ie t . H is l a b o r a to r y r e s u lt s a re w i th in n o rm a l l im it s . H e m o g l o b i n A 1 C i s 7 .2 . C XR , E C G , a n d u ri n a l y s i s a r e n o rm a l . H is B P t o d a y i s b e tw e e n 1 4 0 /9 0 a n d 1 4 5 /9 5 . P h y s ic a l e x a m i n a ti o n is u n c h a n g e d f ro m 2 m o n th s a g o . W h a t is y o u r r e c o m m e n d e d t re a tm e n t ? 5 3 . A 1 7 - y e a r- o l d f e m a le i s r e f e r re d t o t h e E D b y h e r p r im a ry p h y s i c ia n ; s h e p re s e n ts wi t h a 3 d a y h i s to ry o f f e v e rs , d y s u r ia , a n d v o mi t in g . S h e d e n ie s v ag in a l d i s c ha rg e , a b d o m in a l p a i n , o r d ia rrh e a . S h e is s e x u a ll y a c tiv e wi t h h e r b o y f rie n d . V it a l s i g n s a re a s f o l lo w s : t e m p e ra t u re = 1 0 3 , R R = 2 0 , B P = 9 8 /6 5 , p u ls e = 1 0 0 . S h e a p p e a r s il l a n d is u n a b le t o to l e ra t e l iq u i d s , b u t s h e is a l e r t a n d o ri e n t e d . H e r e x a m in a ti o n is p o s i ti v e f o r s u p ra p u b ic a s w e ll a s c o s to v e rt e b ra l a n g l e te n d e rn e s s b i la t e ra l l y . U ri n a l y s is re v ea ls n u m e ro u s W B C s a n d b a c t e r ia , a n d it is p o s i tiv e f o r W B C c a s ts . O th e r l a b o r a t o ry s tu d y re s u lt s a re w it h i n n o rm a l li mi t s . W h a t is th e l ik e l y d ia g n o s is ? D e s c ri b e th e a p p ro p r ia te n e x t s te p s i n m a n a g e m e n t o f t h i s p a ti e n t. 5 4 . A 4 2 - y e a r- o l d f e m a le p r e s e n t s t o th e E D w i th a c o mp l a in t o f s e v e re lo w b a c k p a in s i n c e l a s t n ig h t. S h e w a s b e n d i n g o v e r to p i c k u p a h e a v y s u i tc as e w h e n s h e fe lt

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P.495

s u d d e n p a i n in h e r lo w b a c k . Ib u p ro fe n d o e s r e l ie v e t h e p a i n , b u t n o t c o mp l e te l y . S h e d e n i e s a n y p a i n o r n u m b n e s s in t h e lo w e r e xt r e m i t ie s . B o w e l a n d b la d d e r f u n c ti o n is n o rm a l. P h y s i c a l e xa m i n a ti o n re v e a l s a mo d e ra te l y o v e rw e i g h t f e m a l e in a c u te d is t r e s s . Sh e is l y i n g o n h e r s id e o n th e e x a m i n a t i o n ta b le h o ld in g h e r b a c k ; s h e c a n n o t li e s up in e b e c a u s e o f s e v er e b a c k p a i n . S h e h a s v e ry m in im a l te n d e rn e s s o n p a l p a ti o n o f h e r lo w b a c k . N e u ro l o g ic e xa m in a t io n i s n o r ma l . W h a t is t h e a p p ro p r ia t e n e xt s t e p i n m a n a g in g th is p a t ie n t? 5 5 . A 2 9 - y e a r- o l d m a le w it h a h i s to r y o f a s t h m a p re s e n ts to t h e E D wi t h s e v e r e S O B f o r t h e p a s t 2 d a y s . H e a ls o c o m p la in s o f s o re th r o a t , g e n e ra l i z e d m a l a is e , a n d a n o n p ro d u c ti v e c o u g h . H e d e n ie s c h e s t p a in , fe v e r, a n d c h i ll s . Te m p e ra tu re = 9 8 . 9 , H R = 9 5 , R R = 3 3 , B P = 1 4 0 /8 2 , a n d O 2 s a tu ra ti o n = 9 0 % o n ro o m a i r. B re a t h i n g is la b o r e d , a n d h e is s p e a k in g in s h o r t g a s p s . L u n g a u s c u lt a t io n r e v e a ls b il a t e ra l d if f u s e e x p ir a t o r y wh e e z i n g . A B G i s d r a w n : 7 .4 2 /4 3 /7 0 / 2 2 . W h a t is th e a p p ro p ri a t e n e xt s te p i n m a n a g i n g t h is p a ti e n t ? 5 6 . A 2 2 - y e a r- o l d f e m a le p r e s e n t s t o th e E D w i th a b ru p t o n s e t o f a ra s h , h i g h fe v e r, a n d v o m i ti n g . V it a l s i g n s a re a s fo l lo w s : te m p e ra t u re = 1 0 4 , H R = 1 1 8 , R R = 2 2 , B P = 7 6 /4 0 , a n d p u ls e o x im e t ry = 9 8 % o n r o o m a i r . O n e x a m in a ti o n s h e a p p e a rs c o n f u s e d a n d d is o ri e n t e d . H e r s k in i s w a r m , a n d t h e re is a d i ff u s e m a c u l a r r a s h o v e r h e r b o d y . S h e is a d m i tt e d t o t h e IC U a n d s u b s e q u e n t l y d e v e lo p s m u lt is y s t e m o r g a n d ys f u n c ti o n . W h a t is t h e d i a g n o s i s ? D e s c ri b e t h e a p p ro p ria te m a n a g e m e n t o f th is p a tie n t . 5 7 . A 3 3 - y e a r- o l d C a u c a s i a n m a le c o m e s to t h e c l in i c w i th a 4 -d a y h is to ry o f c h e s t p a i n . T h e p a in r a d i a t e s t o t h e r ig h t s id e o f th e n e c k a n d is wo rs e n e d b y d e e p i n s p i ra t i o n a n d i m p r o v e d b y l e a n in g fo r wa rd . S e v e ra l w e e k s a g o h e h a d a f e v e r a n d c o u g h , wh ic h h a ve b o t h s in c e i m p ro v e d . H e i s a fe b ri le , B P is 1 3 0 /8 5 , a n d p u l s e i s 8 8 . O n e xa m i n a tio n , th e r e i s a s c r a tc h i n g s o u n d h e a rd o v e r t h e le ft s te r n a l b o r d e r o n e x pi ra t i o n . E C G s h o w s S T e l e v a ti o n i n l e a d s I , I I , I II , a v L , a n d V 2 to V 6 . W h a t i s th e e ti o lo g y o f h is c o n d i ti o n a n d w h a t m e d ic a ti o n s s h o u ld b e a d m i n is te re d ? 5 8 . A 2 0 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e c om p la in i n g o f l o w b a c k p a in fo r s e v e ra l m o n t h s . H e r e p o rts im p ro v e m e n t o f th e p a in w it h m o v e m e n t a n d e x e rc is e , b u t th a t r e s t w o r s e n s t h e p a i n . H e d e n i e s a n y p a i n i n h is le g s b u t d o e s h a v e p a i n in h is rig h t s h o u l d e r o n o c c a s i o n . H e a ls o f e e l s fa t i g u e d m u c h o f t h e ti m e . H i s l o w b a c k p a i n h a s g ra d u a ll y wo rs e n e d , a n d h e n o w h a s p a i n wh e n h e li e s o n h i s b a c k . Me d i c a l h is to ry is u n re m a rk a b l e . O n p h y s ic a l e xa m i n a ti o n , h e h a s l im it e d r a n g e o f m o t io n i n h is l u m b a r s pi n e o n f le xi o n a n d e x t e n s i o n , a n d f u l l e x t e n s io n o f th e s p i n e is n o t p o s s ib l e . H e h a s t e n d e rn e s s o v e r th e s p in o u s p ro c e s s es o f T 1 2 - L 4 v er te b ra e . V i ta l s i g n s a re a s f o l lo ws : te m p e r a t u re = 1 0 0 . 9 , H R = 6 8 , R R = 1 6 , B P = 1 2 4 /7 6 . W h a t is t h e l ik e ly d i a g n o s i s ? W h a t is th e a p p ro p ri a t e m a n a g e m e n t o f t h is p a ti e n t? 5 9 . Y o u a re p a g e d t o c o m e a n d e v a lu a te a 7 3 -y e a r -o ld fe ma l e w i th S O B a n d ta c h y c ar d ia . S h e w a s a d m i t te d 1 w e e k a g o f o r a C V A . F o r t h e p a s t 4 d a y s s h e h a s b e e n fe b ri le , a n d h e r b l o o d c u lt u r e s a r e p o s i ti v e fo r E s c h e ri c h i a co l i . H e r s e p s is is b e in g tr e a t e d wi t h m u l ti p l e b r o a d s p e c tru m a n t ib i o t ic s . S h e h a d n o p re v i o u s h is to ry o f c a rd i o v a s c u l a r o r re s p ira t o ry d i s e a s e . H e r n u r s e te l ls y o u t h a t to d a y s h e i s m o r e c o n fu s e d a n d a p p e a rs q u it e i l l. T e m p e ra t u re = 1 0 0 . 4 , p u ls e = 1 1 6 , B P = 1 1 6 / 5 6 , R R = 3 6 . O xy g e n s a tu r a t io n i s 8 7 % o n r o o m a ir . E x a m i n a t i o n s h o ws

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u s e o f a c c e s s o ry m u s c le s o n in s p i ra t i o n . W h a t a re t h e a p p r o p r ia t e in i t ia l s t e p s to ta k e i n th e m a n a g e m e n t o f th is p a t ie n t? 6 0 . A 2 0 - y e a r- o l d m a le h e m o p h il ia c p a t ie n t p r e s e n ts wi t h a n i n t e n s e l y p a in fu l rig h t k n e e . H is ri g h t k n e e is s wo l le n , w a r m , a n d te n d e r t o p a l p a t io n , a n d th e s k in is e r y th e m a t o u s . H i s r i g h t k n e e h a s a v e r y li mi t e d ra n g e o f m o ti o n . H is e xa m i n a t io n i s o th e r w is e n o r m a l , w it h n o o t h e r j o in t s a ff e c t e d . W h a t a re th e a p p r o p ri a te s te p s t o ta k e in th is p a t ie n t? 6 1 . A 2 0 - y e a r- o l d m a le p r e s e n ts wi t h a 1 -w e e k h is to ry o f s e v e re s o r e th ro a t, fe v e r, a n d m a la is e . H e h a s o th e r n o n s p e c i fic c o m p l a i n ts s u c h a s h e a d a c h e , c h il ls , a n d n a u s e a . O n e xa m i n a ti o n , h i s l u n g s a r e c l e a r to a u s c u lta ti o n , b u t p h a r y nge a l e x u d a te s a re e v id e n t o n e xa m i n a ti o n o f h is th ro a t. H i s e y e s a p p e a r s w o ll e n , a n d h e h a s te n d e r p o s t e r io r c e r v i c al l y m p h n o d e s . W h a t is th e d ia g n o s i s ? H o w wo u l d y o u m a n a g e t h i s p a ti e n t? P.496

6 2 . A 2 1 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e w it h c h ie f c om p la i n t o f c oug h a n d a s o r e th ro a t f o r 3 d a y s . H e a ls o c o m p l a i n s o f n a s a l d is c h a rg e a n d c o n g e s ti o n a s we ll a s b a c k p a i n . H e d e n i e s a n y c h e s t p a i n o r s h o rt n e s s o f b re a th . T h e r e i s n o s p u t u m p ro d u c ti o n . V ita l s i g n s a re : t e m p e r a tu re = 1 0 0 . 4 , B P = 1 2 4 / 8 2 , p u ls e = 7 6 , R R = 1 6 . O n p h y s i c a l e x am i n a ti o n , h is l u n g s a re c l e a r to a u s c u l ta t i o n b i la t e ra ll y , a n d h e h a s a n e r y th e m a t o u s o ro p h a ry n x w i th o u t p h a ry n g e a l e x u d a te s . W h a t is t h e a p p ro p ri a t e m a n a g e m e n t o f t h i s p a ti e n t ? 6 3 . A 3 5 - y e a r- o l d m a le p r e s e n ts wi t h c o m p la in t o f a 6 -m o n t h h is to r y o f f a tig u e a n d l e t h a r g y . H i s m e d ic a l h i s to ry i s u n r e m a r k a b le . H e d e n ie s m e le n a a n d r e c e n t t ra u m a o r s u rg e ry . H e re p o rt s t h a t h e d o e s n o t d r i n k a l c o h o l , s m o k e , o r ta k e a n y m e d i c a ti o n s . H is f a m il y h i s to ry is n o n c o n t ri b u to r y . H e a p p e a rs w e l l n o u ri s h e d . V it a l s i g n s a r e a s fo l l o w s : RR = 1 6 , B P = 1 3 0 /8 0 , p u ls e = 7 0 . L a b o r a to ry te s t r e s u lt s a re a s f o l lo w s : H b = 7 . 6 , H c t = 2 2 . 8 % , a n d MC V = 6 8 . T h e re m a i n d e r o f h is la b o ra to ry t e s t re s u l ts a re n o r m a l . W h a t i s th e l ik e l y d ia g n o s is ? D e s c ri b e th e a p p ro p ria te m a n a g e m e n t o f t h is p a tie n t . 6 4 . A 5 6 - y e a r- o l d f e m a le p r e s e n t s t o th e E D w i th a c o m p l a i n t o f s e v e re a b d o m i n a l p a in , p ri m a r il y i n th e R U Q a n d e p ig a s t ric re g i o n . S h e h a s h a d t wo e p i s od e s o f v o m it i n g in th e p a s t 5 h o u rs . S h e d e s c ri b e s t h e p a in a s s h a r p , w i th o u t ra d ia t io n t o h e r b a c k . P M H is s ig n i f ic a n t fo r D M , H T N , a l c o h o li s m , a s t h m a , a n d c h ro n ic l o w b a c k p a i n . H e r c u rr e n t m e d i c at io n s in c l u d e i n s u li n , a te n o lo l, a lb u te ro l in h a l e r, a n d o x y c o d o n e . S h e h a s h a d a b d o m in a l p a i n s ev e ra l ti m e s i n th e p a s t y e a r, b u t n e v e r th i s s e v e re a n d n e v e r a s s o c i a te d w it h v o m i ti n g . O n e x a m in a ti o n , s h e h a s t e n d e r n e s s i n th e e p ig a s t ri c re g io n . T h e re is n o g u a rd i n g o r r e b o u n d . P h y s ic a l e xa m i n a ti o n is o t h e rw i s e u n re m a r k a b le . T e mp e ra t u re = 1 0 1 .3 , B P = 1 3 6 / 8 8 , p u ls e = 1 1 6 . Sh e i s a l e rt a n d o r ie n te d a n d is i n o b v io u s d is tre s s . W h a t a r e t h e a p p r o p r ia te n e xt s t e p s i n th e m a n a g e m e n t o f th is p a t ie n t? 6 5 . A 3 7 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e wi t h a h i s to ry o f f a t ig u e fo r th e p a s t f e w m o n t h s . S h e d o e s n o t h a v e a n y o th e r c o m p la i n ts . A f t e r a th o ro u g h m e d ic a l h is to r y , s h e a d m i ts t o m il d c on s t ip a ti o n t h a t i s n o t t ro u b le s o me fo r h e r . S h e r e p o rt s a 5 -l b w e ig h t g a in o v e r t h e p a s t 6 m o n t h s , w h ic h s h e a t tr ib u te s to li v i n g a mo re s e d e n ta ry li f e o f la te d u e t o h e r f a ti g u e a n d le th a rg y . H e r p h y s ic a l e xa m i n a tio n is u n r e m a r k a b le ; h e r th y r o i d d o e s n o t s e e m e n l a rg e d ,

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a lt h o u g h h e r fa c e is s li g h tl y p u f f y . Y o u o r d e r t h y ro i d fu n c ti o n s tu d ie s , w h i c h s h o w a n e l e v a te d T S H l e v e l . W h a t is th e l ik e l y d ia g n o s is ? H o w w o u l d y ou m a n a g e th i s p a tie n t ? 6 6 . A 2 1 - y e a r- o l d m a le c o ll e g e s tu d e n t is b ro u g h t t o th e E D b y h i s fr i e n d s a f t e r d e v el o p i n g f e v e r, n e c k s tif f n e s s , a n d c o n f u s i o n . V i ta l s i g n s o n a d m i s s io n a re a s f o ll o w s : te m p e ra t u re = 1 0 5 , R R = 2 0 , B P = 1 2 0 /7 5 , p u ls e = 9 2 , a n d p u l s e o xi m e t ry 9 9 % o n ro o m a i r. E xa m in a t io n re v e a ls n u c h a l r ig i d i t y a n d a d if f u s e m a c u l o p a p u la r ra s h w it h p e te c h ia e s c a tt e r e d o v e r h is t ru n k a n d e xt re m i ti e s . W h a t o rg a n is m i s re s p o n s ib l e f o r t h is ? H o w s h o u l d h is c o ll e g e f ri e n d s a n d c o n ta c ts b e t re a te d ? 6 7 . A 6 4 - y e a r- o l d m a le p r e s e n ts wi t h b a c k p a in fo r th e p a s t 5 to 6 m o n th s . T w o d a y s a g o h e f e l l wh i le s h o v e li n g s n o w , a n d h e h a s p a i n in h is ri g h t a rm a s w e ll . P la i n f ilm s o f th e s p i n e s h o w s e ve ra l s m a ll l y t ic le s i o n s i n t h e v e rt e b r a l b o d i e s a t th e L 3 -L 4 l e v e l. R i g h t h u m e ru s f il m s re v e a l l y ti c a r e a s i n th e m e ta p h y s is a n d d i a p h y s is o f th e rig h t h u m e ru s . T h e r e i s a fr a c t u re li n e t h r o u g h t h e a b n o rm a l a re a o n th e h u m e r u s fi lm . P h y s ic a l e xa m i n a t io n re v e a ls te n d e rn e s s o n p a lp a ti o n o f th e l o w b a c k a n d ri g h t h u m e ru s , b u t i s o t h e r w is e u n re m a rk a b le . T h e re is n o s p le n o m e g a l y o r l y m p h a d e n o p a th y . C B C re s u l ts a re a s f o l lo w s : H b = 9 . 1 g / d L , H c t = 2 7 .6 % MC V = 9 0 , p l a t e le t c o u n t = 1 5 0 ,0 0 0 / L . S e ru m c he m is t rie s a re a s f o ll o ws : s od iu m = 1 3 7 m m o l /L , p o t a s s i u m = 4 .1 m m o l/L , c h l o rid e = 1 0 7 m m o l /L , C O 2 = 2 4 m m o l /L , g l u c o s e = 8 9 m g /d L , B U N = 4 6 m g / d L , C r = 3 . 5 m g /d L . W h a t is t h e li k e l y d i a g n o s i s ? D e s c rib e th e a p p ro p ria te m a n a g e m e n t o f th is p a tie n t . 6 8 . A 4 7 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e w it h s e v er e l o w b a c k p a in fo r t h e p a s t 2 d a y s . T h i s m o rn i n g h e h a d a n e p is o d e o f l o s s o f c o n t ro l o f h is u r i n e , f o ll o we d b y p r o g re s s i v e w e a k n e s s i n b il a t e r a l lo w e r e x tr e m it i e s . Hi s l o w b a c k p a in is s e v e re a n d s h a rp , a n d it r a d i a t e s i n t o t h e r ig h t lo w e r e xt r e m i ty . P MH i s s ig n i fi c a n t fo r m il d a s t h m a . H e h a s h a d i n te r m it te n t lo w b a c k p a in fo r t h e p a s t 2 y e a rs b u t n e v e r P.497

t h is s e v e re a n d n e v e r a s s o c i a t e d wi t h w e a k ne s s o r u rin a ry s y m p t o m s . O n p h y s ic a l e xa m i n a ti o n , h e h a s v e r y l i m it e d m o tio n o f h i s lu m b a r s p in e s e c o n d a ry to p a in . H e h a s 3 / 5 s tr e n g th in g a s tro c n e m iu s m u s c l e s b i la te r a l ly a n d 2 /5 s tre n g t h w it h g r e a t to e d o rs i f le x i o n b ila t e ra ll y . H e h a s d im in is h e d s e n s a ti o n th r o u g h o u t h i s lo we r e xt re m i tie s , a n d re f le x e s a re d im i n i s h e d . W h a t i s th e m o s t a p p ro p ri a te n e x t s t e p in th e m a n a g e m e n t o f th is p a ti e n t? 6 9 . A 6 7 - y e a r- o l d f e m a le p r e s e n t s t o th e E D a ft e r a tr a n s ie n t e p i s o d e o f v is u a l lo s s in h e r ri g h t e y e . S h e re p o r ts th a t s h e h a s h a d r ig h t -s id e d h e a d a c h e s f o r s e v e ra l m o n t h s , fo r w h ic h s h e t a k e s ib u p r o fe n , w i th s o m e re l ie f . O n p h y s ic a l e x a m in a ti o n , s h e h a s te n d e rn e s s o v e r h e r s c a lp i n th e l e ft te m p o r a l r e g i o n a n d c o m p la in s t h a t h e r ja w " g e t s ti re d wi t h c h e wi n g . " N e u ro l o g i c e xa m i n a ti o n is n o rm a l w it h n o fo c a l d e f ic i ts . V i ta l s ig n s a re a s fo l lo ws : te m p e ra t u r e = 1 0 1 . 1 , H R = 7 2 , R R = 1 6 , B P = 1 4 0 /8 2 . W h a t i s t h e l ik e ly d i a g n o s is a n d t h e a p p ro p r ia t e m a n a g e m e n t o f th i s p a t ie n t? 7 0 . A 6 3 - y e a r- o l d f e m a le i s b ro u g h t to th e E D b y t h e re s c u e s q u a d a f t e r a n e p i s o d e o f s y n c o p e a t h o m e . H e r h u s b a n d w it n e s s e d th e e v en t. H e d e s c r ib e s th e p a t ie n t a s fa ll in g s u d d e n ly to th e f lo o r f ro m a s ta n d in g p o s it i o n wi t h o u t a n y p ro d ro m a l s y m p t o m s a n d l o s i n g c o n s c io u s n e s s f o r a b o u t 5 s e c o n d s , a f te r w h ic h s h e ra p i d ly r e g a in e d c o n s c i o u s n e s s a n d w a s o rie n te d a n d

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a p p ro p ria te . N o b o we l o r b l a d d e r in c on ti n e n c e w a s n o t e d . P MH i s s i g n i fi c ant fo r D M, H T N , a n d d e p re s s io n . S h e d e n i e s a n y c h e s t p a in o r S O B . V i t a l s i g n s a re : t e m p e ra tu re = 1 0 0 .2 , B P = 1 1 8 /6 8 , p u l s e = 8 4 , R R = 1 8 . O xy g e n s a tu r a ti o n o n r o o m a i r is 9 6 % . P h ys ic a l e xa m i n a t io n i s s ig n i fic a n t o n l y f o r b ru i s in g o f h e r le ft w r is t a n d th i g h . H e a rt a n d l u n g e x am i n a ti o n is n o rm a l. W h a t a r e t h e a p p r o p r ia te n e x t s te p s i n m a n a g i n g th is p a ti e n t? 7 1 . A 6 3 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e wi t h c o m p la in t o f m i d t o l o w b a c k p a in f o r th e l a s t y e a r, w h i c h h a s b e c o m e wo rs e o ve r th e p a s t 3 m o n th s . S h e d e n i e s a n y w e a k n e s s o r ra d ia t in g p a i n in h e r l o w e r e x t re m it i e s . S h e c u rr e n tl y ta k e s o x y c o d o n e f o r h e r b a c k p a i n wi t h i n a d e q u a te re l ie f. S h e h a s d i ff ic u l ty s le e p i n g a t n ig h t b e c aus e o f th e b a c k p a i n . P M H i s s ig n i fic a n t f o r H T N , fo r w h i c h s h e t a k e s a - b l o c k e r. T h o r a c i c a n d l u m b a r s pi n e r a d i o g r a p h s

+

s h o w m u l ti p l e c o m p re s s io n f ra c t u r e s a t T 8 , T 1 1 , L 3 , a n d L 4 , a s we l l a s d if f u s e o s te o p e n i a . L a b o ra to r y s tu d ie s a re a s fo l lo ws : W B C 8 , h e m o g lo b i n 9 .7 , h e m a t o c ri t 2 9 % , p la te le t s 1 8 9 , N a
-

1 4 2 , K 4 .1 , B U N 4 3 , c r e a t i n i n e 2 .3 , cal c i u m 1 4 . 3 . P h y s ic a l e x a m in a ti o n re v ea ls t e n d e r n e s s o n p a lp a ti o n o f th o ra c i c a n d l u m b a r s p i n e . S h e h a s li m i te d l u m b a r fl e x i o n d u e t o p a in . N e u r o lo g i c a l e xa m i n a t i o n is n o rm a l . W h a t is t h e a p p ro p ri a t e n e x t s te p i n m a n a g in g t h is p a t ie n t? 7 2 . A 6 2 - y e a r- o l d f e m a le i s b ro u g h t to th e E D b y E MS f o r c o n fu s io n , h e a d a c h e , a n d v o m it in g o v e r t h e p a s t 1 2 h o u r s . V it a l s ig n s a r e a s f o l lo w s : t e m p e r a tu re = 9 6 . 9 , H R = 1 0 0 , R R = 2 2 , B P = 2 2 0 / 1 5 0 . S h e is d i s o rie n t e d a n d u n c o o p e ra ti v e. E xa m i n a ti o n is o t h e r w is e u n re m a rk a b le . W h a t is t h e m o s t li k e l y d i a g n o s i s , a n d w h a t is t h e m o s t a p p ro p ria te m a n a g e m e n t ? 7 3 . A 7 4 - y e a r- o l d m a le is b ro u g h t t o y o u r o f fic e b y h i s d a u g h te r, w h o is h a v i n g in c re a s in g p ro b le m s c a r in g f o r h i m a t h o m e . S h e s ta t e s t h a t h e b e h a v e s i n a p p r o p ria te l y a t t im e s , a n d o n t wo o c c a s i o n s h e h a s w a n d e re d o u ts id e th e h o m e a n d h a s g o t te n l o s t . H e m is p l a c e s ite m s f re q u e n tl y , a n d h is p e r s o n a li ty h a s c h a n g e d to b e i n g m o re b e l li g e re n t a n d d e m a n d i n g . H e s e e m s t o la c k ju d g m e n t in s o c ia l s i tu a ti o n s , a n d h e n e v e r h a d t h i s p ro b l e m in t h e p a s t. S h e s ta te s t h a t th e s e p ro b l e m s h a v e b e c o m e w o r s e g ra d u a ll y o v e r t h e p a s t 4 to 5 y e a rs . P h y s ic a l e xa m i n a ti o n is u n re m a rk a b l e . W h a t is t h e li k e ly d i a g n o s is ? H o w w o u l d y ou m a n a g e t h i s p a t ie n t? 7 4 . A 7 3 - y e a r- o l d f e m a le i s b ro u g h t to th e E D b y E MS w i th a c om p la i n t o f S O B a n d m i ld c h e s t p a in t h a t b e g a n s u d d e n ly a fe w h o u rs a g o . H e r m e d i c al h is t o ry i s s i g n i f ic a n t f o r a p r e v io u s M I 5 y e a rs a g o a n d m i l d C H F . T w o w e e k s a g o , th e p a t i e n t f e ll a n d f ra c tu re d h e r ri g h t h ip , w h i c h w a s r e p a i re d s u rg i c a ll y . S h e w a s d is c h a rg e d fr o m th e h o s p ita l 1 0 d a y s a g o a n d h a s b e e n re s tin g a t h o m e s in c e th e n . H e r c h e s t p a in is wo rs e wi t h i n s p ir a ti o n . O n p h y s ic a l e xa m i n a t io n , s h e is in m o d e ra te re s p i ra t o r y d is t r e s s ; th e e xa m i n a ti o n is o th e rw i s e u n re m a rk a b l e . T e m p e ra t u re = 9 9 .1 , B P = 1 3 8 /7 5 , p u ls e = 9 6 , R R = 2 8 . C X R i s n o rm a l . R o u t in e la b o r a t o r y v a lu e s a re a l l n o rm a l . W h a t i s th e a p p r o p r ia te m a n a g e m e n t? P.498

7 5 . A 3 9 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e wi t h a 3 -y e a r h i s to ry o f h e a d a c h e s . T h e y o c c u r o n c e o r tw i c e p e r w e e k , la s ti n g s e v er a l h o u rs . Th e h e a d a c hes a re th ro b b i n g a n d a re u s u a ll y o n h e r l e ft s i d e . D u r i n g th e s e e p is o d e s , th e p a t ie n t is i n c a p a c it a t e d a n d m u s t l ie d o wn

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i n a d a r k ro o m fo r s e v e ra l h o u rs . S h e i s s e n s i tiv e to l ig h t d u rin g th e e p is o d e s a n d c a n n o t mo ve b e c a u s e o f th e p a in . S h e i s o ft e n n a u s e a te d a n d h a s v om i te d o n tw o o c c as i o n s . Me d i c a l h is t o r y is s i g n ifi c a n t f o r h y p o t h y r o i d ism , fo r wh i c h s h e ta k e s l e v o t h y r o x i n e ( S y n th ro id ) . H e r p h y s ic a l e x a m in a ti o n i s u n r e m a rk a b l e . W h a t i s th e a p p ro p ria te n e x t s te p i n m a n a g in g th i s p a t ie n t? 7 6 . A 5 5 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e f o r a ro u ti n e f o l lo w - u p e x a m in a ti o n . Me d i c al h is t o r y is s i g n ifi c a n t f o r p o o rl y c o n tr o ll e d D M (2 0 -y e a r h i s to r y ), H T N , a n d o s te o a rt h ri t is o f b ila t e ra l k n e e s . S h e a l s o h a s h a d c h ro n i c re n a l i n s u ffi c i e n c y fo r th e p a s t 5 y e a r s . H e r c u rr e n t m e d i c a t io n s in c l u d e h y d ro c h lo ro t h i a z i d e , l is i n o p ril , in s u l in , a n d m e to p ro l o l . S h e h a s b e e n t a k i n g i n c r e a s in g a m o u n t s o f N S A I Ds fo r t h e p a s t s e v e ra l w e e k s fo r h e r p a in fu l k n e e s . S h e i s o b e s e wi t h 2 + p e ri p h e r a l p i tt in g e d e m a . H e r e x a m i n a ti o n is o th e rw i s e u n re m a rk a b le . L a b o ra to r y t e s ts r e v e a l th e fo l lo w in g : Na

+ + -

= 135, K

= 4 .9 , C l = 1 0 4 , H C O 3 = 2 7 , C r = 3 .6 ,

W B C = 7 . 9 , Hg b = 8 . 2 , Hc t = 2 4 . 6 , MC V = 7 5 . O n u r in a l y s i s , s h e h a s 3 + p ro t e i n u ria . O n h e r l a s t v is it 3 m o n th s a g o , h e r C r wa s 2 . 3 . W h a t i s th e a p p ro p ria t e n e x t s te p in m a n a g i n g t h i s p a t ie n t? 7 7 . A 6 4 - y e a r- o l d f e m a le p r e s e n t s t o th e E D w i th s u d d e n o n s e t o f s e v e re c h e s t p a in . S h e h a s a h is t o r y o f a n g in a a n d t a k e s n it ro g l yc e r in , b u t t h i s t i m e th e p a in i s m u c h wo r s e a n d is n o t re l ie v e d w i th n i tr o g l y c e ri n . P MH is s i g n i fi c a n t f o r H T N . S h e is a fe b ril e , a n d H R = 1 0 5 , B P = 1 6 0 /1 0 5 , R R = 1 7 . C a rd i a c e n z y m e s a re n e g a ti v e. C X R s h o ws a wi d e n e d m e d ia s t in u m . W h a t i s t h e li k e l y d i a g n o s i s ? 7 8 . A 1 7 - y e a r- o l d m a le p r e s e n ts to th e E D wi t h s e v e re p a in in h is ri g h t a rm a n d b a c k t h a t b e g a n s u d d e n l y a f e w h o u rs a g o . T h e p a i n is s h a rp a n d th r o b b in g . H e h a s a h i s to ry o f s ic k l e c e ll d is e a s e wi t h f r e q u e n t p a i n fu l c ris e s re q u i r in g h o s p ita li z a tio n o n c e o r tw ic e p e r y e a r . H e h a s n o o t h e r m e d ic a l p ro b l e m s . V ita l s i g n s a r e a s f o ll o ws : te m p e ra t u re = 9 7 .6 , H R = 9 4 , R R = 2 0 , B P = 1 3 2 /8 4 . O x y g e n s a tu ra t io n is 9 7 % o n r o o m a i r. H i s ri g h t e x tr e m ity i s v e ry te n d e r, a s i s h is l o w b a c k in th e m id li n e . H is e xa m i n a t io n i s o t h e rw is e u n re m a rk a b le . C B C re s u l ts a re a s f o l lo ws : H b = 7 . 0 , H c t = 2 1 % , MC V = 9 4 . W h a t is t h e a p p ro p ria te m a n a g e m e n t o f t h is p a ti e n t? 7 9 . A 4 2 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e b e c a u s e h e n o t ic e d a " lu m p " in h i s n e c k 1 m o n t h a g o . H e d e n i e s a n y r e c e n t w e i g h t lo s s , p a lp i ta t io n s , p a in , o r d y s p h a g i a . O n p h y s i c a l e xa m i n a ti o n , y o u n o t e a n o n te n d e r , fi rm n o d u l e a b o u t 2 c m in s i z e t o t h e le ft o f th e m id l in e in t h e re g i o n o f t h e th y ro id g l a n d . V i ta l s i g n s a re a s f o l lo w s : B P = 1 2 5 / 8 2 , p u ls e = 7 5 . H e d o e s n o t ta k e a n y m e d i c a t i o n s a n d h a s n o s i g n if ic a n t m e d ic a l h i s t o r y . H e d e n ie s a n y fa m il y h is to ry o f th y ro id d is e a s e o r c a n c e r . H is ro u t in e s e ru m l a b o ra to ry v a l u e s ( C B C , e le c t ro l y t e s , B U N , c re a ti n i n e ) a re n o rm a l . W h a t i s th e a p p ro p ria te n e xt s t e p i n m a n a g e m e n t o f t h i s p a ti e n t? 8 0 . A 6 4 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e wi t h a o n e m o n th h is t o ry o f in te rm i t te n t n e c k a n d s h o u l d e r p a in wi t h S O B t h a t n o rm a ll y o c c u rs w h e n s h e d o e s c h o re s a ro u n d t h e h o u s e o r c li m b s s t a i rs . S h e is p r e v i o u s l y h e a l th y a n d d e n ie s a n y me d i c a l c o n d it io n s . B P = 1 4 8 / 8 6 a n d p u ls e = 8 8 . Y o u o rd e r a n E C G , C X R , C B C , a n d e le c t ro ly t e s . W h a t a re th e n e x t a p p r o p r ia te s te p s i n th e ma n a g e m e n t o f t h is p a tie n t ? 8 1 . A 5 4 - y e a r- o l d m a le p r e s e n ts to th e E D wi t h s e v e re p a in in h is ri g h t g re a t to e . H e s a y s t h a t t h e p a in is e xt re m e a n d in t o le r a b l e , a n d h e is i n o b v i o u s d is t re s s . O n e x a m in a t io n , th e re i s e xq u i s ite t e n d e r n e s s , e ry t h e m a , a n d s w e ll in g o f th e ri g h t g re a t t o e a s w e l l a s t h e d o rs u m o f

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t h e fo o t , a n d i t fe e ls v e ry w a r m to th e to u c h . T h e p a in b e g a n s u d d e n l y a fe w h o u r s a g o . H e d e n i e s a n y p re v i o u s e p i s o d e s o r p a i n in a n y o th e r j o in ts . H e d e n ie s a n y t ra u m a . M e d ic a l h is t o r y is s i g n ifi c a n t f o r o s te o a rt h ri t is o f h i s ri g h t k n e e , fo r w h ic h h e ta k es i b u p ro fe n . H e d o e s n o t ta k e a n y o th e r m e d ic a ti o n s . V it a l s i g n s a re a s f o l lo w s : t e m p e ra t u re = 9 8 .5 , R R = 1 6 , B P = 1 4 0 /8 5 , p u l s e = 7 8 . W h at is t h e a p p ro p ri a t e n e x t s te p in m a n a g i n g th is p a t i e n t ? 8 2 . A 4 1 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e w it h a c o m p la in t o f h e a rt b u r n a n d e p ig a s tr ic p a in f o r t h e p a s t s e v e r a l m o n t h s . H e ta k e s o v e r - th e - c o u n t e r a n ta c id s , b u t P.499

s y m p to m s h a v e b e e n wo rs e o v e r th e p a s t m o n t h . H e d e n ie s a n y w e i g h t lo s s , v o m it in g , h e m a t e m e s is , o r m e le n a . T h e d i s c o m f o rt is w o r s e a f te r e a ti n g a n d w h e n h e li e s fl a t i n b e d . H e s o m e tim e s g e t s a h o rr ib le t a s t e in h i s m o u t h . M e d ic a l h i s t o r y i s n o n c o n tr ib u to ry . H e ta k e s n o o th e r m e d ic a ti o n s . H e s m o k e s h a lf a p a c k a d a y o f c i g a r e tt e s a n d d ri n k s a l c o h o l s o c i a l ly a b o u t o n c e p e r w e e k . P h y s i c a l e xa m i n a ti o n is u n re m a rk a b le e x c e p t fo r m i l d e p ig a s tri c te n d e rn e s s . W h a t is t h e a p p ro p r ia t e n e x t s te p in m a n a g i n g th i s p a ti e n t ? 8 3 . A n 8 1 - y e a r -o ld fe m a le w a s in a m o t o r v e h ic l e a c c i d e n t 3 d a y s a g o a n d s u ff e re d a l e f t fe m u r f ra c tu re , fo r w h ic h s h e h a d s u r g e r y o n t h e s a m e d a y . S h e h a s b e e n h o s p it a l i z ed s i n c e t h e d a y o f s u r g e r y a n d h a s b e e n t a k i n g p a rt in d a il y p h y s ic a l th e ra p y w i th o u t d iff ic u l ty . H e r f a m il y (h u s b a n d a n d d a u g h t e r) re p o rt t h a t s he h a s n o t b e e n " a c t in g l ik e h e rs e l f " a t ti m e s wh e n t h e y c o m e to v is i t h e r. S h e b e c o m e s a g i ta te d a n d is b e ll ig e re n t t o w a r d th e m , a n d s h e s om e ti m e s w o n d e rs w h y s h e is i n t h e h o s p i t a l. At o th e r t im e s , th e p a ti e n t is d o in g v ery w e l l , a n d th e y d o n o t n o ti c e t h e s e i n c o n s i s te n c i e s . T h e p a ti e n t h a s a h is to ry o f b o rd e r li n e HT N . C u r re n t m e d i c a t io n s in c l u d e a s to o l s o ft e n e r a n d m o r p h i n e f o r p a in c o n t ro l . O n e x a m in a ti o n , th e p a ti e n t i s a l e rt a n d o r ie n te d to tim e /p l a c e / p e rs on a n d is a p p ro p r ia te l y re s p o n d in g t o q u e s t io n s . Sh e d e n i e s a n y h a l lu c in a ti o n s . N e u r o lo g i c e xa m i n a tio n is n o rm a l. W h a t i s th e a p p ro p ria t e n e x t s te p i n m a n a g in g th i s p a ti e n t? 8 4 . A 4 9 - y e a r- o l d f e m a le p r e s e n t s t o th e E D w i th c o m p l a i n t o f s e v e re e p i g a s t ri c a n d R U Q a b d o m in a l p a in . H e r s y m p to m s s ta r t e d 3 d a y s a g o b u t h a v e p ro g r e s s i v e ly wo rs e n e d o v er t h e p a s t 1 2 h o u rs . H e r s y mp t o ms a re w o r s e w i th m e a ls . S h e h a s h a d t wo e p is od e s o f v o m i ti n g in t h e p a s t 1 2 h o u rs a n d is n a u s e o u s c u rr e n t l y . P M H i s s i g n i f ic an t fo r d i a b e t e s , o s t e o a rt h r iti s , a n d H T N . T e m p e ra t u r e = 1 0 2 . 3 , B P = 1 4 6 /8 0 , p u ls e = 1 1 0 , R R = 1 6 . O n p h y s ic a l e x a m i n a t io n , t h e re is te n d e rn e s s i n th e R U Q a n d re b o u n d t e n d e rn e s s . B o we l s ou n d s a re d im in is he d . T h e p a t ie n t is l y in g o n h e r s id e h o ld i n g a n e m e s is b a s i n . W h a t i s t h e m o s t a p p r o p ria te n e xt s t e p i n t h e m a n a g e m e n t o f th is p a ti e n t? 8 5 . A 3 1 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e wi t h m u l ti p l e mu s c u lo s k e le ta l a c h e s a n d p a i n s i n c l u d in g , b u t n o t l im i te d to , h e r s h o u l d e rs , e lb o w s , k n e e s , n e c k , a n d b u t to c k s . S h e h a s h a d t h e s e s y m p to m s f o r a t l e a s t th e p a s t y ea r. S h e d o e s n o t s l e e p v e r y w e l l w h e n th e p a i n i s s e v e re a n d h a s n o re li e f wi t h N S A I D s . O n p a l p a tio n , s h e h a s m a rk e d te n d e rn e s s o v e r b o th l a t e ra l e p i c o n d y le s , t h e a n t e ri o r a s p e c t o f h e r le ft s h o u l d e r, t h e m e d ia l a s p e c t o f h e r r ig h t k n e e , h e r p o s t e ri o r n e c k , a n d h e r l e f t g r e a t e r tr o c h a n te r . T h e re a r e n o e f fu s io n s a t a n y o f th e a b o v e s it e s . R o u t in e l a b o r a t o ry t e s t r e s u lts a re n o rm a l . W h a t is th e a p p ro p ri a t e n e x t s t e p in m a n a g in g t h i s p a t ie n t?

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8 6 . A 5 2 - y e a r- o l d m a le w it h a l o n g -s ta n d in g h is to ry o f a lc o h o l a b u s e is b r o u g h t to th e E D b y h is w if e f o r v o mi t in g b lo o d . H e v o m it e d b rig h t re d b lo o d a t l e a s t t w ic e th i s m o r n in g . P M H is s ig n i fic a n t f o r c i rr h o s is , H T N , a n d a rt h ri t is . H e h a s n e v e r v om i te d b lo o d b e f o re . O n e xa m i n a ti o n , t h e p a ti e n t i s a wa k e b u t a p p e a rs n e r v o u s a n d i s in m o d e r a te d i s t re s s . Y o u a re a b le t o d e t e rm in e th a t h e h a s v o m i te d a p p ro x im a te l y 2 l it e rs o f b lo o d o v e r th e p a s t 6 h o u rs . V i t a l s i g n s a re : t e m p e ra tu r e = 9 9 . 2 , B P = 9 5 /6 0 , H R = 1 3 4 , R R = 2 0 . P u l s e o x i m e tr y s h o ws 9 8 % o x y g e n a ti o n o n r o o m a i r. De s c r ib e th e n e x t s te p s i n m a n a g i n g th is p a ti e n t. 8 7 . A 5 7 - y e a r- o l d f e m a le p r e s e n t s t o th e E D w i th a c o m p l a i n t o f a b d o m in a l p a i n . T h e p a i n is d if fu s e a n d p o o rl y l o c a l iz e d . S h e h a s h a d t h e s e s y m p t o m s fo r th e p a s t m o n t h a n d h a s b e e n c o n s ti p a t e d d u ri n g t h is t im e . S h e h a s n o s i g n i fi c a n t P M H . V i t a l s i g n s a re : te m p e ra t u r e = 9 9 .2 , B P = 1 2 8 /7 8 , H R = 7 8 , RR = 1 6 . O n p h y s i c a l e xa m i n a tio n , t h e r e i s m i ld a b d o m i n a l d is te n ti o n a n d n o g u a rd in g o r re b o u n d te n d e rn e s s . T h e re m a in d e r o f th e e xa m i n a t i o n is n o rm a l. W h a t is t h e n e xt a p p ro p ri a te s t e p in t h e m a n a g e m e n t o f th i s p a t i e n t ? 8 8 . A 5 3 - y e a r- o l d m a le p r e s e n ts to th e E D wi t h a 4 - h o u r h i s t o r y o f le f t fl a n k p a i n r a d i a t in g t o h is l e ft g ro in . T h e p a i n w a s s u d d e n in o n s e t b u t w a s m il d a t fi rs t . H o w e v e r, i t h a s b e e n i n c re a s in g i n s e v e ri ty o ve r t h e p a s t 2 t o 3 h o u rs . T h e p a in is n o w c o n s ta n t a n d e x c r u c ia ti n g . I t w a s a s s o c i a t e d wi t h n a u s e a a n d v o m i ti n g , b u t t h e p a t i e n t d e n i e s fe v e r s /c h i ll s . H e d e n i e s s e e i n g a n y g ro s s b lo o d in h is u r i n e . M e d ic a l h i s t o r y i s i n s ig n i fi c a n t. Vi t a l s i g n s a re a s f o l lo w s : t e m p e r a tu re = 9 8 . 1 , R R = 2 4 , P.500

B P = 1 4 8 /8 8 , p u ls e = 9 3 . O n p h y s i c a l e x a m in a t io n , th e p a ti e n t i s in o b v i o u s d i s t re s s , w r it h i n g i n p a i n . H e h a s m a rk e d te n d e rn e s s a l o n g t h e le f t fl a n k , b u t th e e x a m in a ti o n is o th e r wi s e u n r e m a rk a b l e . U r in a l y s is r e v e a l s 2 + h e m e . U ri n e s e d im e n t r e v e a ls n o c a s ts b u t m a n y R B Cs a n d fe w W B C s p e r H PF . L a b o r a to ry t e s ts r e v e a l t h e fo l lo w i n g : W B C 8 .2 , H g b 1 1 . 9 , H c t 3 6 .1 , B U N 1 4 , C r 0 .9 . W h a t is t h e a p p ro p ri a te n e x t s t e p in m a n a g i n g th is p a t ie n t ? 8 9 . A 3 9 - y e a r- o l d f e m a le i s b ro u g h t to th e E D b y h e r h u s b a n d w i th t h e c h i e f c o m p l a i n t o f a c u t e S O B a n d a n xi e ty t h a t s ta r te d s u d d e n ly 2 to 3 h o u rs a g o w h i le s h e wa s w o r k i n g a r o u n d t h e h o u s e . S h e d e n i e s c h e s t p a in . H e r P MH i s u n r e m a r k ab le . S h e ta k e s o ra l c o n t r a c e p ti v e s b u t n o o th e r m e d ic a ti o n s . V it a l s i g n s a re : te m p e r a tu re = 9 9 .1 , R R = 3 4 , B P = 1 4 8 / 9 0 , p u ls e = 1 0 0 . O x y g e n s a tu r a ti o n is 9 4 % o n ro o m a ir . O n e x a m in a t io n , th e p a t ie n t a p p e a r s h e a lt h y a l th o u g h i n m o d e r a t e re s p i ra t o r y d i s t re s s . H e r e xa m i n a tio n is o t h e r wi s e u n r e m a r k a b le . L a b o ra t o r y te s ts re v e a l : W B C = 7 .1 , H g b = 1 2 . 2 , H c t = 3 7 . 3 , N a
+ + -

= 138, K

= 4 .7 , C l = 1 0 9 , H C O 3 = 2 5 , B U N =
-

1 4 , C r = 0 . 9 , g l u c o s e = 1 0 6 . A B G s a re o b t a i n e d a n d r e v e a l: p H = 7 .5 2 , H C O 3 = 2 0 , P a C O 2 = 2 6 , P a O 2 = 7 0 . C X R a n d E C G a r e n o r m a l . W h a t i s t h e a c i d -b a s e d i s o rd e r? W h a t is th e a p p ro p ria te m a n a g e m e n t o f th is p a tie n t ? 9 0 . A 6 3 - y e a r- o l d m a le is b ro u g h t t o th e E D b y h is w i fe fo r a l te re d m e n t a l s t a tu s . T h e p a ti e n t re g u la rly d ri n k s a l c o h o l a n d h a s a l o n g -s ta n d in g h i s t o r y o f a lc o h o l u s e . O v e r th e p a s t 2 4 h o u rs , h e h a s b e c o m e m o r e c o n fu s e d a n d is n o t " a c ti n g li k e h im s e lf " a c c o rd i n g to h is w i fe . S h e s ta t e s t h a t h e h a s n e v e r a c te d l ik e th i s b e fo r e . O n fu rt h e r q u e s ti o n in g , th e p a t ie n t h a d a n e p i s od e o f m a s s i v e h e m a t e m e s is la s t y e a r t h a t r e q u ir e d a d m i s s i o n t o t h e h o s p i ta l, n e c i s s ita ti n g b l o o d t ra n s f u s i o n a n d o th e r tr e a t m e n t th a t th e w if e d o e s n o t re c a ll . O n p h y s i c a l e xa m i n a ti o n , t h e

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p a t ie n t is a ro u s a b l e a n d i s a le rt to p e r s o n b u t n o t t o p l a c e o r ti me . H e is c a c he c ti c , wi t h p ro mi n e n t v e in s o v e r h is a b d o m e n . H e h a s a s ig n if ic a n t a s c i t e s . T h e re a re s e v era l d i la te d s u p e rf ic ia l a rte ri o l e s s c a t t e r e d th r o u g h o u t h is b o d y . W h a t i s th e l ik e ly d ia g n o s is ? Ho w w o u ld y o u m a n a g e th is p r o b l e m ? 9 1 . A 6 5 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e wi t h a c h i e f c o m p l a i n t o f l o w b a c k p a i n . S h e h a s h a d t h is p a i n f o r 6 o r 7 m o n t h s . S h e d e n i e s a n y re c e n t tra u m a o r a n y e v en t th a t s h e re c a ll s p re c i p it a t in g t h e p a in . O n e y e a r a g o s h e s u ff e r e d a d is ta l ra d iu s fr a c tu re w h e n s h e t ri p p e d i n h e r b e d ro o m a n d la n d e d o n h e r o u t s tre t c h e d le f t a rm . Me d i c a l h is to ry is s ig n if ic a n t f o r H T N , fo r wh ic h s h e ta k e s h y d r o c h lo ro th ia z i d e . S h e s m o k e s a p p ro xi m a t e ly 1 2 c i g a re tte s p e r d a y a n d h a s a 2 5 p a c k - p e r-y e a r h i s t o r y o f s m o k i n g . S h e d e n i e s a n y a lc o h o l u s e . S h e d o e s n o t e xe rc i s e . O n p h y s i c a l e x a m in a ti o n , y o u n o te te n d e r n e s s o n p a l p a ti o n o f t h e lo w e r b a c k in t h e re g io n o f L 4 -L 5 . S h e h a s n o ra d ic u la r s y m p to m s , a n d t h e s t ra ig h t -l e g te s t i s n e g a ti v e . W h a t i s t h e a p p ro p ri a te n e x t s t e p in m a n a g i n g th is p a t ie n t ? 9 2 . A 7 6 - y e a r- o l d m a le p r e s e n ts to y o u r o f fi c e w it h t h e c o m p la i n t o f f a ti g u e f o r t h e p a s t 2 m o n t h s . H e d o e s n o t a b u s e a lc o h o l . H i s m e d ic a l h i s t o r y i s s ig n if ic a n t fo r H T N , f o r wh i c h h e t a k e s m e t o p ro lo l . H e d e n i e s m e l e n a , h e ma t o c h e z i a , o r a n y o th e r b l o o d l o s s . H i s fa m i l y h is t o ry i s n o n c o n tr ib u to ry . H e h a s n o s y m p t o m s o t h e r th a n fa t ig u e . H e a d m i ts h e d o e s n o t h a v e a g o o d d ie t. V i ta l s ig n s a r e : B P = 1 3 5 /8 5 , p u ls e = 7 0 . P h y s i c a l e x a m in a t io n i s u n re m a rk a b le e x c e p t f o r m i ld p a ll o r . S t o o l i s n e g a t i v e f o r o c c u l t b lo o d . L a b o ra to r y te s t re s ul ts a re : H b = 9 . 2 , H c t = 2 7 . 6 , MC V = 1 1 7 . E C G i s n o rm a l. W h a t is th e a p p ro p ri a t e n e x t s t e p in m a n a g in g t h is p a ti e n t? 9 3 . A 4 1 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e fo r a ro u t in e c h e c k u p . T h r e e m o n th s a g o s he h a d a n e l e v a te d B P o f 1 5 5 /9 4 . Y o u re c o m m e n d e d c o n s e r v a ti v e t h e r a p y in c lu d i n g w e i g h t lo s s , re g u la r e x e r c i s e , a n d a lo w - s o d iu m d i e t a n d h a d h e r fo l lo w -u p in 3 m o n th s . O n t o d a y 's v is it , h e r B P is 1 5 8 / 9 6 . Sh e is a s y m p t o m a ti c . Me d i c a l h is to ry is n e g a t i v e . Sh e s m o k e s o n e p a c k o f c ig a re tt e s p e r d a y a n d h a s a 2 0 -p a c k -p e r- y e a r h i s t o r y . H e r fa th e r d i e d o f a n M I a t a g e 5 4 , b u t s h e h a s n o o th e r f a m il y h is to ry o f c a rd i o v as c u l a r d i s e a s e . H e r to ta l s e ru m c h o l e s te ro l c o n c e n t ra t i o n is 1 7 5 m g /d L a n d H D L is 4 0 m g /d L . R o u ti n e l a b o ra to ry te s t re s u l ts a re w it h i n n o r ma l li m it s . W h a t is t h e a p p ro p ri a t e n e x t s te p in m a n a g i n g th is p a t ie n t? 9 4 . A 7 3 - y e a r- o l d m a le is b ro u g h t t o th e E D i n a c o m a . H e w a s d e li v e re d to t h e E D fr o m a n u r s in g h o m e a n d wa s re p o rte d b y th e n u rs in g h o m e s ta f f to h a v e h a d a P.501

s e i z u r e th a t la s te d l e s s th a n 1 m i n u t e . H e w a s s u b s e q u e n t ly c on fu s e d a n d s o o n th e re a fte r e n t e re d a c o m a t o s e s ta te . H is m e d ic a l h i s t o r y i s s ig n i fic a n t f o r t y p e I I D M r e q u ir in g i n s u li n , H T N , a n d m ild C H F . I n th e E D , t h e p a ti e n t i s v ery l e t h a r g i c a n d r e s p o n d s o n l y t o p a in s ti m u li . H i s v i ta l s ig n s a re s ta b l e , a n d C B C a n d e le c t ro l y te l e v e ls a re n o r m a l . S e ru m g l u c o s e is 1 6 m g /d L . W h a t a re th e fi rs t s te p s in t h e m a n a g e me n t o f th is p a ti e n t? W h a t i s th e l ik e l y c a u s e o f t h is p a t ie n t 's c o n d i tio n ? 9 5 . A 7 8 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e fo r a ro u t in e c h e c k u p . H e r o n l y c o m p la in t i s u ri n a r y i n c o n t in e n c e t h a t s h e h a s h a d f o r s e v e r a l y e a rs b u t th a t h a s b e c o m e w o r s e o v e r th e p a s t s e v e ra l we e k s . S h e h a s n e v e r s o u g h t tr e a t m e n t fo r th i s p ro b l e m . H e r m e d ic a l h is to r y i s s ig n i fic a n t f o r H T N a n d D M. S h e h a s f o u r c h il d re n , a l l d e liv e r e d v agi n a ll y . Me d i c a ti o n s i n c lu d e

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h y d r o c h lo ro th i a z id e f o r h e r H TN , i n s u li n , a n d a d a il y a s p ir in . S h e w e a rs a d u l t p a d s b e c a u s e s h e lo s e s l a r g e v o l u m e s o f u ri n e t h ro u g h o u t th e d a y a n d u s u a ll y c a n n o t r e a c h th e b a t h ro o m in t im e . S h e h a s th e s u d d e n u r g e t o u rin a t e e v er y h o u r o r s o a n d a ls o l o s e s u ri n e d u rin g th e n ig h t. Sh e a ls o re p o r ts lo s i n g u r in e wh e n s h e la u g h s o r c o u g h s . P h y s ic a l e x a m in a t io n i s u n r e m a rk a b le . V it a l s i g n s a re u n re m a rk a b l e . R o u t in e la b o ra to ry te s t r e s u l ts a r e w it h i n n o rm a l l im i ts e x c e p t f o r a ra n d o m b l o o d g lu c o s e l e v el o f 2 1 0 . U r in a l y s i s s h o ws p o s iti v e n i t ri te s a n d b a c t e r ia . W h a t is th e a p p ro p r ia te n e xt s t e p i n m a n a g i n g t h is p a ti e n t ? 9 6 . A 3 3 - y e a r- o l d f e m a le p r e s e n t s t o y o u r o ff ic e wi t h th e c o m p l a i n t o f i n s o m n i a a n d d i f fic u l ty c o n c e n t ra t i n g a t w o rk fo r s e v e ra l w e e k s . S h e re p o r ts a 2 0 - lb w e ig h t lo s s o v e r t h e p a s t 2 t o 3 m o n t h s , d e s p ite e a t in g m o re . W h e n q u e s t i o n e d , s h e r e p o rts t h a t s h e f re q u e n tl y f e e l s " h o t a n d s we a t y " a t w o rk a n d a t h o m e . S h e d e n ie s c h e s t p a i n o r p a lp ita t io n s b u t d o e s h a v e d i a r rh e a f re q u e n tl y . V it a l s i g n s a re : t e m p e ra t u r e = 9 8 . 9 , R R = 1 5 , B P = 1 3 0 /8 0 , p u l s e = 9 8 . S h e a p p e a rs w o r ri e d . O n p h y s i c a l e xa m i n a tio n , s h e h a s w a r m a n d m o is t s k i n . S h e h a s a s l ig h t h a n d tre m o r . O n p a lp a t io n o f h e r t h y ro id , y o u n o te a d i f fu s e l y e n l a rg e d t h y r o id g la n d th a t is n o n t e n d e r . A b ru it is a u s c u lt a t e d o v e r th e th y ro id e n la r g e m e n t . W h a t i s th e a p p ro p ri a te n e x t s t e p i n m a n a g in g t h i s p a t ie n t? 9 7 . A 7 2 - y e a r- o l d f e m a le i s b ro u g h t to th e E D b y E MS a f t e r s u f fe rin g s m o k e i n h a la ti o n f ro m a h o u s e f i re . S h e l i v e s a lo n e , a n d h e r s o n s ta te s th a t s h e h a s b e e n l e a v in g t h e s t o v e o n a ft e r s h e c o o k s . H e r s o n r e p o r t s th a t o v e r t h e p a s t 5 y e a rs , s he h a s h a d a s i g n i fi c a n t d e c li n e in h e r m e m o r y . S h e i s s c a re d b u t is v e r y p le a s a n t a n d i s a w a k e, a l e rt, a n d fu ll y o ri e n t e d . Me d i c a l h is t o r y is s i g n ifi c a n t f o r s t ro k e 5 y e a r s a g o , a n d a t le a s t th re e e p is o d e s o f T IA t h a t th e s o n c a n re c a ll o v e r t h e p a s t 8 y e a r s . V ita l s i g n s a re : te m p e r a tu re = 9 7 . 8 , R R = 2 2 , B P = 1 6 4 / 8 5 , p u ls e = 8 8 . P u l s e o xi m e tr y i s in i t ia ll y 8 9 % b u t in c r e a s e s t o 9 5 % o n 2 L n a s a l c a n n u l a O 2 . B re a t h s o u n d s a re c o a rs e , b u t p h y s ic a l e x a m i n a t io n i s o th e r wi s e n e g a ti v e . A f te r th e p a tie n t is s ta b il iz e d , y o u p e rfo rm a m in i -m e n t a l s t a tu s e x a m in a ti o n . Y o u d i s c o v e r th a t h e r re c en t m e m o r y i s i m p a ir e d a n d s h e c a n n o t c a r ry o u t s im p l e c al c u la ti o n s . H e r s on a s k s yo u if y o u th in k s h e is " g o i n g s en il e . " W h a t is y o u r re s p o n s e ? W h a t is th e a p p ro p ri a t e n e x t s te p i n m a n a g i n g t h is p a t ie n t? 9 8 . A 7 1 - y e a r- o l d f e m a le i s b ro u g h t to th e E D a fte r a fa ll . I m m e d i a te ly a f te r th e fa l l s h e w a s a s y m p t o m a tic b u t o v e r th e e n s u in g h o u rs b e c o m e l e th a rg ic a n d m o re c o n f u s e d . P MH i s s ig n i fic a n t f o r H T N . S h e u n d e r w e n t a ri g h t to t a l h i p re p la c em e n t 5 w e e k s a g o a n d w a s d ia g n o s e d w it h a D V T 2 w e e k s a ft e r t h e o p e r a ti o n . Me d i c at io n s in c l u d e h y d r o c h lo ro t h i a z i d e , w a rf a r in , a n d a to r v a s ta tin . T w o we e k s a g o , h e r IN R wa s 2 .7 . O n e x a m in a t i o n , p a t ie n t h a s s lu rre d s p e e c h a n d a p p e a r s c o n f u s e d . S h e is o r ie n te d t o p e rs o n b u t n o t t o p l a c e o r t im e . N e u r o lo g i c e x a m i n a ti o n is n o rm a l. T h e re m a in d e r o f p h y s ic a l e xa m i n a tio n i s n o r m a l. W h a t i s t h e m o s t a p p ro p ri a te in i ti a l s te p t h a t wo u l d h e l p g u i d e th e m a n a g e me n t o f t h i s p a tie n t ? 9 9 . A 6 6 - y e a r- o l d m a le is b ro u g h t t o y o u r o f fic e b y h i s w if e w it h c om p la in t o f p r o d u c ti v e c o u g h , f e v e r, a n d c h i ll s fo r t h e p a s t 2 d a y s . T h e p a t ie n t li v e s w i t h h i s w if e a n d i s r e t i re d . P MH i s s ig n i fic a n t f o r D M , f o r w h i c h h e ta k e s i n s u l i n ; C H F , w i th a n e je c t io n f ra c ti o n o f 4 0 % ; a n d a h is t o r y o f r e n a l i n s u ff ic ie n c y . H e i s a l e r t a n d o rie n te d . T h e r e i s n o h i s to ry o f s m o k i n g o r a lc o h o l u s e . O n p h y s ic a l e x a m i n a t io n , h e h a s c r a c k l e s o v e r t h e le f t l o w e r l u n g . C a rd io v as c u la r e xa m i n a ti o n is n o rm a l. V i ta l s i g n s a r e : t e m p e ra tu re

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P.502

= 1 0 3 . 3 , B P = 1 3 0 /6 4 , H R = 1 2 8 , R R = 2 4 . O x y g e n s a tu ra ti o n o n ro o m a ir i s 9 7 % . C X R s ho ws i n f il tra t e s a n d c o n s o li d a ti o n in t h e l e ft l o w e r l o b e o f t h e l u n g . L a b o r a to ry te s t r e s u lt s s h o w W B C 1 5 , h e m a to c r it 3 6 , N a 1 4 2 , g l u c o s e 1 6 7 , B U N 3 6 , c re a ti n in e 1 . 5 . W ha t is th e n e xt a p p ro p ria te s t e p i n m a n a g in g th i s p a t i e n t ? 1 0 0 . -Y o u a re c a ll e d to s e e a 6 9 -y e a r -o l d m a le wi th a c u t e S O B . V i t a l s i g n s a r e : te m p e ra t u re = 1 0 0 .1 , B P = 1 6 6 /8 8 , p u ls e = 1 3 0 , R R = 3 3 . Yo u ru s h to s e e th e p a ti e n t a n d o n y o u r a r ri v al , o xy g e n s a tu r a ti o n is 7 9 % o n a 1 0 0 % o xy g e n n o n r e b re a th e r fa c e m a s k . T h e n u rs e i n f o r ms y ou t h a t h is o x y g e n s a t u r a ti o n w a s 6 8 % o n ro o m a ir . H e c u r re n t ly h a s h e a v i l y l a b o re d b re a th i n g a n d a p p e a rs c y a n o t ic . T h e n u r s e in fo r m s y o u t h a t t h e p a ti e n t w a s a d m itt e d 2 d a y s a g o f o r c e ll u l i tis i n v o l v i n g h is le ft l e g , wh i c h w a s t re a te d w i th a n t ib io tic s . T h e c e l lu li ti s h a s n o t i m p ro v e d , a n d th e p l a n w a s t o o b ta i n a n M R I t o m o rro w t o ru le o u t a n a b s c e s s . W h a t is t h e a p p ro p ria te f irs t s t e p in th e m a n a g e m e n t o f th i s p a t i e n t ?

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Answers
1 . An s w e r: I n d e v e l o p e d c o u n t rie s , b r o n c h o g e n i c c a rc in o m a a n d b r o n c h it is a re th e m o s t c o m m o n c a u s e s o f h e m o p t y s is , re p l a c in g T B a n d b ro n c h i e c ta s is . B ro n c h o s c o p y s h o u ld b e p e r fo r m e d in m o s t p a ti e n t s w it h h e m o p t y s i s , a lth o u g h n o s tu d y h a s c le a rl y s h o w n wh e t h e r C T s c a n o r b ro n c h o s c o p y s h o u l d b e th e in i ti a l t e s t, e s p e c ia l ly i f th e C X R d o e s n o t re v ea l a n y l o c a li z e d l e s i o n s . G i v e n t h is p a tie n t 's s m o k i n g h is t o r y , lu n g c a n c e r m u s t b e r u le d o u t w i th b ro n c h o s c o p y ; h o w e v e r , g i v e n th e a c u te n e s s o f h is i ll n e s s (la s t m o n th ), b ro n c h i ti s i s a l s o a p o s s ib ili t y . 2 . An s w e r: T h i s p a t ie n t l ik e l y h a s d i v e rti c u li ti s (L L Q p a i n , f e v e r, a n d le u k o c y to s is a re k e y s t o d ia g n o s is ). O b ta i n a C T s c a n o f th e a b d o m e n a n d p e l v i s t o c on fi rm th e d ia g n o s i s . F o r t h e f ir st e p is o d e o f d i v e r ti c u l i tis , s u r g e r y is n o t i n d ic a t e d u n l e s s s y m p to m s p e rs is t a ft e r 3 to 4 d a y s . B r o a d -s p e c t ru m I V a n t ib i o t ic t h e r a p y , b o we l re s t (N P O ), a n d I V flu i d s a re a p p ro p r ia t e n e xt s te p s . 3 . An s w e r: T h e in c re a s e d s e v e ri t y a n d d u ra t io n o f c h e s t p a in s u g g e s t e i th e r u n s ta b le a n g i n a o r a c u te MI . T h e o n l y o b j e c ti v e m e a n s o f ru li n g o u t a n MI is v ia c a rd i a c e n z y m e s . T h is p a ti e n t s h o u ld b e a d m it t e d a n d c l o s e l y m o n i to re d . In it ia l t re a tm e n t i n c l u d e s a -b lo c k er , A C E i n h i b i to r ,

a s p i ri n , n i t ro g ly c e r in , o x y g e n , a n d c o n s i d e r m o rp h i n e . P e rf o rm a 1 2 - l e a d E C G w h e n th e p a t ie n t i s h a v in g c h e s t p a i n , a n d a g a in w h e n s h e is p a i n - f re e . C o m p a re wi t h a n o l d E C G i f o n e i s a v a i la b le . 4 . An s w e r: T h i s i s a c la s s i c d e s c ri p ti o n o f a ma u ro s i s fu g a x , w h ic h is a h a ll m a r k s y m p t o m o f a T I A . B y d e f in i ti o n , s y m p to ms d u r in g a T I A la s t le s s th a n 2 4 h o u rs . A m a u ro s i s fu g a x i s th o u g h t t o b e c a u s e d b y e m b o l i to t h e o p h th a l m ic a r t e r y . T h e f irs t te s t y o u s h o u ld o b t a in i s a n u lt ra s o u n d o f t h e c a ro t i d a rt e ri e s t o d e t e rm in e t h e d e g re e o f s t e n o s is . C a ro t id e n d a rt e re c to m y m a y b e in d ic a t e d d e p e n d i n g o n d e g r e e o f s te n o s is . 5 . An s w e r: T h i s p a t ie n t l ik e l y h a s v i ta m in B 1 2 d e fi c i e n c y . A f te r g a s tr e c t o m y , l a c k o f in tri n s ic f a c to r l e a d s t o v i ta m in B 1 2 d e fic ie n c y . T h e p a ti e n t 's n e u r o lo g ic d e f ic i ts a re c ons is te n t w i th v i ta m i n B 1 2 d e fic ie n c y . Ch e c k ro u ti n e l a b o ra t o r y va lu e s to d o c u me n t a n e m ia a n d th e p a t ie n t' s MC V ( s h o u l d b e h ig h ) . Ch e c k th e s e ru m v i t a m in B 1 2 le v e l . S e ru m h o m o c y s t e in e a n d m e th y lm a l o n ic a c id m a y a l s o b e h e l p fu l . 6 . An s w e r: B a s e d o n h e r h is to ry , a n d p a r ti c u l a rly o n t h e e x a m in a ti o n f in d in g s , t h i s p a t ie n t l ik e l y h a s C u s h in g ' s s y n d ro m e , w h ic h c a n b e c o n fi rm e d b y a n o v e r n ig h t d e xa m e th a s o n e s u p p re s s i o n te s t . O n c e th e s y n d r o m e is d i a g n o s e d , y o u r n e x t s te p i s t o d e t e r m in e w h e t h e r t h e c o r tis o l e x c e s s is A C T H -d e p e n d e n t o r A C T H -i n d e p e n d e n t, w h i c h c a n b e d o n e v ia t h e h i g h - d o se d e x a m e t h a s o n e s u p p re s s i o n te s t. 7 . An s w e r: T h i s p a t ie n t i s s u ffe ri n g f ro m a n a c u te a n te ri o r -w a l l M I. C u r re n t e v i d e n c e in d i c a t e s t h a t re v a s c u l a riz a t io n re d u c e s m o r t a li t y a n d re in fa rc ti o n m o r e th a n th r o m b o l y ti c th e ra p y in a n a c u t e S T s e g m e n t e l e v a ti o n MI if i t c a n b e p e rf o r m e d w it h in 2 h o u rs o f p re s e n t a t io n . T h r o m b o l y t ic th e r a p y is th e t re a tm e n t o f c h o i c e i n a n o n -S T s egm e n t e le v at io n M I i f t h e r e a re n o c o n t ra in d ic a t io n s . 8 . An s w e r: T h i s p a t ie n t h a s a m e ta b o l ic a lk a lo s i s (h i g h b ic a rb o n a te , h ig h p H ) wi t h re s p i ra t o r y c o m p e n s a ti o n ( wh ic h e x p l a i n s t h e h i g h P a C O 2 ). V o m it in g i s th e l ik e l y c a u s e o f h e r m e ta b o l ic

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a lk a lo s is

a s H C l is l o s t d u ri n g v o m i ti n g , th e s to m a c h g e n e ra te s b ic a rb o n a te , wh i c h c aus e s

t h e a l k a lo s is . E x a m i n a ti o n (a n d o rt h o s ta ti c B P c h a n g e s ) r e v e a l s v o l u m e d e p le ti o n , w h ic h is a h a ll m a r k fin d in g i n s a l in e - s e n s i t iv e m e t a b o li c a l k a l o s is . T h is p a ti e n t li k e l y h a s a v i ra l g a s tro e n t e ri ti s . N o rm a l s a l in e p l u s p o t a s s i u m s u p p le m e n t a ti o n w il l re s t o re t h e E C F v o lu m e . I n t h i s p a t ie n t, a n a n t ie m e ti c a g e n t s h o u l d b e c o n s id e r e d . P.504

9 . An s w e r: A l t h o u g h th e p o s i ti v e p r e d ic t iv e v alu e o f th e H e m o c c ul t te s t i n d i a g n o s i n g c o lo n c a n c e r is l o w ( 2 0 % ) , a ll p a ti e n ts w it h a p o s i t iv e te s t r e s u lt s h o u l d u n d e r g o a c o l o n o s c o p y t o ru l e o u t c o lo r e c ta l c a n c e r. 1 0 . A n s w e r : B a s e d o n th e h i s t o r y , th is p a t ie n t's u p p e r G I b l e e d in g i s mo s t l ik e l y d u e to a b le e d i n g p e p ti c u l c e r ( NS A I D s ) o r e ro s iv e e s o p h a g i tis ( p o s s i b le G E R D ). B a s e d o n h i s v it a l s ig n s , t h i s p a ti e n t i s i n th e e a rl y s ta g e s o f h y p o v ol e m i c s h o c k . In i ti a l m a n a g e m e n t in v o l v e s h e m o d y n a m ic s ta b il iz a tio n (i n c l u d in g tra n s f u s io n i f n e c e s s a r y ). A n u p p e r e n d o s c o p y s h o u l d f o l lo w t o id e n t if y th e c a u s e o f th e b l e e d in g . C o n s id e r s ta r ti n g a c i d s u p p re s s i o n b e fo re endoscopy. 1 1 . A n s w e r : T h i s p re s e n t a t io n s u g g e s t s a n a c u te C V A . T h e s y m p t o m s a r e c o n s is te n t wi t h a l e s i o n in v o lv i n g th e le ft c e re b ra l h e m i s p h e r e i n th e MC A d is tr ib u t io n . Th e a b ru p t o n s e t s u g g e s t s a n e m b o li c s o u rc e . T h e fir s t t e s t t o o b ta in is a n o n c o n t ra s t C T o f t h e h e a d to ru l e o u t h e m o r rh a g e o r a n y m a s s l e s io n . T h e t im e wi n d o w ( 3 h o u rs ) fo r t h r o m b o l y t ic t h e ra p y h a s p a s s e d , s o m a n a g e m e n t i n v o l v e s a s p i rin , p r e v e n ti o n o f a s p ir a t io n , a n d c au ti o u s c o n tro l o f B P. U l ti m a te ly , p h y s ic a l th e ra p y a n d re h a b i li t a ti o n a re th e m o s t i m p o r t a n t th e ra p e u t ic m e a s u re s . 1 2 . A n s w e r : T h e m o s t l ik e l y d i a g n o s is i s d i v e rtic u l o s i s , wh ic h i s u s u a l ly a s y m p to m a ti c . B a ri u m e n e m a i s th e t e s t o f c h o ic e fo r d i a g n o s is . T h e p a t ie n t s h o u l d b e tr e a t e d c o n s e rv at i v e l y wi t h h ig h - f ib e r fo o d s . 1 3 . A n s w e r : H e m o p h il ia i s u n l ik e l y g i v e n t h a t h e r b le e d i n g is s o s u p e rf ic ia l . G i v en th a t s h e h a s n o rm a l p la te l e t c o u n t s , t h is p a ti e n t m a y h a v e a d e f e c t i n p l a t e le t fu n c t io n . vW D is th e m o s t c o m m o n i n h e ri te d b le e d in g d i s o rd e r . T e s t s th a t m a y h e lp i n d ia g n o s i s i n c lu d e a b le e d i n g ti m e , m e a s u re me n t o f c o n c e n tra ti o n o f vW F a n t ig e n , o r p la t e le t a g g re g a ti o n te s t s wi t h ri s to c e tin . It i s i m p o r ta n t t h a t p a t ie n ts w i th vW D a v oi d u s e o f N S A I D s a n d o th e r a n t ip la te le t a g e n ts . D D A V P i s t h e t re a tm e n t o f c h o i c e . 1 4 . A n s w e r : T h i s p a t ie n t m a y h a v e m u l ti p l e s c l e ro s i s (M S ) . T ra n s i e n t s e n s o ry d e f ic it s a r e a c o m m o n p re s e n t i n g fe a tu r e o f M S , a s a re v is u a l d i s t u r b a n c e s ( d u e t o o p ti c n e u ri ti s ) . F irs t o b t a in a n MR I o f th e b ra in t o l o o k f o r a n y d e m y e l in a t in g l e s io n s in t h e C N S . 15. Answ er: This woman has COP D s p e c i f ic al l y , s he h a s c h ro n i c b r o n c h it i s , a fo rm o f C O P D

d e f in e d b y a c o u g h wi t h s p u t u m p ro d u c ti o n f o r a t l e a s t 3 m o n t h s o f th e y e a r f o r a t l e a s t 2 y e a r s . C i g a r e t te s m o k i n g is t h e m a i n ris k fa c t o r fo r c hr o n i c b ro n c h it is . T h e d e g r e e o f d y s p n e a i s re f le c t iv e o f th e s e v e rit y o f d i s e a s e . C O P D m a y a l s o c a u s e p u l m o n a r y H T N a n d c o r p u lm o n a le . C X R f i n d i n g s t h a t wo u l d sug g e s t le f t -s id e d h e a r t fa i lu r e a s th e m a i n c a u s e o f h e r d y s p n e a w o u ld b e c a r d io m e g a l y , p u lm o n a r y e d e m a , a n d p o s s i b l y p le u ra l e ff u s io n s .

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1 6 . A n s w e r : T h e re is m u c h c o n t ro v e rs y re g a r d i n g u s e o f P S A fo r d e t e c ti o n o f p r o s ta te c a n c e r, e s p e c ia ll y wi t h le v e l s b e tw e e n 4 .1 a n d 1 0 a n d a n o rm a l D R E . R e g a r d l e s s o f th e u l ti m a t e t re a tm e n t d e c i s i o n (o b s e rv a t i o n v s . T R U S w it h b io p s y ) , e d u c a t e t h i s p a t ie n t a b o u t t h e ro le o f P S A a n d i ts s h o rt c o m i n g s a s a s c re e n i n g to o l , g iv e n t h a t T R U S w i th b io p s y i s a n u n c o m fo rta b l e p ro c e d u re . 1 7 . A n s w e r : T h e k e y p i e c e o f in f o rm a t io n i n th is q u e s tio n is a h i p fr a c t u re w it h o u t a h i s to ry o f f a l l o r i n ju ry . A h ip f ra c tu r e i n th e a b s e n c e o f a fa ll o r s p e c if ic i n ju ry s h o u l d ra is e t h e s u s p ic i o n o f a p a t h o l o g i c fr a c t u r e , a n d in t h e e ld e rl y p a ti e n t, m e t a s t a t ic d i s ea s e m u s t b e ru le d o u t. A s e a rc h f o r a p ri m a r y n e o p la s m s h o u ld b e i n i ti a t e d , w i th a C T s c a n o f t h e c he s t , a b d o m e n , a n d p e l v is , a b o n e s c a n , a n d l a b o ra to r y s tu d i e s , i n c l u d i n g P S A l e v e ls . 1 8 . A n s w e r : F a t ig u e i s a c o m mo n c o m p la i n t a m o n g p a ti e n ts , a n d th e r e fo re th e p h y s ic ia n m u s t a s k m a n y q u e s ti o n s t o d e t e rm in e i f th e p ro b le m i s c h r o n ic o r a c u te , w h e th e r it is c li n ic a ll y s ig n i fic a n t, a n d wh e t h e r t h e re is a c l e a r u n d e rl y i n g li fe s t y le o r m e d ic a l c au s e . U n e x p l a i n e d , s ig n i fic a n t f a t ig u e s u c h a s th a t d e s c r ib e d in t h is q u e s ti o n th a t h a s b e e n p r e s e n t f o r 6 m o n th s o r m o r e i s c le a rly c h ro n ic a n d wa rr a n t s fu rth e r t e s t in g . L a b o ra t o r y s tu d ie s t o c o n s id e r i n t h e w o r k u p o f f a ti g u e i n c lu d e C B C (a n e m i a ), T S H (h y p o t h y r o i d i s m ) , fa s ti n g g l u c o s e ( d ia b e t e s ), b a s i c m e t a b o li c p a n e l (e l e c tro l y te a b n o rm a l it ie s ), E S R , u rin a l y s i s , a n d re n a l p a n e l a n d l iv e r f u n c t io n te s t s . O n e m u s t a ls o ru l e o u t p re g n a n c y a s a n u n d e r ly in g c a u s e , a l th o u g h o n e w o u l d e xp e c t i t to b e k n o w n to t h e p a ti e n t a t th i s p o i n t. C h r o n i c fa ti g u e s y n d r o m e is a d ia g n o s is o f e xc l u s io n a fte r m e d i c a l c o n d it io n s t h a t c o u l d c a u s e fa t ig u e h a v e b e e n r u l e d o u t . P.505

1 9 . A n s w e r : T h i s p a t ie n t h a s a ri g h t l o we r l o b e p n e u m o n ia , wh i c h s ho u l d b e t re a te d w i th a n t ib i o t ic s . H o we v e r, th e ro u n d o p a c i t y i n t h e l e ft l o w e r lo b e ra is es th e q u e s t io n o f p o s s i b le m a li g n a n c y a n d s h o u ld b e in v e s tig a t e d . T h e fi rs t s te p i n in v e s ti g a t io n o f a s ol i ta r y p u l m o n a ry n o d u le is t o o b t a i n a p re v i o u s C X R fo r c o mp a r is o n . Ma li g n a n t n o d u l e s t e n d t o g ro w q u ic k l y , a n d th e g ro w th i s t y p ic a ll y e v i d e n t w i th i n m o n th s . Th e o n ly r a d i o g r a p h ic fi n d in g s th a t a r e re l ia b le f o r a b e n ig n l e s io n a re la c k o f g r o w t h f o r a t l e a s t 2 y ea rs a n d a d i s t in c ti v e c e n t ra l l a m i n a t e d c a lc ifi c a ti o n p a t t e rn . A C T s c an m a y a ls o b e o b ta i n e d fo r fu rth e r e v a l u a t io n b e c a u s e i t is m o re s e n s i ti v e in d e fi n i n g th e n o d u le . 2 0 . A n s w e r : T h i s p a t ie n t h a s t h i rd -d e g r e e (c o m p le t e ) A V n o d a l b l o c k . In th i s rh y t h m , th e a t ri a a n d v e n tr ic le s c o n t ra c t in d e p e n d e n t l y o f e a c h o th e r . T h is p a ti e n t' s h e a rt b l o c k m a y h a v e b e e n c a u s e d b y h e r m u lt ip le MI s , wh ic h o fte n a ff e c t th e c o n d u c t io n s y s te m . O t h e r c a u s es i n c l u d e d ig o xi n t o x i c i t y a n d a d e g e n e r a ti v e A V n o d a l c o n d u c t io n . T h ird -d e g r e e h e a r t b l o c k is a lw a y s a n i n d i c a tio n fo r p e rm a n e n t p a c e m a k e r p l a c e m e n t. If t h e p a ti e n t i s u n s t a b l e , th e n te m p o r a r y p a c i n g ( tra n s v e n o u s o r tr a n s c u ta n e o u s ) s h o u ld b e p e rf o rm e d u n t il a p e rm a n e n t p a c e m a k e r c a n b e p la c e d . T h i s p a ti e n t i s c l e a r ly s y m p t o m a t ic , a n d th e r e f o re i f o n l y s e c o n d - d e g r e e A V b lo c k w e r e p r e s e n t , a p a c e m a k e r w o u ld s t il l b e i n d i c a te d . 2 1 . A n s w e r : T h i s p a t ie n t li k e ly h a s P U D . Y o u c a n i n iti a t e e m p i ri c th e ra p y w i th o u t e n d o s c o p y o r b a r iu m s t u d y i f th e re a re n o s ig n s o f c o m p l ic a t io n s o f th e d is e a s e , b u t th i s is s o m e wh a t c o n t ro v e rs i a l. A lt h o u g h e n d o s c o p y is in i ti a l ly m o re e x p e n s iv e , it s u s e re d u c e s t h e n u m b e r o f

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p a t ie n ts tr e a t e d i n a p p ro p ri a t e l y . A c id s u p p r e s s io n w i th a n H 2 b lo c k e r o r P P I is a p p ro p ria te i n t h is p a t i e n t . I t is a c c e p ta b le t o t e s t o r t re a t e m p i ric a l ly f o r H e li c o b a c t e r p y lo ri b e c a u s e h e d o e s n o t h a v e a n y o th e r o b v io u s c a u s e s o f P U D , a l th o u g h t h i s , t o o , i s d e b a t a b le . 2 2 . A n s w e r : T h i s p a t ie n t li k e ly h a s I B S . T h is is a c li n i c a l d ia g n o s is , a n d e x te n s i v e t e s t i n g is unnecessary. 2 3 . A n s w e r : T h i s p a t ie n t m o s t l ik e l y h a s C H F g i v en t h e in fo rm a t io n p ro v id e d . Ho we v e r, t h e re a re m u lti p l e o th e r c a u s e s o f S O B wi t h h y p o x ia th a t m u s t b e c ons id e r e d . A p re v io u s MI a n d l o n g - s ta n d in g H T N a re b o th c a u s e s o f C H F . If a p a tie n t h a s a k n o wn h is to r y o f C H F , it is i m p o rt a n t t o a s k h i m o r h e r a b o u t m e d i c at i o n c o m p l ia n c e (e s p e c i a l ly d i u re t i c s ). O th e r p re c ip i t a n t s o f C H F e xa c e rb a ti o n s i n c l u d e h ig h s o d i u m in ta k e, i ll n e s s o r in f e c ti o n , a n d m y o c a rd ia l i s c h e m i a /i n fa rc t io n . S e ri a l c a r d ia c e n z y m e te s t s a n d E C G s s h o u ld b e p e rf o rm e d to ru l e o u t a n M I. S h e s h o u l d b e g i v e n o xy g e n a n d d i u re t ic s , a n d u rin e o u t p u t s h o u l d b e n o t e d . A t ra n s t h o r a c i c e c h o c a rd io g ra m s h o u l d b e p e rfo rm e d t o e v a lu a te h e r c h a m b e rs , v a l v e s , a n d s y s t o l ic fu n c t io n . 2 4 . A n s w e r : T h i s p a t ie n t h a s p a i n s u g g e s t iv e o f a n g i n a . B e c a u s e h is s y m p t o m s o c c u rre d a t re s t, t h is is a n e x a m p l e o f u n s ta b le a n g i n a . Th e p a tie n t s h o u l d b e a d m i tte d t o a f l o o r w i th c o n t in u o u s c a rd i a c m o n i to ri n g . Th e fo ll o w i n g in t e rv e n ti o n s a re i n d i c a te d : h e p a ri n , a s pi ri n , b lo c k e r , n i t ra t e s , a n d o x y g e n . 2 5 . A n s w e r : T h i s p a t ie n t li k e ly h a s p y e l o n e p h r it is . If s h e is n o t p r o p e rl y tre a te d , s ep s i s a n d e v e n s e p t ic s h o c k c a n e n s u e . Se p s is o c c u r s in 1 0 % to 2 5 % o f p a ti e n ts w it h p y e l o n e p h ri ti s . O r d e r th e f o ll o wi n g : C B C , r e n a l p a n e l , u ri n a l y s is , a n d u r in e a n d b lo o d c u l tu r e s . T h i s p a t ie n t w il l p ro b a b l y n o t b e a b l e to t o le ra te o ra l a n ti b i o ti c s a n d s h o u ld b e a d m i tte d to t h e h o s p i ta l , w h e re I V fl u id s a n d b ro a d - s p e c t ru m I V a n t ib i o t ic s ( c i p r o fl o x a c i n , o r a m p i c il li n p lu s g e n ta m i c i n ) s h o u ld b e s t a r te d . 2 6 . A n s w e r : T h e p a tie n t 's p re s e n ta t io n s u g g e s ts a h e m o rr h a g ic s t ro k e . A n is c h e m ic s tr o k e i s l e s s l ik e l y g iv e n h e r l o s s o f c o n s c i o u s n e s s a n d v o m it i n g / h e a d a c h e . A t te n ti o n s h o u l d b e d ir e c t e d to th e m a n a g e me n t o f A B C s ( a i rw a y , b r e a t h i n g , a n d c i rc u la t io n ); th e p a ti e n t m a y n e e d t o b e in tu b a te d g i v e n h e r a l te re d m e n ta l s ta tu s . T h i s p a ti e n t l ik e l y n e e d s t o b e a d m it te d t o th e I C U fo r c lo s e m o n i t o ri n g , e s p e c i a ll y o f h e r in tr a c ra n i a l p r e s s ur e . I f s h e is s ta b l e , o b t a i n a C T s c a n o f h e r h e a d t o l o o k fo r h e mo rr h a g e . H e r B P i s h i g h ; l o w e r it c a u ti o u s ly b e c a u s e h y p o te n s i o n c a n l o w e r c e r e b ra l b lo o d flo w . 2 7 . A n s w e r : T h i s p a t ie n t li k e ly h a s a c u t e m e s e n te r i c i s c h e m i a (s u d d e n o n s e t o f s e v e r e a b d o m in a l p a in d i s p r o p o r ti o n a l t o p h y s ic a l fi n d in g s i s th e k e y to d ia g n o s is ). O b t a i n a m e s e n te ric a n g i o g r a m e m e rg e n tl y ; it is c ri ti c al f o r d e fi n i ti v e d ia g n o s i s a n d t h e r a p y . If u n d i a g n o s e d , t h e m o r ta l it y r a t e is v e ry h i g h d u e to i n te s ti n a l in f a rc t io n . P.506 -

2 8 . A n s w e r : T h i s p a t ie n t h a s a c u t e p e r ic a rd iti s . H e h a s a h is to ry o f re c en t u p p e r r e s p i ra to ry i n f e c t io n , a n d th e p e ri c a rd i tis i s li k e l y p o s tv ira l . In a c u te p e ric a r d i tis , th e c h e s t p a i n i s p o s i ti o n a l a n d p le u ri ti c . P e ri c a rd i a l f ri c ti o n r u b is a c l a s s ic f in d in g o n e x a m in a ti o n . T h e d ia g n o s is re s t s o n a c o m b in a t io n o f h is to ry , p e r ic a r d i a l f ric t io n ru b , a n d t yp ic a l E C G c h a n g e s

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(p a tie n t h a s d i ffu s e S T e l e v a ti o n ). A l th o u g h n o t p re s e n t i n t h i s p a ti e n t, P R d e p re s s io n i s a s p e c if ic f in d i n g i n a c u te p e ric a rd i ti s . Mo s t c as e s o f a c u te p e ri c a rd i ti s a r e s e lf - li m i te d . T re a t m e n t w i th a n N S A ID i s m a in s t a y o f th e r a p y . 2 9 . A n s w e r : T h e fi rs t s te p is to o b t a in a C X R a n d s ta rt 1 0 0 % o xy g e n v i a f a c e m a s k . T h e p a t ie n t 's h is t o ry a n d e xa m i n a t io n s u g g e s t s p o n ta n e o u s p n e u m o t h o r a x , w h ic h w o u l d b e c o n f irm e d o n C X R (v is c e r a l p l e u r a l li n e ). P ri m a ry s p o n t a n e o u s p n e u m o th o ra x i s m o r e c o m mo n i n ta l l, le a n y o u n g m a l e s wi t h o u t u n d e rl y in g l u n g d is e a s e . B e c a u s e h e is s y m p t o m a ti c , a c h e st t u b e i s n e e d e d t o re - e xp a n d t h e l u n g . 3 0 . A n s w e r : T h i s p a t ie n t h a s A Fi b . T h e f irs t s te p in a n y p a t i e n t w h o p re s e n t s w it h A F i b is to d e t e rm in e w h e th e r t h e p a t i e n t i s s ta b le a n d to d e t e r m i n e H R . If th e p a t ie n t is t a c h y c a rd i c , u s e a -b l o c k e r ( a te n o l o l ) t o lo w e r t h e ra te . O th e r o p tio n s a re c a l c i u m c ha n n e l b l o c k e rs a n d

d ig o xi n . T h e d u ra ti o n o f t h i s p a t ie n t 's A F i b i s n o t k n o wn , s o h e wo u l d re q u i re 3 w e e k s o f a n t ic o a g u la ti o n b e f o re u n d e rg o in g a n y c a rd i o v ers i o n . T r e a t m e n t o f p a ti e n t s w i th " l o n e A Fi b " w h o d o n o t h a v e o t h e r ri s k fa c t o rs f o r a s t ro k e a n d a re y oun g (< 6 5 y e a rs ) i s s om e wh a t c o n t ro v e rs i a l. 3 1 . A n s w e r : T h i s m a n h a s a o rti c s te n o s is (A S ) , m o s t li k el y c a u s e d b y l o n g - s t a n d in g H T N . A S c a n a l s o b e s e c o n d a r y t o rh e u m a tic h e a rt d i s e a s e , a c o n g e n it a l b ic u s p i d a o rti c v al v e , o r a c a lc if ic a o rt ic v a lv e . T h e t h r e e c l a s s ic s y m p t o m s o f A S a r e a n g in a , s y n c o p e , a n d h e a r t fa il u re (i n o r d e r o f p r o g r e s s in g s e v e rit y ) . O n c e s y m p t o m s a re p re s e n t , A S i s a d v an c e d . C la s s i fi c at i o n o f s e v e r ity i n v o lv e s m e a s u r e m e n t o f t h e a o rti c v a l v e a r e a , a s w e ll a s th e p re s s u re g r a d i e n t a c r o s s t h e v a l v e . V a lv e re p la c e m e n t i s t h e o n ly d e fi n i ti v e tr e a t m e n t a n d s h o u l d b e p e rfo rm e d i f s y m p to m s a r e p r e s e n t b u t b e f o re o v e rt h e a rt f a i lu r e i s p r e s e n t . S tr e n u o u s a c t i v it y a n d n e g a t ive i n o tro p e s s h o u l d b e a v o id e d i f a o r ti c s te n o s i s is s e v e r e . V a s o d il a t o rs (s u c h a s n i tra te s ) s ho u l d a ls o b e a v o i d e d . 3 2 . A n s w e r : T h i s p a t ie n t h a s p a te l l o fe m o r a l p a in , w h i c h i s a n te r io r k n e e p a i n c a u s ed b y e it h e r c h o n d ro m a l a c i a o f t h e p a t e l la o r p a t e l lo f e m o ra l a r th ri ti s . T h is i s a v e r y c o mm o n c a u s e o f k n e e p a in . C la s s ic h i s t o r y i s a n t e ri o r k n e e p a in th a t i s w o r s e w i th c li m b i n g o r d e s c e n d i n g s t a i rs . P a ti e n ts m a y d e s c r i b e o c c a s i o n a l e f fu s io n s . P la in ra d io g ra p h s a re in d ic a te d to e v a lu a te th e k n e e fo r o s te o a rt h r it ic c h a n g e s , e s p e c i a ll y i n t h e p a t e l lo fe m o ra l c o m p a r tm e n t. P h y s i c a l th e ra p y i s i n d ic a t e d a n d i s v e r y e ff e c ti v e fo r p a t e l lo fe m o r a l p a in . A q u a d r ic ep s / h a m s tr in g re h a b i li ta ti o n p ro g ra m a im e d a t s tr e t c h i n g a n d s tr e n g th e n i n g th e s e m u s c l e s h e lp s u n lo a d th e p a te l l a a n d s h if t th e lo a d to th e th ig h m u s c le s . 3 3 . A n s w e r : G i v e n tw o b l o o d g l u c o s e m e a s u re m e n t s o f > 1 2 6 m g /d L , th is p a ti e n t h a s d i a b e te s . D i e t a n d e x e r c is e s h o u ld b e th e i n i t ia l m e a s u re s t a k e n . I f c ons e rv a ti v e th e r a p y fa i ls , a n o r a l h y p o g l y c e m ic a g e n t m a y b e i n iti a t e d (m e tf o r mi n o r g l i p i z id e ). O rd e r a n H b A 1 c t e s t to g e t a n i d e a o f h is a v e r a g e b l o o d g lu c o s e o v e r t h e p a s t fe w m o n t h s . P e rf o r m a th o ro u g h e xa m i n a t i o n (w i th a t te n ti o n t o t h e f e e t) . P r o v i d e te a c h i n g o n s e l f -m o n i to r in g o f g l u c o s e a s w e l l a s d i e t a r y a n d e xe rc i s e e d u c a t io n . S c r e e n fo r m ic r o a l b u m i n u r i a , a n d re f e r th e p a t ie n t to a n o p h th a l m o l o g is t . 3 4 . A n s w e r : T h i s c o n s te ll a ti o n o f f in d i n g s (y ou n g A f ri c a n -A m e ric a n f e m a le wi t h re s p i ra to r y c o m p la i n t s , b l u r re d v is i o n , e ry th e m a n o d o s u m , a n d b i la te ra l h il a r a d e n o p a t h y ) i s s u g g e s ti v e o f s a rc o i d o s is . O rd e r th e f o l lo wi n g t e s t s : A C E l e v e l, C B C , re n a l p a n e l, c a lc iu m , L F T s .

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H y p e r c a l c e m ia i s re la t i ve l y c o m m o n i n s a r c o id o s i s . F o r d e fi n i ti v e d ia g n o s i s , a b r o n c h o s c o p y w it h t ra n s b ro n c h ia l b io p s y i s re q u i r e d . T h e h a l lm a r k o f s a rc o id o s is is n o n c a s e a t in g g ra n u l o m a s . P u lm o n a ry fu n c t i o n te s ts s h o u l d a l s o b e o r d e re d , wh i c h s h o w r e d u c t io n i n v i ta l c a p a c i ty, t o t a l lu n g c a p a c it y , a n d d if fu s i o n c a p a c i ty o f c a rb o n m o n o xi d e , a s w e ll a s a d e c r e a s e d F E V 1 / F V C ra tio . 3 5 . A n s w e r : T h i s p a t ie n t h a s h y p o n a tr e m i a . Y o u n e e d t o in v es t ig a te fu r th e r t o d e te rm i n e th e c a u s e o f th e h y p o n a tre m ia . G i v e n th e h is to ry o f s m a ll c e ll c a rc in o m a , S IA D H i s a li k e l y c a u s e , b u t b e c a u s e S I A D H is a d i a g n o s is o f e x c lu s io n a ft e r o t h e r c aus e s o f h y p o n a tr e m ia h a v e b e e n ru l e d o u t , la b o r a t o r y i n v e s t ig a ti o n s h o u l d b e g in wi t h a p l a s m a a n d u ri n e P.507

o s m o la l it y , a s we ll a s a u ri n e c h e m is t ry (u r i n e s o d i u m , o s m o l a l it y ) . C o n s id e r p l a s m a t ri g l y c e ri d e s . N o t e t h a t in S I A D H th e r e i s n o e d e m a o r c l in ic a l e v id e n c e o f E C F wa t e r e xp a n s i o n o r d e p le t io n . A l s o , th e u ri n e is c o n c e n tr a t e d , wi t h a u ri n e o s mo l a li ty > 3 0 0 (n a tri u r e s i s ) , a n d B U N a n d C r l e v e ls a r e l o w (a s i n th is c a s e ) . N e u ro l o g ic s y m p to m s a re t yp i c a l l y n o t s e e n u n t il th e s o d iu m l e v e l d r o p s b e l o w 1 2 0 . In t h i s p a t ie n t , w a t e r re s t ri c ti o n m a y b e e n o u g h to re v e rs e th e h y p o n a t re m i a . C o n s i d e r a d d i n g a lo o p d i u re ti c a n d g iv i n g s a lt t a b le ts . D o n o t in c re a s e th e s e ru m s o d i u m ra p id l y b e c a u s e c en tra l p o n ti n e d e m y el in a t io n c a n o c c u r. 3 6 . A n s w e r : T h e m o s t l ik e l y s o u r c e o f th e h e m a tu ri a is t h e g l o m e ru l u s . I s o la te d h e m a t u r ia is c o m m o n l y s e e n in p a t ie n t s w i th n e p h r o l it h i a s i s , t ra u m a , o r n e o p l a s m . O t h e r c a u s e s o f h e m a t u ria i n c l u d e s i c k le c e ll a n e m i a , h e m o p h il ia , o r N S A I D a b u s e . T h e p re s e n c e o f R B C c as t s a n d d y s m o r p h i c R B C s s u g g e s ts g l o m e ru l a r i n v o l v e m e n t . T h is p a tie n t m o s t l ik e ly h a s I g A n e p h ro p a t h y , wh ic h i s th e m o s t c o m m o n g l o m e ru l a r c a u s e o f re c u r re n t h e m a tu r i a . I t i s m o s t c o m m o n l y d i a g n o s e d in y o u n g m e n , a n d t h e d is e a s e c o u rs e is v ari a b le . Ap p r o x i m a te l y h a l f o f p a t ie n ts w i th I g A n e p h ro p a t h y d e v e lo p C R F w i th in 2 0 t o 3 0 y ea rs . P a t ie n ts a re o ft e n a s y m p to m a ti c wh e n d ia g n o s e d o r m a y h a v e tr a n s i e n t f lu -li k e s y m p t o m s . P ro te i n u ri a m a y o r m a y n o t b e p re s e n t. 3 7 . A n s w e r : T h i s p a t ie n t h a s S L E . F o u r o f th e 1 1 c r it e r ia m u s t b e fu lfi ll e d ( s ee B o x 6 - 1 : Us e f u l C r it e r ia f o r D i a g n o s i n g S L E ). S h e h a s a r th ri ti s , ma l a r ra s h , o ra l u lc e rs , a n d h e m a t o lo g i c a b n o rm a l it i e s (l e u k o p e n ia , t h ro m b o c y to p e n i a ). O rd e r t h e a p p ro p ri a te s e r o lo g ic te s ts (e .g . , A N A , a n ti - d s D N A ), a s w e l l a s r o u t in e l a b o r a to ry t e s ts (C B C , B U N , c r e a t in i n e , u ri n a l y s i s , s e r u m e le c t ro l y t e s ) . R e fe r t h is p a ti e n t to a rh e u m a t o l o g i s t f o r tr e a t m e n t. 3 8 . A n s w e r : G i v e n th e h i s to r y o f re s t in g t u m o r , b ra d y k in e s i a , a n d e x pr e s s i o n l e s s f a c e , th is p a t ie n t li k e l y h a s t h e b e g in n i n g s o f P a r k in s o n 's d i s e a s e . C a rb i d o p a -l e v o d o p a ( S in e m e t) is t h e a g e n t o f c h o ic e , a l t h o u g h y o u m a y wi s h t o d e l a y th e u s e o f t h i s d r u g in fa v o r o f o n e o f t h e d o p a m in e r e c e p t o r a g o n is t s . R e fe r th is p a t ie n t to a n e u r o lo g i s t f o r p h a rm a c o l o g i c tr e a t m e n t. 3 9 . A n s w e r : T h i s p a t ie n t c o u ld h a v e IB D . A b s e n c e o f b lo o d i n h i s s to o l a n d R L Q te n d e r n e s s m a k e C ro h n 's d i s e a s e mo re l ik e l y th a n u lc e ra ti v e c o l it is , b u t a c o lo n o s c opy i s n e e d e d t o e s ta b l is h t h e d i a g n o s is . O th e r c o n d iti o n s i n th e d if f e re n ti a l i n c l u d e d iv e rt ic u l o s i s (u n l ik el y g iv e n h is a g e ), v i ra l i n f e c t io n ( d ia r rh e a o v e r th e p a s t 1 t o 2 y e a rs m a k e s t h is u n l ik e ly ), a n d IB S (a d ia g n o s is o f e x c lu s i o n ). O t h e r in i ti a l s tu d ie s in c l u d e s to o l c u ltu re s fo r C l o s tr id i u m d i ff ic i le

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a n d o v a a n d p a ra s it e s to ru le o u t th e s e d i a g n o s e s , a s we ll a s a s to o l c ul tu re t o d e t e rm in e W BC c o u n t. 4 0 . A n s w e r : H a n d n u m b n e s s a n d t in g li n g m a y b e c a u s ed b y c a rp a l t u n n e l s y n d ro m e , a v a ri e t y o f n e r v e e n tr a p m e n t s y n d r o m e s i n th e u p p e r e x tr e m it y , a n d b y c e rv ic a l r a d i c u lo p a t h y . A l wa y s p e r fo r m a c e rv ic a l s p i n e e x a m i n a tio n in a n y p a ti e n t p re s e n ti n g w it h n u m b n e s s a n d t in g li n g i n t h e u p p e r e x tr e m i ti e s . A lt h o u g h c a rp a l t u n n e l s y nd ro m e is th e m o s t c o m m o n c a u s e o f t h e s e s y m p to m s , n e rv e ro o t im p in g e m e n t in th e c e rv ic a l s p i n e c a n m i m i c t h e s e fi n d i n g s a n d th i s s h o u ld b e r u le d o u t . If a p a t ie n t h a s n o rm a l ra n g e o f m o ti o n o f th e n e c k w i th o u t p a i n , n o h is t o r y o f n e c k p a i n , a n d n o ra d ia ti n g p a i n d o w n th e a rm , o n e c an r e a s o n a b ly r u le o u t c e rv ic al d is e a s e . If a n y d o u b t e xi s ts , e le c t ro d ia g n o s ti c s tu d ie s (E M G a n d n e r v e c o n d u c ti o n s t u d i e s ) c a n c la ri fy th e s o u r c e o f n e rv e c o m p re s s i o n . Th e t re a tm e n t o f c a rp a l tu n n e l s y n d r o m e is i n i tia ll y c o n s e r v a ti v e w i th wr is t s p lin t s , N S A ID s . a n d p o s s i b l y c o rti c o s te ro i d in j e c ti o n s i f n e e d e d . 4 1 . A n s w e r : A s u d d e n i n c r e a s e in o xy g e n re q u i re m e n t s h o u l d r a i s e t h e s u s p ic io n o f a p u lm o n a ry e m b o l u s . A h i s t o r y o f re c e n t i m m o b i liz a t io n is a c l a s s i c ri s k f a c to r fo r a D V T w i th c o n v e rs io n t o P E . A [ V w i th d o t a b o v e] / [Q wi t h d o t a b o v e ] s c a n o r h e li c a l C T s c a n s h o u l d b e o b t a in e d . I o d i n a te d c o n t ra s t a g e n t s a re n e e d e d fo r h e l ic al C T s c a n s , a n d t h e re f o r e o n e s h o u ld i n q u ir e a b o u t a h is to ry o f a ll e rg y t o c o n tr a s t m a te r ia l a n d k n o w t h e p a t ie n t's re n a l fu n c t io n b e f o re o r d e ri n g th i s te s t , b e c a u s e i ts u s e m a y b e c o n t ra in d i c a te d in s u c h c a s e s . 4 2 . A n s w e r : S u s ta in e d V T i s t h e m o s t li k e l y c a u s e o f th e c a rd i a c a r r e s t. V T i s a t a c h y a r rh y t h m ia o f t e n c a u s e d b y C A D , M I, h y p o xi a , s e v er e e le c tr o l y te d is tu r b a n c e s , C H F , o r m e d i c a t io n t o x i c i t y . T h e Q R S c o m p l e x e s a re w id e (u s u a ll y > 0 . 1 4 s e c ), a n d t h e r h y t h m is c h a ra c t e ri s ti c a l ly u n re s p o n s i v e to v a g a l m a n e u v e r s . If th e p a ti e n t i s h e m o d y na m ic a l l y u n s t a b l e (e . g ., p u ls e l e s s o r h y p o te n s i v e ) , im m e d i a t e e le c tr ic a l s y n c h ro n iz e d c a rd i o v e r s i o n i s i n d i c a te d . I f th e p a t ie n t is s t a b le , th e n I V li d o c a i n e s h o u l d b e a d m i n is te re d . E v a lu a te a n d tr e a t a ll p o t e n t ia l c a u s e s . P.508

4 3 . A n s w e r : H e r m e d i c a l h is to ry s u g g e s ts p o s s i b l e rh e u m a to id a rt h rit is (R A ), wi t h th e c h a ra c t e ri s ti c m o rn in g s ti ff n e s s a n d s y m m e t ri c a l p o l y ar th r it is . O b t a in r o u t in e l a b o r a to ry te s ts (C B C , c h e m i s t ry p a n e l) a n d rh e u m a t o id fa c t o r . Pl a in r a d i o g r a p h s o f i n v o lv e d j o i n ts c a n a i d i n d ia g n o s is . A c ti v e l y s e a r c h fo r a n y e x t ra - a rt ic u la r m a n i f e s ta ti o n s o f R A . I f th e d ia g n o s is i s e s ta b l is h e d ( p a t ie n t h a s f o u r o f th e s e v e n c ri te ria i n B o x 6 -5 : D ia g n o s i s o f R h e u m a to i d A r th ri ti s ) , th e n re fe r t h e p a ti e n t t o a rh e u m a t o l o g i s t f o r i n it ia ti o n o f d i s e a s e -m o d i fy i n g th e ra p y . Me t h o tr e x a t e i s u s u a ll y th e fi rs t - li n e a g e n t. 4 4 . A n s w e r : T h i s w o m a n h a s c l a s s i c f in d i n g s o f c ho la n g i ti s (R U Q p a in , fe v e r, a n d ja u n d ic e a re t h e k e y s to d ia g n o s i s ). A d m in is t e r I V a n ti b io t ic s a n d I V f lu id s a n d m o n it o r h e m o d y na m i c s . E a rl y re l i e f o f b i l ia r y o b s t ru c t io n is im p o r ta n t o p ti o n s i n c l u d e E R C P , P T C , a n d s ur g e r y .

4 5 . A n s w e r : B r o n c h o d il a to r th e r a p y is th e fi r s t -li n e t re a tm e n t o f C O P D e x a c e rb a ti o n s . B e ta 2 a g o n is t s (e .g . , a l b u te r o l ) a n d a n ti c h o li n e rg i c s (e .g . , i p r a tr o p i u m b r o m i d e ) w o r k s y n e rg i s t ic a l ly i n c o m b in a ti o n . S y s te m i c s t e ro id s (e .g . , IV m e t h y lp r e d n is o l o n e ) a re t y pi c a lly g iv e n fo r a c u te

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e xa c e rb a ti o n s re q u i rin g h o s p i ta l a d m i s s i o n . S u p p le m e n t a l o xy g e n a n d a n t i b io t ic s a l s o p l a y a n i m p o rt a n t ro le . 4 6 . A n s w e r : T h i s p a t ie n t' s p re s e n t a t io n s u g g e s t s o s te o a rt h r it is . T h e t ra u m a s u s t a i n e d i n th e m o to r v e h i c l e a c c id e n t i s a r is k fa c to r fo r o s t e o a rth r it is (m a c ro t ra u m a ) . O b t a i n r a d i o g ra p h s f o r e v a l u a t io n (l o o k f o r jo in t s p a c e n a r ro wi n g a n d o s t e o p h y t e s ). I f o s t e o a r th r it is i s n o t e d o n ra d io g ra p h s , t re a tm e n t in c l u d e s a c e ta m in o p h e n o r N S A I D s , p h y s ic a l th e ra p y , a c t iv it y m o d i fi c a t io n , a n d p o s s ib l y u s e o f a c a n e i f n e e d e d . If t h e s e m o d a l it i e s fa i l, d e p e n d i n g o n s e v e ri ty o f d is e a s e , a c o r ti s o n e in j e c ti o n o r v is c o s u p p l e m e n ta t i o n m a y b e in d i c a t e d ( s ee C h a p te r 1 2 ) . 4 7 . A n s w e r : T h i s p a t ie n t h a s a m e t a b o li c a c i d o s is . T h e fi rs t s t e p in e v al u a t i o n o f a p a tie n t in m e ta b o l ic a c id o s is is c a l c u la t io n o f th e a n i o n g a p ( A G ). Th i s p a t ie n t h a s a n i n c re a s e d A G (2 7 ) m e ta b o l ic a c id o s is . T h e d i ffe re n t ia l d ia g n o s is i n c l u d e s D K A ; a l c o h o l ic k e to a c i d o s is ; la c ti c a c id o s i s ; s ta rv a t i o n ; re n a l fa il u r e ; a n d o v er d o s e o f s al ic y la te , m e t h a n o l, o r e th y l e n e g l y c o l . G i v e n th a t th is p a tie n t is n o t d i a b e ti c a n d h a s a g l u c os e le v e l o f 1 1 4 , D K A i s u n l ik e l y . A ls o , h is re n a l fu n c t io n is n o t im p a i re d . B e c a u s e it is u n c le a r wh a t t h e c au s e is i n t h is p a ti e n t, f u rt h e r t e s ti n g is n e e d e d . I n it ia l t e s ts s h o u l d in c lu d e s e ru m k et o n e l e v e l s , s er u m s a l ic y l a te a n d la c t a te l e v e ls , b l o o d a l c o h o l l e v e ls , a n d m e th a n o l a n d e th y le n e g l y c o l l e v e l s . T h e n e x t s te p i s to d e t e rm in e w h e th e r t h is is a p rim a r y a c id -b a s e d is o r d e r o r a m i x e d d i s o rd e r. U s i n g W in te r 's f o r m u l a [ 1 . 5 (m e a s u r e d H C O 3 - ) + 8 2 ] , t h e e xp e c te d Pa C O 2 le v el i n th is p a ti e n t i s i n t h e ra n g e o f 2 2 . 5 to 2 6 . 5 . W ith a P a C O 2 o f 2 3 , th is p a ti e n t h a s a n a p p r o p r ia te re s p ira to r y c o m p e n s a to ry re s p o n s e (R R o f 3 4 ). I n th e a b s e n c e o f h y per v en ti la tio n , P a C O 2 w o u ld b e h ig h e r , a n d t h e p H wo u l d b e e v e n lo w e r th a n i t i s . 4 8 . A n s w e r : T h e tw o m o s t li k e l y d i a g n o s e s a re PE a n d MI . T h e fi rs t s t e p is t o o b t a in a " s ta t " C X R a n d E C G . A [ V w i th d o t a b o v e ] /[ Q wi t h d o t a b o v e ] s c a n o r h e l ic a l C T s c a n i s i n d ic a t e d to ru l e o u t P E . I f th e s e tw o d i a g n o s e s a re ru l e d o u t , o n e m u s t a l s o c o n s i d e r t h y r o i d s to rm , wh i ch i s a li fe -t h r e a t e n i n g c o n d i ti o n w it h a m o r ta l it y ra te o f u p to 2 0 % . T h e re i s u s u a ll y a p re c ip i t a ti n g f a c t o r s u c h a s s u rg e ry , s e v e re t ra u m a , in f e c tio n , o r D K A . T h e o p e ra t io n m a y h a ve t ri g g e re d a t h y r o i d h o rm o n e i mb a l a n c e . T re a t m e n t in v o l v es , o x y g e n , I V f lu i d s , b e ta - b lo c k e rs t o c o n t ro l h e a rt ra t e , c o o l i n g b l a n k e ts , a n d a n a n ti th y r o i d a g e n t (s u c h a s p ro p y l th io u ra c i l) . 4 9 . A n s w e r : G r o s s p a i n le s s h e m a tu ri a i s a s i g n o f b l a d d e r o r k id n e y m a l ig n a n c y u n t il p ro v e n o th e r wi s e . T h e re f o re , a c y s to s c o p y is i n d i c a te d to e v a lu a te th e b l a d d e r. B l o o d te s ts , i n c lu d in g C B C , re n a l p a n e l, a n d c o a g u la t i o n s t u d i e s , s h o u l d a l s o b e o rd e re d . 5 0 . A n s w e r : T h i s p a t ie n t h a s s y m p t o m s a n d s ig n s o f a c u te b ro n c h it is . T h e m a i n d if f e re n ti a l h e r e i s p n e u m o n ia v e rs u s a c u te b ro n c h i t is . C X R is t h e b e s t wa y to d i f fe r e n t i a te t h e s e t w o e n t it ie s n o in fi lt ra te s a re s e e n wi t h a c u te b ro n c h i tis . A c u te b r o n c h i ti s m o s t c o m m o n ly h a s a

v i ra l e t io lo g y , a n d n o a n tib io ti c tre a t m e n t i s n e c e s s a r y . T h e p a t ie n t s h o u ld b e a d v i s e d t o q u i t s mo k i n g , b e c a u s e s m o k in g is a c o n tr i b u t in g f a c t o r t o d e v e lo p m e n t o f a c u t e b r o n c h i tis . 5 1 . A n s w e r : B e c a u s e th is i s th e f irs t ti m e y o u a re s e e i n g th is p a ti e n t , a b a s e li n e s e t o f l a b o ra to r y a n d d i a g n o s ti c s t u d i e s , i n c l u d in g C X R , E C G , C B C , b a s i c me t a b o li c p a n e l, u ri n a l y s is, f a s ti n g g lu c o s e a n d l ip i d p r o fi le , a n d h e m o g lo b i n A 1 C s h o u l d b e o b ta i n e d . T h e p a t i e n t i s a d ia b e ti c a n d y o u s h o u l d c h e c k fo r mi c ro a l b u m in u ri a . Hi s H T N n e e d s t o b e f o l lo w e d c l o s e ly , a n d

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t h e p a ti e n t s h o u ld b e s c h e d u l e d fo r f o l lo w - u p wi t h i n a p p ro xi m a te l y 4 w e e k s fo r a r e p e a t B P m e a s u re me n t . P.509

T h i s p a t ie n t d o e s n o t h a v e s e v e re H T N o r e v id e n c e o f e n d -o rg a n d a m a g e ( ta rg e t o r g a n s a re h e a rt, k i d n e y s , e y e s , a n d C N S t h e la b o ra t o ry s tu d ie s y o u o r d e re d w o u ld id e n tif y h e a rt a n d

k id n e y d a m a g e ), a n d t h e re fo re o n e s h o u ld n o t d ia g n o s e H T N b a s ed o n o n e B P re a d i n g a l o n e . I n th e m e a n t im e , th e p a ti e n t s h o u ld b e a d v i s ed o n l if e s t y l e c h a n g e s , s u c h a s r e g u l a r e x e r c is e , h e a l th y d ie t, a n d w e i g h t l o s s . If o n h is n e x t v i s i t h e i s h y pe rt e n s iv e , g o a l is to l o o k fo r a n y s e c o n d a ry c a u s e s o f H T N (o rd e r a ld o s te r o n e , re n i n , a n d th y ro i d f u n c ti o n s t u d i e s ). F u rt h e rm o r e , h i s o v e ra l l c a r d io v a s c u l a r r is k s h o u l d b e a s s e s s e d a n d tre a tm e n t b a s e d o n th e s e f a c to r s (s e e B o x 1 2 - 1 : Ri s k F a c t o rs f o r C o r o n a ry A rt e r y D is e a s e [ C A D ] i n E v a lu a t io n o f P a ti e n ts W it h H y p e rl ip id e m ia ). A l o w -s o d iu m d ie t a n d a n ti h y p e r te n s i v e m e d i c a tio n s h o u l d b e s ta rte d a t th a t ti m e . 5 2 . A n s w e r : T h i s p a t ie n t h a s s t a g e 1 H T N . H e h a s m u l ti p l e c a rd i o v a s c u l a r ri s k f a c t o rs , i n c l u d in g m a le g e n d e r, d i a b e te s , H T N , a n d f a m i ly h is t o r y o f p re m a t u re C AD ( fe m a le fir s t d e g re e re la t i v e d i e d w h e n y o u n g e r t h a n 6 5 y e a rs o f a g e ) , b u t h a s n o e v id e n c e o f ta r g e t o rg a n d a m a g e ; th is p u ts h im i n ri s k g r o u p B . L if e s ty l e m o d if ic a ti o n h a s n o t a c h ie v e d t h e g o a l o f 1 3 0 /8 0 m m H g f o r t h i s d ia b e tic p a ti e n t. T h i a z i d e d iu re t ic s s ho u l d b e i n i ti a te d a n d h a v e b e e n s h o wn t o re d u c e m o rta li ty . I n a d d i t io n , a n A C E i n h i b i to r s ho u ld b e s ta r t e d ; th e s e d ru g s h a v e b e e n s h o w n t o d e c r e a s e t h e ra t e o f p r o g r e s s i o n o f d ia b e t ic n e p h ro p a t h y a n d r e t in o p a t h y . A t t h is p o i n t, y o u s h o u l d a ls o lo o k fo r s e c o n d a ry c au s e s o f H T N (o rd e r a l d o s t e ro n e , re n in , a n d t h y r o i d fu n c t i o n s t u d i e s ). 5 3 . A n s w e r : T h i s p a t ie n t h a s a c u t e p y e l o n e p h ri tis , a n u p p e r U T I in v ol v i n g th e u re te r a n d k id n e y s . It i s m o s t c o m m o n l y s e e n in s e x u a l ly a c ti v e y o u n g fe m a l e s . Co m p l ic a t io n s m a y i n c l u d e s e p s is , re n a l i m p a i rm e n t, a n d re n a l a b s c e s s . P y e lo n e p h ri ti s in m a le s i s le s s c om m o n a n d u s u a l ly i n d i c a te s s tru c tu ra l a b n o rm a l i ti e s s u c h a s v es ic o u r e te ra l re f lu x o r g e n it o u r i n a r y o b s t ru c t io n . Th e p re s e n c e o f fe v e r, c h i ll s , a n d fl a n k p a i n d if fe re n ti a t e s p y e lo n e p h ri ti s c li n ic a l ly , a s d o e s th e p re s e n c e o f W B C c a s ts o n u rin a l y s i s . I f p a t i e n ts h a v e n o s ig n s o f s e p si s a n d a r e n o t v e ry i ll , t h e y m a y b e t re a te d wi t h 1 4 d a y s o f o ra l a n t ib i o tic s (u s u a l ly a f lu o ro q u i n o lo n e o r a n a m i n o g l y c o s id e ). Th i s p a t ie n t is i l l a n d c a n n o t t o l e r a te P O l iq u i d . S h e s h o u ld p r o b a b l y b e a d m it t e d t o t h e h o s p i ta l fo r IV a n tib io ti c s (u s u a ll y a m p i c i ll in p lu s g e n ta m i c i n o r a th i rd -g e n e ra tio n c e p h a lo s p o ri n ) u n t il s h e i m p ro v e s c li n ic al l y a n d c an b e g iv e n o ra l a n t ib i o t ic s . 5 4 . A n s w e r : T h i s p a t ie n t li k e ly h a s a m u s c l e s tr a in . R a d i o g r a p h s a re n o t in d ic a t e d , a n d t re a tm e n t i n v o l v e s a v e ry s h o rt p e r i o d o f b e d re s t (n o m o re th a n 1 -2 d a y s ), N S A I D s , a n d re a s s u ra n c e . I f s y m p to m s p e rs is t fo r 3 we e k s o r lo n g e r, th e n fu rth e r im a g in g s t u d i e s a r e a p p ro p ria te . 5 5 . A n s w e r : T h i s p a t ie n t is h a v in g a s ev e re e xa c e rb a t io n o f a s th m a , m o s t l ik e l y t ri g g e re d b y a n u p p e r re s p i ra to r y in f e c t io n . Do n o t b e m is le d b y t h e A B G . A p a t i e n t w h o is wo rk in g th a t h a r d t o b re a th e is i n t r o u b le . F o r a p a t i e n t w h o i s th is ta c h y p n e ic , th e a rt e ri a l P C O 2 s h o u ld b e lo w

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a n d th e p a t ie n t s h o u ld h a v e a r e s p ir a to ry a l k a lo s is . T h i s p a t ie n t n e e d s o x y ge n ,

- a g o n is t s , a n d

I V s te ro i d s , a n d i f t h e s e m e a s u re s d o n o t im p ro v e h is d is tr e s s , h e m a y r e q u i re in t u b a ti o n . 5 6 . A n s w e r : T h i s w o m a n m o s t l ik e l y h a s T S S , wh i c h is m o s t c l a s s i c a ll y a s s o c ia t e d w i th m e n s tru a ti n g w o m e n we a r in g v a g i n a l ta m p o n s . It i s c a u s ed b y a n e n te ro t o x i n o f S t a p h y l o c o c c u s a u r e u s a n d is c h a ra c te ri z ed b y a b ru p t o n s e t o f fe v e r , h y p o t e n s io n , a n d r a s h t h a t e v e n tu a ll y d e s q u a ma t e s . A s i n o th e r f o rm s o f s e p ti c s h o c k , t h e re is d i ff u s e p e ri p h e ra l v a s o d il a t i o n c a u s in g t h e s k i n to b e wa rm . C a rd i a c o u tp u t i s h ig h , b u t b e c a u s e t h e p e r i p h e ra l v a s c u l a r re s is ta n c e is s o l o w, s y s te m i c h y p o t e n s io n p re v a i ls . T h e re is u s u a l l y in v o l v e m e n t o f a t le a s t t h r e e o rg a n s y s te m s i n T S S . (T S S i s n o t l im i te d to w o m e n , a n d m a y o c c u r in p a ti e n t s o f b o t h s e xe s w it h s u rg i c a l wo u n d s , b u rn s , a n d i n s e c t b i t e s . ) P o s iti v e b l o o d c ul tu re s a re n o t re q u ir e d fo r d ia g n o s is ; it i s th e t o xi n th a t c a u s e s t h e i l ln e s s . T S S i s a li fe -t h r e a t e n i n g c o n d i ti o n t h a t s h o u ld b e tre a te d w ith a g g re s s i v e fl u id re s u s c i ta ti o n , I V a n t ib io tic s , a n d r e m o v a l o f th e tampon or wound packing. 5 7 . A n s w e r : T h i s m a n h a s a c u te p e ri c a r d i ti s . M o s t c a s e s o f p e r ic a rd i t is a re i d i o p a th i c a n d o ft e n a re s e e n i n th e p o s t v i ra l p e ri o d . A c ut e v i ra l a n d id io p a t h ic fo rm s o f p e ric a rd i ti s a re u s u a ll y s e l f - li m i tin g . A s p ir i n , in d o m e th a c i n , o r N SA ID s a re th e f i rs t -li n e t re a t m e n t m e d i c a ti o n s . 5 8 . A n s w e r : T h i s p a t ie n t li k e ly h a s a n k y lo s in g s p o n d y li tis . K e y d ia g n o s ti c f a c to rs in c l u d e t h e l im i t e d ra n g e o f m o ti o n in h is s p i n e , e x a c e rb a tio n w i th re s t, a n d im p ro v e m e n t wi t h e x e r c is e . S a c r o i li a c jo in t in v o l v e m e n t is a h a ll ma rk o f t h is d i s eas e , a n d it s p r e s e n c e is r e q u ir e d t o m a k e t h e d i a g n o s is . O b ta i n p l a i n f i lm s o f t h e s p in e a n d p e l v i s to v is ua li z e t h e s a c ro il ia c j o i n ts . In it ia l t h e ra p y i n v o l v e s N S A ID s a n d p h y s i c al t h e r a p y . P.510

5 9 . A n s w e r : T h i s p a t ie n t h a s d e v e l o p e d a d u l t r e s p i r a to ry d i s t re s s s y n d ro m e (A R D S ) c a u s e d b y s e p s is . T a c h y p n e a , t a c h y c a rd ia , a n d h y p o xi a s h o u l d ra is e s u s p i c i o n f o r A R D S , e s p e c i a l ly in t h e s e tt in g o f s e p s is . H ig h - f lo w o x y g e n s ho u l d b e g i v e n i m m e d i a te l y to p r e v e n t f u rt h e r d a m a g e t o th e l u n g s . H o we v e r, A R D S c h a r a c te ris ti c al ly d o e s n o t re s p o n d we ll to 1 0 0 % o x y ge n , a n d m e c h a n ic a l v e n t il a t io n i s t y p ic a ll y re q u i re d . O t h e r a c ti o n s s h o u ld b e ta k e n s im u lt a n e o u s ly , s u c h a s o rd e ri n g a C X R a n d A B G . 6 0 . A n s w e r : G i v e a n a l g e s ic s f o r p a i n ( c od e i n e wi t h o r w it h o u t a c e ta m i n o p h e n ) , im m o b i li z e t h e j o in t , d o n o t a ll o w h im t o b e a r a n y we ig h t o n h i s ri g h t l o we r e x t re m it y , a n d a d m i n i s t e r fa c t o r V I II c o n c e n t r a te . N e e d le a s p ir a ti o n o f th e b l o o d (to re l ie v e s w e l li n g ) is n o t re c o m m e n d e d b e c a u s e o f th e ri s k o f c a u s in g f u rth e r b l e e d in g a n d th e c h a n c e o f in t ro d u c in g a n in f e c tio n . H e m o p h il ia c s s h o u l d a ls o re c e i v e fa c t o r V I II c o n c e n tr a t e b e f o re a n y s u r g e r y o r d e n ta l p ro c e d u re s . 6 1 . A n s w e r : T h i s p a t ie n t h a s a c la s s ic p re s e n t a ti o n o f in f e c tio u s m o n o n u c l e o s is . O rd e r th e f o l lo wi n g te s t s : m o n o s p o t t e s t , th ro a t c u l t u re , C B C , a n d p e r i p h e ra l b lo o d s m e a r (a ty p ic a l l y m p h o c yt o s i s i s a h a l lm a rk o f i n f e c ti o u s m o n o n u c l e o s i s ). (T h e t e s t fo r EB V - s p e c i f ic a n tib o d ie s [ a n ti - E A a n d a n ti - Ig M-V C A ti t e rs ] is n o t a n a p p ro p r ia t e te s t to o rd e r in i t ia l l y b e c a u s e E B V s p e c if ic a n tib o d ie s h e l p i n d ia g n o s i n g c a s e s t h a t a r e h e te r o p h il e - n e g a t iv e ; h o we v e r, 9 0 % o f c a s e s a re h e te ro p h i le - p o s i ti v e . ) A d v is e t h e p a ti e n t t o re s t a n d d ri n k p l e n t y o f fl u i d s . A n t iv i ra l

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t h e ra p y i s n o t i n d i c a te d in m o n o n u c l e o s i s , a n d a n t ib io ti c s a r e n e e d e d o n l y i f a t h ro a t c u l tu r e re v e a ls g ro u p A -h e m o ly t i c s t re p to c o c c i.

6 2 . A n s w e r : T h i s p a t ie n t h a s a n a c u te u p p e r re s p i ra to r y tr a c t i n f e c tio n . H i s s y m p to m s (n o n p r o d u c ti v e c o u g h , s o re th r o a t , rh in o rr h e a , n a s a l c o n g e s t io n , m y a lg i a s ) a re s u g g e s ti v e o f a v i ra l in fe c ti o n . T h e re f o re , s y m p to m a ti c t re a tm e n t i n c lu d i n g h y d ra t io n , r e s t , a n d a n a l g e s ic s i s a p p ro p ria te . T h e m a i n c o n c e r n w it h a s o re t h r o a t i s i n f e c t i o n wi t h g ro u p A -h e m o l y ti c

s tr e p to c o c c u s (c a n c a u s e rh e u m a ti c f e v er ). A l th o u g h i t is a t t im e s d i ffi c u lt t o d i ffe re n t ia t e b e t we e n a v i ra l a n d b a c te ri a l i n f e c ti o n , th e p re s enc e o f a c o u g h , r h i n o rrh e a , n a s a l c o n g e s ti o n , a n d m y a lg i a s i s s u g g e s tiv e o f a v i ra l i n f e c t io n . 6 3 . A n s w e r : T h i s p a t ie n t h a s a m ic ro c y t ic a n e m ia c a u s e s i n c l u d e ir o n d e f ic ie n c y ,

t h a la s s e m ia s , rin g s id e ro b la s ti c a n e mi a , a n d a n e m ia o f c h r o n i c d is e a s e . D r a w b l o o d fo r i ro n s tu d ie s (fe rri t in , T IB C , t ra n s fe rri n g , se ru m ir o n ). If i r o n d e f ic ie n c y a n e m i a i s d i a g n o s e d , l o o k f o r a s o u rc e o f b l e e d in g ( c h ro n ic b l o o d l o s s i s t h e m o s t c o m m o n c a u s e o f ir o n d e f ic ie n c y a n e m i a in a d u lt s ). I f i ro n s tu d ie s a re w it h in n o rm a l li m its , c on s i d e r t h e p o s s i b il i ty o f t h a la s s e m ia a n d p e r fo r m a h e m o g lo b in e l e c tro p h o re s i s . 6 4 . A n s w e r : T h i s p a t ie n t p r e s e n t s w it h s ig n s a n d s y m p t o m s o f a c u t e p a n c re a t iti s . H o w e v e r , g a ll b l a d d e r d i s e a s e m u s t a l s o b e ru l e d o u t wi t h a R U Q u l t ra s o u n d . A fu ll s e t o f l a b o ra to ry te s ts i s i n d ic a t e d : C B C , re n a l p a n e l, e le c t ro l y t e s , a m y la s e, li p a s e , L F T s , a n d L D H . A C T s c a n o f th e a b d o m e n m a y b e o b t a i n e d ; t h is is th e m o s t a c c u ra t e te s t fo r d i a g n o s is o f a c ut e p a n c r e a t it is . T re a t m e n t o f a c u t e p a n c re a ti ti s in c l u d e s b o w e l re s t ( N P O ) , I V f lu i d s , a n d p a in c o n t ro l. 6 5 . A n s w e r : T h i s p a t ie n t m o s t l ik e l y h a s H a s h i m o t o 's th y r o i d i ti s (m o s t c om m o n c a u s e o f p ri m a r y h y p o th y ro i d is m a n d m o re c o m m o n in wo m e n ). T h e d i a g n o s i s i s c on f irm e d b y th e p re s e n c e o f a n ti th y ro g l o b u li n a n ti b o d i e s , a n ti m ic r o s o m a l a n t ib o d i e s , o r b o th . T h y ro i d h o rm o n e re p la c e m e n t (w it h l e v o th y r o x i n e ) i s a p p r o p ri a te . 6 6 . A n s w e r : N e is s e ria me n i n g it id i s is t h e m o s t lik e l y o r g a n i s m c a u s in g a c u te b a c t e ri a l m e n i n g i ti s . A l th o u g h S t re p t o c o c c u s p n e u m o n i a e i s s t il l th e m o s t c o m m o n o r g a n is m c a u s i n g m e n i n g i ti s i n p e o p l e o v e r 1 5 y e a rs o f a g e , th e ra s h is c h a r a c t e ri s t ic o f N . m e n i n g i ti d is (m e n i n g o c o c c a l ) m e n i n g i ti s . T h i s o rg a n i s m is c o m m o n l y a s s o c i a t e d w it h e p i d e m i c s o f m e n i n g i ti s i n c o l le g e d o rm i to ri e s a n d e v e n i n h ig h s c h o o l s . C l o s e c o n t a c ts s hou l d r e c e i v e c h e m o p r o p h y la x is , w h i c h c o n s i s t s o f o r a l ri fa m p i n f o r 2 d a y s . (T h e m e n i n g o c oc c a l v a c c in e is e ff e c ti v e a g a in s t s e ro ty p e s A a n d C , b u t u n fo r tu n a t e l y i t is s e ro ty p e B t h a t m o s t c o m m o n ly c a u s e s e p i d e m ic s o f m e n i n g iti s i n t h e U n it e d S t a te s .) Th i s p a t ie n t s h o u ld b e tre a t e d w i th p e n i c i ll in G ; c h l o ra m p h e n ic o l ; o r a th i rd - g e n e ra t io n c e p h a lo s p o ri n , s u c h a s c e f t ria x on e o r c e fo ta x im e . I f t h e m i c ro b i o lo g i c c a u s e is u n c er ta i n , t re a t w i th c e ft ri a x o n e o r a c e p h a l o s p o r in . P e rf o rm a l u m b a r p u n c t u re a n d o b t a i n b lo o d c ul tu r e s t o c o n f i rm th e d ia g n o s i s . P.511

6 7 . A n s w e r : B o n e p a i n is t h e m o s t c h a r a c te ris ti c p r e s e n ti n g s y m p to m i n m u lt ip l e m y e lo ma . L y ti c le s io n s a re p re s e n t in t h is p a ti e n t, a s i s a p a t h o l o g ic f ra c tu r e o f th e ri g h t h u m e r u s . P a ti e n ts w it h m u l ti p l e m y e l o m a m a y h a v e b o n e p a i n fo r s e v e ra l m o n t h s b e f o r e d ia g n o s is i s m a d e . T h is p a t ie n t h a s a m il d a n e m ia a n d re n a l in s uf f ic i e n c y ; b o th fin d i n g s th a t m a y b e

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p re s e n t i n p a t i e n ts w i th m u lt i p le m y e lo m a . O b t a in s e ru m a n d u ri n e e l e c tro p h o re s is i n th i s p a t ie n t fo r d e t e c t io n o f m o n o c l o n a l p r o te in ( M - s p i k e ) . P e rf o rm a b o n e m a rr o w b i o p s y fo r c o n f irm a t io n . 6 8 . A n s w e r : T h i s p a t ie n t h a s a c a u d a e q u i n e s y n d r o m e . A n e m e rg e n t MR I o f t h e lu m b a r s p in e s h o u ld b e o rd e re d , a n d th e p a t ie n t n e e d s i mm e d i a t e re f e rra l t o a s p i n e s pe c ia l is t fo r s u r g ic a l d e c o m p r e s s i o n . A n y p a tie n t w h o p re s e n t s w i th l o w b a c k p a i n a n d u r in a r y o r b o w e l d y s fu n c t io n r e q u ir e s a n e m e rg e n t M R I . 6 9 . A n s w e r : T h i s p a t ie n t's p re s e n ta t i o n is c l a s s ic fo r te m p o ra l a r t e ri ti s , w it h k e y d ia g n o s t ic f a c to r s in c lu d in g te n d e rn e s s o v e r t e m p o ra l a r te ry , u n i la t e ra l h e a d a c h e s i n th e t e m p o ra l re g i o n , v i s u a l l o s s , a n d lo w -g ra d e fe v e r. B e c a u s e t h e r e i s a h is to r y o f v is u a l lo s s , a d m i t th e p a t ie n t to t h e h o s p i ta l a n d s t a rt e m p i ri c a l tre a tm e n t wi t h h ig h - d o s e IV c o rti c o s t e r o id s i m m e d ia t e l y . C o n s u l t o p h t h a l m o lo g y , a n d o rd e r a n E S R . A l th o u g h a te m p o ra l a r t e r y b i o p s y i s re q u i r e d fo r d e f in i ti v e d i a g n o s is , d o n o t w a i t fo r b io p s y re s u lt s to i n i tia te t re a tm e n t. Pa t ie n ts s u s p e c t e d o f h a v i n g t e m p o ra l a rt e r iti s s h o u ld b e tre a te d w it h h ig h -d o s e s t e r o id s u n til a n a lt e r n a t e d ia g n o s is i s p ro v e d o r t h e ir t re a tm e n t i s c o m p l e t e , b e c a u s e ir re v e rs ib l e b li n d n e s s is a r is k . 7 0 . A n s w e r : B r o a d ly , s y n c o p e c a n b e d i v i d e d in to c ar d ia c a n d n o n c a rd ia c c a u s e s , a n d wo rk u p s h o u ld b e f o c u s e d o n r u li n g o u t li fe -th re a te n i n g c o n d i t io n s fi rs t ( MI , a rr h y th m i a s , h e m o r rh a g e ) a n d d i ff e r e n t ia tin g b e tw e e n c a r d ia c a n d n o n c a r d i a c e t io lo g ie s . T h e p ro g n o s i s i s p o o re s t fo r p a t ie n ts w i th u n d e r l y in g h e a rt d i s e a s e. P h y s ic a l e x a m in a ti o n s h o u l d fo c u s o n c a r d io v a s c ul a r e xa m i n a ti o n a n d t h e id e n t i fi c a t io n o f a n y f o c a l n e u ro l o g ic d e fi c i ts . O rt h o s ta ti c v it a l s i g n s s h o u ld b e o b ta in e d . A l w a y s c h e c k th e p a t ie n t 's m e d i c a t io n s ( e s p e c i a ll y in e ld e rl y p a t ie n ts ). A n E C G i s o b ta i n e d i n a ll p a t i e n t s . L a b o ra t o ry s t u d ie s th a t s h o u ld b e o rd e re d i n c lu d e C B C a n d m e ta b o l ic p a n e l . A n e c h o c a rd io g r a m i s u s e fu l to s c re e n f o r a n y s t ru c tu ra l h e a rt d is e a s e . A d d i ti o n a l d ia g n o s t ic t e s ts a re b a s e d o n t h e s us p e c te d e tio l o g y f ro m th e h i s to r y a n d p h y s i c al e xa m i n a ti o n . 7 1 . A n s w e r : T h i s p a t ie n t's p re s e n ta t i o n (m u lti p l e c o m p re s s i o n fra c t u r e s , b a c k p a i n , r e n a l f a i lu re , h y p e rc a lc e m i a , a n e m i a , a n d t h r o m b o c y t o p e n i a ) is s u g g e s t iv e o f m u lt i p l e m y e lo m a . T h e re f o re , th e n e x t s te p i s to o r d e r s e ru m a n d u r in e p ro te i n e le c t ro p h o re s i s . T h e p re s e n c e o f a n e m i a a n d t h r o m b o c y t o p e n i a i n d i c a te m o r e a d va n c e d d is e a s e . O t h e r k ey fi n d i n g s i n m u l ti p l e m y e l o m a i n c lu d e r e c u rre n t in fe c ti o n s , ly tic b o n e l e s io n s , ro u l e a u x fo rm a ti o n o f R B C o n th e p e r ip h e ra l s m e a r, a n d B e n c e J o n e s p ro t e in s in th e u ri n e . T h e o t h e r k e y d i a g n o s i s o n th e d if fe r e n t ia l li s t i s m e t a s ta ti c d i s e a s e . T h e r e f o re , i f t h e p r o te i n e le c tr o p h o re s i s s t u d y is n e g a ti v e , a w o rk u p fo r m e t a s ta ti c d is e a s e , in c l u d in g C T s c a n o f c he s t , a b d o m e n , a n d p e lv is , a s well as a bone scan, should be ordered. 7 2 . A n s w e r : T h i s p a t ie n t is p r o b a b l y s u f fe r i n g fro m h y pe rt e n s i v e e n c e p h a lo p a th y d u e to a h y p e rt e n s i v e e m e rg e n c y , w h i c h i s d e f in e d a s e v i d e n c e o f s e v e re H T N a c c o m p a n ie d b y e v id e n c e o f e n d -o rg a n d a m a g e . A n y o f th e f o l lo wi n g q u a l if y a s e v i d e n c e o f e n d -o rg a n d a m a g e : h y p e rt e n s i v e e n c e p h a lo p a t h y , m y o c a rd ia l i s c h e m ia o r in fa r c t io n , p u lm o n a ry e d e m a , a c u t e C V A (h e mo rr h a g i c o r i s c h e m i c ) , a o r ti c d is s e c ti o n , a c ut e re n a l in s u ff ic ie n c y , a n d m ic ro a n g i o p a th ic h e m o l y t ic a n e m i a . It is e s s e n t ia l to re d u c e th e B P i m m e d ia t e ly . I V n it ro p ru s s i d e o r l a b e ta lo l a re u s u a l ly t h e a g e n ts o f c h o ic e . It i s i m p o rt a n t, h o we v e r , n o t t o a c h i e v e a d ra s tic r e d u c t io n i n B P . T h e i n i ti a l g o a l s h o u l d b e to r e d u c e t h e m e a n a r te ri a l p re s s u re b y a p p r o x i m a t e ly 2 5 %.

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T h e re f o re t h e p a tie n t 's B P m u s t b e m o n ito re d a c u t e l y . A l t h o u g h th e e x am in a ti o n i s u n r e m a rk a b le , th i s p a t ie n t s h o u l d h a v e a C T s c a n o f t h e h e a d , E C G , a n d p e rt in e n t l a b o ra to r y t e s ts p e rfo rm e d t o ru le o u t s o m e o f t h e a b o v e m e n t io n e d c o m p li c a ti o n s . 7 3 . A n s w e r : T h i s c l in ic a l p re s e n t a t io n i s t y p ic a l o f A l z h e im e r' s d is e a s e . In i t ia te d o n e p e z i l a s t h e fi rs t - li n e a g e n t a t th i s ti m e , b u t it s b e n e fi ts a r e m a r g i n a l . 7 4 . A n s w e r : T h e re c e n t s u r g e r y a n d s u b s e q u e n t im m o b i li z at i o n m a y h a v e c a u s e d v e n o u s t h r o m b o s is . S u d d e n o n s e t o f d y s p n e a in th is c l in i c a l s c e n a ri o s u g g e s t s P E , a n d th i s s h o u l d b e ru l e d o u t . A [V w i th d o t a b o v e ] /[ Q wi t h d o t a b o v e ] s c a n s h o u ld b e o b t a in e d fo r d ia g n o s i s . H o we v e r , h e p a ri n s h o u ld b e i n i ti a t e d ri g h t a w a y , g i v en t h e h ig h c li n i c al s u s p ic io n (o n e s h o u ld n o t w a i t f o r s tu d y r e s u l t s i f th e r e is a h i g h c l in i c a l s us p ic io n ). S u p p le m e n ta l o x y g e n is a p p ro p ria te . A n A B G a n a l y s is is im p o rta n t t o a s s e s s o xy g e n a t i o n , v ent il a ti o n , a n d a c id b a s e s ta tu s . P.512

7 5 . A n s w e r: T h i s p a t ie n t s u ffe rs f ro m m ig ra i n e h e a d a c h e s . A tr i a l o f s u m a t ri p t a n is a p p ro p ria te . T h is m e d i c a t io n s h o u ld b e t a k e n a s s o o n a s s y m p to m s a p p e a r. C o n s i d e r p ro p h y l a c t ic tre a tm e n t , d e p e n d in g o n th e r e s p o n s e . 7 6 . A n s w e r : T h i s p a t ie n t h a s c h ro n ic r e n a l in s u f f ic i e n c y d u e t o d ia b e ti c n e p h ro p a t h y w it h s u p e rim p o s e d A R F . C a u s e s o f A R F c a n b e g ro u p e d i n t o p re r e n a l , r e n a l , a n d p o s tr e n a l c a u s es . T h i s p a t ie n t h a s b e e n t a k i n g in c re a s in g a m o u n ts o f N S A I Ds re c e n t l y , w h ic h c a n c a u s e i n t rin si c re n a l d a m a g e (e s p e c ia lly i n c o mb in a ti o n w i th A CE i n h i b i to rs ) a n d a d e t e r io r a ti o n o f re n a l f u n c ti o n . F u r th e r la b o ra to r y te s t s ( u ri n e c h e m i s t ri e s ) m a y h e l p to e l u c i d a te t h e c a u s e o f t h e A R F . A re n a l u l t ra s o u n d m a y b e o rd e r e d to r u le o u t o b s tru c t io n . 7 7 . A n s w e r : A l t h o u g h th e h is t o r y i s s u g g e s ti v e o f i s c h e m i c c h e s t p a i n , a wi d e n e d m e d ia s ti n u m s u g g e s t s a n a o r ti c d i s s e c t io n . S h e s h o u l d u n d e r g o im m e d ia t e C T o r tr a n s e s o p h a g e a l e c h o c a r d io g ra p h y t o d i a g n o s e a n a o r ti c d is s e c t io n . I t i s im p o r ta n t to r e a l iz e t h a t a wi d e n e d m e d i a s t in u m m a y n o t a lw a y s b e a p p a re n t o n C X R . A h ig h i n d e x o f s u s p ic i o n m a y b e n e e d e d t o d ia g n o s e a d is s e c ti o n b e c a u s e th e c l a s s i c f in d i n g o f s ta b b in g c h e s t p a in ra d ia ti n g to th e b a c k m a y n o t b e p re s e n t. C a rd i a c e n z y m e l e v e ls s h o u l d a l s o b e te s te d . 7 8 . A n s w e r : T h e p a tie n t s h o u l d b e a d m it te d to th e h o s p i t a l. IV m o r p h i n e is i n d ic a te d f o r r e li e f o f p a i n . O t h e r m e a s u re s i n c l u d e IV fl u i d s f o r h y d ra t io n a n d k ee p in g th e p a ti e n t w a r m . 7 9 . A n s w e r : F i n e n e e d l e a s p ir a t io n s h o u ld b e t h e i n it ia l p ro c e d u re i n t h i s p a t ie n t. It h a s a h i g h s e n s it i v i ty a n d s p e c if ic ity f o r m a li g n a n c y . C y t o lo g i c a n a l y s i s re v e a ls w h e th e r t h e n o d u le is b e n i g n , ma li g n a n t , o r i n d e t e rm in a t e . If b e n ig n , o b s e rv a ti o n is a p p ro p ria te . I f m a l ig n a n t , s u rg e ry i s i n d ic a t e d . I f in d e t e rm in a t e , a t h y ro i d s c a n s h o u ld b e o b ta in e d . 8 0 . A n s w e r : T h e p a tie n t in t h is c a s e p re s e n t s wi t h s i g n s o f is c h e m i c h e a rt d is e a s e . I t is i m p o rt a n t t o h a v e a h i g h s u s p i c io n o f i s c h e m ic h e a r t d i s eas e , p a rt ic u la rl y i n wo m e n , t h e e ld e rl y , a n d p a tie n ts w i th d ia b e t e s , i n w h o m is c h e m ic h e a rt d i s eas e m a y m a n if e s t w i th s y m p to m s o t h e r th a n c la s s i c c h e s t p a in . O xy g e n a n d s u b l in g u a l n it r o g l y c e ri n s h o u ld b e a d m i n is te re d . Im p ro v e m e n t o f s y m p to m s w i th n itr a t e s p o in t s to i s c h e m i c h e a r t d is e a s e a s a l ik e l y c a u s e . N i t ra t e s i n c r e a s e th e s u p p l y o f o x y g e n b y r e d u c in g v en tr ic u la r w o r k .

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8 1 . A n s w e r : I f a p a tie n t p r e s e n ts wi t h m o n o a rt ic u la r a r th r it is , s e p ti c a rt h ri ti s is t h e m o s t w o r ri s o m e d i a g n o s i s a n d m u s t b e e x c lu d e d . T h e d if fe re n ti a l d i a g n o s is i n th i s c a s e in c l u d e s c e ll u l i tis , g o u t, a n d p s e u d o g o u t . G i v en th e lo c a t io n o f th e p a in (g re a t to e ) a n d l a c k o f fe v er, s e p t ic a rth ri ti s is le s s l ik e l y , a n d th e p re s e n ta ti o n i s ty p ic a l f o r a fi rs t a c u t e g o u ty a tta c k . O r d e r a C B C , E S R , a n d b l o o d c u lt u r e s . A l s o , o b ta in s y n o v i a l f lu id c u ltu re s . F o r a d e f in i ti v e d i a g n o s is o f g o u t, j o i n t a s p ir a te i s n e c e s s a ry to d e te c t n e e d le -s h a p e d , n e g a t i v el y b i r e f ri n g e n t c r y s t a l s u n d e r p o l a ri z e d l ig h t . If th e W BC c o u n t is n o t e l e v a te d , a n d th e p a t ie n t is a f e b ril e , m a k e a p re s u m p ti v e d ia g n o s i s o f g o u t a n d tre a t w i th i n d o m e t h a c in o r c o l c h ic i n e (if r e n a l fu n c tio n is n o r ma l ). 8 2 . A n s w e r : T h i s p a t ie n t li k e ly h a s G E R D . H e h a s n o a l a rm i n g s y m p t o m s th a t wo u l d s u g g e s t s e r io u s d is e a s e . R e c o m m e n d li f e s t y le m o d i fic a tio n s s uc h a s s l e e p in g wi th t h e h e a d o f t h e b e d e le v a t e d , s m o k i n g c e s s a t io n , a n d n o t e a ti n g b e fo r e b e d t im e . E n d o s c o p y is n o t in d ic a t e d a t t h is t im e , a n d e m p i ri c t h e r a p y m a y b e i n it ia te d . H e h a s a l re a d y t ri e d a n ta c id s ; th e r e fo re , it w o u l d b e a p p ro p ria t e t o p re s c r ib e a n H 2 b lo c k e r o r a P PI . 8 3 . A n s w e r : T h i s p a t ie n t p r o b a b ly h a s p o s t o p e r a ti v e d e li ri u m , wh ic h is c o m m o n i n e l d e r ly p a t ie n ts a f t e r m a jo r s u rg e ry . H e r p r e s e n t a ti o n is t y pi c a l o f d e li ri u m i n th a t h e r s y m p to ms wa x a n d w a n e d u ri n g t h e c o u rs e o f th e d a y ( th e y a re ty p i c al l y wo rs e a t n i g h t), w h i c h is s o m e ti m e s c o n f u s i n g a n d f ru s t ra t i n g t o fa mi l y m e m b e rs . B e c a u s e n a r c o ti c s c a n wo rs e n th e d e l ir iu m , d is c o n t in u e t h e m ; o r, i f p a i n p e rs is ts , l o we r t h e d o s e a s m u c h a s p o s s ib le . 8 4 . A n s w e r : R U Q u l t ra s o u n d is th e s t u d y o f c h o ic e fo r a c u te c ho l e c y s ti ti s , w i th h ig h s e n s i t iv it y a n d s p e c i fi c it y . I n i ti a l t re a tm e n t i s b o w e l re s t (N P O ), IV fl u i d s , a n t ib i o t ic s , a n d p a i n m e d i c a t io n . G e n e ra l s u r g e ry c o n s u lt s h o u l d b e o b t a i n e d f o r c h o le c ys te c to m y . 8 5 . A n s w e r : T h i s p a t ie n t c o u ld h a v e fi b r o m y a lg i a . H o w e v e r, to d i a g n o s e f ib r o m y al g ia , th e p a t ie n t s ho u l d h a v e a t l e a s t 1 1 o f 1 8 te n d e r p o in ts . R u l e o u t t h e f o ll o w i n g c o n d i ti o n s b e fo re c o n s id e ri n g f ib r o m y a l g ia : m y o fa s c ia l s y n d ro m e s , r h e u m a to id d is e a s e , p o l y m y a lg ia r h e u m a ti c a , a n k y lo s in g s p o n d y l i ti s , s p o n d y l o a rth ro p a th y , c h ro n i c f a tig u e s y n d ro m e , L y m e d is e a s e , P.513

h y p o th y ro i d i s m , p o l y m y o s it is , d e p r e s s i o n , s o m a tiz a ti o n d is o rd e r, a n d h y p e r tr o p h ic o s te o a rth ro p a t h y . T h is re q u i r e s o rd e ri n g t h e a p p ro p r ia t e la b o ra t o r y te s t s ( A N A , rh e u m a to i d f a c to r , L y m e t i te rs , E S R , TS H l e v e l , a p p ro p ri a te ra d io g r a p h s ). O n c e y o u a r e a b l e to ru le o u t t h e s e c o n d it i o n s , c o n s id e r f ib r o m y a lg ia a s a d i a g n o s i s o f e xc l u s i o n . P a t ie n ts wi t h f ib ro m y a l g i a a re v e ry d i ff ic u l t t o tr e a t , a n d t h e r e a r e n o t m a n y t h e ra p e u t ic o p t io n s . 8 6 . A n s w e r : T h e in i t ia l g o a l i n m a n a g i n g a p a t ie n t wi t h v ar ic e a l b le e d i n g fro m c i rrh o s i s i s h e m o d y n a m ic s ta b ili z a tio n (A B C s ) . T h i s p a ti e n t h a s u n s t a b l e v i ta l s ig n s . A f te r a s s e s s m e n t o f a ir wa y a n d b re a th i n g , la rg e - b o re IV a c c es s i s o b ta i n e d , a n d IV fl u i d re s u s c ita t io n s h o u ld b e s ta rte d im m e d ia te l y . B lo o d tra n s fu s io n (P R B Cs ) s h o u l d b e o rd e r e d a n d a n a s o g a s tric tu b e p la c e d . O n c e th e p a tie n t is h e m o d y n a m ic a ll y s t a b l e , a n e m e r g e n t u p p e r G I e n d o s c o p y i s p e r fo r m e d , wh ic h i s d i a g n o s t ic a n d th e ra p e u ti c . V a r i c e a l b a n d l ig a ti o n is th e p re f e r re d i n i ti a l t re a tm e n t , is u s u a l l y e f f e c t i v e i n c o n tro l li n g b l e e d i n g , a n d h a s a l o w e r r a te o f re b le e d i n g th a n s c le ro t h e ra p y . Al s o , n o t e t h a t a lt h o u g h b l e e d in g va ri c e s c aus e m o s t e p is o d e s o f G I b le e d i n g in

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c ir rh o s is p a t ie n ts , Ma ll o ry -W e is s te a rs o r u l c e rs m a y b e th e s o u rc e o f b l e e d in g i n a s u b s t a n t ia l n u m b e r o f p a ti e n t s . 8 7 . A n s w e r : P l a i n ra d io g ra p h s o f t h e a b d o m e n in t h e s upi n e a n d u p r ig h t p o s i ti o n s s h o u ld b e o b t a in e d . He r p re s e n ta ti o n i s s u g g e s t iv e o f b o w e l o b s t ru c t i o n . C o lo re c t a l c a n c e r is t h e m o s t c o m m o n c a u s e o f la rg e b o w e l o b s tru ct io n i n a d u l ts . Y o u s h o u ld a l s o s e n d a f e c a l o c c u l t b l o o d t e s t. 8 8 . A n s w e r : T h i s p a t ie n t li k e ly h a s n e p h ro l it h i a s i s . O b ta in a K U B f o r v i s ual i z a ti o n o f s to n e s . If i t is n o t d ia g n o s tic , a C T s c a n o f th e a b d o m e n a n d p e l v is w o u l d re v e a l t h e s t o n e . Th e p a tie n t s h o u ld b e k e p t w e l l -h y d ra te d w i th IV fl u i d s . Pa i n m e d ic a tio n s ho u ld b e g iv e n . 8 9 . A n s w e r : T h i s p a t ie n t h a s r e s p i r a to ry a lk al o s is . H e r h y p e rv en t il a ti o n m a y r e s u l t f ro m p u lm o n a ry e m b o l is m , o r f ro m a n u m b e r o f o t h e r c o n d i t io n s , i n c l u d i n g p a n i c a tt a c k s . G iv e n th e h ig h c lin ic a l s u s p i c i o n f o r p u l m o n a ry e m b o li s m (s u d d e n o n s e t o f d y s p n e a , o ra l c on t ra c e p ti v e u s e , a n d h y p o x e m ia ), s t a r t th e p a ti e n t o n h e p a ri n a n d o b t a in a [ V wi t h d o t a b o v e ]/[ Q wi t h d o t a b o v e ] s c a n o r a s p ira l C T s c a n . 9 0 . A n s w e r : T h i s p a t ie n t h a s a l c o h o l ic c i r rh o s i s a n d p re s e n ts wi t h h e p a ti c e n c e p h a lo p a t h y . A f u l l s e t o f la b s , i n c l u d in g C B C , re n a l p a n e l, e l e c tro ly te s , P T / P T T , L F T , a n d a m m o n ia le v e l s h o u ld b e o rd e re d . A p a ra c e n t e s i s m a y b e r e q u i re d . T h e t re a tm e n t o f h e p a t ic e n c e p h a lo p a t h y i s l a c tu l o s e , w h ic h c o n v e r t s a m m o n ia (N H 3 ) to a m m o n i u m (N H 4 ), w h i c h c a n n o t b e a b s o rb e d in t h e g u t. 9 1 . A n s w e r : O b ta in p l a i n fi lm s o f th e s p in e t o ru l e o u t p o s s ib le v e rte b r a l c om p r e s s io n f ra c tu re s e c o n d a ry to o s te o p o ro s i s . Qu a n t i ta t i v e a s s e s s m e n t o f b o n e m a s s d e n s i ty v ia D E X A s c a n is i m p o rt a n t i n c o n f i rm i n g a d i a g n o s is o f o s te o p o ro s i s a n d i n d e t e rm i n in g f ra c tu re ri s k . C a l c iu m a n d v i ta m in D s u p p l e m e n t s a r e a p p ro p ri a te , a s is w e ig h t -b e a r in g e x e rc is e . I f o s t e o p o ro s i s is d ia g n o s e d , p h a rm a c o lo g ic t h e ra p y i s a p p ro p ri a t e : h o rm o n e re p la c e me n t t h e r a p y a n d e i th e r b is p h o s p h o n a te s , ra lo x i fe n e , o r c a l c i t o n i n . 9 2 . A n s w e r : T h i s p a t ie n t h a s m e g a l o b l a s ti c a n e m i a . I t is u n c l e a r wh e t h e r t h is is d u e t o v it a m i n B 1 2 o r f o l a te d e fi c i e n c y . D ra w b l o o d fo r s e r u m v i ta m in B 1 2 a n d fo l a t e l e v els . T ra n s f u s io n i s p ro b a b ly u n n e c e s s a ry a t t h is tim e . O n c e t h e c a u s e o f m e g a l o b l a s tic a n e m ia is k n o wn , a d m i n is te r th e a p p ro p ria t e v i t a m in . 9 3 . A n s w e r : T h i s p a t ie n t h a s s t a g e I ( m i ld ) H TN . W ith h e r s m o k in g a n d fa m i ly h is t o r y o f c a r d io v a s c u l a r d i s e a s e , s h e f a ll s in to ri s k g ro u p B . L if e s ty l e m o d if ic a t io n i s re c o m m e n d e d a s t h e in it i a l th e ra p y in p a ti e n ts in r is k g ro u p B wh o h a v e s ta g e I H T N . H o w e v e r, th e d e c i s i o n o f w h e n to s ta rt p h a rm a c o lo g ic t h e ra p y i s o ft e n a j u d g me n t c a l l. I n it ia ti n g a n a n ti h y p e rt e n s i v e a g e n t in th is p a ti e n t, e i th e r a n A C E i n h i b i to r, h yd ro c h l o r o th i a z id e , o r a - b lo c k er , w o u ld a l s o

b e a p p ro p ria t e . S c h e d u le r e g u la r fo l lo w - u p a p p o in t m e n ts w i th t h is p a t ie n t fo r B P c h e c k s a n d f o r m o n it o rin g o f h e r s e ru m e le c tro l y te s o n c e s h e b e g in s d ru g t r e a t m e n t. 9 4 . A n s w e r : F i rs t, i m m e d ia te l y a d m i n i s t e r th ia mi n e 1 0 0 m g , t h e n a b o l u s o f IV D 5 0 W . F o l lo w w it h a n i n f u s i o n o f D 5W t o in c re a s e b lo o d g lu c o s e le v e l s . T h is p a ti e n t i s d i a b e tic , a n d t h e m o s t l ik e l y c a u s e o f h is h y p o g l y c e m ia is a d m i n is t ra t io n o f to o m u c h i n s u l i n . O n c e h e i s s t a b i li z e d , a tt e m p t t o fi n d o u t w h e th e r a n y re c e n t c ha n g e s h a v e b e e n m a d e to h i s i n s u li n r e g i m e n a t th e n u r s in g h o m e . P.514

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9 5 . A n s w e r : T h i s p a t ie n t h a s s y m p t o m s o f u rg e in c o n t in e n c e , th e m o s t c om m o n t y p e o f i n c o n t in e n c e in e l d e r ly p a ti e n ts . H o w e v e r, s h e li k e ly a ls o h a s s t re s s i n c o n ti n e n c e g i v e n t h e l o s s o f u ri n e w i th l a u g h in g /c o u g h in g a n d th e h i s to ry o f fo u r v a g in a l d e li v er ie s . T h re e a s p e c ts o f h e r h i s t o r y w a rr a n t a tt e n t io n : ( 1 ) s h e t a k e s a d i u re t ic , wh i c h e x a c e rb a te s h e r c o n d i ti o n ; (2 ) sh e i s d i a b e ti c ; a n d (3 ) h y p e rg l y c e m ia c a n i n d u c e o s m o t ic d iu r e s is . F i n a l l y , s he h a s a U T I (u ri n a ly s is -p o s i ti v e ) , w h ic h c a n w o rs e n u ri n a r y u rg e n c y a n d f re q u e n c y . A ll o f th e s e is s u e s m u s t b e a d d re s s e d a n d tre a t e d . B e h a v io ra l t h e r a p y i n th e fo rm o f b l a d d e r re tr a i n in g c an b e h e l p fu l i n p a t ie n ts wi t h u rg e i n c o n t in e n c e . A l s o , K e g e l e x e rc is e s a n d u s e o f a p e s s a ry a re c o n s e r v a ti v e o p ti o n s fo r tr e a ti n g h e r s tr e s s i n c o n ti n e n c e . 9 6 . A n s w e r : G i v e n th e h i s to r y a n d e xa m in a tio n f in d i n g s ( d i ff u s e e n la rg e m e n t o f th y ro id w it h b ru it) , th is p a ti e n t l ik e l y h a s G ra v e s ' d is e a s e . O rd e r a s e ru m T S H l e v e l fo r d ia g n o s i s . I f t h e d ia g n o s is i s e s t a b l is h e d , i n it ia t e a -b lo c k e r (e . g ., p ro p ra n o lo l ) f o r c o n t ro l o f s y m p to m s (ta p e r

- b lo c k e r a fte r 4 to 8 w e e k s ) a lo n g w it h m e t h im a z o l e , a n d c o n ti n u e fo r 1 t o 2 y e a rs . 9 7 . A n s w e r : T h i s w o m a n is s u ff e ri n g f ro m d e m e n t ia . A lt h o u g h th e m o s t c o m m o n c a u s e o f d e m e n ti a i s A l z h e im e r's d i s e a s e , w i th t h i s w o m a n 's m e d i c a l h is t o r y (o f s tr o k e a n d T I A s ), c o n s id e r a v a s c u l a r e t io lo g y a s w e l l (m u lt i -i n fa rc t d e m e n ti a ). C T s c a n o f th e h e a d w o u ld l ik e ly re v e a l o ld m u l ti -in fa r c t s a n d c e re b ra l a t ro p h y . In a l l c a s e s o f d e m e n tia , c o g n i tiv e d e c l in e i s u s u a ll y g r a d u a l a n d p a t ie n ts a re g e n e ra ll y a w a k e a n d o rie n t e d . A tte m p t to e xc l u d e r e v e rs ib le c a u s e s a n d r e v i e w a l l m e d ic a ti o n s . If A lz h e i m e r' s d i s eas e is c o n f i rm e d , c o n s id e r p h a rm a c o lo g i c t h e r a p y a n d p ro v i d e a m u l ti d is c i p li n a ry a p p r o a c h . 9 8 . A n s w e r : T h e a n s w e r i s C T s c a n o f th e h e a d . P a t i e n ts o n wa rf a rin t h e ra p y r is k s u s ta i n i n g i n t ra c ra n ia l b le e d i n g a ft e r a fa l l. A C T s c a n s h o u l d b e o b t a i n e d t o ru le o u t a s u b d u r a l o r e p id u r a l h e m a t o m a . I f a h e m a to m a i s f o u n d , th e g o a l i s to r e v e rs e t h e a c u te b l e e d in g t h a t r e s u lts fro m w a r fa r in t h e ra p y . Th e q u ic k e s t m e t h o d o f r e v e rs in g t h e e f fe c ts o f w a r fa rin is a d m i n is t ra ti o n o f f re s h fro z e n p la s m a . 9 9 . A n s w e r : T h i s p a t ie n t h a s C A P . T h e c ri tic a l d e c is i o n to m a k e in e v alu a ti n g a p a tie n t w i th p n e u m o n i a is w h e t h e r to a d m i t t h e p a t ie n t o r to tre a t a s a n o u tp a t ie n t. F a c t o rs to c o n s id e r i n m a k i n g th i s d e c is i o n , in a d d i tio n to c l in ic a l ju d g m e n t , a r e a g e , p re s e n c e o f c o m o rb id c o n d i ti o n s (l i v e r d is e a s e , c a n c e r, C H F , c e r e b r o v a s c u l a r d is e a s e , re n a l d is e a s e ) , m e n ta l s ta t u s , v i ta l s i g n s a n d s e v e ra l la b o ra t o r y m a r k e r s (s e e T a b le 1 0 -1 : P n e u m o n i a S e v e rit y In d e x ). U s i n g th is in d e x , t h e p o in t to t a l f o r th is p a t i e n t i s 9 6 (c la s s II I) , a n d t h e re c o m m e n d a ti o n is a b ri e f p e ri o d o f h o s p it a li z a ti o n . T h is i n d e x i s a g e n e r a l g u id e l in e , a n d c lin ic a l j u d g m e n t is m o re im p o r t a n t (a n d o ft e n re l ie d o n ) i n m a k in g t h is d e c is io n . A n ti b io t ic t re a tm e n t w it h a fl u o ro q u in o lo n e s uc h a s l e v o fl o x a c i n i s a p p ro p ri a t e . 1 0 0 . A n s w e r: T h i s p a ti e n t i s i n a c u t e re s p i ra t o r y f a il u re . A lt h o u g h th e re a r e m a n y a c t io n s th a t s h o u ld b e t a k e n t o d e t e rm in e th e c a u s e o f t h e r e s p i ra t o ry f a il u re , t h e fi rs t s t e p m u s t b e to s ta b il iz e th e p a ti e n t . G i v e n th e d e g re e o f re s p i ra t o r y d is tr e s s , h y p o x ia , a n d fa i l u re t o re s p o n d t o o x y g e n , m e c h a n i c a l v e n ti la ti o n is i n d i c a t e d , a n d it s h o u l d n o t b e d e l a y e d fo r th e re s u l ts o f d ia g n o s ti c t e s ti n g , i n c lu d i n g A B G s . T h is p a ti e n t s ho u l d b e i n tu b a te d , a n d m e c h a n i c a l v e n t il a t io n s h o u l d b e i n it ia te d wi t h o u t fu r th e r d e la y .

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