clinical cases (1) june 30, 13
TRANSCRIPT
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
CURSO DE INGLÉS
ENGLISH COURSE
Dr. Juan Carlos Díaz TorrePediatra Neonató[email protected]
(779) 100 - 40 - 26
1
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
BRIEF CLINICAL CASES CASOS CLÍNICOS BREVES
(13)
Dr. Juan Carlos Díaz Torre
Pediatra Neonató[email protected]
(779) 100 - 40 - 26
2
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
3
Case # 161
A 58-year-old male who works with heavy machinery at a local factory presents to your office for evaluation of hearing loss of several years’ progression. He notes that the loss is mainly in the left ear and he also has mild tinnitus. He has had no trauma to his head, and he has no history of ear infections.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
4
Examination of the ears reveals normal tympanic membranes and a neurologic examination is negative. When a tuning fork is placed in the center of his forehead, he says the sound is much louder on the right side (Weber test). Comparing sound in front of the ear to the sound when the tuning fork is placed on the mastoid (the Rinne test) reveals that air conduction is better than bone conduction in the left ear.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
5
Which one of the following is true regarding further evaluation and management? :
a) Carotid ultrasonography should be ordered
b) No treatment or further diagnostic studies are indicated
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
6
c) A hearing aid plus better hearing protection is all that is needed
d) Audiometry is the best initial screening test
e) A tympanogram is indicated
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
7
Case # 162
A 6-year-old male is brought to your office 10 days after the onset of a cough and low-grade fever.On examination, his temperature is 37.9° C (100.2° F), pulse 100 beats/min, respirations 22/min, and O2 saturation 94%. He has diffuse wheezes on auscultation of his chest.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
8
His WBC count is 9800/mm (N 4,500 –11,000) with a slight left shift. His C-reactive protein level is mildly elevated and a chest radiograph reveals an interstitial infiltrate.
Which one of the following would be the most appropriate initial therapy?:
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
9
a) A Beta-lactam antibiotic
b) A macrolide antibiotic
c) Amoxicillin
d) Ceftriaxone (Rocephin)
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
10
Case # 163
A 75-year-old male is brought in by his family due to concerns about memory loss.
Which one of the following is best for determining whether or not he has dementia? :
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
11
a) A Mini-Mental State Examination (MMSE)
b) Non–contrast-enhanced CT of the head
c) An electroencephalogram
d) A lumbar puncture
e) MRI of the head
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
12
Case # 164
Of the following, which one has the greatest potential to spread via human-to-human transmission?:
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
13
a) Pneumonic plague
b) Botulism
c) Typhoidal tularemia
d) Coxiella burnetii (Q fever)
e) Inhalation anthrax
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
14
Case # 165
The mother of a 3-year-old male is concerned that he doesn’t like being held, doesn’t interact much with other children, and rarely smiles.
Of the following, which feature would be most helpful in distinguishing Asperger’s syndrome from autism in this patient?
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
15
a) Repetitive fine motor mannerisms
b) Delayed gross motor development
c) Normal language development
d) Preoccupation with parts of objects
e) Focused patterns of intense interest
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
16
Case # 166
A 76-year-old male is brought to your office by his son. The patient complains of dizziness that has slowly been worsening over the past year. His description is vague, but he says that he notices the dizziness when he tries to walk.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
17
The review of systems is normal, except for increasing problems with his “prostate” in the last 6 months, with dribbling and accidents at times.
His Mini-Mental State Examination (MMSE) score is 22 out of 30. No tremor is noted. A CBC, creatinine level, TSH level, vitamin B 12 level, and VDRL are all normal. Which one of the following should you do next?:
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
18
a) Order a brainstem auditory evoked potential
b) Prescribe sertraline (Zoloft)
c) Order physical therapy
d) Order a brain MRI
e) Prescribe carbidopa/levodopa (Sinemet)
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
19
Case # 167The most appropriate initial pharmacologic treatment of panic disorder is:
a) Valproic acid (Depakene)
b) Lithium
c) An SSRI
d) A tricyclic antidepressant
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
20
Case # 168
A 24-year-old worker at a local day-care center has not had a menstrual period in over 2 months. A home pregnancy test is positive and is confirmed in your office. She is concerned because she was recently exposed to a child who was diagnosed with rubella. A serum rubella IgG antibody test is negative.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
21
Which one of the following would be the best course of action?
a) Order level III ultrasonography to screen for congenital anomalies
b) Repeat the serologic testing in 2–3 weeks
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
22
c) Administer rubella immune globulin
d) Tell the patient she is immune to rubella and is not at risk
e) Administer live-virus rubella vaccine
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
23
Case # 169
A 23-year-old male with Down syndrome is brought to your office by his parents. The patient has had a low-grade fever (approximately 100° F) for 7 days. The fever is not associated with rhinorrhea, sore throat, cough, dysuria, or shortness of breath. The parents note that their son has complained of aches in various places, and has not been eating well for several weeks.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
24
The physical examination is remarkable for swollen lymph glands in multiple places, pale conjunctivae, and an 8-lb weight loss since his last visit 1 month ago.
Which one of the following is most consistent with this patient’s symptoms?
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
25
a) Urinary tract infection
b) Atypical pneumonia
c) Acute myeloid leukemia
d) Hodgkin’s lymphoma
e) Myocarditis
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
26
Case # 170
Which one of the following is true regarding Osgood-Schlatter disease?
a) Complete symptom resolution usually occurs in 18–24 months
b) Effusions are often present on examination and knee range of motion is limited
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
27
c) Most cases are triggered by a single traumatic event
d) Pain is localized to the inferior patellar pole at the origin of the patellar tendon
e) Pain usually begins at 20°– 30° of flexion
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
28
Case # 171
You see a 9-month-old white male for a routine examination. He was seen at 2 months and 4 months for routine care and immunizations, but was not brought back at 6 months. The mother states that he has an excellent appetite. She expresses no concerns except that the baby "seems cranky”.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
29
The child is somewhat obese and pale, but the rest of the physical examination is unremarkable. A heel stick hematocrit done in your office is 26%
Known risk factors for iron deficiency at this age include:
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
30
a) Maternal iron deficiency without anemia during pregnancy ( ) True ( ) False
b) Mild maternal anemia during pregnancy
( ) True ( ) False
c) Excessive blood loss during delivery( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
31
d) Prematurity ( ) True ( ) False
e) Breastfeeding ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
32
Case # 172
You learn that the child drinks 1.5 quarts of whole cow's milk per day, with a daily dose of iron mixed into the milk. Therapeutic interventions could include
a) Dietary instruction regarding overfeeding
( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
33
b) Limiting cow's milk to 1 pint a day or less ( ) True ( ) False
c) Blood transfusion ( ) True ( ) False
d) Continuing oral iron therapy, and advising the mother to avoid mixing it in the milk ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
34
e) Parenteral iron therapy ( ) True ( ) False
f) Oral vitamin C therapy ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
35
Case # 173
A 42-year-old white male wants a dark mole removed from his thigh because he is afraid it is a melanoma.
a) A biopsy is indicated if the lesion has increased in size recently.
( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
36
b) Has an irregular, notched border ( ) True ( ) False
c) Is mixed reddish-blue in color ( ) True ( ) False
d) Is pruritic ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
37
Case # 174
A biopsy confirms malignant melanoma in the superficial 0. 7 mm of the tissue submitted. Initial treatment should include:
a) Wide local excision ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
38
b) 8,000 rad local radiation ( ) True ( ) False
c) Regional node dissection ( ) True ( ) False
d) Fluoxymesterone (Halotestin), 10 mg orally
( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
39
Case # 175
A 56-year-old white female complains of painful, burning dysesthesias in her hands and feet. Her past history is positive for cancer of the ovary treated with chemotherapy. Physical examination is normal except for evidence of a purely sensory peripheral neuropathy.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
40
The etiology of peripheral neuropathy includes
a) Toxic effects of antineoplastic medications ( ) True ( ) False
b) Paraneoplastic syndrome ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
41
c) Vitamin B12 deficiency ( ) True ( ) False
d) Diabetes mellitus ( ) True ( ) False
e) Diabetes insipidus ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
42
Treatment options include
a) Chelation therapy ( ) True ( ) False
b) Carbamazepine (Tegretol) ( ) True ( ) False
c) Tricyclic antidepressants such as amitriptyline (Elavil)( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
43
Case # 176
A 60-year-old white male has pain that starts in the hypogastric area that subsequently localizes in the left lower quadrant. His maximum temperature is 38.5 ° C ( 101.3 ° F) and he is able to take oral fluids without difficulty .He is mildly tender in the left lower quadrant on examination and has no rebound tenderness.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
44
Appropriate management at this time would include
a) Emergency surgical consultation( ) True ( ) False
b) CBC ( ) True ( ) False
c) Urinalysis ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
45
d) Rectal examination ( ) True ( ) False
e) A liquid diet ( ) True ( ) False
f) Oral antibiotics ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
46
In 10 days the patient is reevaluated. His abdominal pain has resolved and he is afebrile. Appropriate measures would now include
a) A low-residue diet ( ) True ( ) False
b) Colonoscopy( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
47
Case # 177
He follows your recommendations and does well until 2 years later when the symptoms recur. He has delayed seeing you because he thought the symptoms would go away. Examination shows him to be extremely uncomfortable, with a temperature of 38.8° C (102.0° F), and tenderness in the left lower quadrant.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
48
On palpation, you suspect there may be a left lower quadrant mass. His abdomen is moderately distended with decreased bowel sounds. Appropriate measures at this time would include
a) A barium enema ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
49
b) A CT scan of the abdomen ( ) True ( ) False
c) A full liquid diet ( ) True ( ) False
d) Parenteral narcotics as needed ( ) True ( ) False
e) Broad-spectrum antibiotics ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
50
Case # 178
You are covering the emergency department at your local community hospital. A 24-year-old previously healthy white female presents with complaints of dry mouth and blurred vision associated with nausea, malaise, and the recent onset of diplopia. You learn that 2 days ago she enjoyed home-canned foods at a friend's house.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
51
On examination you note a slight but definite ptosis and a slightly disconjugate gaze. Her examination is otherwise unremarkable and comprehensive blood chemistries are normal.
You decide which of the following tests might be diagnostic? :
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
52
a) An MRI to rule out Guillain-Barre syndrome
( ) True ( ) False
b) A lumbar puncture to rule out a cerebrovascular accident ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
53
c) A doxycyline challenge for tick paralysis ( ) True ( ) False
d) A psychiatric consultation for hysteria
( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
54
Results of appropriate testing are normal. The patient complains that she is getting weaker and notes a feeling of dyspnea. Appropriate actions at this time would include which of the following?:
a) Admit the patient to the intensive-care unit
( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
55
b) Obtain psychiatric consultation ( ) True ( ) False
c) Begin intravenous ciprofloxacin (Cipro) ( ) True ( ) False
d) Monitor respiratory status closely ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
56
Case # 179
An obese 51-year-o1d white female consults you about her menstrual periods. For the past 6 months her menses have been irregular, spaced anywhere from 3-6 weeks apart. In addition, the flow has been considerably heavier and more prolonged than in the past. The only medication she is taking is a ginseng extract. She is not sexually active. Pelvic examination is normal.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
57
Appropriate diagnostic studies at this time include which of the following?
a) Thyroid-stimulating hormone (TSH) level( ) True ( ) False
b) CBC ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
58
c) Papanicolaou (Pap) test ( ) True ( ) False
d) Office endometrial biopsy ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
59
All laboratory tests ordered reveal normal results. The best approach to management at this time would include
a) Discontinuing ginseng ( ) True ( ) False
b) Dilatation and curettage ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
60
c) Endometrial ablation ( ) True ( ) False
d) Medroxyprogesterone acetate (Provera), 5-10 mg daily 10 days of each month
( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
61
Within 8 months, she has no further bleeding but reports hot flushes. After discussion with the patient, appropriate therapeutic options include which of the following?: a) Prescribe conjugated estrogen supplementation
( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
62
b) Prescribe combined estrogen and progesterone therapy ( ) True ( ) False
c) Recommend dilatation and curettage
( ) True ( ) False
d) Begin therapy with danazol (Danocrine) ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
63
Case # 180
An 84-year-old white male with a 5-year history of Alzheimer's disease is admitted to the nursing home because his family is having difficulty caring for him at home, due to increased confusion, incontinence, and combativeness. For the last week he has been having visual hallucinations.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
64
On admission to the nursing home he remains combative, striking out at staff and other residents, and is resistive to care. He is inattentive and distractible, and resists attempts at physical examination. His vital signs are stable, and a physical examination and laboratory workup fail to reveal any acute infections or other significant changes.
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
65
Current medications likely contributing to his altered mental state include which of the following?
a) Lisinopril (Zestril) ( ) True ( ) False
b) Cimetidine (Tagamet) ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
66
c) Nitroglycerin patch (Nitro-Dur) ( ) True ( ) False
d) Propoxyphene/acetaminophen (Darvocet-N 100)
( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
67
Which of the following historical features would suggest delirium, rather than progressive dementia, as a cause of his worsening condition?
a) Altered level of consciousness ( ) True ( ) False
b) Visual hallucinations for 1 week ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
68
c) Short-term memory impairment ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
69
He improves with behavioral management and medication changes, but remains combative and exhibits delusional and paranoid ideation. Which of the following neuroleptics could help control these problems with a relatively low risk of sedation and extrapyramidal side effects?
a) Olanzapine (Zyprexa) ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orre
70
a) Risperidone (Risperdal)( ) True ( ) False
b) Haloperidol (Haldol) ( ) True ( ) False
c) Thioridazine (Mellaril) ( ) True ( ) False
DR.
JCDT
Dr. Juan Carlo
s Díaz T
orreGracias por su atención
Dr. Juan Carlos Díaz Torre Pediatra Neonatólogo
[email protected](779) 100 – 40 - 26
71