Pearls & Pitfalls

1. Pearls & Pitfalls

2. 63 y/o man with long standing HTN, hyperlipidemia arrives in office Friday afternoon with chest pain • 80 pack-year smoker • 1 year ago: cardiac cath: 3v CAD, not amenable to CABG/PCI – medical management (beta blocker, ASA, statin) • Severe pain centrally, to left arm and back

3. BP 180/110, pulse 90, resp 14, afebrile • No CHF, new AI murmur • Otherwise unremarkable exam

4. EKG

5. You start ASA, give a dose of metoprolol • Call Cardiology

6. What is your next step (diagnostic/therapeutic?)

8. Aortic dissection • h/o HTN, “tearing” pain, radiation to back • Can dissect into renal / mesenteric / carotid / coronary arteries (presents as acute MI, as in this case) • New AI murmur from aortic dilatation • PITFALL: no thrombolytics/anticoagulation if dissection suspected • Diagnosis confirmed with ECHO, CT, MRI • Call CT surgery

9. Objective: recognize the clinical presentation of aortic dissection

10. 27 year old man is admitted with chest pain after a rear-end motor vehicle accident 6 days ago • belted, 10 mph • History of HIV • Occasional thrush, no other opportunistic infections

11. How do you manage this patient?

12. Tube thoracostomy • 2. Bactrim for presumed PCP Objective: recognize PCP as a cause of spontaneous pneumothorax in patients with HIV

13. 50 year old man is admitted with chest pain • Becomes confused, clammy • Bp 90/58, pulse 106, rr 22 • Which ABG below would most likely fit the clinical picture? a) 7.40/40/100 c) 7.32/52/82 b) 7.52/26/90 d) 7.30/28/88 Objective: identify the blood gas findings in a patient with acute MI / cardiogenic shock

14. You evaluate a 47 year old woman with chronic kidney disease for hypertension. She has no history of diabetes, no cardiac problems, and other medical problems. She has followed a low sodium diet. She does not smoke or drink alcohol. • She is 5’ 8” tall and weighs 230 lbs. BMI is 35. • Blood pressure is 158/92, pulse 70. The exam is unremarkable. She appears well hydrated. • Creatinine is 3.2, glucose 90, and the remainder of the metabolic panel is normal. • Urinalysis shows 2+ proteinuria.

15. Which of the following interventions is most likely to reduce this patient’s risk of requiring dialysis in the future? a) implementing a low protein diet b) starting hydrochlorothiazide c) starting an ACE inhibitor d) starting amlodipine e) weight reduction until BMI is ≤ 30

16. Which of the following interventions is most likely to reduce this patient’s risk of requiring dialysis in the future? a) implementing a low protein diet b) starting hydrochlorothiazide c) starting an ACE inhibitor d) starting amlodipine e) weight reduction until BMI is ≤ 30

17. ACE inhibitors and kidney disease • Clearly reduce progression to ESRD in diabetic patients (especially with proteinuria – micro or macro) • Nondiabetic patients have similar benefit: • MDRD trial • Benazapril trial • REIN trial • REIN 2 trial • AASK trial • Even patients with creatinines up to 5.0 mg/dL had reductions in progression to ESRD • Be sure the patient is well hydrated, evaluate diuretic use. • AARBs – similar antiproteinuric effect, but outcome trials lacking Objective: Rx to limit progression renal disease in a 47 y/o woman w/chronic renal insufficiency

18. 64 year old woman with DM II for 20 years, gout, HTN seen in the office • No S3, no displacement of PMI, no increased JVD, no rales • History of “blood clot,” very high cholesterol (TC 320) • Findings below on BOTH legs: • Most likely cause of the exam finding? • CHF • Nephrotic syndrome • DVT • Gout • e) An overly aggressive GT3 exam Objective: identify cause of edema in patients with diabetic nephropathy

19. 35 year old woman with malaise, abdominal pain, diarrhea, nausea/vomiting • Recently visited here • What are you likely to find on stool gram stain? a) normal flora b) large parasites with few eggs, many RBC c) gram positive rods which are germ tube positive d) gram positive cocci in grape-like clusters e) the lost colony of Atlantis Objective: understand the most common cause of traveler’s diarrhea and how to identify it

20. You see a 32 year old man in the emergency department for fever, stiff neck and malaise. He has a petechial rash on his ankle. Gram stain of his CSF shows the following:

21. What therapy is warranted for the household family members of this patient? a) no therapy, watchful waiting is appropriate b) Penicillin V-K, 500 mg orally three times daily x 7 days c) Ciprofloxacin, 500 mg x1 (adults), oral rifampin x 2 days (children) d) meningococcal vaccine, post-exposure dose e) respiratory isolation, culture anterior nares, no therapy

22. What therapy is warranted for the household family members of this patient? a) no therapy, watchful waiting is appropriate b) Penicillin V-K, 500 mg orally three times daily x 7 days c) Ciprofloxacin, 500 mg x1 (adults), oral rifampin x 2 days (children) d) meningococcal vaccine, post-exposure dose e) respiratory isolation, culture anterior nares, no therapy Objective: recognize drug treatment for the family of a patient with meningococcal meningitis.

23. Meningococcal prophylaixs • Indicated for high risk exposure: • household contacts • >4 hours spent with patient for 5 of 7 days prior • dorms, barrack roommates, day care • mouth-to-mouth • Prophylaxis regimens: • rifampin (600mg q 12h x 4) – there is resistance to rifampin in some areas • cipro 500-750 mg x 1 • ceftriaxone 250 mg IM x 1

24. 35 year old man with this finding on tuberculin skin testing: • He begins treatment. Which of the following will help prevent symptomatic side effects of therapy? a) Vitamin B12, 1000mcg monthly b) Vitamin B3, 1 mg daily c) Vitamin B6, 50 mg daily d) folic acid, 1 mg daily e) Jack Daniels, nightly Objective: recall the management of side effects of anti-TB medications

25. You are consulted to see a 72 year old man whose urine output has diminished 48 hours after aortofemoral bypass grafting. He has Type II diabetes and hypertension, and has had claudication for 1 year, which was angiographically confirmed the morning of surgery. • He appears well hydrated. Blood pressure is 148/84; otherwise vital signs are normal. There is an S4 on exam, but no other abnormalities. Distal pulses are 1+ and symmetric. • Serum creatinine is 2.5 (baseline 1.2).

26. What is the most likely cause of the renal failure? a) contrast-induced nephropathy b) surgical error c) renal artery thrombosis d) atheroembolism to the renal artery e) post-op MI with congestive heart failure

27. What is the most likely cause of the renal failure? a) contrast-induced nephropathy b) surgical error c) renal artery thrombosis d) atheroembolism to the renal artery e) post-op MI with congestive heart failure Objective: recognize contrast nephropathy.

28. You are called to admit a 50 year old man from the emergency department for obtundation. The family states he has been complaining of fatigue for nine months, and two weeks of vomiting. He has also lost approximately 20 lbs. over the previous two months. • He has no other past medical history, and takes no medications. • Vital signs: • BP 96/60 P 88 R 20 T 38.4 C • On exam, the patient is obtunded but responds to painful and loud verbal stimuli. He grimaces when you palpate his abdomen. You notice dark coloration of his palmar creases.

29. What is the best initial management for this patient? a) Broad spectrum antibiotics b) Vasopressors c) Glucocorticoids d) L-thyroxine e) Thiamine

30. What is the best initial management for this patient? a) Broad spectrum antibiotics b) Vasopressors c) Glucocorticoids d) L-thyroxine e) Thiamine Objective: Understand initial treatment for a 50 y/o man w/fatigability/vomiting/wt loss/obtunded/brown palmar creases.

31. You see a 65 year old woman with Type II Diabetes who complains of exertional pain in the chest for the past three weeks. The episodes last a few minutes, are not associated with nausea or dyspnea, and resolve either with rest or spontaneously. She has no history of cardiac or pulmonary disease. She now presents with a similar episode of chest pain which has lasted about 35 minutes. • Her exam is normal. • EKG is completely normal.

32. What is the best initial management for this patient? a) Admission, cardiac enzymes, medical therapy for acute coronary syndrome b) Reassurance, prescribe GI cocktail c) Begin aspirin, schedule outpatient stress test d) Send for CT of the chest with PE protocol e) Immediate cardiac catheterization

33. What is the best initial management for this patient? a) Admission, cardiac enzymes, medical therapy for acute coronary syndrome b) Reassurance, prescribe GI cocktail c) Begin aspirin, schedule outpatient stress test d) Send for CT of the chest with PE protocol e) Immediate cardiac catheterization

34. EKG in Acute Coronary Syndrome • Initial ECG is often not diagnostic in patients with an ACS • In two series, • not diagnostic in 45 percent • normal in 20 percent of patients subsequently shown to have an acute MI • Patients with history suggestive of ischemia / ACS should be managed as such despite a normal or non-diagnostic EKG Objective: Manage a 64 yo woman w/type 2 DM with 3 weeks of exertional chest pressure and a normal ECG.

35. A 62 year old man with a history of chronic bronchitis is admitted to the hospital with lobar pneumonia. He presented to his physician after one day of cough and shortness of breath. He has no other chronic medical conditions. Baseline arterial blood gas is as follows: • pH 7.34 pCO2 68 pO2 60 • Vital signs on admission: • BP 130/80 P 100 R 24 afebrile • Pulse oximetry shows an SAO2 of 84% on room air. • He is begun on cefuroxime and azithromycin, oxygen therapy (40% by face mask), and IV fluids. • Twelve hours later, he appears somnolent. Arterial blood gas shows the following: • pH 7.18 pCO2 88 pO2 160

36. What is the most likely reason for the blood gas findings in this patient? a) Worsening pneumonia; non-responsive to chosen antibiotics b) Antibiotic-induced respiratory depression c) Exacerbation of chronic COPD d) Reduction in ventilation caused oxygen therapy e) Exacerbation of heart failure from excessive IV fluids

37. What is the most likely reason for the blood gas findings in this patient? a) Worsening pneumonia; non-responsive to chosen antibiotics b) Antibiotic-induced respiratory depression c) Exacerbation of chronic COPD d) Reduction in ventilation caused oxygen therapy e) Exacerbation of heart failure from excessive IV fluids Objective: Understand the cause ofblood gas changes in a 62 y/o man w/lobar pneumonia and chronic bronchitis.

38. A 48 year old man with no past medical history complains of six months of pain in his buttocks, especially when walking. He has had no chest pain or shortness of breath, and no leg pain. He is a smoker (1-2 packs per day) since high school but does not drink alcohol. He takes no medications. • Review of systems is positive only for erectile dysfunction; he asks you for a prescription for the “blue pill.”

39. Further studies would be most likely to show which of the following? a) Central disc herniation in the L4-L5 area b) A hard, nodular prostate exam with an elevated PSA c) Colonic dilatation on CT scan d) Reduced arterial blood flow in the distal legs e) Loss of the sacroiliac joint space on plain X-rays

40. Further studies would be most likely to show which of the following? a) Central disc herniation in the L4-L5 area b) A hard, nodular prostate exam with an elevated PSA c) Colonic dilatation on CT scan d) Reduced arterial blood flow in the distal legs e) Loss of the sacroiliac joint space on plain X-rays Objective: Diagnosis in a 48 y/o man with a 6-month history of pain in the buttocks w/walking and erectile dysfunction.

41. An 80 year old woman complains of fatigue and weakness for the past two months. She has otherwise been in good health, and takes no medications. Her age-appropriate cancer screening is up to date. • She appears well but pale. Vital signs are normal. There is loss of vibratory and position sense of both legs. • Initial labs show a hemoglobin of 9.0 g/dL; peripheral smear is shown below: What is the most likely diagnosis in this patient?

42. Pernicious anemia • Vitamin B12 deficiency • Megaloblastic anemia (hypersegmented PMN) • MCV often very high (>110) • Other cell lines may be affected in severe disease • “Subacute combined degeneration of the posterior (and lateral) columns” - neurologic disease not seen with folic acid deficiency • Paresthesias, ataxia, vibratory/position sense Objective: diagnose a patient with fatigue / anemia, a hemoglobin of 9, and an abnormal peripheral blood smear

43. You see a patient with knee pain and this joint aspirate. His liver is slightly enlarged and his blood glucose is 211. How do you work up the underlying hereditary disorder? Transferrin saturation (UIBC): Fe/TIBC [HFE gene] DX: CPPD/hemachromatosis (hyperparathyroidism, hypomagnesemia, hypophosphatemia)

44. A 59 year old man with a history of alcoholism is admitted to the hospital for cellulitis. He is coherent, and MMSE is 28/30. • Upon admission, his blood alcohol level is 10 mg/dL (BAC = 0.01). He is begun on antibiotics. • 24 hours later, you are called to evaluate him for “altered mental status.” He is afebrile; no rash is noted. His MMSE is 27/30, and his neurologic exam is non-focal. He describes “spiders” crawling on the walls and on his arms, and thinks he saw his dead mother sitting in the nurses station. • WBC is normal.

45. What is the most likely cause of this patient’s change in mental status? a) Delirium tremens b) Vitamin B12 deficiency c) Acute Wernicke’s encephalopathy d) Alcoholic hallucinosis e) Adverse effect of antibiotics

46. What is the most likely cause of this patient’s change in mental status? a) Delirium tremens b) Vitamin B12 deficiency c) Acute Wernicke’s encephalopathy d) Alcoholic hallucinosis e) Adverse effect of antibiotics

47. Alcohol withdrawal syndromes • Acute Wernicke’s usually rapid onset after administration of glucose in patients with underlying thiamine deficiency • Hallucinosis: • usually visual, but may be auditory • No clouding of sensorium • DTs: • Later manifestation Objective: explain the change in mental status 24 hours after admission in a patient with alcoholism

48. You see a 28 year old man with hyperlipidemia. His father, grandfather, and uncle all had coronary artery disease at an early age, and multiple family members have Type II diabetes. He does aerobic exercise regularly. • On exam, he appears well. Height 67 inches, weight 180 lbs. (BMI = 28) • Vital signs: bp 126/78 p 52 r 14 t 35.9 • His exam is normal. • Labs: TC 270 LDL 190 HDL 36 TG 220 • You start a statin. In addition to checking liver enzymes in a month, and a fasting serum glucose, what other lab tests would you order? Objective: recognize secondary causes of hyperlipidemia (hypothyroidism - up to 4% of patients with hyperlipidemia). TSH

49. 60 year old man, in good health, has a positive FOBT • Colonoscopy at age 51 was “normal” • Sent for colonoscopy – one polyp is found (pedunculated, hyperplastic by pathology) • When is his next colonoscopy due, assuming no abnormal signs/symptoms and negative FOBT in the interval? • 6 months • 1 year • 3 years • 7-10 years • Depends upon polyp size

50. Hyperplastic polyps • No malignant potential • “routine” screening interval • Need to differentiate from adenomatous polyp (ALL have malignant potential) • Tubular • Tubulovillous • Villous (highest potential) • Sessile polyps – harder to fully remove than pedunculated (but this is simply descriptive, no relation to malignant potential)