TEST 41
QId: 2742
Angina
Classic
-typical location (substernal), quality & duration
-provoked by exercise or emotional stress
-relieved by rest or nitroglycerin
Atypical
-2 of 3 characteristics of classic angina
Nonangina
-<2 of the 3 characteristics of classic angina
40sM epigastric burning not relieved by antacids.... sensation brought on by heavy lifting at
work.
h/o for SLE. exam: BP 140/90mm.
EKG nml.
Q = management?
A = Exercise EKG (initially).....
confirm: Coronary Angiogram
epigastric discomfort on exertion that's NOT RELIEVED BY ANTACIDS***** (concerning for
heart pathology/ischemia)
Epigastric discomfort relieved by antacid (maybe GERD; peptic ulcer, esoph motility); w/no
evidence for heart ischemia....then maybe EGD
--------
SLE is RISK for accelerated atherosclerosis, and premature coronary heart disease
Medicine - Cardiovascular System
QId: 3340
Lactational Amenorrhea & anovulation dt high prolactin....has inhibitory effect on GnRH
production... (low GnRH inhibits LH, FSH production)
Lactation SUPPRESSES ovulation (thus it's a natural form of contraception for first 6 months
postpartum if mom is breastfreeding exclusively)
AFTER 6months; women resume ovulation (so another contraception method considered)
------
No FSH/LH; LOW prolactin (dt postpartum hemorrhage causing pituitary infarction: Sheehan
syndrome)
ss: cannot lactate, amenorrhea, HoTN (if pt has nml BP & can breastfeed... means nml pituitary
function)
*Prolactin causes continuous suppression of GnRH....results in reduced ESTROGEN levels
Lactation ? LOW estrogen = ss: menopause ss: (vagina atrophy, hot flashes, night sweats)
1
Unregulated Endometrium proliferation dt unopposed Estrogen (PCOS, obesity, tamoxifen) ss:
abnml uterine bleed
*Uterus adhesions (asherman sd) dt uterus curettage for abortion or retained placenta
*nml B-hCG undetectable 2-4wks after delvy
Obstetrics & Gynecology - Female Reproductive System & Breast
QId: 4459
High-Output cardiac failure
Congenital: patent ductus arteriosus; angiomas; pulmonary AVF; CNS AVF
Acquired: trauma; iatrogenic (femoral cath); Atherosclerosis (aortocaval fistula); cancer
-----
Adult: weakness and exertional dyspnea
h/o stab wound in THIGH right thigh
-R leg feels warmer & more flushed
Carotid upstroke brisk
Point max impulse displaced to left, soft systolic murmur; doesn't change w/valsalva
Q = most likely cause of pt's ss?
A = Increased cardiac preload
symptomatic AVF = abnml connection b/n arterial & venous systems that bypasses capillary
beds.
ss: wide pulse pressure, strong peripheral arterial pulsation (brisk carotid upstroke), flow
murmur, flushed limbs.
LV hypertrophy**; PMI displaced to left**
EKG LV hypertrophy
High output CF dt: thiamine def (alcohol), paget dz; thyrotoxicosis; anemia***
dx = doppler Ultrasound the limb
tx = surgery for large AVF
?CO in ischemic heart, htn, CM (nml or ?pulse P, weak carotid stroke, cold/pale limb
*
Medicine - Cardiovascular System
QId: 4753
Pneumonia w/parapenumonic effusion
-(transudate vs exudates)
-transudates dt to imbalance b/n hydrostatic & oncotic pressures that increases fluid movement
across capillaries into visceral pleura & pleural space
CHF, RA, chronic hep C w/early liver cirrhosis complains of difficulty breathing.
Resp 28/min. Thoracentesis show pleural fluid w/glucose 28mg and lactate DH 252.
2
Q = which explains low pleural fluid glucose concentration?
A = High WBC content of pleural fluid
Exudative effusions (pleural & lung inflammation ? ?capillary & pleural membrane permeability)
Pleural gluc <60mg dt Rheumatoid pleurisy, complicated parapneumonic effusion or empyema,
malignant effusion, TB pleurisy, lupus pleuritis, esoph rupture
-----
wrong:
*?pleura amylase (pleural effusion) dt esoph rupture or pancreatitis
*?capillary hydrostatic P (for transudative pleural effusions)
*?permeability of R hemidiaphragm ? R pleural effusions in cirrhosis (hepatic hydrothorax)
(cirrhosis ? transudate
Medicine - Pulmonary & Critical Care
QId: 4761
Congenital Torticollis
-head tilt to one side, neck mass, chin deviation....muscular torticollis
*congenital muscular torticollis
When baby lies down with HEAD FACING the preferred side; flattening of head on that side
------wrong:
*Cystic Hyromas - congenital lymphatic malformations located in posterior triangle of neck;
aneuploidy.
Fluctuant mass that transilluminates
*clavical fracture at birth = shoulder dystocia - crepitus, swelling decr ROM of ipsi upper limb
*Craniosynostosis - premature closure of cranial sutures...skull deformed but not anterior
displacement of ear and forehead (won't see head tile & neck mass)
*Acquired torticollis (from posterior fossa tumor)*** - ss: head tilt 2/2 tonsillar hernia &
compensatino for visual disturbances (neuro: ss: CN palsy) (not neck mass)
Pediatrics - Rheumatology/Orthopedics & Sports
QId: 11998
Leiomyomata uteri
20sF...LMP 9wks ago.
ros: feeling of incomplete bladder emptying*** (Frequently needs to go pee sensation)
"been happening for a while" prior to pregnancy..."
exam 15wk size, mobile uterus w/an irregular contour.
Q = likely etiology of her size date discrepancy?
A = Leiomyomata uteri (benign uterine fibroids)
ss: pelvic pressure, urine frequency to bathroom or incomplete voiding, constipation
3
-irregular uterine contour
fibroids can cause SIZE-date discrepency (on ultrasound)
(unsure gestation age)
large/multiple fibroids = risks ob complications: malpresentation, abruptio placenta, preterm birth
*adenomyosis - heavy menses bleeding; large uterus
*complete bole pregnancy - vagina bleed, hyperemesis gravidarum***, large uterus w/regular
contour shape
*Incorrect dating & multiple gestation causes size-date discrepancy but not etiology of pt dt
irregular uterine contour
*Polyhydramnios - ?size-date discrepancy in 2 & 3rd Tri...sob & large uterus
Obstetrics & Gynecology - Pregnancy, Childbirth & Puerperium
QId: 12328
Atypical Glandular Cells on Pap test can be dt cervical or endometrial adenocarcinoma
42yo sex active
-had tubal ligation.
-no abnml bleeding
Regular menses 3-5d, LMP 3wks ago.
exam: cervic w/o visible lesions, smal anteverted uterus, no adnexal masses.
**Pap test see atypical***** grandular cells
Q = next step mgmt?
A = Endometrial Biopsy
age >45: abnml uterus bleeding; postmenopause bleeding
<45: AUB + unopposed estrogen (lots E: obese, anovulation); failed medical mgmt; Lynch sd
(hereditary nonpolyposis colorectal cancer)
>35: Atypical glandular cells on pap test...
Obstetrics & Gynecology - Female Reproductive System & Breast
