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Question of the Week #49

An 80 year-old male presents with lethargy and anorexia for three days duration. He has a history of atrial fibrillation and has been rate controlled for several years with digoxin. His history is otherwise unremarkable, and his physical exam is within normal limits. After labs are drawn he is found to have a plasma potassium level of 6.0 mEq/L and a digoxin level of 4.0 (normal therapeutic levels are between 0.8 - 2.0).

Each of the following may be a direct consequence of severe magnesium deficiency except:
a) digitalis induced arrhythmias
b) hypocalcemia
c) hypokalemia
d) hyponatremia
e) confusion
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Question of the week #12 by

A 22 year old female presents to a university health clinic with a 3-day history of urinary urgency and frequency. She states that she has had two prior urinary tract infections and feels she has developed another one. Urinalysis confirms the diagnosis of cystitis and you recommend a 3-day course of ciprofloxacin.

The mechanism of action of ciprofloxacin includes which of the following:

a)  Inhibition of cell wall synthesis.

b)  Inhibition of topoisomeras II/IV

c)  Inhibition of ribosomal protein synthesis

d)  Inhibition of mitochondria electron transfer

e)  Inhibition of folic acid metabolism
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Question of the week #11 by

A 42-year-old woman has noted increasing dyspnea for the past 6 years. On examination rales are auscultated in both lungs. She is afebrile. A chest radiograph shows an enlarged cardiac silhouette and bilateral pulmonary edema. Past history reveals that, as a child, she suffered recurrent bouts of pharyngitis with group A beta hemolytic streptococcal.

Which of the following cardiac valves are most likely to be abnormal in this woman?

a)  Aortic and tricuspid

b)  Mitral and pulmonic

c)   Aortic and pulmonic

d)  Tricuspid and pulmonic

e)  Mitral and aortic
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Question of the week #10 by

A 7 year old male is brought to the emergency department by his grandmother for evaluation of altered mental status.  You assess the patient, noting a somnolent child who moans in response to noxious stimuli. Vital signs include temperature 37.1 C, pulse 132 bpm, respirations 20/min, blood pressure 174/100, and oxygen saturation 94% in room air.  As you begin the physical examination, the patient experiences a generalized, tonic-clonic seizure. Seizure activity stops following a dose of intravenous lorazepam.   

Which of the following is the most appropriate next step in the management of this patient?

a)  Computed tomography (CT) of the head without intravenous contrast

b)  Lumbar puncture

c)  Sublingual nifedipine

d)  Intravenous fosphenytoin

e)  Intravenous nitroprusside
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Question of the week #9 by

An agitated and combative 23 year old female is brought to the emergency department by her concerned roommate.  Laboratory evaluation shows:

Sodium 143 mEq/L

Potassium 4.3 mEq/L

Chloride 101 mEq/L

Bicarbonate 9 mEq/L

Blood urea nitrogen 18 mg/dL

Creatinine 0.8 mg/dL

Glucose 74 mg/dL

An arterial blood gas shows pH 7.33, pCO2 26 mm Hg, pAO2 103 mm Hg, and a base excess of -15. 

Which of the following is the most appropriate interpretation of this patient's acid-base disorder?

a)  Acute respiratory acidosis without evidence of compensation

b)  Acute metabolic acidosis without evidence of compensation

c)  Acute respiratory acidosis with simultaneous acute metabolic acidosis

d)  Acute metabolic acidosis with partial respiratory compensation

e)  Acute respiratory acidosis with partial metabolic compensation
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Question of the week #8

You are looking after a 50 year old man who has severe acute pancreatitis secondary to biliary tract stones. He develops chills and rigors, and spikes a fever of 39.5 Celsius. He is complaining of increasing abdominal pain.

On exam he is jaundiced, and his blood pressure is 100/70 mmHg when supine falling to 90/60 mmHg when sitting, with an increase in heart rate from 95 to 120 beats per minute. His jugular venous pressure appears to be low. His abdomen is distended and clinically consistent with ascites. Over the next few hours his urine output falls from 50 ml/h to 15 ml/h.

Which of the following statements is FALSE?

a)  This man is at high risk of acute kidney injury due to obstructive jaundice and hypovolemia

b)  Urine sodium of 10 mmol/L would be consistent with ischemic ATN

c)  He should receive boluses of isotonic saline or colloid until the JVP and BP are normalized, with frequent review of the physical findings

d)  At this time administration of furosemide to increase urine flow is contraindicated

e)  Renal function should be monitored at least daily using serum creatinine
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Question of the Week #7

A 68 year old man is brought to the ER by EMS after being found unresponsive by his wife. He underwent a radical resection of his bladder for bladder carcinoma a month ago and has been experiencing persistent diarrhea since his discharge two weeks prior. His only other medical issues are glaucoma (treated with acetazolamide) and previous myocardial infarction but a complete history was not available.

On physical exam, the patient is unarousable even with sternal rubs and the rest of the exam is unremarkable. His vitals are temperature of 37.2 degrees, BP 115/70, HR 95 and RR of 22. A stat metabolic panel reveals:

Na: 137

K: 3.6

Cl: 95

HCO3: 20

BUN: 60

Cr: 3.4

Glucose: 342

Which of the following would explain the patient’s metabolic acidosis?

a) treatment of glaucoma

b) radical surgery of urinary bladder cancer

c) Persistent diarrhea

d) renal tubular acidosis type IV

e) diabetic ketoacidosis
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Question of the Week #6

A six year old girl comes to your office for her annual check up. On physical examination, you note a normal S1 and S2 as well as a soft systolic murmur with a vibratory character, heard best over the right upper sternal border. You suspect an innocent murmur, but her mother asks if she should be referred to a cardiologist.

Each of the following findings would support the diagnosis of a pathological murmur EXCEPT:

a) the murmur occurs in diastole
b) the murmur is associated with a thrill
c) the murmur is louder in the supine position and softer when the child sits upright
d) the child has mild finger clubbing
e) there is a loud P2 component of the second heart sound
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Question of the Week #5

You are called to assess a 4600g newborn who was noted be cyanotic. Upon arrival, you note a bluish discoloration of the patient's extremities, face, and trunk. An initial arterial blood gas analysis indicates a pAO2 of 40 mm Hg. Physical examination reveals a grade 2/6 systolic murmur and a loud second heart sound. The chest radiograph reveals a normal sized heart and decreased pulmonary vascular markings. After placing the infant under a hood containing 100% oxygen, his cyanosis improves, and you obtain the following arterial blood gas sample:

pH = 7.36

pCO2 = 37 mm Hg

pAO2 = 101 mm Hg

HCO3- = 20

Base excess = -3

Which of the following is the most appropriate interpretation of this infant's diagnostic evaluation?

a) The normal pAO2 on 100% oxygen indicates that cyanosis is likely due to methemoglobinemia

b) The arterial blood gas suggests alveolar hypoventilation is the mechanism for cyanosis

c) There is increased pulmonary vascular resistance, leading to a right-to-left shunt at the atrial or ductal levels

d) There is a right-to-left shunt at the ventricular level, likely due to complex congenital heart disease

e) This is acrocyanosis, and is a normal finding in a young newborn
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