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December 15, 2020

Question Recap:  A patient experienced a subarachnoid hemorrhage (SAH).

Which of the following is predicted by the modified Fisher scale?

Responses Received from Members (460 Total):

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Correct Response is:  A.  Risk of vasospasm

Question Explanation:  The modified Fisher scale is a method for grading SAH secondary to intracranial aneurysm rupture, usually present in the anterior portion of the circle of Willis. Smoking, alcohol, hypertension, and polycystic kidney disease are risk factors for SAH. Both the thickness of the blood and the presence of intraventricular extensions are used to determine the modified Fisher scale. The neurological outcome, severity, and mortality of SAH are assessed using the Hunt and Hess scale. Embolization is superior to surgical clipping in SAH. Nimodipine is a lipophilic calcium channel blocker that prevents subsequent stroke after SAH. Up to 70% of SAH patients who re-bleed will die.


December 8, 2020

Question Recap:  A 35-year-old woman presents to the emergency department with palpitations and anxiety that started 30 minutes ago. She has had similar episodes in the past and was able to improve her symptoms using the Valsalva maneuver. This time, however, her symptoms persisted. She has no chest pain or shortness of breath. Her medical history is unremarkable. An EKG is obtained and shown below.

What is the most likely diagnosis?

 

 

 

 

 

Responses Received from Members (555 Total):

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Correct Response is: B. AVNRT

Question Explanation:  AVNRT is the most common type of SVT. The EKG shows rapid, regular, and narrow complex tachycardia with short P waves in the ST segment (leads I, III, aVL, and V4), which is characteristic of short RP tachycardia due to AVNRT.

Atrial fibrillation is an irregularly irregular rhythm exhibiting long RP. Similarly, AVRT does not typically present with short RP. This EKG shows an isoelectric line following the QRS complex, which is not present in atrial flutter. The QRS complexes do not twist around the isoelectric line, making TdP an unlikely diagnosis.


December 1, 2020

Question Recap:  A 59-year-old woman presents to clinic for follow up because she had elevated transaminases during her last physical three months ago (ALT 58 U/L and AST 67 U/L). Her medical history is significant for hypertension, dyslipidemia, and type 2 diabetes mellitus. She takes chlorthalidone, metformin and lovastatin. She lives with her husband with whom she is monogamous and drinks 1-2 glasses of wine on weekends. She does not smoke or use illicit drugs.

Her physical examination is unremarkable. Her BMI is 31. Laboratory results include: hemoglobin 12 g/dL, hematocrit 40%, leukocytes 5,100/cc, platelets 140,000/cc, ALT 79 U/L, AST 85 U/L, INR 1.0, sodium 142 mEq/L, potassium 3.3 mEq/L, and HbA1c 7.7%.

What is the best next step in the management of this patient?

Responses Received from Members (451 Total):


 

 

 

 

Correct Response is: E. Follow up in 3-6 months

Question Explanation:  The most likely diagnosis in this patient with high BMI and metabolic syndrome is non-alcoholic fatty liver disease (NAFLD), causing the slight elevation in her liver enzymes. She should be counseled on diet modification and exercise to lower BMI and cardio-circulatory function because the most common cause of death in NAFLD is cardiac disease, not hepatic disease. Thus, the patient should be followed up regularly with serial transaminases every 3-6 months.

The American College of Physicians recommends HbA1c between 7-8% among patients with type 2 diabetes with no history of cardiac disease. This patient’s HbA1c is within recommended range and stopping metformin, her only anti-diabetes drug, is not the best option.

While statins, such as lovastatin, are associated with elevated transaminases, the rise is often subtle and transient. Statins should be discontinued if the transaminases rise by more than 3-5 times the upper normal limit.

Transient elastography is a non-invasive way to diagnose and assess liver cirrhosis. This patient has no hepatosplenomegaly, and her platelets are within normal range, suggesting no cirrhosis.

The amount of red wine this patient drinks on weekly basis in not considered harmful and is an unlikely cause behind the elevated liver enzymes, so a recommendation to stop alcohol completely is not warranted. NAFLD is the most likely diagnosis in this case.


November 24, 2020

Question Recap:  A 57-year-old man presents to clinic with left hand and right foot pain. His symptoms started 24 hours ago. During the past three days, he has been feeling a tingling sensation in both affected extremities. His medical history is significant for diabetes mellitus and hypertension.

His blood pressure is 150/90 mmHg, pulse 85/min, respiratory rate 15/min, and temperature 98F. Upon physical examination, there are varicose veins in the right leg with stasis dermatitis and an absence of pain sensation in the right leg with preserved vibratory sensation. Cranial nerve examination is unremarkable. Reflexes are normal in both arms but absent in both ankles.

Laboratory results include: hemoglobin 11 g/dL, hematocrit 40%, platelets 145,000/cc, RPR nonreactive, homocysteine 10 umol/L, methylmalonic acid (MMA) 0.1 umol/L, creatinine 0.9 mg/dL, sodium 140 mEq/L, potassium 3.7 mEq/L, INR 0.9.

What is the most likely diagnosis?

Responses Received from Members (411 Total):

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Correct Response is: D. Mononeuritis multiplex

Question Explanation:  The most likely diagnosis in this diabetic patient with multiple asymmetric peripheral neuropathy is mononeuritis multiplex. Mononeuritis multiplex is a painful asymmetrical sensory and motor peripheral neuropathy. It affects two or more nerves in the body located at two separate but distinct anatomical locations. Long nerves like sciatic, tibial, radial, and ulnar are affected first. In advanced cases, shorter nerves are affected and the disease is more symmetrical in nature.

Mononeuritis multiplex is commonly present in PAN, diabetes, SLE, and other connective tissue diseases, or with vascular inflammation. Clinical manifestations in a patient with a disease strongly associated with mononeuritis multiplex is often sufficient to make the diagnosis, but the most accurate test is biopsy of the nerve in the affected area. Treatment is directed towards the underlying cause. If symptoms persist, tricyclic antidepressants, gabapentin, or pregabalin can be used. Steroids are not effective.

ALS does not affect sensory neurons. MS does not affect the peripheral nervous system. The hands are not affected in L5 radiculopathy. The only two diseases that affect the posterior column are syphilis and vitamin B12 deficiency. However, the RPR is nonreactive in this patient and neither the MMA nor homocysteine levels are elevated, thus excluding syphilis and vitamin B12 deficiency, respectively.

Defects of the posterior column would affect position and vibratory sense, and this question specifically says vibratory sense is preserved.


November 17, 2020

Question Recap:  A 46-year-old woman presents to clinic for follow-up. She was diagnosed with celiac disease six months ago, but her symptoms improved after adhering to a gluten-free diet. Endoscopy with biopsy showed no lymphoma. Her vitals are normal and physical exam is unremarkable. She has no other medical conditions and does not smoke or drink.

Which of the following vaccinations should be administered at this time?

Responses Received from Members (497 Total):

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Correct Response is: E. Pneumococcus

Question Explanation:  Hyposplenism (functional asplenia) is common in celiac disease, and vaccination against encapsulated microorganisms like pneumococcus and meningococcus is warranted regardless of age.

Shingles vaccine is recommended at age 50, and the age cut-off for HPV vaccine is 45. Celiac disease patients are not at an increased risk for HBV or HAV. However, all diabetics should receive HBV vaccine and men who have sex with men as well as homeless persons should get HAV vaccine.


November 10, 2020

Question Recap:  A 69-year-old woman with a history of depression, congestive heart failure, and mitral valve replacement surgery presents to clinic with fatigue. Her blood pressure is 115/75 mmHg, pulse 68/min, respiratory rate 14/min, and temperature 98F.

Upon physical examination, there is no jugular venous distention, and the lungs are clear. Her heart exam reveals a laterally displaced point of maximum impulse and 2/6 crescendo-decrescendo systolic murmur at the left sternal border. Laboratory results include hemoglobin 10 g/dL, hematocrit 30%, WBC 5,000/cc, platelet 205,000/cc, MCV 96 fL, reticulocyte count 8%, and creatinine 0.9 mg/dL. Her aPTT, PT, and INR are within normal range. Peripheral blood smear is obtained and shown below.

Blood smear image

What is the best next step in the management of this patient?

Responses Received from Members (450 Total):

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Correct Response is:  A.  Obtain echocardiogram

Question Explanation:  The correct answer is obtain echocardiogram. The peripheral blood smear in this case shows schistocytes, which is consistent with microangiopathic hemolytic anemia (MAHA). The differential diagnosis of MAHA includes thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS), disseminated intravascular coagulation (DIC), uncontrolled hypertension, and prosthetic valvular disease.

This patient does not have fever, thrombocytopenia, neurologic changes, or renal disease, so TTP and HUS are unlikely. Additionally, she does not have hypertension, and her coagulation parameters are normal, so DIC is also unlikely.

MAHA in a patient with a prosthetic valve requires evaluation with an echocardiogram to ensure that the valve is functioning properly and rule out the need for valve replacement.


November 3, 2020

Question Recap:  A 27-year-old man with pancytopenia is found to have hypocellularity and absence of hematopoietic cells on bone marrow biopsy. Cytogenetic analysis of the bone marrow does not reveal abnormalities. Despite red blood cell and platelet transfusions, his pancytopenia worsens. He is an only child and his parents died in a motor vehicle accident when he was a teenager.

What is the best next step in the management of this patient?

Responses Received from Members (492 Total):


 

 

 

 

 

Correct Response is:  A.  Antithymocyte globulin, cyclosporine, and prednisone.

Question Explanation:  The correct answer is antithymocyte globulin, cyclosporine, and prednisone.

This patient has aplastic anemia, which is characterized by the T-cells attacking the bone marrow. While supportive treatment with transfusions is necessary, most aplastic anemia cases are not self-limited and have high recurrence rate.

Allogeneic bone marrow transplantation is the most efficacious option for patients with a suitable donor because survival rate is greater than 90%. If a marrow transplantation from a live match is not an option, a combination regimen consisting of antithymocyte globulin, cyclosporine (T-cell suppressor), and prednisone is the treatment of choice because the response rate is 75-85%.This patient has no donors.

Alemtuzumab is a monoclonal antibody against CD52 also used in the treatment of aplastic anemia.

Eculizumab is a monoclonal antibody against C5 compliment used in the treatment of hemolytic uremic syndrome, paroxysmal nocturnal hemoglobinuria, and myasthenia gravis. It is not efficacious against aplastic anemia.

You cannot do an autologous bone marrow transplantation when the person is not producing bone marrow.

 

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