A 34F, w/ long Hx of RA refractory to tmt w/corticosteroids & MTX presents d/t a 2-wks Hx of increasingly severe low back pain, decreased appetite, & malaise. She has never had low back pain in the past. She has not had fever, LE weakness, constipation, bladder or bowel incontinence, wt loss, or sensory changes. 6-wks ago, she began tmt w/infliximab b/c of bilateral wrist, hand, & knee pain. Temp is 98,6F. PE shows mild tenderness over the L1-L2 vertebrae. Labs show:
An MRI of the spine shows osteomyelitis of L1-L2 w/destruction of the intervertebral disc space & a 1.2-cm adjacent abscess. The abscess is debrided, & samples of the abscess & bone tissue are sent for analysis. A gram stain is neg. Pathologic exam of the bone specimen shows acute & chronic inflammation w/granuloma formation.
Which of the following is the most likely cause of these findings?
A 4B, presents to the ED 6 hrs after she noticed that his urine was red. He is otherwise feeling well. Fifteen days ago, the pt had sore throat, fever, & cough. His mother thought he had a flu & treated him symptomatically w/rest & analgesics, & his status improved until now. Temp is 101.3F, Pulse is 110/min, RR is 22/min, BP is 100/50. PE shows normal breath & cardiac sounds, no organomegaly, & 1+ LE edema, bilaterally. Labs show:
Which of the following is the most likely Dx?
A 10B, who was adopted from the Congo 2 wks ago presents for an initial exam. He appears slim, has thin extremities, & is in no distress. Temp is 99.1F, BP is 118/68, RR is 20/min. The lungs are clear to auscultation, & heart sounds are normal. The abd is soft & nontender, & there is no hepatosplenomegaly. There are four 0.5-mm, firm, nontender nodules: two over the right iliac crest, one on the left thigh, & one on the left knee. Exam of a skin snip shows microfilariae.
Which of the following is the most likely vector of this pt's infection?
A 55M, presents to the ED b/c of a 1-hr Hx of severe chest pain, nausea, & vomiting. He is agitated, clammy, & sweating profusely. Temp is 98F, pulse is 130/min, RR is 36/min, BP is 85/45. JVP is 12 & crackles are heard in the lung bases bilaterally.
Which of the following is most likely in this pt?
A previously healthy 32M, is brought to the ED by friends 45 mins after sudden onset of severe headaches, seizures, left-sided weakness, & nausea that began while they were attending a party. His friends believe there may have been drugs at the party. On arrival, he is alert & cooperative. He appears to be in pain. Pulse is 120/min, RR is 16/min, BP is 160/100. Neurologic exam shows bilateral dilated pupils, hyper-reflexia, & mild hemiparesis on the left side. He is oriented to person, place, & time. A CT of the head shows a 1.5-cm hemorrhage in the right basal ganglia.
Which of the following is the most appropriate next step in Dx?
Decreased sodium bicarbonate reabsorption in the proximal tubule
-Pt has Fanconi's syndrome → which presents w/:
1-Wasting a variable amounts of phosphate, glucose, amino acids, & bicarbonate by the Proximal renal tubule
Defects are associated w/reduced ATP & Na+/K+ ATPase activity
Causes of fanconi syndrome
1-Inborn errors of metabolism (cystinosis, galactosemia, fructosemia, tyrinosemia (most common)
[Pt probably has galactosemia (dehydration, decreased muscle tone]
2-X-linked syndromes (Lowe syndrome, Dent's disease)
3-Metals (Wilson's, heavy metal tox)
pt has crystals in slit lamp exam which indicates Wilson's
4-Meds (chemo, immunosuppressants, gentamicin, tenofovir, expired tetracyclines)
Signs & symptoms
4-Bone deformities pt has bowing of legs
-made by finding in urine:
DECREASED H+ ION SECRETION IN PROXIMAL TUBULE
-Seen in renal tubular acidosis type I
-Renal tubular acidosis is associated with a defect in the ability of the alpha intercalated cells to secrete H+ -> this would cause an increased pH
[pt has decreased pH*
A 40F, presents b/c of a 1-year Hx of progressive facial puffiness & wt gain. She also has had several URTI's during the the past 8 months. Temp is 99F, pulse is 82/min, RR is 18/min, BP is 160/95. PE shows increased fat around the neck, facial plethora, moon facies, red striae over the breasts, abd, & buttocks, & proximal muscle weakness. Serum studies show a mildly increased ACTH conc that is suppressed after an oral administration of dexamethasone for several days.
The most likely cause of the findings in this pt is hypersecretion of a hormone from a tumor located in which of the following organs?
-Usually presents w/:
1-People that travel to Middle East
2-Intermittent/spiking fever (w/weakness secondary to anemia)
3-Splenomegaly ± hepatomegaly
4-Pancytopenia (anemia, leukopenia, thrombocytopenia → pts can die of hemorrhage)
5-Kala-azar (black fever) → skin hyperpigmentation (fair skinned pts)
6-Papule at bite site → which expands & ulcerates (boils)
-Usually associated w/ bladder
-presents w/ localized erythema, pruritic maculopapular rash
-Acute onset fever, myalgias/malaise, abd pain, hepatosplenomegaly, headache, urticaria, cough, diarrhea (potentially bloody), lymphadenopathy
-Pt presents w/signs and symptoms of hypoparathyroidism → ↓PTH which will cause ↓Ca+
1-Tingling or burning (paresthesias) in fingertips, toes and lips
-Mucsle aches or cramps in legs, feet abd, face
-Twitching or spasms of muscles, particularly in around mouth, but also in hands, arms, throat → Pt has involuntary contractions
1-Fatigue or weakness
3-Patchy hair loss
4-Dry coats skin
6-Depression or anxiety
7-Ca+ deposits in brain leading to seizures
-Main symptoms are neurologic (altered mental status, weakness, twitching, seizures, coma)
[no pins & needles sensation]