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Formative examination tutorial for internal medicine residents

Veerapong Vattanavanit, M.D. 3rd year Resident, PSU

Be prepare !All guidelines (esp. Thai version) Old MCQ sheets Find your weak points

SAQ, year 2010

SAQ 1

40 3 .. CT CT brain without and with contrast

SAQ 2

60 film

SAQ 3

60

SAQ 4

40 HIV on ARV DM HTN on metformin, HCTZ, hydralazine

SAQ 5

arterial blood gas ABG 2

pH 7.2 pCO2 50 pO2 65 HCO3 22

SAQ 6

40

SAQ 7

Grotton rash : a raised violaceous rash or papules at the knuckles, prominent in metacarpophalangeal and interphalangeal joints

Heliotrope rash : blue-purple discolouration on the upper eyelids in many cases associated with oedema

V sign : an erythematous rash on the face, neck, and anterior chest

Periungual telangiectasia : dilated capillary loops at base of fingernail with irregular, thickened and distorted cuticle

Mechanics hands : The lateral and palmar areas of the fingers may become rough with cracked, dirty horizontal lines,

Shawl sign : Poikilodermatous macules appear in a "shawl" distribution over the shoulder, arms and upper back

sites of compression (elbows, buttocks, back)

Malignant disorder

Ovary GI tract Lung Breast NHL Nasopharyngeal carcinoma

Complete annual exam

PV Mammogram Rectal radiographs Chest film CT : increased yield by 28%

EKG

SAQ 8

SAQ 9

38 blood smear 3

SAQ 10

Lab MEQ 25 2 1 . ascites smear ascites fluid Wright stain . .

Lab MEQ 25 . 6 BT 37.5 C cachexia oral thrush special strain . . .

Lab MEQ 35 3 Wright stain . . 3

Lab MEQ 35 . . 4

Lab MEQ 30 2-3 . . 3 . 1

Lab MEQ 30 3 4-5 eye ground . .

MCQ for resident 1

1. Toxin

1.Toxin

2

2

3.Keyword :Tissue diagnosis Primary tumor

4

5. Pancreatic pseudocyst

Indications for drainage Presence of symptoms (> 6 wks) Enlargement of pseudocyst ( > 6 cm) Complications Suspicion of malignancy

Intervention Percutaneous drainage Endoscopic drainage Surgical drainage

6

J hypertension, 2008

7

8

9

10

11Weil-Felix Test : Antibody to P.Mirabilis (OX-K) Agglutinins O. Tsutsugamushi crossreactivity Proteus sensitivity 73.3% specificity 52.5% false positive 55.6%

12

Diabetic neuropathy Distal symmetric diabetic polyneuropathy Autonomic neuropathy Focal and multifocal neuropathy CN III (pupil sparing) Median, ulnar, radial, peroneal n. Proximal diabetic neuropathy of the lower limbs (PDN) = diabetic amyotrophy = Bruns-Garland sydrome = femoral-sciatic neuropathy

12

Meralgia paresthetica is a symptom complex that includes numbness, paresthesias, and pain in the anterolateral thigh, which may result from either an entrapment neuropathy or a neuroma of the lateral femoral cutaneous nerve (LFCN).

13

-13

13

14

15

Blood test : lipid profile, FBS ,VDRL Cardiac work up : CXR , EKG

Echocardiogram, Holter monitoring 45 atherosclerosis DM, HT, smoking 1. ESR 2. ANA profile 3. Coagulogram , protein C , protein S , antithrombin III , anticardiolipin 4. Vascular work up Vascular work up : Carotid duplex ultrasound, Transcranial Doppler ultrasound, Magnetic resonance angiography, CT angiography

15

North American Symptomatic Carotid Endarterectomy Trial (NASCET). This trial confirmed the effectiveness of carotid endarterectomy in preventing stroke in 659 symptomatic patients who had TIAs or minor strokes with high-grade (70 to 99 percent), diameter-reducing carotid artery stenosis

17. Streptococcal toxic shock syndrome

18

19

NEJM, 2005

20

Hb>18.5 (M),16.5 (F) Epo JAK2 V167F mutation

21

22

22

23

Most patients with VT have a significant heart disorder, particularly prior MI or a cardiomyopathy. Electrolyte abnormalities (particularly hypokalemia or hypomagnesemia), acidemia, hypoxemia, and adverse drug effects contribute. Because nonsustained VT is a marker for increased risk of sudden death in patients with a structural heart disorder, such patients (particularly those with an ejection fraction < 0.35) require further evaluation. Such patients should receive an ICD.

24

Hereditary neuropathy

Group of diseases insidious onset and indolent course over years to decades Consider the possibility of an inherited neuropathies in any patient with a chronic acquired neuropathy who is refractory to treatment

Charcot-Marie-Tooth Diseasean estimated prevalence of 1 in 2500 in the United States Syndrome of peroneal muscular atrophy

Charcot-Marie-Tooth Disease

two main groups: the hypertrophic or demyelinating form (CMT1), in which there is marked reduction in motor NCVs and nerve biopsy findings of demyelination and onion bulb formation the axonal form of CMT disease (CMT2), in which motor NCVs are normal or near normal, with nerve biopsy findings of axonal loss without demyelination

Charcot-Marie-Tooth Disease 1

Onset at the first or second decade of life

Symmetrical weakness and wasting is found in intrinsic foot, peroneal, and anterior tibial muscles, pes cavus and hammer toe Absent ankle reflexes are universal

Charcot-Marie-Tooth Disease 2

Onset at the second decade peripheral nerves are not enlarged and upper limb involvement, tremor, and general areflexia occur less frequently

28

Muscle specific tyrosine kinase (MuSK) is a surface membrane enzyme that is essential in aggregating AChR during the development of the neuromuscular junction Recent studies have shown that antibodies to MuSK are present in patients with generalized seronegative MG. Anti-MuSK antibodies have been described in 40% to 70% of patients with generalized SN-MG, but not in patients with ocular myasthenia or antibodies to the acetylcholine receptor.

29

sign of Leser-Trlat

tripe palms

29

30

Behcets syndrome

33

HypervitaminosisA : C : D : E :

35

36

42

CD4 CD4 350-500 /.. . CD4 200-350 /.. CD4 200 /.. . CD4 .

46

Lancet, 2002

47

47

47

48 Thalassemia

Thalassemia

thalassemia and hemoglobinopathy Non disease forms thalassemia 1 trait (/--) thalassemia 2 trait (/-) homozygous thalassemia 2 (-/-) Hb CS trait (CS-/) Bart hydrop fetalis (--/--) HbH disease and HbH/CS disease (-/--) and (CS/--) AE Barts disease (-/--/HbE) and (CS/--/HbE) homozygous Hb CS (CS-/CS-)

Disease forms

thalassemia and hemoglobinopathy Non disease forms

Disease forms

thalassemia trait (/-) Hb E trait (/E) homozygous Hb E (E/E) homozygous thalassemia (-/-) thalassemia/Hb E disease (-/E)

48

48

48

48

A 27-year-old woman with 24th week of her second pregnancy was proving large fetus for gestational age had BP of 140/95 mmHg, mild pedal edema, protienuria 2+ on urinalysis. U/S revealed a large fetus with enlarged liver and spleen, ascites and pleural effusion CBC : Hb 10.3 g/dl, Hct 33%, MCV 69 fl, WBC 9.8x109/L, platelet 188 x109/L. Hb electrophoresis was performed : Hb A 97%, Hb A2 2.5% What is the hematological diagnosis in the father of the child? A. alpha-thalassemia-1 heterozygote B. alpha-thalassemia-2 heterozygote C. alpha-thalassemia-2 homozygote D. alpha-thalassemia Hb Constant Spring E. beta-thalassemia heterozygote

Thai Board exam 2543

Station advice

25 . 28 . : Hb 11 g/dl, Hct 33%, MCV 65 fl, MCH 21 pg Hb typing A 92%, A2 7%, F 1% : Hb 13 g/dl, Hct 38%, MCV 74 fl, MCH 28 pg Hb typing A 82%, E 18%

Station advice : thal trait : HbE trait

thal/Hb E thal trait

25% 25%

Hb E trait 25% Normal (A2A) 25%

prenatal diagnosis amniocytes PCR DNA

50Calcium (oxalate > P) 70% of kidney stones Urine characteristics : Ca oxalate urate pH citrate volume 24-h urine identifies specific urine risk factor Na and meat intake, thiazide ( urine Ca) Depending on 24-h urine :K-citrate, dietary oxalate restriction, allopurinol High dietary Ca is likely benificial by oxalate absorp., unclear role of Ca supplement

51

52

52Perhaps the most serious complication is amebic metastasis from the liver. Rarely, trophozoites end up in other regions of the body, such as the brain, spleen, lungs, and genitourinary tract, through hematogenous or direct spread. Brain abscesses are extremely rare and are associated with high mortality rates.

54

55

56

AIDS. 2007 Nov 30;21(18):2455-64. Risk factors for lactic acidosis and severe hyperlactataemia in HIV-1-infected adults exposed to antiretroviral therapy. METHODS: Lactic acidosis was defined as pH < 7.35, bicarbonate < 20 mmol/l and raised lactate; hyperlactataemia as two consecutive lactates > 5 mmol/l. The case-control study of 110 cases and 220 controls(two randomly selected from treated patients by centre and calendar year) from centres in 10 countries RESULTS: After adjusting for age, gender and current CD4 cell count, hyperlactataemia/lactic acidosis remained associated with