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1. Clinical Vignettes


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Anatomy Clinical Vignettes
p. 68, 69
Baby vomits milk when fed and has gastric air bubble. What kind of fistula is present?
blind esophagus with lower segment of esophagus attached to trachea
20-year old dancer with decreased plantar flexion and decreased sensation over the back of her thigh, calf, and lateral half of foot. What spinal nerve?
Tibial (L4 to S3)
Patient with decreased pain and temp sensation over lateral aspects of both arms. Lesion?
Penlight in patient's right eye produces bilateral pupillary constriction. In left eye, there is paradoxical bilateral pupillary dilation. Defect?
atrophy of left optic nerve
Patient with decreased prick sensation on lateral aspect of leg and foot. A deficit in what muscular action can also be expected?
dorsiflexion and eversion of foot (common peroneal nerve)
Elderly woman with arthritis and tingling over lateral digits of right hand. Diagnosis?
Carpal tunnel syndrome, median nerve compression.
Woman in car accident cannot turn her head to the left and has right shoulder droop. What structure is damaged?
Right CN XI (runs through jugular foramen with CN IX and X), innervating sternocleidomastoid and trapezius muscles)
Man with one wild, flailing arm. Where is lesion?
contralateral subthalamic nucleus (hemiballismus)
Pregnant woman in 3rd trimester has normal blood pressure when standing and sitting. When supine, BP drops to 90/50. Diagnosis?
compression of IVC
Soccer player was kicked in leg and suffered a damaged medial meniscus. What else is likely to be damaged?
anterior cruciate ligament (remember the "unhappy triad")
Gymnast dislocates her shoulder anteriorly. What nerve is most likely to have been damaged?
Axillary nerve (C5, C6)
Patient with cortical lesion does not know that he has a disease. Where is lesion?
Right parietal lobe.
Child presents with cleft lip. Which embryologic process failed?
Fusion of maxillary and medial nasal processes.
Patient cannot protrude tongue toward left side and has right sided spastic paralysis. Where is lesion?
left medulla, CN XII
Teen falls while rollerblading and hurts his elbow. He can't feel the medial part of his palm. Which nerve and what injury?
Ulnar nerve due to broken medial condyle
24-year-old male develops testicular cancer. Metastatic spread occurs by what route?
para-aortic lymph nodes (recal descent of testes during development)
Field hockey player presents to ER after falling on her arm during practice. X-ray shows mid-shaft break of humerus. Which nerve and what artery are most likely damaged?
Radial nerve and deep brachial artery, which run together.
Patient cannot blink his right eye or seal his lips and has mild ptosis on the right side. What is diagnosis, and what nerve is often affected?
Bell's palsy; CNVII
Patient complains of pain, numbness, and tingling sensation. On exam, she has wasting of thenar eminence. What is diagnosis, and what nerve is often affected?
Carpal tunnel syndrome, median nerve
Behavioral Science Vignettes
p. 114,115
Woman with anxiety about gyn exam is told to relax and imagine going through steps of exam. What process does this exemplify?
systematic desensitization
65-year-old man is diagnosed with incurable metastatic pancreatic adenocarcinoma. His family asks you not to tell the patient. What do you do?
Assess whether telling patient will negatively affect his health. If not, tell him.
Man admitted for chest pain is medicated for ventricular tachycardia. The next day he jumps out of bed and does 50 pushups to show the nurses he has not had a heart attack. What defense mechanism?
You are attracted to your 26-year-old patient. What do you say?
Nothing! Tone must be professional. It is not acceptable to have romantic relationship with patients. Invite a chaperone into room if you think your actions may be misinterpreted.
Large group of people followed over 10 years. Every 2 years, it is determined who develops heart disease and who does not. What type of study?
cohort study
Girl can groom herself, can hop on one foot, and has an imaginary friend. How old is she?
Four years old
Man has flashbacks about his girlfriend's death 2 months ago following a hit-and-run accident. He often cries and wishes for the death of the culprit. Diagnosis?
normal bereavement
36-year-old woman with strong family history of breast cancer refuses a mammogram because she heard it hurts. What do you do?
Discuss risks and benefits of not having mammogram. Patients must give informed consent. If she refuses, you must abide by her wishes.
During a particular stage of sleep, man has variable blood pressure, penile tumescence, and variable EEG. What stage of sleep is he in?
REM sleep
15-year-old girl of normal height and weight for her age has enlarged parotid glands but no other complaints. The mother confides that she found laxatives in the daughter's closet. Diagnosis?
11-year-old girl exhibits Tanner stage 4 development (almost full breasts and pubic hair). Diagnosis?
advanced stage, early development.
4-year-old girl complains of burning feeling in her genitalia; otherwise she behaves and sleeps normally. Smear of discharge shows N. gonorrhoeae. How was she infected?
sexual abuse
72-year-old man insists on stopping treatment for his heart condition because it makes him feel "funny." What do you do?
Although you want to encourage him to take his medication, the patient has the final say. You should investigate the "funny" feeling and determine if there are drugs available that don't elicit this side effect.
Person demands only the best and most famous doctor in town. Personality disorder?
Nurse has episodes of hypoglycemia; blood analysis reveals no elevation in C protein. Diagnosis?
Factitious disorder; self-scripted insulin.
55-year-old businessman complains of lack of successful sexual contacts with women and lack of ability to reach full erection. Two years ago he had a heart attack. What might be the cause of his problem?
Fear of sudden death during intercourse.
Biochemistry Clinical Vignettes
p. 138
Full-term neonate of uneventful delivery becomes mentally retarded and hyperactive and has a musty odor. Diagnosis?
Stressed executive comes home from work, consumes 7 or 8 martinis in rapid succession before dinner, and becomes hypoglycemic. Mechanism?
NADH increase prevents gluconeogenesis by shunting pyruvate and oxaloacetate to lactate and malate.
2-year-old has increased abdominal girth, failure to thrive, and skin and hair depigmentation. Diagnosis?
Alcoholic develops rash, diarrhea, and altered mental status. Vitamin deficiency?
Vitamin B3 (pellagra)
20-year-old man presents with idiopathic hyperbilirubinemia. Most common cause?
Gilbert's disease
51-year-old man has black spots in his sclera and has noted that his urine turns black when he is standing. Diagnosis?
25-year-old male complains of severe chest pain and has xanthomas of his Achilles tendons. What is the disease, and where is the defect?
Familial hypercholesterolemia; LDL receptor
Microbiology Vignettes
An alcoholic vomits gastric contents and has foul smelling sputum. What organisms are most likely?
Middle-age man has acute monoarticular joint pain and bilateral Bell's palsy. What disease and how?
Lyme, Ixodes tick
Pt with Mycoplasma pneumoniae, cryoagglutinins. What Ig types?
U/A with WBC casts. Dx?
Young child with tetany, candidiasis, hypocalcemia, and immunosuppression. What cell is deficient?
Tcell (DiGeorge)
Pt with "rose gardener's" (thorn prick, ulcers along lymph drainage). What bug?
Sporothrix schenckii
25yr old med student has "burning" gut after meals. Gram negative rods in Bx. What organism?
H. pylori
32yr old man w/ "cauliflower" skin lesions. Bx shows broad-based budding yeasts. Organism?
Breast feeding woman w/ redness & swelling of right breast. Fluctuant mass. Dx?
Mastitis by S. aureus
Young child w/ recurrent lung infxns & granulomatous lesions. What defect in neutrophils?
NADPH oxidase (chronic granulomatous disease)
20yr old college student w/ lymphadenopathy, fever, hepatosplenomegaly. Serum agglutinates sheep RBCs. What cell infected?
B-cell (EBV; infectious mononucleosis)
1hr after eating custard at a picnic, whole family vomits. After 10hrs all better. Organism?
S. aureus(produces preformed enterotoxin)
Infant eats honey -> flaccid. Organism? Mechanism?
Clostridium botulinum; inhibited release of Ach
Man w/ squamous cell carcinoma, penis. what virus?
Pt w/ endocarditis 3wks after prosthetic heart valve. Organism?
S. aureus or S. epidermis
Pathology Vignettes
Woman w/ previous C-section has scar in lower uterus close to opening of the os. Risk for what?
Placenta previa
35yr old man w/ hi BP in arms. Low in legs. Dx?
Coarctation of Aorta
Woman w/ diffuse goiter and hyperthyroidism. Values of TSH and thyroid hormones?
Low TSH, and high thyroid hormones
Pt w/ extended expiratory phase. Disease process?
Obstructive Lung Disease
Woman w/ headache, visual disturbance, galactorrhea, amenorrhea. Dx?
Baby has foul smelling stool and recurrent pulmonary infxns. Dx? Test to confirm?
Cystic fibrosis. Chloride sweat test.
Obese woman w/ hirsutism and hi serum testosterone. Dx?
Polycyctic ovarian syndrome
Man w/ pain and swelling in knees, subcutaneous nodules around the joints and Achilles, exquisite pain in the metatarsophalangeal join of right big toe. Bx shows needle-like crystals. Dx?
Gouty arthritis
48yr old female w/ progressive lethargy and extreme sensitivity to cold temp. Dx?
Pt w/ elevated serum cortisol levels undergoes dexamethasone supp. test. 1mg doesn't lower cortisol. 8mgs does. Dx?
Pituitary tumor.
During a football game, player collapses/dies immediately. Likely Cardiac disease?
Hypertrophic cardiomyopathy
Child anemic since birth. Splenectomy would lead to an increased Hct in what disease.
Spherocytosis (intrinsic, extravascular hemolysis due to spectrin or ankyrin defect)
43yr old man experiences dizziness/tinnitus. CT shows enlarged internal acoustic meatus. Dx?
Child exhibits weakness and enlarges calves. Disease? How inherited?
Duchenne's muscular dystrophy, X-linked recessive.
25yr old female w/ sudden uniocular vision loss and slightly slurred speech. Hx of weakness and pareshesias that have resolved. Dx?
Multiple Sclerosis
Teenager w/ nephritic syndrome & hearing loss. Dx?
Alport's syndrome
Tall thin male teenager w/ abrupt-onset dyspnea & left-sided chest pain. Hyperresonant percussion on the affected side & diminished breath sounds. Dx?
Young man concerned about wife's URIs and inability to conceive. Also dextrocardia. What protein?
Dynein (Kartagener's)
55yr old man who smokes & drinks has cough & flu-like Sx. Gram stain shows nothing. Silver shows gram-neg rods. Dx?
Pt has stoke after incurring multiple long bone fractures in trauma stemming from MVA. Cause?
Fat emboli.
25yr old woman w/ a low grade fever, rash across nose from sun, widespread edema. Should be concerned about what disease?
50yr old man w/ diarrhea, PE reveals plethoric face and heart murmur. Dx?
Carcinoid syndrome
Elderly woman w/ a headache and jaw pain. Elevated ESR. Dx?
Temporal arteritis.
80yr old man w/ a systolic crescendo-decrescendo murmur. Most likely cause?
Aortic stenosis
Woman of short stature w/ short 4th and 5th metacarpals. Endocrine disorder?
Albright's hereditary osteodystrophy or pseudohypoparathyroidism
After stressful event, 30yr old man w/ diarrhea and blood per rectum. Intestinal bx shows transmural inflamm. Dx?
Young man w' mental deterioration and tremors. Brown pigmentation in a ring around periphery of cornea and altered LFTs. Tx?
Penicillamine for Wilson's disease.
Pt w/ fatigue, blood tests show macrocytic, megaloblastic anemia. Why danger to give folate alone?
Masks signs of neural damage w/ vitamin B12 deficiency
10yr old "spaces out" in class (stops talking midsentence and then continues as if nothing had happened). During spells, quivering of lips. Dx?
Absence seizure.
85yr old man w/ knee pain and swelling. X-ray shows increased joint space w/o erosion. Dx? What does aspirate show?
Pseudogout. Rhomboid calcium pyrophosphate crystals.
X-ray shows bilateral hilar lymphadenopathy. Dx?
5yr old boy w/ systolic murmur and a wide, fixed split S2. Dx?
Pharmacology Vignettes
28yr old chemist w/ MPTP exposure. Neurotransmitter depleted?
Woman taking tetracycline is photosensitive. Clinical manifestations?
Rash on sun-exposed regions of body
Non-diabetic pt has hypoglycemia but low C-peptide. Dx?
Surreptitious insulin injection
African-american man who goes to Africa develops a hemolytic anemia after taking malarial prophylaxis. Enzyme deficiency?
Glucose-6-Phosphate Dehydrogenase
27yr old female w/ hx of psych illness now has urinary retention due to a neuroleptic. Tx?
Farmer presents w/ dyspnea, salivation, miosis, diarrhea, cramping, blurry vision. Cause & mechanism?
Insecticide poisioning; inhibition of ACh-Esterase
Pt w/ recent kidney transplant is on cyclosporine for immunosuppression. Requires antifungal agent for candidiasis. What antifungal -> cyclosporine toxicity?
Man on several meds including antidepressants and antihypertensives, has mydriasis and becomes constipated. Cause?
55yr old postmenopausal woman is on tamoxifen therapy. Risk?
Endometrial carcinoma
Woman on MAO inh has hypertensive crisis after a meal. What did she eat?
Tyramine (wine/cheese)
After taking clindamycin, pt dev toxic megacolon and diarrhea. Mechanism?
Clostridium difficileovergrowth
Man starts meds for hyperlipidemia. Then rash, pruritus, and upset GI. Drug?
Pt on carbamazepine. What routine workup should always be done?
23yr old female who is on rifampin for TB prophylaxis and on birth control (estrogen) gets pregnant. Why?
Rifampin augments estrogen metabolism in the liver, rendering it less effective.
Pt develops cough and must discontinue captopril. What is a good replacement? Why not same side effects?
Losartan, an angiotensin II receptor antagonist, does not increase bradykinin as captopril does.

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