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Test: ABIM core scripts
Young adult, no meds, presents with non-pitting lip edema that: Began in adolescence Triggered by strong emotions, crying Preceded by tingling lips and swelling over 24 hrs Resolves in 1-2 days 2-4 attacks/ year Unresponsive to antihistamines low C4 during episodes - Hereditary angioedema Young female with 6 month H/O Fever, wt loss, arthralgias Recurrent sinus infections Intermittent hematuria Papulosquamous rash on cheeks, extends to nose, spares nasolabial folds Violaceous mottled rash on forearms, thighs Bilateral active synovitis of MCPs Low WBC, Hgb, plts, + Coombs, hematuria, proteinuria, + anti-dsDNA and anti-Sm H/O childhood pneumonia with one episode of pneumococcal bacteremia - SLE presenting with early complement deficiency See complement deficiency, esp C1q Young adult, H/O N. meningitidis bacteremia at age 15, presents with: Fever HA Stable BP Diffuse erythematous maculopapular rash on extremities and thorax. Petechiae on oral mucosa and conjunctiva Absent Kernig, Brudzinski BCx- Gram neg cocci - N. men meningitis with terminal complement deficiency Usually have a less fulminant disease course Healthy patient with acute onset of: Generalized hives Dyspnea, wheezing after using latex gloves for the first time Tachycardia hypoxia Decreased air movement in lungs with audible wheezing - Anaphylaxis Do NOT require HoTN Common triggers: drugs (B-lactams), insect stings, foods (shellfish, peanuts), food additives Healthy pt with: Itchy hives on thighs, chest after exercise and hot showers
No wheezing, dyspnea - Cholinergic urticaria Healthy pt with: Chronic rhinorrhea and nasal congestion in the spring and fall Bilateral conjunctival injection, dark circles around the eyes, Dennie-Morgan lines (accentuated lines under the eyes) Pale blue nasal mucose with edema of the turbinates - Allergic rhinitis Pt presents with: Chronic nasal congestion, worse in spring and fall Swollen and "beefy red" or "boggy, erythematous" nasal mucosa - Rhinitis medicamentosa Note nasal exam is different from AR Young patient with: Diarrhea Foul smelling stools PMH: frequent ear, sinus infections as a child, allergies to several foods
- Giardia stool antigen - Selective IgA deficiency 85% have no symptoms Can see false positive pregnancy test, anaphylaxis with blood transfusion Previously healthy person presents with 1 week of: Exertional dyspnea and fatigue Chest discomfort and fullness Leg edema with clear lungs Low BP, SBP drops >10 with ispiration JVD with rapid x descent (nl/ absent y descent) EKG: sinus tach, low voltage, diffuse ST elevation with some T wave inversions CXR- enlarged cardiac silhouette - Acute pericarditis with tamponade Subacute onset, usually idiopathic Pulsus paradoxus (also in asthma, COPD, PE) Could see PA cath with equalization of diastolic pressures DDx - constrictive pericarditis (both x+y descent), MI (different EKG), Ao dissection (no JVD, edema) Pt with HO HTN, presents with acute CP and: HoTN JVD, increased a+v waves EKG: sinus brady, ST elevation in II, III, aVF, and V4R-V6R PA cath: low CO, PCWP, increased RAP - IWMI with RV infarct
Complete HB Slow HR with wide QRS makes it an escape rhythm, unlike wide complex tachycardia Female patient, smoker, on OCPs, presents with acute onset of: Dyspnea, pleuritic CP Hypotention, increased HR Increased P2 component of S low pO High D-dimer High troponin - Pulmonary embolism Young patient with history of primary Raynaud syndrome presents with: Acute chest discomfort HTN Positive UDS for cocaine EKG: ST elevation >1mm in II, III, aVF, returns to nl as soon as chest discomfort subsides Cath- nl coronaries - Variant angina (Prinzmetal;s) Vasospasm is usually inferion MI- EKG doesn't return to nl that quick See it more often in pts with H/O raynauds Pt with hyperlipidemia, HTN now with MI, 3 days ago: Acute dyspnea Hypotension Bilateral rales +/- JVD Hyperdynamic precordium with new systolic murmur at the apex with wide radiation - Papillary muscle rupture See acute onset new MR murmur Patient post-MI 3 days with: Hypotension JVD, bilateral rales, edema Hyperdynamic precordium with a thrill, new loud, harsh, holosystolic murmur at the LLSB with wide radiation - Ventricular septal rupture See biventricular failure, murmur in different location Pt with MI, now 3-5 days out, presents with: Acute recurrent CP Nausea Restlessness Hypotension PR prolongation and ST elevation consistent with pericarditis - Ventricular free wall rupture
Leads to tamponade, then death This was an incomplete rupture that clotted over 40-50 y/o smoker presents with: Claudication in feet and calves +/- hands, which progresses to rest pain Ulceration on the toes and fingers Negative ANA, RF, anti-centromere, anti-Scl-70, APLA Nl complement TEE: no intracardiac thrombus, valve lesions - Thromboangiitis obliterans Smoking activates it Think about with smoker and PVD symptoms Exclude autoimmune vasculitis, endocarditis 60 y/o male presents with Acute, severe, sharp CP, radiating to back and abdomen Hypotension, >20 SBP between the upper extremities Nl JVP Diastolic, decrescendo murmur loudest at R 2nd ICS EKG: non-specific ST, T wave changes CXR- widened mediastinuim - Aortic dissection With dissection near the AoV, can see it affect coronaries, give MI like EKG changes, but the pain here is like dissection Tearing, ripping, sharp pain Male pt with know bicuspid AoV presents with: Hypertension in the arms Diminished femoral pulses Low BP in the legs - Coarctation of the aorta Look for HTN with unequal pulses, pulse delay in the femoral artery Know assc of Coarc and bifid AoV Adolescent with HO sore throat and fever 2 weeks ago, now with: Migratory swelling and pain in large joints Erythematous, serpiginous rash on thorax Fever Systolic murmur at the apex Nl JVP, clear lungs EKG: prolonged PR interval - Rheumatic fever Most common valve lesion is MS, can see MR/AR Jones criteria: Major- arthritis, carditis, chorea, erythema marginatum, SQ nodules Minor- arthralgias, fever, increased ESR, prolonged PR
Healthy pt presents with: Mid-systolic click near S1, after the carotid upstroke, when standing Late systolic murmur, loudest at the apex - Mitral valve prolapse Click moves closer to S1 with lower volume (standing), which differentiates it from other systolic sounds Ejection clicks are very near S1, occur before the carotid upstroke IVDU with one week of: Fever Abd pain and fullness Lower extremity edema Increased JVP, more marker with inspiration Pulsatile hepatomegaly Holosystolic murmur at the mid-sternum - Tricuspid regurgitation from endocarditis If staph, tend to embolize vegetations into lungs Could include cough, dyspnea, pneumatoceles on CXR Stable pt. with COPD on chronic oxygen, inhaled steroids, long acting bronchodilators, short acting beta agonists, and theophylline presents with: Palpitations HR> EKG: 3 distinct P wave morphologies - Multifocal atrial tacycardia Theophylline use could trigger the ectopic focus Male patient with family history of sudden cardiac death has the following: Fatigue Exertional dyspnea Left ventricular lift Harsh, systolic, crescendo-decrescendo murmur at the left 2nd IC space and apex, decreases with squatting and increases with valsalva and standing from a squat - Hypertrophic cardiomyopathy Key is the murmur description and family history of SCD Usually autosomal dominant Pt. with recent history of ischemic HD and CABG presents with days to weeks H/O: Fatigue Recurrent chest discomfort Fever Leukocytosis +/_ pericardial friction rub CXR- increased cardiac silhouette - Post-pericardiotomy syndrome Without the H/O CABG, it would have been acute pericarditis- the surgery is the key!
Similar to post-MI infarction syndrome (Dressler's) Pt. with a recent history of MI, presents with days to weeks h/o: fatigue Recurrent chest disconfort Fever Leukocytosis +/- pericardial friction rub CXR- increased cardiac silhouette - Post-MI syndrome (Dressler) Pt presents with acute onset of: Fever Chronic, pleuritic chest pain, improved by leaning forward Audible scratch, loudest at the L sternal border EKG: nl voltage, depressed PR interval V5-V6, diffuse ST-segment elevation CXR- nl - Acute pericarditis Different from MI with prolonged pain, diffuse ST elevation Adolescent with asthma presents with: long standing intermittent, pruritic, papulosquamous eruption over antecubital fossa, behind knees; worse after hot showers - Atopic dermatitis (eczema) Adult pt with: "dandruff" and scaly rash around the nose with underlying redness when the scales are removed - Seborrheic dermatitis Can also present on eyebrows, lashes, facial hair HIV can have a much worse presentation Pt develops: Itchy, papulosquamous rash on abdomen- scaly, well circumscribed lesion at the area of the belt buckle - Contact dermatitis Common triggers: plants (poison ivy, oak), nickle, perfumes, rubber, synthetic shoe materials Adolescent develops: Erythematous, nodular, painful papules and pustules on the face, thorax, back Multiple open and closed comedones and inflamed, deep nodular lesions on the forehead, cheeks, thorax, and back - Acne vulgaris Severe acne with nodules can form sinus tracts - called acne conglobata- on chest and back Middle-aged female develops: "Acne" on the cheeks
Fever Sore throat 3 wks painful, erythematous nodules on shins-> bruises - Erythema nodosum Bilateral painful nodules over shins= E. nodosum! Assc. with GAS pharyngitis, Coccidiodes, Histoplasmosis, TB, sarcoidosis (with hilar adenopathy), IBD (with abd pain) 75% idiopathic Pt with active ulcerative colitis presents with: Pretibial sore, began as erythematous pustule->nodular->ulcer, ragged with purple raised border kin bx- tissue necrosis with neutrophilic infiltrate cx- Staph, no AFB, fungi - Pyoderma gangrenosum Keys: UC, neutrophilic infiltrate Pt with: Pain with walking Multiple raised verrucous growths on the heels and balls of the feet that obscure the nl skin markings and are painful when palpated - Verrucus vulgaris (plantar warts) Keys: wt bearing parts of feet, verrucous appearance, disruption of nl skin lines Sexually active pt with: multiple painless, cauliflower-like, verrucous lesions on the external genitalia - Condyloma accuminata Confused with condyloma lata of syphilis (flat, wet, not verrucous) Pt with: Multiple, painless clustered papules with central umbilication on the arm (or anywhere else) - Molluscum contagiosum Key- central umbilication Have depressed center to the lesions Can be large, numerous with HIV African American male, complains of hair loss after getting his hair cut by an electric razor Annular scaly patch of hair loss Small black dots over the hair follicles Palpable small posterior cervical lymph nodes - Tinea capitis Keys: elderly, African American, barber, black dots. Usually an unclean razor Pt with: annular scaly rash on arm, present since week after getting a new cat Clear towards center of rash with raised advancing erythematous margin and scale - Tinea corporis
Clues: cat. Could be wrestler. Often confused with herald patch of pityriasis, but that doesn't itch. Granuloma annulare doesn't scale. Nummular eczema looks different on micro Pt wears heavy shoes and goes to then gym with: Itchy rash between toes Multiple intensely pruritic pinpoint vesicles between the toes - Tinea pedis Can also see vesicles, nail thickening Dark skinned individual prEsents with: Scaly rash on chest Numerous hypo and hyper pigmented areas No large isolated patch No itching KOH stain- spaghetti and meatball fungal hyphae - Tinea versicolor Patches tend to be worse in the summer Disseminated skin rashes can be syphilis, micro gives diagnosis From malassezia furfur Adolescent from a group home with: Scalp itching Erythema at the base of the scalp Mild bilateral posterior auricular lymphadenopathy Woods lamp- small area of pale blue fluorescence at the base of multiple hair shafts - Pediculosis capitus= head lice Might see nits, louse picture Young sexually active adult with: Itching in pubic region Multiple small bluish macules along the upper abdomen and inner thighs Palpable small inguinal lymph node - Pediculosis pubis = pubic lice Blue macules not always present Can be visible Ddx scabies- see itching in other parts of the body as well Nursing home pt with: Itching, worse at night, x1 month Multiple excoriations in both axilla and groin, on the wrists, between fingers - Scabies May describe mite burrow Intense itching, ESP axillary and interdigital webs Middle aged Caucasian woman with:
Rash on forearm Multiple small painful blisters on external genitalia with surrounding erythema Several small target shaped lesions on forearm without scale or itch No mucosal lesions - Erythema multiforme with genital HSV Usually assc with new HSV infection, can also see with mycoplasma infection Pt with HIV: prescribed Bactrim for presumed pneumocystis infection 2 days later, gets fever, painful erythematous blistering rash on <10% of body surface, including mucous membranes, mouth, and conjunctiva - Stevens-Johnson syndrome Triggers: sulfas, abxs, allopurinol, antiepileptics (esp phenytoin, carbamazapine), NSAIDs Skin sloughing of >30%= toxic epidermal necrolysis Young patient with: Asymtomatic rash on back 1 wk after circular salmon-colored scaly patch on chest Multiple plaques on back with long axis oriented in direction of skin lines in "chrIstmas tree" distribution - Pityriasis rosea Obese pt with: Polyuria Velvety pigmented rash in folds of neck and axilla Fasting glucose >125 - Acanthosis nigricans Can see with DM, new GI or lung malignancies that are aggressive and quickly spreading Diabetic pt with: Yellowish irregular plaques with purplish pigment at the edges over both shins - Necrobiosis lipoidica diabeticorum Painful nodules would be E. Nodosa. These are yellow plaques Female with no PMH with: Chronic headaches Secondary amenorrhea Galactorrhea Possible bitemporal hemianopsia Low FSH, LH - Pituitary prolactinoma Increased PRL causes low LH, FSH, causing amenorrhea Galactorhhea= prolactinoma or hypothyroidism Postmenopausal female on no Meds with: HA, weight gain, constipation Alopecia
Delayed reflexes Low Na, FSH, LH, glycoprotein alpha- subunits - Pituitary gonadotroph tumor causing mass effect, hypogonadism, secondary hypothyroidism GP alpha subunits are seen in some pituitary tumors Premenopausal female with: Chronic malaise Constipation Alopecia Cold intolerance Galactorrhea MRI- increased pituitary size Prolactin level high, but <200 - Primary Hypothyroidism causing hyperprolactinemia Usually severe hypothyroidism Prolactinoma itself shouldn't cause hypothyroid symptoms Postmenopausal female with: Gradual development of HA and mental fogginess Constipation Alopecia Episodes of diaphoresis, pallor, tremors that improve with eating Low Hgb, Hct with nl MCV, MCHC Low Na, nl K High cholesterol, low FSH, LH - Hpopituitarism Has secondary hypothyroidism, adrenal insufficiency, hypogonadatropic hypogonadism. Hypogonadism, hypoglycemia from secondary adrenal insuff. Primary adrenal insuff would have hypokalemia; secondary doesn't Pt with HO: Primary hypothyroidism, adherent to thyroid replacement Takes multiple vitamins Chronic elevated TSH at FU - Malabsorption of Levothyroxine from Ca intake Male with OSA and : increased ring and shoe size Frontal bossing Deepening of voice Paresthesias in ring and pinky fingers Tan colored fleshy rash in armpits Multiple dental caries High fasting plasma glucose - Acromegaly Screen for with IGF-1 level
Middle aged pt with HO gradual alopecia and fatigue develops: Confusion Hypothermia, low BP, low HR Delayed reflexes Non-pitting ankle edema Low Hgb, Hct with l MCV, MCHC - Myxedema coma If you add hypoglycemia, you'd have to consider adrenal insufficiency Pt with gradual onset of: Tremulousness, anxiety, wt loss Diffuse muscle weakness Diarrhea Amenorrhea or ED HTN, tachycardia, possible atrial fibrillation and lid lag Low Hgb, Hct, nl MCV, MCHC High Ca, alk phos - Hyperthyroidism Expect undetectable low TSH, high FT These are all classic s/sx Pt with gradual onset of: Trenulousness, anxiety, wt loss, diffuse muscle weakness, diarrhea, amenorrhea or ED HTN, elevated HR, +/- a. fib and exopthalamos Low Hgb, Hct with nl MCV, MCHC HyperCa, elevated alk phos Uptake and scan: diffusely increased - Graves disease Classic hyperthyroid with the RAIU shows dx Can rarely see with Hashitoxicosis (early chronic autoimmune hypothyroidism) Pt with HO chronic anxiety, tremulousness, tachycardia, diarrhea develops: Acute illness, such as pneumonia, then becomes confused, febrile, hypertensive, delirious Low platelets, high Ca, High alk phos - Thyroid storm with preexisting Graves disease healthy pt with: Fatigue Painful swallowing Neck pain Very tender goiter decreased RAIU - Subacute hyperthyroidism Due to a virus
Healthy pt with: Recent onset anxiety, tremulousness that improves within days to weeks Decreased TSH, increased FT Decreased RAIU - Painless hyperthyroidism self resolving, has the decreased RAIU Reasonable amount go on to chronic autoimmune hypothyroidism Postpartum patient develops: Anxiety and tremulousness Nontender goiter
- anti-TPO - Postpartum thyroiditis same as painless, but positive anti-TPO and pregnant Healthy patient with: Midline palpable thyroid nodule Nl TSH US- solid mass without suspicious characteristics Thyroid scan= single cold nodule - Single cold thyroid nodule Needs bx Healthy pt develops: Gradual onset anxiety, tremulousness Palpable thyroid nodule Undetectable TSH Thyroid scan= single hot nodule - Toxic thyroid adenoma does not need bx Healthy pt with: Gradual onset anxiety, tremulousness, increasing neck mass Multiple palpable thyroid nodules of varying sizes Undetectable TSH Thyroid scan=multiple hot nodules with prominent cold nodule - Toxic nodular goiter with suspicious nodule The cold nodule needs biopsy Premenopausal female with: Gradual onset truncal weight gain, acne, amennorhea HTN, excess hair on chin and cheeks, fat in cervicaodorsal distribution, moon facies, plethora, bright purple abdominal striae High fasting glucose Nl anion gap Hypokalemia, alkalosis
Fever Hypotension, tanned skin Hyponatremia, hyperkalemia, low glucose, may have eosinophilia Cosyntropin stim- cortisol 7 at 60 min - Primary adrenal insufficiency Primary, you see increased ACTH-> tanning and high K; these are absent if secondary Gradual onset of: Weakness, N/V, sporadic abd pain Fevers Low glucose, +/- eosinophilia Nl HCO3 and K 60 min after cosyntropin stim: cortisol <20 - Secondary adrenal insufficiency No tanning or hyperK, so secondary Low stim test tells AI, not source Type 1 DM, gradual onset of: Fever, weakness, N/V, episodic abd tenderness Alopecia Low glu on previously stable insulin regimen HoTN, tanned skin, delayed reflexes Hyponatremia, hyperK, high TSH - Hypothyroidism and adrenal insufficiency Could be part of polyglandular autoimmune syndrome Must replace cortisol before thyroid! Tanned, so primary adrenal dz High TSH, so primary thryroid dz Three failing glands (all primary)= polyglandular syndrome 25 yo, no FH of HTN, develops: Hypertension low K - Secondary hyperaldosteronism from fibromuscular dysplasia; hyperreninemic hyperaldosteronism Always think of secondary cause of HTN with K abnormality Check PRA:PAC ratio 60 yo male, no PMH, no meds, develops: HTN Hypokalemia - Secondary hyperaldosteronism from renal artery stenosis hyperreninemic hyperaldosteronism Always think of secondary cause of HTN with K abnormality Check PRA:PAC ratio
35 yo female, no PMH, no meds, develops: HTN Hypokalemia Low plasma renin activity high plasma aldosterone concentration - Adrenal tumor: primary hyperaldosteronism with hyporeninemic hyperaldosteronism Tumor produces aldo, suppresses renin 55 yo, long standing HTN and DM, uncontrolled blood glucose, microscopic proteinuria, develops: Gradual increase K Stage 2-3 CKD on ACE Recent orthostatic HoTN mild low bicarb nl AG - secondary hyperaldosteroninsm caused by long standing DM Kidney complication of DM See the NAGMA= RTA Cosyntropin stim test would exclude hypoaldo (HoTN and HyperK) Healthy 30-40 yo, gradual development of episodic: HA Palpitations Sweating HTN - Pheochromocytoma 20 yo, primary amennorhea with: short stature wide spaced nipples minimal breast development webbed neck minimal axillary and pubic hair - Turner syndrome 45, XO 52 yo female with: Amenorrhea Episodes of diaphoresis and heat intolerance high FSH, LH - Menopause Pheo can do everything but the amenorrhea 38 yo female, HO other autoimmune diseases (ex. chronic autoimmune hypothyroidism) develops: Amenorrhea
