Expand the main groups of rheumatic diseases in old age, their physiological and clinical features
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Case 3 A 66-year-old man comes into your clinic as a new patient. Seven years ago at a work-related health screening, he was diagnosed with hypertension and hypercholesterolemia. At that time, he saw a physician who prescribed a diuretic and encouraged him to lose some weight and to diet and exercise. Since that time, the patient has not sought medical attention. During the past 2 months, he has been experiencing occasional headaches, which he attributes to increased stress at work. He denies chest pain, shortness of breath, dyspnea on exertion, or paroxysmal nocturnal dyspnea. He smokes one pack of cigarettes per day and has done so since he was 15 years old. He typically drinks two glasses of wine with dinner. On examination, the patient is obese, and you calculate his body mass index (BMI) as 30 kg/m2. His blood pressure is 168/98 mm Hg in the right arm and 170/94 mm Hg in the left arm. His blood pressure did not change with changes in position. His heart rate is 84 bpm. He has no thyromegaly or lymphadenopathy. Funduscopic examination reveals narrowing of the arteries, arteriovenous nicking, and flame-shaped hemorrhages with cotton wool exudates. Cardiac examination reveals that his point of maximal impulse is displaced 2 cm left of the midclavicular line. There is an S4 gallop. No murmurs are auscultated. Lung and abdomen examinations are normal.
What are your next steps? Ticket 4
Tell the effect of the change in the musculoskeletal system on the respiratory system. MCQ 1.A 65-year-old man with a history of rheumatoid arthritis is found to have a microcytic anemia. He had a colonoscopy 1 year ago which was normal and stool guaiac is negative. Which of the following is the most likely cause of his anemia? A. Iron deficiency B. Chronic disease C. Pernicious anemia D. Folate deficiency 2. A 68-year-old man is found to have an incidental finding of anemia while hospitalized with pneumonia. His physical examination is normal except for crackles in the left lower lobe. Serum laboratory examinations reveal a normal MMA and a decreased serum folate level. Which of the following is the best next step? A. Administer CAGE questionnaire B. Esophagogastroduodenoscopy C. Serum iron assay D. Neurology Consultation 3. A 70-year-old woman presents for evaluation of a lesion on her left cheek. It has been present for several months. It is slowly enlarging and bleeds if she scratches it. On examination, you find a 7 mm diameter pearly appearing papule with visible telangiectasias on the surface. Which of the following is the appropriate management of this lesion? A. Close observation and reexamination in 3 months B. Reassurance of the benign nature of the lesion C. Excision D. Local destruction by freezing with liquid nitrogen 4. A 78-year-old man with multiple medical problems presents with dysuria and is found to have microscopic hematuria. His examination is only positive for a very tender and boggy prostate. Which of the following is the best next step? A. Stat urology referral. B. Treat the prostatitis with 1 month of antibiotics and reevaluate the patient with a follow-up urinalysis and culture posttreatment. C. Obtain an IVP followed by cystoscopy. D. Obtain a CT of the abdomen and pelvis, followed by cystoscopy.
A 66-year-old man comes to the ER complaining of chest discomfort. He describes the discomfort as a severe, retrosternal pressure sensation that had awakened him from sleep 3 hours earlier. He previously had been well but has a medical history of hypercholesterolemia and a 40-pack-year history of smoking. On examination, he appears uncomfortable and diaphoretic, with a heart rate of 116 bpm, blood pressure of 166/102 mm Hg, respiratory rate of 22 breaths per minute, and oxygen saturation of 96% on room air. Jugular venous pressure appears normal. Auscultation of the chest reveals clear lung fields, a regular rhythm with an S4 gallop, and no murmurs or rubs. A chest radiograph shows clear lungs and a normal cardiac silhouette. The electrocardiogram (ECG) is shown ST-segment elevation. Elevated CK-MB isoenzyme (Creatine Phosphokinase)
_ What is the next step in therapy? Ticket 5
Select the features of the examination of the bronchopulmonary system in the elderly and senile age. 2.MCQ
In Nephrotic syndrome, all serum proteins are reduced except - Transferrin b) Fibrinogen Albumin d) Ceruloplasmin Most common cause of nephrotic range proteinuria in an adult is - Diabetes Mellitus Amyloidosis Hypertensive nephropathy Wegner's Granulomatosis Clinical feature of minimal glomerulonephritis are all except - Hypertension b) Edema Selective proteinuria d) Fever 4. A 67 -year-old man comes to the physician due to 2 days of back pain. He was moving boxes in his garage when the pain started. The pain is not relieved by lying down and increases in intensity when straining and coughing. He cannot sleep during the night due to pain, and has taken several acetaminophen tablets without relief. He has never had such pain before. He has point tenderness to palpation and percussion along the midline at the fourth lumbar vertebra. Which of the following is the most likely underlying etiology of this patient's current condition? A. Apophyseal joint arthritis B. Nerve root demyelinization C. Ligamentous sprain [35%1 D. loss of bone mineral density E. Nerve root demyelinization 3. Case Case 5 A 42-year-old Hispanic woman presents to the ED complaining of 24 hours of severe, steady epigastric abdominal pain, radiating to her back, with several episodes of nausea and vomiting. She has experienced similar painful episodes in the past, usually in the evening following heavy meals, but the episodes always resolved spontaneously within an hour or two. This time the pain did not improve, so she sought medical attention. She has no medical history and takes no medications. She is married, has three children, and does not drink alcohol or smoke cigarettes. On examination, she is afebrile, tachycardic with a heart rate of 104 bpm, blood pressure 115/74 mm Hg, and shallow respirations of 22 breaths per minute. She is moving uncomfortably on the stretcher, her skin is warm and diaphoretic, and she has scleral icterus. Her abdomen is soft, mildly distended with marked rightupper quadrant and epigastric tenderness to palpation, hypoactive bowel sounds, and no masses or organomegaly appreciated. Her stool is negative for occult blood. Laboratory studies are significant for a total bilirubin (9.2 g/dL) with a direct fraction of 4.8 g/dL, alkaline phosphatase 285 IU/L, aspartate aminotransferase (AST) 78 IU/L, alanine aminotransferase (ALT) 92 IU/L, and elevated amylase level 1249 IU/L. Her leukocyte count is 16,500/mm3 with 82% polymorphonuclear cells and 16% lymphocytes. A plain film of the abdomen shows a nonspecific gas pattern and no pneumoperitoneum. _ What is the most likely diagnosis? _ What is the most likely underlying etiology? _ What is your next diagnostic step? Ticket 6
List the common diseases of the bronchopulmonary system in the elderly and senile age. 2.MCQ
A. Hydrochlorothiazide B. Furosemide C. Carvedilol D. Spironolactone E. Digitalis
A 70-year-old African American man with New York Heart Association Class III heart failure sees you for follow-up. He has shortness of breath with minimal exertion. The patient is adherent to his medication regimen. His current medications include lisinopril 40 mg twice daily, carvedilol 25 mg twice daily, and furosemide 80 mg daily. His blood pressure is 100/60 mm Hg, and his pulse rate is 70 bpm and regular. Physical examination findings include a few scattered bibasilar rales, an S3 gallop, and no peripheral edema. An ECG reveals a left bundle branch block and echocardiography reveals an ejection fraction of 25%. Which of the following is the best next step for this patient? A. Increase the furosemide dosage to 80 mg twice daily. B. Refer for coronary angiography. C. Increase the lisinopril dosage to 80 mg twice daily. D. Increase the carvedilol dosage to 50 mg twice daily. E. Refer for cardiac resynchronization therapy. A 66-year-old woman has an average blood pressure of 150/70 mm Hg despite appropriate lifestyle modification efforts. Her only other medical problems are osteoporosis and mild depression. Her last lipid panel revealed a total cholesterol of 160 mg/dL, high-density lipoprotein (HDL) 40 mg/dL, and low-density lipoprotein (LDL) 90 mg/dL. Which of the following would be the most appropriate treatment at this time? A. Lisinopril (Prinivil, Zestril) B. Propranolol (Inderal) C. Amlodipine (Norvasc) D. Hydrochlorothiazide E. Clonidine (Catapres) 4.A pt presents with longstanding gastric reflux, dysphagia and chest pain. On barium enema, dilation of esophagus with tapering end is noted. He was found with Barrett’s esophagus. He had progressive dysphagia to solids and then liquids. What is the single most appropriate dx? a. Esophageal carcinoma b. Esophageal spasm c. GERD
d. Barrett’s esophagus 3. Case Case 6 A 64-year-old man presents with sudden onset of shaking chills, fever, and productive cough. He was in his usual state of good health until 1 week ago, when he developed mild nasal congestion and achiness. He otherwise felt well until last night, when he became fatigued and feverish, and developed a cough associated with right-sided pleuritic chest pain. His medical history is remarkable only for his 15-pack per year smoking habit. In your office, his vital signs are normal except for a temperature of 102°F. His oxygen saturation on room air is 100%. He is comfortable, except when he coughs. His physical examination is unremarkable except for bronchial breath sounds and end-inspiratory crackles in the right lower lung field. _ What is your diagnosis? _ What is your next step? Ticket 7
Make a investigation plan for pneumonia in the elderly and senile age. 2.MCQ
A. Pneumonia B. Intraperitoneal leak from bowel injury C. Surgical site infection D. Deep tissue abscess 2. A 78yo woman presents with unilateral headache and pain on chewing. ESR= 70mm/hr. She is on oral steroids. What is the appropriate additional tx? a. Bisphosphonates b. HRT hormonal replacement therapy c. ACEi d. IFN
e. IV steroids 3. The body of a 65yo man who was treated for TB and bronchitis was seen at autopsy. His legs were swollen and his liver showed signs of a transudate fluid. What was the cause of the transudate? a. Liver cirrhosis. b. Alcoholic liver disease. c. Cardiac failure. d. Budd-chiari syndrome. e. TB.
pain comes in waves and is accompanied by nausea. Nothing seems to relieve the pain. He feels hot and sweaty but has normal temp. What is the most appropriate next inv: A.US Abdomen b. ERCP c. MRCP
d. Serum amylase e. UGI endoscopy 3.Case Case 7
A 72-year-old man is admitted to the hospital because of acute onset of a right facial droop, right arm weakness, and some difficulty speaking. These symptoms started 6 hours ago while he was sitting at the breakfast table. He had no headache, no diminishment of consciousness, and no abnormal involuntary movements. Two weeks ago, he had a transient painless loss of vision in his left eye, which resolved spontaneously within a few hours. His medical history is significant for long-standing hypertension and a myocardial infarction (MI) 4 years previously, which was treated with percutaneous angioplasty. His medications include a daily aspirin, metoprolol, and simvastatin. He does not smoke. When you see him in the emergency room, his symptoms have nearly resolved. He is afebrile, heart rate 62 bpm, and blood pressure 135/87 mm Hg. The corner of his mouth droops, with slight flattening of the right nasolabial fold, but he is able to fully elevate his eyebrows. His strength is 4/5 in his right arm and hand, and the rest of his neurologic examination is normal. He has no carotid bruits, his heart rhythm is regular with no murmur but with an S4 gallop. The remainder of his physical examination is normal. Laboratory studies, including renal function, liver function, lipid profile, and complete blood count (CBC), all are normal. Within a few hours, all of the patient’s symptoms have resolved. _ What is the most likely diagnosis? _ What is the next step? Ticket 8
Assess the severity of the condition with pneumonia in the elderly and senile age. 2. MCQ
1. 65yo male with epigastric discomfort has been given triple therapy. He has now returned after 4wks of epigastric discomfort. What inv would you do for him?
ECG H pylori breath test Endoscopy and biopsy US 2. An elderly male pt with prior hx of hematemesis is having hx of long term use of aspirin and other drugs, now presents with severe epigastric pain, dysphagia and vomiting. He was connected to vital monitors which were not reassuring. What is the management? a. Oral antacids b. IV PPI c. Oral PPI d. Endoscopy 3. A 14yo boy has been dx with nephrotic syndrome. 5d later he presents with flank pain, hematuria and fluctuating urea levels. A dx of renal vein thrombosis is made. What is the most likely cause for renal vein thrombosis? a. Protein C deficiency b. Vasculitis c. Loss of antithrombin III d. High estrogen levels 4. A 67 yo man, known smoker, comes to the hospital with complaints of painless hematuria, urgency and dysuria. He has been worried about his loss of weight and reduced general activity. Which inv would be diagnostic of his condition? a. Urine microscopy b. Cystoscopy with biopsy c. CT d. Cystoscopy e. US abdomen 3. Case
Case 8 A 68-year-old man comes to see you because of shortness of breath. He has experienced mild dyspnea on exertion for a few years, but more recently he has noted worsening shortness of breath with minimal exercise and the onset of dyspnea at rest. He has difficulty reclining, and, as a result, he spends the night sitting up in a chair trying to sleep. He reports a cough with production of yellowish-brown sputum every morning throughout the year. He denies chest pain, fever, chills, or lower extremity edema. He has smoked about two packs of cigarettes per day since age 15 years. He does not drink alcohol. A few months ago, the patient went to an urgent care clinic for evaluation of his symptoms, and he received a prescription for some inhalers, the names of which he does not remember. He was also told to find a primary care physician for further evaluation. On physical examination, his blood pressure is 135/85 mm Hg, heart rate 96 bpm, respiratory rate 28 breaths per minute, and temperature 97.6°F. He is sitting in a chair, leaning forward, with his arms braced on his knees. He appears uncomfortable with labored respirations and cyanotic lips. He is using accessory muscles of respiration, and chest examination reveals wheezes and rhonchi bilaterally, but no crackles are noted. The anteroposterior diameter of the chest wall appears increased, and he has inward movement of the lower rib cage with inspiration. Cardiovascular examination reveals distant heart sounds but with a regular rate and rhythm, and his jugular venous pressure is normal. His extremities show no cyanosis, edema, or clubbing. _ What is the most likely diagnosis? _ What is the next best diagnostic test? _ What is the best initial treatment? Ticket 9
List the features of age-related alteration in digestion.(5 points) 2. MCQ
A. Upper endoscopy B. Removal of angiotensin-converting enzyme (ACE) inhibitor C. Nitroglycerine patch D. Chest radiograph 2. A 64yo alcoholic who has been dx with liver cirrhosis presents with a massive ascites. What is the mechanism of fluid accumulation in a pt with liver disease? a. Cirrhosis b. Portal HTN c. Hypoalbuminemia d. Liver failure e. Hepatic encephalopathy 3. A 66 yo man has an intermittent epigastric pain for 3wks. It is worse by food but helped by some tablets he obtained from the pharmacy. He had a similar episode 3yrs ago and his doctor gave him a course of 3 types of tablets at the time. What is the most appropriate next inv? a. Abdomen US b. Barium meal c. Serum H.Pylori antibodies d. Urea breath test e. Upper GI endoscopy 4. A 65yo man complains of hematuria, frequency, hesistancy and nocturia. He reports that on certain occasions he finds it difficult to control the urge to pass u9rine. Urine microscopy confirms the presence of blood but no other features. What is the most porbable dx? a. BPH b. Bladder ca c. Prostatic cancer d. Pyelonephritis e. Prostatitis 3. Case
Case 9 A 61-year-old woman presents to the ER complaining of a 4-week history of progressive abdominal swelling and discomfort. She has no other gastrointestinal symptoms, and she has a normal appetite and normal bowel habits. Her medical history is significant only for three pregnancies, one of which was complicated by excessive blood loss, requiring a blood transfusion. She has been married and monogamous for 20 years, exercises, does not smoke, and drinks only occasionally. On pointed questioning, however, she does admit that she was “wild” in her youth, and she had snorted cocaine once or twice at parties many years ago. She does not use drugs now. She was HIV negative at the time of the birth of her last child. On examination, her temperature is 100.3°F, heart rate 88 bpm, and blood pressure 94/60 mm Hg. She is thin, her complexion is sallow, her sclerae are icteric, her chest is clear, and her heart rhythm is regular with no murmur. Her abdomen is distended, with mild diffuse tenderness, hypoactive bowel sounds, shifting dullness to percussion, and a fluid wave. She has no peripheral edema. Laboratory studies are normal except for Na 129 mEq/L (normal 135-145), albumin 2.8 g/dL (normal 3.5-5 g/dL), total bilirubin 4 mg/dL, prothrombin time 15 seconds (normal 11-13.5 s), hemoglobin 12 g/dL with mean cell volume (MCV) 102 fL (normal 78-95), and platelet count 78,000/mm3 (normal 150 000-500 000). _ What is the most likely diagnosis? _ What is your next step? Ticket 10 1.Expand the main groups of rheumatic diseases in old age, their physiological and clinical features 2.MCQ 1. A 65yo man presented with frank hematuria. He has no other urinary symptoms. What is the most appropriate next step that will lead to the dx? a. Transrectal US b. US Abdomen c. Cystoscopy d. Mid-stream urine for culture
of waking up in the night to go to the washroom and has urgency as well as dribbling. What is the most likely dx? a. Bladder carcinoma b. Prostatitis c. UTI d. Prostate carcinoma 3.A young boy presented with bilateral periorbital edema, ankle swelling and increase in body weight. What is the most likely dx? a. Chronic heart failure b. Nephrotic syndrome c. Renal failure d. Acute heart failure e. Glomerulonephritis
hot bath. He also has nocturia, polyuria and nausea and vomiting. Exam: pallor, pigmentation and generalized edema. What is the single most likely dx? a. Hyperthyroidism b. Chronic renal failure. c. Liver failure d. Eczema 3. Case
Case 10 A 65-year-old man comes to an outpatient clinic complaining of low-grade fever and sore throat, and he receives an injection of intramuscular penicillin for presumed streptococcal pharyngitis. Within 20 minutes, he begins to complain of swelling of his face and difficulty breathing. He looks dyspneic and frightened. His heart rate is 130 bpm, blood pressure 90/47 mm Hg, and respiratory rate 28 breaths per minute and shallow. His face and lips are edematous, and he can barely open his eyes because of swelling. He is wheezing diffusely, and he has multiple raised urticarial lesions on his skin. An ambulance has been called. _ What is the most likely diagnosis? _ What is your next step? Ticket 11 Tell the main research methods in cardiology practice in elderly patients and their indication and contraindication 2. MCQ 1. A 66 year old woman presents with generalized edema, skin ulceration and hypertension. Urine examination shows subnephrotic proteinuria (< 2gm) and microscopic haematuria. Serum complement levels are decreased and she is positive for antihepatitisс antibodies. The likely diagnosis is - PSGN Essential mixed cryoglobulinemia Membrano proliferative glomerulonephritis Focal segmental glomerulosclerosis 2.Urinalysis shows RBC casts; likely source is - a) Kidney b) Ureter Bladder d) Urethra 3. A 65yo man with colon cancer now develops increased thirst, increased frequency in urination and weight loss. His fasting blood glucose=9mmol/L. what is the most appropriate management? a. Oral hypoglycemic b. Insulin long acting c. Short acting insulin before meal d. IV insulin e. Subcutaneous insulin 4. A 61yo man who had stroke 2y ago is on aspirin. He has RA but suffers from pain and can’t tolerate it. He is taking senna for constipation. What is the best med to relieve his pain? a. DMARDs b. Ibuprofen c. Co-codamol- cause constipation d. Paracetamol- osteoarthritis
Case Case 11
A 61-year-old man presents to your office with the complaint of cough. The cough began approximately 3 months prior to this appointment, and it has become more annoying to the patient. The cough is nonproductive and worse at night and after exercise. He has had a sedentary lifestyle but recently started an exercise program, including jogging, and says he is having a much harder time with the exertion. He just runs out of breath earlier than he used to previously, and he coughs a great deal. He has not had any fever, blood-tinged sputum, or weight loss. He denies nasal congestion and headaches. He does not smoke and has no significant medical history. His examination is notable for a blood pressure of 134/78 mm Hg and lungs that are clear to auscultation bilaterally, except for an occasional expiratory wheeze on forced expiration. A chest radiograph is read as normal. _ What is the most likely diagnosis? _ How would you confirm the diagnosis? Ticket 12 1.Describe the clinic in elderly people and complications of AMI
1. Central nervous system manifestion in chronic renal failure are a result of all of the following except - a) Hyperosmolarityb) Hypocalcemiac) Acidosis d) Hyponatremia
Anaemia Small kidneys Heperproteinemia Constrictive pericarditis e)Peripheralneuropathy 3.Progressive dysphagia is seen in- a) Carcinoma esophagus b) Globus hystericus Presbyesophagus d) Achalasia 4.All are used in treatment of Helicobacter pylori, EXCEPT- Colloid bismuth b) Cisapride Clarithromycin d) Metronidazole Download 48,75 Kb. Do'stlaringiz bilan baham:
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