1. A 65-year-old male comes to the office on a hot summer afternoon.

He complains of blisters and intense itching ait over his body for the past 2 days. He has been having "itchy red swelling all over" for the past 2 months, which he thinks is due to the summer heat. His pulse is 82/min, blood pressure is 140/80 mm Hg, respirations are 14/min, and temperature is 36.8C(98.4F). On examination, lesions are seen on both normal and erythematous skin overflexural areas of the groin, axilla and legs. An image of one of these lesions is shown below. Which of the following is most likely seen with this patient's condition? A. IgG and C3 deposits at the dermal-epidermal junction, B. igG deposits intercellularly in the epidermis. C. IgG deposits in a linear band at the dermal-epidermal junction. D. C3atthe basement membrane zone. E. Intradermal edema with leukocyte infiltration. PICTURE OF A TENSE BLISTER ON THE LEG. The answer is A. its bullous pemphigoid, wich is m/c in elderly pts. causes are u.v.rays,sulfa drugs,penicillamines n frusemide. blisters r tense,at dermo-epidermal jn.on biopsy shows IgG and c3. 2. A 24-year-old woman, who has not conceived after two years of unprotected intercourse, presents because she is concerned she may have endometriosis. This concern has arisen because she has a friend who was recently diagnosed with this condition. Which one of the following symptom profiles is most likely if endometriosis is actually present in this woman? A. Dysmenorrheal from the time of the menarche. B. Dyspareunic C. Menorrhagia. D. Mid-cycle vaginal bleeding. E. No abnormal bleeding or pain. 3. A full-term 6-day-old boy presents to a physicians office for routine care. He is tolerating breast milk well. He is urinating, defecating, and sleeping normally. Physical examination reveals an alert newborn with mild eczema,good skin turgor, normal refl exes, and a musty odor. His newborn laboratory screen is notable for phenylketones in the urine. What is the best advice to give his parents regarding the boys diet? (A) Increase iron (B) Increase niacin (C) Increase phenylalanine (d) Increase tyrosine (E) Increase vitamin D its PKU ans is D (def of Phenylalanin hydroxylase) no conversion of Ph ala to tyrosine so treatment should be reduced Ph ala in diet and incresed Tyrosine. The musty odour is typical of PKU 4. A 64-year-old female presents with complaints of lesions over her breasts and thighs. She had been experiencing severe pain in those areas prior to developing redness and blisters. Her past medical history is significant for valvular heart disease with atrial fibrillation, ulcerative colitis diagnosed 20 years ago, and a resection of part of her colon. She is a known patient of yours, and four days ago, you started her on treatment for atrial fibrillation with

antiarrhythmics and oral anticoagulants. Her pulse is 82/min, blood pressure is 140/90 mm Hg, respirations are 14/min, and temperature is 36.8C (98.4F). On examination, you notice well-demarcated lesions with bullae and necrotic changes over her thighs and breasts. What is the most likely diagnosis? A. Necrotizing fasciitis B. Venous gangrene C. Warfarin-induced necrosis D.Pyoderrma gangrenosum E. Cholesterol embolisation syndrome warfarin skin necrosis Warfarin-induced skin necrosis is a serious complication of oral anticoagulants. Protein C deficiency is sometimes associated with this condition. Females are most commonly affected. The commonly involved sites are the breasts buttocks, thighs, and abdomen. The initial complaint is pain, followed by bullae formation and skin necrosis. It mostly occurs within weeks after starting therapy. Vitamin K should be promptly administered in the early stages of the lesion, and warfarin is discontinued if the lesion progresses. Heparin should be used to maintain anticoagulation unfit the necrotic lesions heal. Few patients require skin grafting. (Choice A) Necrotizing fasciitis is a rapidly spreading infection involving the fascia of deep muscles. It occurs after trauma or recent surgery. Typically, there is a history of sudden onset of pain and swelling, which progresses to purplish discoloration of the injured area with bullae and serosanguineous discharge. (Choice B) Venous gangrene usually affects the distal part of the limb, appendix, small intestine, and rarely, organs such as the gall bladder, pancreas and testis. It is characterized by poor or absent peripheral pulse, venous return and capillary response to pressure. The involved area changes color from pale gray to greenish-black or black. (Choice D) Pyoderma gangrenosum is an ulcerative skin lesion. The initial lesion is often described as a bite- like reaction with a small papule or pustule. Pain is the main complaint. Malaise and arthralgia may also be present. (Choice E) Cholesterol embolization syndrome should be suspected in patients who develop worsening renal function, hypertension or distal ischemia following an invasive arterial procedure. Livedo reticularis can be seen on skin examination. Educational Objective: Warfarin-induced skin necrosis presents with pain, followed by bullae formation and skin necrosis. The breasts, buttocks, thighs, and abdomen are commonly involved. 5. A 56-year-old man presents to his physician complaining of severe fatigue. He began to feel increasingly tired about 6 months ago, but believes that his fatigue has been worsening over the past 3 weeks. He also notes he has had a nonproductive cough for about 2 weeks and has experienced several episodes of drenching night sweats. On examination he has several large bruises on his extremities but recalls no injuries. Abdominal examination reveals massive enlargement of both the liver and the spleen, without any lymphadenopathy. Laboratory studies show: WBC count: 1200/mm3 Neutrophils: 58% Eosinophils: 7% Lymphocytes: 30% Monocytes: 0% Basophils: 5% RBC count: 3.0/mm3 Hemoglobin: 7.5 mg/dL

Platelet count: 18,000/mm3 Peripheral blood smear reveals irregular nuclei and cell membranes, as well as cytoplasmic projections. Which of the following is the most likely diagnosis? (A) Acute lymphocytic leukemia (B) Hairy cell leukemia (C) Idiopathic thrombocytopenic purpura (d) Infectious mononucleosis (E) Nodular sclerosing Hodgkins lymphoma : is it B??? 6. A 50-year-old white male presents to the family physician for weight loss and abdominal pain. He also complains of diarrhea with bulky, foul smelling stools, abdominal distension and flatulence. Upon questioning he also describes arthralgias and chronic cough. Physical examination reveals generalized lymphadenopathy, skin hyperpigmentation and a diastolic murmur in the aortic area. His BP is 120/80 mm Hg, PR is 80/min, RR is 18/min, and Temperature is 37.8C (100F). Small bowel biopsy is done which shows numerous PASpositive materials in lamina propria with villous atrophy. What is the most likely diagnosis in this patient? A. Celiac disease B. Tropical sprue C. Crohns disease D. Whipples disease E. Cystic fibrosis Whipple D? arthralgia + fever + diarrhoea with CVS involvement i think this is a classical presentation of whipple PAS positive [5/28/2010 9:53:01 PM] mydoctor: Whipples disease (Choice D) is a rare multi systemic illness, most commonly seen in white men in fourth to sixth decade of life and often presents with weight loss. It is an infectious disease caused by bacillus Tropheryma whippelii. Gastrointestinal symptoms of Whipples disease include abdominal pain, diarrhea, and malabsorption with distension, flatulence, and steatorrhea. Extra intestinal manifestations include migratory polyarthropathy, chronic cough, and myocardial or valvular involvement leading to congestive failure or valvular regurgitation. Later stages of disease may be characterized with dementia and other central nervous system findings such as supranuclear ophthalmoplegia and myoclonus. Intermittent low-grade fever, pigmentation and lymphadenopathy may also be occasionally seen in Whipple s disease. Celiac disease (Choice A), although associated with malabsortion, is not associated with pigmentation and lymphadenopathy. Also, PAS positive material in lamina propria of small intestine is a classical biopsy finding of Whipples disease. Tropical sprue (Choice B) is a chronic diarrheal disease, possibly of infectious origin that should be considered in patients who have lived for more than a month in a tropical area.

Crohns disease (Choice C) can be associated with malabsorption, abdominal pain, fever and arthralgias, but would not explain skin hyperpigmentation, chronic cough and the biopsy findings in this patient. Cystic fibrosis (Choice E) can be associated with chronic cough and malabsorption. It is not associated with arthralgias or skin hyperpigmentation. Educational Objective: Whipples disease is a multi systemic illness characterized by arthralgias, weight loss, fever, diarrhea and abdominal pain. PAS positive material in lamina propria on small intestine is a classical biopsy finding of Whipples disease. A 27-year-old Caucasian woman has had intermittent moderate to severe right lower quadrant pain and diarrhea for 2-months. She has had a 2kg(4.5lb) weight loss. Since the last 48 hours the pain has worsened and she has had fever. Vital signs are: PR: 100/min; BP: 120/70mm Hg; RR: 12/min; Temperature: 37.6C(99.6F). Her abdomen is tender in right lower quadrant without rebound. Rectal exam is positive for some mucus. Rectal temperature is 38.4C(101.4F). Rectosigmoidoscopy is unremarkable. Abdominal film shows gas in small and large bowel. Laboratory results are: Hb 10.2gm/dL WBC 16,500/cmm ESR 38/hr ALT 97mg/dL AST 82mg/dL Most likely the diagnosis is: A. Diverticulitis B. Colon cancer C. Acute appendicitis D. Crohns disease E. Chronic ulcerative colitis Chrons The clinical picture is most consistent with Crohns disease exacerbation (Option D). Hepatic enzymes could be elevated in Crohns disease. Also, every chronic inflammatory disease can result in anemia. Colon cancer rarely causes pain unless it is very advanced (Option B). Also colon cancer is unlikely in a young patient. A 2-month history is too long for acute appendicitis and she doesnt have any other signs of that disease like rebound tenderness and guarding. Axillary to rectal temperature difference is not specific for appendicitis (Option C). Diverticulitis is associated with constipation rather than diarrhea and it usually produces left lower quadrant pain (Option A). Ulcerative colitis nearly always involves the rectal mucosa and it usually produces bloody diarrhea (Option E). Educational Objective: Always suspect Crohns disease as a cause for chronic diarrhea in a young patient... A 41-year-old male presents to his family physician for heartburn, gnawing abdominal pain and diarrhea. He states that he has had these symptoms intermittently since 5 years. He has

tried H-2 blockers without any relief. His past medical history is suggestive of chronic renal stones. He has an extensive family history of peptic ulcer disease. Physical exam is unremarkable. What is the most likely diagnosis in this patient? A. Gastric ulcer B. Gastrinoma C. Duodenal ulcer D. GERD E. Chronic pancreatitis Echocardiogram Echocardiogram (heart ultrasound) is the best non-invasive test to evaluate the aortic valve anatomy and function. The aortic valve area can be calculated non-invasively using echocardiographic flow velocities. Using the velocity of the blood through the valve, the pressure gradient across can be calculated by the modified Bernoulli's equation:Gradient = 4(velocity) mmHg A normal aortic valve has no gradient. If the mean gradient is <25 mm Hg, the stenosis is mild; if the mean gradient is between 25 mm Hg and 50 mm Hg, the stenosis is moderate; if the mean gradient is >50 mm Hg the stenosis is severe; and when the gradient is greater than 70 mm Hg, the stenosis is critical. A normal aortic valve area is >2 cm2. If the valve area is between 1.6 and 2.0 cm2, the stenosis is mild; if the valve area is between 1.3 and 1.6 cm2, the stenosis is mild-moderate; if the valve area is between 1.0 and 1.3 cm2, the stenosis is moderate; if the valve area is between 0.7 and 1.0 cm2, the stenosis is moderate-severe; areas of less than 0.7 cm2 constitute severe aortic stenosis. (However, this gradient can be abnormally low in the presence of mitral stenosis, heart failure or co-existent aortic regurgitation.) Collection A 65 years old woman had abdominal USG,and she was found to have ovarian mass. Biopsy was done, and it is confirmed that the mass is a metastatic tumor. which of the following primary tumor will most likely to metastasize to the ovaries? A) breast B)lung C)liver D)kidney E)bowel 3 year old boy doesn't say any word. He has history of 3 ear infection before. On exam, hearing decreased. which one is the most probable cause of this? A) sensorineural deafness B) recurrent acute supurative otitis media C) otitis extra D) conduction of deafness A pregnant woman in 36 weeks. she wants to labour now because her husband is leaving in a few days. P/E: cervix is closed.she is not in labour. what is the management? A)induce the next day B) talk to her husband to stay C) refuse her resquest D) admit her and induce when her cervix is ready to labour.