CK- UWSA 3- Block 3

Patient Information

Age: 38 years

Gender: F, self-identified

Race/Ethnicity: unspecified

Site of Care: office

History

Reason for Visit/Chief Concern: “My face and legs are swollen.”

History of Present Illness:

• 6 weeks of facial edema, lower extremity edema, and weight gain of 7 kg (15 lb)

• frothy urine; no dysuria or hematuria

Past Medical History:

• none

Medications:

• none

Allergies:

• no known drug allergies

Family History:

• noncontributory

Psychosocial History:

• restaurant manager

• 1-2 alcoholic drinks/day

• does not use tobacco or recreational drugs

Physical Examination

• Appearance: alert; oriented

• Pulmonary: diffuse crackles; diminished breath sounds at bilateral bases

• Cardiac: regular rhythm; S₁ and S₂

• Abdominal: soft, nontender

• Musculoskeletal: bilateral pitting edema

Diagnostic Studies

• Creatinine: 1.1 mg/dL

• Urinalysis: 4+ protein

• Kidney biopsy: diffuse thickening of the glomerular basement membrane without an increase in cellularity or evidence of active inflammation; immune staining: diffuse granular deposits of IgG and C3 along the basement membrane; electron microscopy: numerous subepithelial electron-dense deposits

Question: In addition to ACE inhibitor and diuretic therapy, which of the following interventions is needed?

A 3-month-old girl is brought to the office due to a worsening rash.  The mother first noted a few red spots on the child’s feet 2 weeks ago, but the rash has since spread diffusely.  The patient has been more irritable than normal, particularly overnight.  There has been no fever, vomiting, diarrhea, or cough.  The mother recently developed a few erythematous papules along the wrists and elbows for which she has applied an over-the-counter topical lotion.  The 5-year-old brother and the father are asymptomatic.  Both the patient and the brother are unvaccinated.  Examination shows a fussy but consolable infant.  There are diffuse, 3- to 4-mm, erythematous papules, pustules, and vesicles on the trunk, extremities, fingers, soles, face, and scalp.  The rest of the examination is unremarkable.  The rash on the feet is shown below.

The treatment plan for this patient’s diagnosis is discussed.  Medical intervention should be provided to which of the following people?

A 70-year-old woman comes to the emergency department due to an 8-hour history of right groin pain, nausea, and vomiting.  Medical history is significant for end-stage renal disease for which the patient undergoes hemodialysis 3 times a week.  The last hemodialysis session was 24 hours ago.  The patient lives alone and manages her activities of daily living.  Temperature is 39 C (102.2 F), blood pressure is 92/58 mm Hg, and pulse is 114/min.  Physical examination shows a 6-cm, firm, tender, right inguinal mass.  Lungs are clear to auscultation.  Trace lower extremity edema is present bilaterally.  Laboratory results are as follows:

ECG shows no abnormalities.  Intravenous fluids and empiric intravenous antibiotics are initiated.  Which of the following is the most appropriate next step in management of this patient?

A 62-year-old hospitalized man is evaluated for worsening renal dysfunction.  The patient has a history of cirrhosis due to nonalcoholic fatty liver disease.  He was admitted 4 days ago with coffee-ground emesis and melena.  Esophagogastroduodenoscopy revealed bleeding gastric antral vascular ectasia that was treated endoscopically.  The patient has had no further bleeding, and hemoglobin has remained stable.  However, serum creatinine has increased to 2.6 mg/dL from 1.3 mg/dL.  The patient’s home furosemide and spironolactone were stopped at admission, and his current medications are pantoprazole, lactulose, and prophylactic ceftriaxone.  Urine output over the last 24 hours has been 800 mL.  Temperature is 36.9 C (98.4 F), blood pressure is 90/62 mm Hg, and pulse is 78/min.  Physical examination shows clear lungs, normal heart sounds, and normal jugular venous pressure.  Abdominal examination shows moderate ascites without tenderness.  There are scattered spider angiomas but no other rashes.  The remainder of the physical examination is unremarkable.  The most recent laboratory studies are as follows:

Urine sodium is 5 mEq/L.  Renal ultrasonography reveals no abnormalities.  Treatment for this patient’s kidney dysfunction is aimed primarily at which of the following parameters?

A 47-year-old, previously healthy man comes to the office due to substernal burning and regurgitation of sour fluids intermittently for the past year.  The patient’s symptoms are partially relieved by over-the-counter famotidine.  Review of systems is also notable for occasional hoarseness and intermittent cough.  The patient takes no other medications.  He does not use tobacco, alcohol, or recreational drugs.  Family history is unremarkable.  Vital signs are normal.  Physical examination is normal.  Laboratory results are as follows:

Fecal occult blood testing is negative.  Screening colonoscopy 2 years ago was normal.  Which of the following is the most appropriate next step in management of this patient?

A 50-year-old man comes to the office due to a 3-day history of worsening redness and swelling of his left foot.  The patient reports only minimal pain and has had no fever, chills, or malaise.  One day prior to the onset of these symptoms, the patient slightly twisted his foot while getting out of the bathtub, but he recalls no major injury.  Medical history is significant for type 1 diabetes mellitus, hypertension, and hypercholesterolemia.  Temperature is 36.7 C (98.1 F), blood pressure is 124/80 mm Hg, and pulse is 78/min.  On examination, the entire left foot is edematous, erythematous, and warm compared to the right foot, with moderately restricted range of motion.  Monofilament testing reveals significant impairment of sensation of both feet.  No skin ulcers or gross bony abnormalities are noted.  Dorsalis pedis pulses are 2+ and symmetric.  Laboratory results are as follows:

X-rays of the left foot show mild soft tissue edema but no fracture or dislocation.  Which of the following is the most appropriate next step in management of this patient?

A clinic administration committee is analyzing results of patient surveys and finds a recent trend of low satisfaction scores associated with extended wait times.  A clinic-wide brainstorming meeting is held to elicit staff feedback about reasons for the high wait times.  Reasons are grouped into specific categories, including “staffing,” “organization,” “patients,” and “scheduling.”  During the discussion, a medical assistant expresses his observation that although patients may arrive on time, multiple patients are often booked for the same time slot and examination rooms may be fully occupied with other patients when they arrive.  The medical assistant’s observations are most appropriately placed in which position on the fishbone diagram shown below?

A 36-year-old man is brought to the emergency department after sustaining multiple facial and scalp lacerations in an altercation.  He has chronic HIV infection that has been treated with antiretroviral medications, but he has been off therapy for the past 6 months.  The physician irrigates the patient’s lacerations in preparation for repair; she is wearing protective equipment for the face and eyes but accidentally splashes the patient’s blood and contaminated irrigation solution on her exposed neck and upper arm.  The exposed skin is intact, and all visible blood is cleaned with soap and water.  Which of the following is the most appropriate management of this physician’s occupational exposure?

A group of psychiatry residents developed a short test for depression in adolescents.  To evaluate the performance of the test, the residents selected 100 adolescents seeking outpatient psychiatric care.  All 100 adolescents underwent evaluation using the gold standard test for depression in this population and the short test.  Of 50 adolescents found to have depression according to the gold standard test, 35 were found to have depression according to the short test.  Of 50 adolescents found to not have depression according to the gold standard test, 10 were found to have depression according to the short test.

Item 1 of 2

Which of the following is correct about the short test for depression in adolescents developed by the group of residents?

Item 2 of 2

A primary care physician estimates that the prevalence of depression among her adolescent patients is 20%.  The physician decides to implement the short test for depression in adolescents as a screening tool in her practice.  Which of the following measures is expected to be equal in value whether the short test is used on primary care patients or outpatient psychiatric care patients?