OFFICIAL 2005 STEP I Clinical Vignette Thread

[Chandler]

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This thread is for common clinical vignettes (keep it short) you have encountered in your studies (QBank, First Aid, Actual Step 1 etc). Don't mention what your resources are to protect the source. I'll go first. If you don't know the answer, just post a vignette.

1. 4 year old African American Girl with sickle cell disease has recurrent pneumonia. What is the MCC of the pneumonia.

2. 52 y.o. Pharmacist admitted to the ER with hypoglycemia, lab test shows elevated C peptide levels. Dx?

3. 42 Year old HIV Male patient comes in with purple lesion of skin. Silver stain is negative on tissue biopsy.

4. 35 year old woman on a fasting diet, drinks two glasses of wine falls into a coma. Dx?

5. Baby with 46 XY chromosome has simian crease of the hand, vomiting due to duodenal atresia. Dx?

6. 45 year old male has decreased liver function i.e. increase PTT, Elevated AST, ALT, GTT. Blood test shows a decrease in total copper level and no abnormalities of the eye. Dx?

7. Patient with hashimoto's thyroiditis is given an experimental drug. An increase in prognosis would be best expected with an increase in

a) IL1
b) IL 2
c) IL 10
d) MHC II
e) C5a

 

[Thaitanium]

Very cool thread. Exactly what I need.

#2. I've seen a q similar to #2 that had a nurse instead of a pharmacist. In that question, C-peptide was not elevated. The nurse was a malingerer. If C-peptide is elevated think of insulinoma?

#3. Kaposi sarcoma? Silver stains are for pneumocystis carinii.

I don't know if my guesses are right. Correct me I'm wrong.

 

[Chandler]

Very cool thread. Exactly what I need.

#2. I've seen a q similar to #2 that had a nurse instead of a pharmacist. In that question, C-peptide was not elevated. The nurse was a malingerer. If C-peptide is elevated think of insulinoma?

#3. Kaposi sarcoma? Silver stains are for pneumocystis carinii.

I don't know if my guesses are right. Correct me I'm wrong.

Right. #2 is insulinoma. If insulin was high and C-peptide was low than it would be self induced.

#3 Is Kaposi Sarcoma. I added the Silver stain part to distinguish Kaposi from Bacillary Angiomatosis (bartonella henselae). Don't forget the HHV 8 relationship with Kaposi.

 

[jwin]

This thread is for common clinical vignettes (keep it short) you have encountered in your studies (QBank, First Aid, Actual Step 1 etc). Don't mention what your resources are to protect the source. I'll go first. If you don't know the answer, just post a vignette.

1. 4 year old African American Girl with sickle cell disease has recurrent pneumonia. What is the MCC of the pneumonia.

2. 52 y.o. Pharmacist admitted to the ER with hypoglycemia, lab test shows elevated C peptide levels. Dx?

3. 42 Year old HIV Male patient comes in with purple lesion of skin. Silver stain is negative on tissue biopsy.

#2 could still be self-induced/factitious; pharmacists also have easy access to sulfonylureas. the proper diagnosis of insulinoma requires a 72 hour fast with demonstration of whipples triad, insulin levels (not properly suppressed), a c-peptide level (to measure exogenous insulin) AND a sulfonylurea screen (b/c it elevates endogenous insulin production with that would have elevated c peptide levels like an insulinoma)

 

[Chandler]

#2 could still be self-induced/factitious; pharmacists also have easy access to sulfonylureas. the proper diagnosis of insulinoma requires a 72 hour fast with demonstration of whipples triad, insulin levels (not properly suppressed), a c-peptide level (to measure exogenous insulin) AND a sulfonylurea screen (b/c it elevates endogenous insulin production with that would have elevated c peptide levels like an insulinoma)

Good point, but on the USMLE Step 1. Would you pick insulinoma over self induced if given an increase in insulin with an increase in C-peptide? I venture to say both of us would pick insulinoma. Let's be practical guys and go with the MOST COMMONS.

 

[Pittance]

Just guessing, but could #4 be Wernicke–Korsakoff Syndrome due to Thiamine deficiency?

 

[Pox in a box]

1. 4 year old African American Girl with sickle cell disease has recurrent pneumonia. What is the MCC of the pneumonia.

Streptococcus pneumoniae.

 

[Chandler]

Just guessing, but could #4 be Wernicke–Korsakoff Syndrome due to Thiamine deficiency?

That would probably have been my guess. Here is the answer below. I WOULD KNOW THIS. 👍

Nondrug-induced hypoglycemia: Included are fasting hypoglycemia, characterized by CNS manifestations, usually during fasting or exercising, and reactive hypoglycemia, characterized by adrenergic symptoms that occur only when provoked by a meal. Reactive hypoglycemia is usually associated with less marked and briefer decreases in plasma glucose than fasting hypoglycemia. Some disorders that cause symptomatic hypoglycemia characteristically present in childhood or infancy, whereas others present more commonly in adulthood.

Streptococcus pneumoniae.

Correct if S. Pneumoniae is not a given choice look for Hemophilus Influenza. If both are given, go with S. Pneumoniae (most common).

This is why it is important to give pneumovax and HIB vaccines to all sickle cell disease children by age 2. The spleen is responsible for clearing capsulated bacteria. Sickle cell anemia kids slowly lose the function of their spleen hence recurrence of pneumonia by bacteria with capsules. Loss of spleen function can also be seen in blood smears with the presence of Howell Jolly Bodies.

 

[Pox in a box]

34-year-old woman is being intubated. Suddenly, severe and prolonged muscle contractions occur and the anesthesiologist recognizes the complication and calls for the nurse to bring in cool blankets. What drug should also be given to help the patient?

 

[Oana]

34-year-old woman is being intubated. Suddenly, severe and prolonged muscle contractions occur and the anesthesiologist recognizes the complication and calls for the nurse to bring in cool blankets. What drug should also be given to help the patient?

Malignant hyperthermia -- Dantrolene?

5. Baby with 46 XY chromosome has simian crease of the hand, vomiting due to duodenal atresia. Dx?

I would think Down's syndrome; it's quite commonly associated with duodenal atresia.

45 year old male has decreased liver function i.e. increase PTT, Elevated AST, ALT, GTT. Blood test shows a decrease in total copper level and no abnormalities of the eye. Dx?

It's probably Wilson's disease; the Keiser Fleisher ring may be pathognomonic, but it's not *always* present.

 

[Pox in a box]

A 4-year-old girl is D.O.A. (dead on arrival) at the ED (emergency department). The attending physician and a 4th year medical student observe generalized petechial hemorrhages. At the autopsy the same evening, a 2nd year medical student studying pathology tells his classmate that the body has the scent of bitter almonds. What should the physician performing the autopsy write on the death certificate? What is the biochemical pathology associated with the cause of death?

 

[fuegorama]

A 4-year-old girl is D.O.A. (dead on arrival) at the ED (emergency department). The attending physician and a 4th year medical student observe generalized petechial hemorrhages. At the autopsy the same evening, a 2nd year medical student studying pathology tells his classmate that the body has the scent of bitter almonds. What should the physician performing the autopsy write on the death certificate? What is the biochemical pathology associated with the cause of death?

Just guessing here, but with the almond bit.... inactivation of cytochrome oxidase by cyanide?

 

[Idiopathic]

6. 45 year old male has decreased liver function i.e. increase PTT, Elevated AST, ALT, GTT. Blood test shows a decrease in total copper level and no abnormalities of the eye. Dx?

The most likely dx is probably alcoholic liver disease, but I bet what you are going for here is hemochromatosis.

 

[bigfrank]

I was hoping for AAT def. or Chronic HepC

 

[Pox in a box]

Just guessing here, but with the almond bit.... inactivation of cytochrome oxidase by cyanide?

Here's a hint: INFUEGO. By the way, you're right on the pathology.

 

[bigfrank]

Let's not confuse CN- poisoning with CO poisoning.

(And you can forget about the phrase "bitter almonds" on the Step I.)