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A 58-year-old male is brought into the emergency room by his family.
The patient’s family claims that he has been confused and has had difficulty
walking for the past two weeks. |
Past medical history: none
Medication:None
No
known drug allergy
Social history: Chronic alcohol, no tobacco or intravenous
drug abuse
The exam reveals that both eyes are unable to look laterally and he
also has a severe ataxia. You realize that this patient has Wernickes
encephalopathy possibly progressing into Korsakoff’s syndrome. What should you
do?
(A) MRI to rule out other organic causes
(B) Intravenous vitamin B12, this
patient has severe B12 deficiency
(C) Intravenous thiamine
(D) Intravenous
folate
(E) Intravenous dilantin
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B; This 17 year old female has iron
deficiency anemia, probably from dietary deficiency as well as increased blood
loss through menses. This disorder is usually easily treated with iron
supplementation in the form of ferrous sulfate. Transfusion is unnecessary. In
Folate deficiency the anemia is macrocytic and iron studies are normal.
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C; A
young patient with abnormal liver function and psychiatric disorder should raise
the suspicion of Wilson’s disease. The classic ocular finding is the brown
green or yellow brown pigmentation around the periphery of the cornea. (See
Wilson’s Disease Pearl for more detail).
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A, Although this patient
seemingly has many cardiac risk factors, he does not have any of the high risk
variables (critical AS, decompensated CHF, MI <6 months, significant
arrhythmia). The Goldman-Detsky risk index is low (zero points). Because this is
a vascular surgical procedure, the intermediate and low risk variables must also
be considered. Of these, the patient only has diabetes. Although the BP is
mildly elevated, he does not have a known history of hypertension and it is not
“uncontrolled” (repeatedly elevated despite intervention or with signs of
end organ damage such as LVH, MI, CVA). Although his functional capacity is
limited by claudication, he works as an auto mechanic and is presumably able to
do more than 4 METS of activity. Therefore, he is at low risk of cardiac
complications and can proceed directly with surgery. A treadmill stress test is
not indicated in a patient limited by claudication. A resting echocardiogram has
no utility in predicting peri-operative cardiac risk. Although beta-blockers are
proven beneficial in lowering peri-operative cardiac risk, this patient has no
clear indication for use and a relative contra-indication (COPD).
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C; Primary
amenorrhea is defined as no menses and lack of other secondary sexual
development signs by age 14 or lack of menses with normal development of breast
and pelvic hair by age 16. This patient does not meet this definition and hence
does not need a work-up for amenorrhea at this time. However, it is always
important to rule out pregnancy. Once pregnancy is ruled out reassuring the
patient would be appropriate.
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B; This patient has atrial flutter with a
rapid ventricular response which requires control. His stable hemodynamic status
makes this case less urgent and immediate defibrillation is not required. Since
the Pt has had no prior cardiac history, it is likely that the current
arrhythmia is of less than 48hr duration and thus anticoagulation is not
required at this time. Giving more adenosine will only be a transient solution
since adenosine has such a short half-life. The best way to control this patient’s
cardiac rate is with a calcium channel blocker like diltiazem.
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