Alan Soetikno

[Neural Consult @neuralconsult]

MCQ of the Day! See comments for the correct answer. ✅ Generate your own questions at https://t.co/OMytujhn6v
A 21-year-old male presents to the emergency department with severe pain and swelling in his left knee after a minor trauma sustained while playing soccer. He denies any previous significant injuries but mentions that he has experienced prolonged bleeding after dental procedures in the past. His maternal uncle has a history of a bleeding disorder. Physical examination reveals a swollen, warm left knee with a decreased range of motion. There is no evidence of external bleeding or bruising elsewhere on his body. An X-ray of the knee shows no bone fractures or dislocations. Laboratory studies are ordered, which show:
Platelet count: 250,000/mm^3 (normal: 150,000-400,000/mm^3)
Prothrombin time (PT): 12 seconds (normal: 11-13.5 seconds)
Activated partial thromboplastin time (aPTT): 55 seconds (normal: 25-35 seconds)
Fibrinogen level: Normal
Blood urea nitrogen (BUN): 18 mg/dL (normal: 7-20 mg/dL)
Creatinine: 0.9 mg/dL (normal: 0.6-1.2 mg/dL)
Based on the patient's history and laboratory findings, which underlying condition is most likely responsible for his symptoms?

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[Neural Consult @neuralconsult]

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A 22-year-old female college athlete presents to the clinic for a routine health examination before the start of the new soccer season. She reports no complaints and is excited to resume training after a 3-month off-season break. She has been playing soccer since early childhood and participates in competitive matches throughout the year. Her medical history is unremarkable, and she takes no medications. Physical examination reveals a well-nourished, well-hydrated female in no acute distress. Her vitals are within normal limits. Cardiovascular examination reveals a resting heart rate of 52 beats per minute, and her blood pressure is 110/70 mmHg. She has a muscular physique, and neurological examination is normal. An electrocardiogram shows sinus bradycardia with no other abnormalities. Which of the following physiological adaptations is most likely responsible for this athlete's current heart rate?

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[Neural Consult @neuralconsult]

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A 26-year-old woman comes to the clinic complaining of intermittent episodes of heart palpitations, sweating, and a sense of impending doom that resolve spontaneously. These symptoms have been occurring for the past 6 months. She denies any use of caffeine, alcohol, or illicit drugs. Her past medical history is unremarkable, and she is not on any medications. She has no family history of psychiatric disorders. On physical examination, her blood pressure is 140/90 mmHg, heart rate is 98/min, and respiratory rate is 16/min. Her cardiovascular and respiratory examinations are normal. Laboratory studies show normal complete blood count, electrolytes, renal function, and thyroid function tests. Urine toxicology screen is negative. The patient is started on a medication that blocks the reuptake of both serotonin and norepinephrine. What is the most likely diagnosis?

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[Neural Consult @neuralconsult]

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A 16-year-old male presents to the clinic with his parents due to concern about his recent difficulty in keeping up with his peers during soccer practice. Over the past few months, he has noticed increasing fatigue, muscle cramps, and occasionally passing dark urine after exercise. His medical history is unremarkable, and he takes no medications. His older sister has a similar condition that was diagnosed in her late teens. Physical examination reveals hepatomegaly but no splenomegaly or lymphadenopathy. Laboratory studies show elevated creatine kinase levels. A muscle biopsy is performed, and the histological examination shows normal muscle architecture but increased glycogen within the myocytes. There is a lack of staining for myophosphorylase. What is the most likely diagnosis?

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[Neural Consult @neuralconsult]

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A 47-year-old male presents to the emergency department with a sudden onset of severe abdominal pain for the past 6 hours. The pain is localized to the epigastric region and described as sharp and constant. He reports that he had been experiencing intermittent, mild epigastric discomfort after meals for the past three months, which he relieved with over-the-counter antacids. His medical history is significant for hypertension, for which he takes hydrochlorothiazide. He smokes half a pack of cigarettes per day and drinks alcohol occasionally. On examination, his abdomen is rigid and board-like with rebound tenderness. His vital signs show a blood pressure of 130/85 mmHg, heart rate of 110 bpm, respiratory rate of 22 breaths/min, and a fever of 38.3C (101F). Laboratory studies reveal a white blood cell count of 14,000/µL with a left shift, serum amylase of 90 U/L, and lipase of 45 U/L. An upright chest x-ray reveals free air under the diaphragm. What is the most likely diagnosis?

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[Neural Consult @neuralconsult]

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A 28-year-old woman presents to the clinic with complaints of recurrent sinusitis and bronchitis since childhood. She also mentions that she has had difficulty becoming pregnant over the past year. Her past medical history is significant for situs inversus. On physical examination, her vital signs are within normal limits. Auscultation of the chest reveals decreased breath sounds bilaterally with occasional wheezes. She has clubbing of her fingers. A chest x-ray shows dextrocardia. Given her history and the physical findings, which diagnostic test would be most appropriate to confirm the suspected diagnosis?

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[Neural Consult @neuralconsult]

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A 58-year-old woman presents to the emergency department with acute onset of dyspnea and orthopnea that began earlier in the day. She has a history of rheumatic fever in childhood. On examination, her blood pressure is 140/90 mmHg, heart rate is 102 bpm, and respiratory rate is 22 breaths/min. She has bilateral rales halfway up her lung fields and an irregularly irregular pulse. On cardiac auscultation, there is a high-pitched, blowing, decrescendo diastolic murmur heard best at the left sternal border. Additionally, the patient has a low-pitched, rumbling diastolic murmur heard best at the apex with the patient in the left lateral decubitus position. The electrocardiogram shows atrial fibrillation with no ST-segment changes. A chest radiograph reveals pulmonary venous congestion and an enlarged cardiac silhouette. What is the most appropriate next step in the management of this patient's condition?

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[Neural Consult @neuralconsult]

MCQ of the Day! See comments for the correct answer. ✅
A 6-month-old female infant is brought to the pediatrician for a routine health maintenance visit. The mother reports that the infant is exclusively breastfed and has been growing well, meeting all developmental milestones. She is concerned about the infant's nutrition moving forward, as she plans to return to work soon. The infant's weight is in the 50th percentile for her age, and physical examination is unremarkable. The mother inquires about the appropriate timing and types of solid foods to introduce to her infant's diet. According to the American Academy of Pediatrics, what is the recommended age to start introducing solid foods to infants?

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[Neural Consult @neuralconsult]

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A 32-year-old woman presents to the clinic with a 3-month history of fatigue, pallor, and exertional dyspnea. She reports having heavy menstrual periods since menarche, with her last menstrual period occurring 1 week ago, lasting for 7 days, with the need to change her sanitary pads every 2 hours. She denies any postcoital bleeding, intermenstrual bleeding, or melena. Her past medical history is unremarkable, and she is not on any medications. Her diet is well-balanced, and she does not take any supplements. On physical examination, her blood pressure is 110/70 mmHg, heart rate is 95 bpm, and she has conjunctival pallor. A pelvic examination reveals no abnormalities. Laboratory studies reveal:
Hemoglobin: 9.2 g/dL
Mean corpuscular volume (MCV): 78 fL
Serum iron: 30 µg/dL
Total iron-binding capacity (TIBC): 480 µg/dL
Serum ferritin: 8 ng/mL
Platelet count: 325,000/mm
White blood cell count: 7,000/mm
Reticulocyte count: 2.5%
Stool guaiac test: Negative.
What is the most likely cause of this patient's symptoms?

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[Neural Consult @neuralconsult]

MCQ of the Day! See comments for the correct answer. ✅
A 45-year-old woman presents to the clinic with a 6-month history of worsening headaches and recent onset of seizures. She has no significant past medical history except for hypertension, which is well-controlled with medication. She denies any recent trauma or use of new medications. On examination, she is alert and oriented, but she has a mild weakness in her left arm. Her visual fields are intact, and the rest of the neurological examination is unremarkable. Magnetic resonance imaging (MRI) of the brain shows a 2-cm extra-axial, dural-based mass overlying the right parietal lobe. The mass is isointense on T1-weighted images, hyperintense on T2-weighted images, and enhances homogeneously with gadolinium contrast. There is no surrounding edema. The patient is referred to a neurosurgeon for further management. What is the most likely diagnosis ?

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[Neural Consult @neuralconsult]

Question of the Day! See comments for the correct answer. ✅
A 32-year-old male presents to the clinic with a 6-month history of lower back pain that improves with exercise but not with rest. He also reports occasional morning stiffness that lasts for more than an hour. He denies any recent infections or gastrointestinal symptoms. His family history is significant for psoriasis in his mother. On physical examination, there is tenderness at the sacroiliac joints and limited range of motion in the lumbar spine. Chest expansion is slightly decreased compared to normal. Laboratory studies show an elevated C-reactive protein level and erythrocyte sedimentation rate. HLA-B27 typing is positive. A lateral lumbar spine x-ray is ordered, and while awaiting results, the patient inquires about the nature of his condition and its management. What is the most likely diagnosis?

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[Neural Consult @neuralconsult]

Question of the Day! See comments for the correct answer. ✅
A 53-year-old male with a history of alcohol abuse and chronic hepatitis C presents to the emergency department with altered mental status. His wife reports that he has become increasingly confused over the past week. She also notes that he has been more forgetful, and she was alarmed when he did not recognize her this morning. His past medical history is significant for cirrhosis diagnosed two years ago. On physical examination, he is disoriented to time and place, has asterixis, and a distended abdomen with a fluid wave consistent with ascites. His breath has a musty odor. Laboratory studies reveal:
Platelet count: 88,000/mm³
Serum ammonia: Elevated
Serum albumin: 2.9 g/dL
INR: 1.8
Creatinine: 1.2 mg/dL
Bilirubin (total): 3.2 mg/dL
Bilirubin (direct): 0.8 mg/dL
ALT: 50 U/L
AST: 72 U/L
The patient is admitted to the hospital. What is the most appropriate initial clinical intervention to manage his condition?

[Neural Consult @neuralconsult]

Question of the Day! See comments for the correct answer. ✅
A 20-year-old woman presents to the clinic with a two-week history of lower extremity edema and fatigue. She denies any recent infections or drug use. Her medical history is unremarkable, and she is not currently taking any medications. On physical examination, she has 3+ pitting edema in both lower extremities up to the level of her knees. Urinalysis shows 4+ proteinuria and no hematuria. Serum albumin level is 2.9 g/dL, and serum cholesterol is elevated. Antinuclear antibodies and anti-double-stranded DNA antibodies are negative. Hepatitis serologies are unremarkable. Complement levels are normal. Renal biopsy is performed and shows effacement of the podocyte foot processes. Which of the following is the most likely diagnosis?

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[Neural Consult @neuralconsult]

Question of the Day! See comments for the correct answer. ✅
A 58-year-old woman with a history of ovarian cancer presents to the clinic for a follow-up visit after completing her sixth cycle of chemotherapy with cisplatin. She reports that she has been experiencing difficulty hearing her grandchildren when they speak to her, especially when there is background noise. She denies any ear pain, discharge, or recent infections. She has no history of hearing problems and does not take any other medications. On physical examination, her vital signs are within normal limits. Otoscopic examination reveals bilaterally normal tympanic membranes without any signs of effusion or infection. A Weber test lateralizes to the right, and a Rinne test shows air conduction is better than bone conduction in both ears. Which of the following is the most likely cause of this patient's hearing difficulty?

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[Neural Consult @neuralconsult]

Question of the Day! See comments for the correct answer. ✅
A 58-year-old man with a history of hypertension and type 2 diabetes mellitus presents to the clinic for a follow-up visit. He complains of a dry cough that has persisted for a couple of weeks. He denies any fever, sputum production, or shortness of breath. His current medications include metformin, simvastatin, and lisinopril. His blood pressure is well controlled. Laboratory studies show serum creatinine of 1.2 mg/dL, which has increased from a baseline of 0.9 mg/dL six months ago. Urinalysis is unremarkable. Which of the following medications is most likely responsible for the patient's cough and serum creatinine elevation?

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[Neural Consult @neuralconsult]

Question of the Day! See comments for the correct answer. ✅
A 27-year-old woman comes to the clinic complaining of a malodorous vaginal discharge for the past week. She denies any pain, itching, or urinary symptoms. She is sexually active with one partner and uses condoms inconsistently. Her last menstrual period was 3 weeks ago. On examination, the discharge is thin, grayish, and coats the vaginal walls. The pH of the vaginal fluid is 5.5, and the whiff test is positive. A saline wet mount of the discharge reveals clue cells. Which of the following is the most appropriate pharmacotherapy for this patient?

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[Neural Consult @neuralconsult]

A 65-year-old woman with a history of hypertension and hyperlipidemia presents to the emergency department with sudden onset of right-sided weakness and difficulty speaking that started 2 hours ago. Her medications include hydrochlorothiazide and atorvastatin. On examination, she has a right facial droop, right arm and leg weakness, and slurred speech. Her blood pressure is 155/90 mmHg, pulse is 82/min, and she is afebrile. A non-contrast head CT scan shows no hemorrhage or mass effect. Which of the following is the most appropriate next step in management?

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[Neural Consult @neuralconsult]

A 34-year-old painter presents to the emergency department with a 2-hour history of dizziness, headache, and nausea. He reports that he has been working overtime in a poorly ventilated area to meet a project deadline. His vital signs are within normal limits. Physical examination reveals conjunctival irritation and a fruity odor on his breath. His coordination is intact, and no skin lesions are noted. Which of the following is the most likely cause of this patient's symptoms?

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[Neural Consult @neuralconsult]

A 72-year-old woman comes to the physician for a routine health maintenance visit. She has a history of hypertension and type 2 diabetes mellitus, both well-controlled with medications. She mentions that she feels she is 'slowing down a bit' mentally and physically over the past year. She has difficulty keeping up with conversations when her grandchildren speak quickly and sometimes takes longer to perform tasks like balancing her checkbook, which used to be easier for her. She denies any depressive symptoms, sleep disturbances, or issues with her vision or hearing. She lives alone and is able to perform all her daily activities without assistance. Her medications include metformin, lisinopril, and amlodipine. On examination, her vital signs are stable, and the physical examination is unremarkable. Her Mini-Mental State Examination score is 28 out of 30. Which of the following is the most likely explanation for this patient's symptoms?

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[Alan Soetikno @AGSoetikno]

@neuralconsult Respiratory acidosis!