CBM 301-final.pdf

• A 55-year-old man presents to the clinic with complaints of chest pain. He states that for the past 5 months he has noted intermittent substernal chest pressure radiating to the left arm. The pain occurs primarily when exercising vigorously and is relieved with rest. He denies associated shortnes...

• A 55-year-old man presents to the clinic with complaints of chest pain. He states that for the past 5 months he has noted intermittent substernal chest pressure radiating to the left arm. The pain occurs primarily when exercising vigorously and is relieved with rest. He denies associated shortness of breath, nausea, vomiting, or diaphoresis. He has a medical history significant for hypertension and hyperlipidemia. He is taking atenolol for his high blood pressure and is eating a low-cholesterol diet. His family history is notable for a father who died of myocardial infarction at age 56 years. He has a 50-pack-year smoking history and is currently trying to quit. His physical examination is within normal limits with the exception of his blood pressure, which is 145/95 mm Hg, with a heart rate of 75 bpm. What is the likely diagnosis? How would you classify his diagnosis clinically? Selected Answer: Correct Answer: Response Feedback: patient is suffering from ( coronary artery disease ) atherosclerosis. according to the symptoms such as stable angina chest pain during exercise and reliveing in the rest time, radiating the sybsternal chest presurre to the left arm, chronic smoker, having the medical history of hypertnesion and hyperlipidemia, fanily history of mayocardial infraction I diagonse patient as a athersclerosis. and since the patinet doesnt have shortness of breath, nausea, vomiting and pain during rest I rouled out the respiratory system disease. The most likely diagnosis in this patient is coronary artery disease, specifically angina pectoris. Because the symptoms are exertional only and have been stable for several months, this patient would be classified as having stable angina. If the pain occurred at rest, with less and less activity, or more frequently or for a longer duration despite similar activity levels, he would be classified as having unstable angina. [None Given] • Question 2 10 out of 10 points What are this patient’s risk factors for coronary artery disease? Selected Answer: 1) hypertension 2) being chronic smoker 3) hyperlipidemia 3) 55 year old male 4) having the family history of mayocardial infraction and death Correct Answer: This patient has several cardiac risk factors, including male gender, a family history of coronary artery disease, hyperlipidemia, smoking, and hypertension Response Feedback: [None Given] • Question 3 5 out of 5 points A 25-year-old previously well woman presents to your office with complaints of episodic shortness of breath and chest tightness. She has had the symptoms on and off for about 2 years but states that they have worsened lately, occurring two or three times a month. She notes that the symptoms are worse during the spring months. She has no exercise-induced or nocturnal symptoms. The family history is notable for a father with asthma. She is single and works as an administrative assistant in a hightech firm. She lives with a roommate, who moved in approximately 2 months ago. The roommate has a cat. The patient smokes occasionally when out with friends and drinks socially. Examination is notable for mild end-expiratory wheezing. What is the likely diagnosis according to the patients' scenario? Selected Answer: Correct Answer: Response Feedback: Due to the symtoms and signs, patient is most likely suffering from asthma. reagrding to the periodic shorthness of breath and getting worse especially in the spring season, having the family history of asthma, history of living with the cat, being smoker and physical exmination is noticed the mild end- expiratory wheezing I consider the patient most likely as an asthma patient The history and physical examination are consistent with a diagnosis of asthma. [None Given] • Question 4 10 out of 10 points Which clinical clues do help you to diagnosis of the case above? Selected Answer: Correct Answer: Response Feedback: episodic occurance of shortness of breath and getting worse during spring season ( having the particular time) and suffering from it for 2 years which change the disease to the chroic category lead out thinking patheway to the allergic and sthma due to the increasing allergns in this seasons such as flowers. Also having the family history of asthma, history of living with the cat, 25 years old female, being smoker and mild end- respiratory wheezing are the significant clues for my diagnosis. Family history of asthma This patient’s history (seasonal predilection) is most consistent with allergen-induced asthma. The worsening symptoms in the last few months may be due to an allergic reaction to the roommate’s cat. [None Given] • Question 5 5 out of 5 points Which diagnostic test do you need to confirm your diagnosis of the case above? Selected Answer: 1) basic spirometry to check the pulmonary function and volum of the lungs 2) bronchodilator reversibility testing to check the bronchi function/ PEF variability test as well 4) peak flow test to check the airways 5) chest x ray to see the lung and morphological changes in case 6) blood test and allergy test ( skin prik test for check allergy to the pets ) to check about the allergy induced factors Correct Answer: Pulmonary function tests are ordered to confirm the diagnosis. Response Feedback: [None Given] • Question 6 10 out of 10 points Which findings should you expect to confirm your diagnosis? Selected Answer: Correct Answer: Response Feedback: since the patient is suffering from asthma, in the test we will see that FVC/FEV1 ratio will be below 0.8 which indicates the obstructive disease such as asthma. Also the NO rate will be high in the asthmatic patient. in the blood test also the basophil, eosinopil rate will be high. also in the allergic test patient may react to different allergens such as ciggarrette or cold weather. additonally in the peak flow test the result of the test will be below 80% which shows the narrowing of airway due to the asthma. This patient’s symptoms are relatively mild, occurring only intermittently. In between exacerbations, her pulmonary function tests may be normal. During an attack, all indices of expiratory airflow may be reduced, including FEV1, FEV1/FVC, and peak expiratory flow rate. FVC may also be reduced as a result of premature airway closure. Total lung capacity, functional residual capacity, and residual volume may be increased as a consequence of airflow obstruction and incomplete emptying of lung units. DLCO may be increased because of increased lung and capillary blood volume. [None Given] • Question 7 5 out of 5 points A 55-year-old woman presents with one month of worsening swelling in both legs. She has a history of hyperglycemia, well controlled with diet and exercise, with HbA1c of 5.9%. She has no drug or alcohol use, and no significant family or surgical history. On review of systems, she denies headache, shortness of breath, orthopnea, or paroxysmal nocturnal dyspnea, but does note frothy urine for the past 2 weeks. On exam, blood pressure is 130/90, BMI is 18, with normal skin, cardiovascular, and pulmonary exams. She has symmetric 2+ edema of the bilateral lower extremities, to the umbilicus, without erythema. Her abdomen is non-tender, without masses or organomegaly. Initial labs reveal albumin of 2.5 g/dL. Write the patient’s illness script. Selected Answer: Correct Answer: Response Feedback: A 55 year old male who is suffering from hyperglycemia, prediabetic Hba1c and having the well controlled with diet and exerices who comes to the physician with the complaints of acute bilaterla lower exetermities 2+ edema, mild hypertension and hypoalbuminemia. A 55-year-old women with diet-controlled hyperglycemia presents with subacute bilateral 2+ lower extremity edema, frothy urine, 130/90blood pressure, 5.9% HbA1c and 2.5g/dL albumin level. [None Given] • Question 8 3.4 out of 10 points Write three possible differential diagnoses with relevant clinical data according to the patients' scenario. Selected Answer: Correct Answer: Response Feedback: she might suffer from membraneous nephropaty, focal segemntal glomerolosclerosis and acute membranopolorifatve gelpmeroulonephirtis and they are all diagnosis according to the sydnromes such as hypoalbuminemia, bilaterla lower exetermities edema and mild hypertnesion Nephrotic Syndrome: Subacute onset, frothy urine, edema, hypoalbuminemia Cirrhosis: edema, hypoalbuminemia Heart failure: age, blood pressure, edema. • This patient’s age places her at risk for all of the above causes, but she doesn’t have many predisposing risk factors other than hyperglycemia • Edema is a common symptom of all of the above syndromes • The subacute time-course, with normal cardiac and pulmonary exams makes heart failure a less likely cause of edema • Lack of predisposing risk factors or other sequelae of liver failure makes cirrhosis less likely. key features in diagnosing of this case: subacute onset, foamy urine, absence of predisposing risk factors for cirrhosis or heart failure All three written answers are related to the same diagnosis. • Question 9 10 out of 10 points Alper Taş is well known to your emergency department for repeat visits with acute intoxication. Tonight, he presents disheveled as usual. He has urinated and vomited on himself and has a strong odor of alcohol. The resident reports he is somnolent, with no obvious signs of trauma and states he is “just drunk” and needs to “sober to freedom.” You saw the patient twice last week with similar symptoms. About an hour after his arrival, his ETOH level returns at 150. The nurse reports he has been snoring and she placed him on some oxygen because his sats were dropping in his sleep. Around 7 AM the resident tells you he cannot arouse Mr. Taş. A stat head CT reveals a large subdural hematoma, and CXR shows an aspiration pneumonitis. He is transferred to a critical care bay, intubated, and a consult to neurosurgery is placed. He is admitted to the neurosurgical ICU for ICP monitoring. 2 days later, Mr. Taş is noted to have bilateral lower extremity paralysis. A CT scan of his spine reveals a C8 fracture with cord impingement. What types of cognitive bias are at play at various stages in this case? Selected Answer: Correct Answer: 1) premasure closure because of readness of infromation and just refer to the previous cases 2) anchoring because the dr is strciting with his infromation and judgements 3) search satisfication 4) attribution bias Anchoring bias: This involves persistently fixating on a particular finding even when new data suggests an alternative. One hour after arrival, the patient’s EtOH level returned at 150 — not very high for a chronic alcoholic. Despite this relatively low EtOH level, the providers continued to ascribe his somnolence and hypoxia to intoxication for many, many hours before recognizing that something didn’t make sense. Familiarity bias (a form of availability bias): This describes a tendency to revert to “familiar patterns” of patient’s presentations rather than looking for what is novel about this particular presentation. This patient is a known alcoholic with multiple “similar” presentations in the past (we all know these patients, often by name). Confirmation bias: This involves seeking evidence to support your working diagnosis rather than information to refute it. The EtOH level acted to confirm that he was “just drunk.” His snoring respirations confirmed he needed to “sleep it off.” Search Satisfying bias: This involves calling off the search for a diagnosis once something is found. This patient was found to have a Subdural hematoma, likely due to trauma, but the work-up ended there. Once this diagnosis was made, the providers needed to perform a full “trauma assessment” including a CT-C spine (and likely pelvis Xray, which was not done). Diagnosis Momentum: The diagnosis gathers momentum without further evidence being sought. Once the resident told you that this was a “typical” intoxication episode, you, the nurse and the resident all went along with this for >10 hours (and the patient didn’t get properly reassessed in the meantime.) Visceral Bias: Our thinking may be influenced by how we feel about certain types of patients (i.e. chronic intoxicants.) There is a subtle dismissiveness / implicit bias suggested by the phrases “just drunk” and “sober to freedom”. This type of bias can lead providers to act with their gut, perhaps spending less time evaluating the patient. This may be driven by the odor or EtOH, the smell of urine, the smell of vomit, stinky feet, an unkempt / disheveled appearance, etc. Response Feedback: [None Given] • Question 10 10 out of 10 points How could this bias be mitigated proactively if you could “do it over”? Selected Answer: Correct Answer: I would go through more diagnosis and I wouldnt strcit by one idea and judgement and also I would check for more information and look at the datas and ask my self what else might be and consider all possibile avaliblities. Mitigation strategy for Anchoring bias: Avoid sticking with early impressions or judgements. Seek additional information (i.e. trend his EtOH levels - if he lives at 400 and now he is at 150, he is not intoxicated). Treat patients, not numbers. If the numbers don’t correlate with the presentation, ask yourself why? Revisit the case and broaden the differential. Using a mnemonic like VINDICATES* may be helpful. *Vascular, Infection, Neoplastic, Drugs / toxins, Inflammatory / idiopathic, Congenital, Autoimmune, Traumatic, Endocrine / environmental, Something else / pSychological Mitigation strategy for Familiarity bias: Try to look at each case objectively rather than relying on “historical norms.” Look at the facts of this particular case, rather than looking to historical information that may mislead you. Mitigation Strategy for Confirmation bias: Don’t look at a case and ask, “what is wrong with this patient”…rather, look at each case and ask, “how can we blow this case?” This helps you look for exceptions to your mental model rather than confirmation of your mental model. Mitigation Strategies for Search Satisfying bias: Make sure you look at the big picture rather than at a single diagnosis. In this case, the diagnosis should not be Subdural, but rather, TRAUMATIC Head injury, which should prompt one to do a trauma work-up including C-spine imaging to identify other injuries. Mitigation Strategy for Diagnosis Momentum: Consider seeing the patient independent of the resident, perhaps before hearing about the case to form your own impressions. Ask the nurse her impression, too. This type of group think allows each person to bring objective data to bear without being influenced by another’s diagnosis. Keep an open mind and encourage your residents/colleagues/staff to do the same by asking if the objective data they know fit into the mental model that you have — challenge them! Mitigation Strategy for Visceral Bias: Try to become aware of your “triggers” and how they influence your decision making. There may be particular populations of patients where you know you need to force yourself to slow down, do a more careful assessment, and avoid being influenced by your feelings. Response Feedback: [None Given] • Question 11 0.5 out of 5 points A 25-year-old woman presented to her obstetrician for routine prenatal care. She has no current complaints and states that her family is healthy. Her physical exam is within normal limits and her vitals are HR: 84, BP: 122/73, RR: 11, Temp: 36.8°C. Her CBC showed RBC: 5.8 x106/µL, WBC: 6.5 x106/mL, MCV: 70 µm3, MCH: 23 pg, RDW: 13%, Hgb: 9.8 g/dl, Hct: 32%. Iron studies showed Serum Iron: 95 µg/dl, Total Iron Binding Capacity: 305 µg/dl, Ferritin: 140 ng/ml. What is the most likely diagnosis according to the patients' scenario? Please explain with the reasons. Selected Answer: Correct Answer: Response Feedback: since the patient MCV is low ( 80-100), hear rate is normal, blood pressure is normal, RBC and WBC is normal, Hg is low, HCt is loww , RDW is small is and she is pregant so my diagnosis is most likely Iron deficecny anemia. When the CBC results are examined, it is significant that low Hb levels and mild microcytic anemia due to the low MCV levels. Also, the results of iron studies are within normal ranges. Considering that the case does not have any symptoms, the pre-diagnosis of “Thalassemia Minor/ Thalassemia Trait” should come to mind first. [None Given] • Question 12 2.5 out of 5 points Which diagnostic test(s) do you need to confirm your diagnosis of the case above? Selected Answer: 1. ultrasound to check the menstural bleeding 2. endoscopy to check the belleding from hertia hernia 3. colonoscopy o ruling out the interstial problems Correct Answer: 1. Peripheral blood smear 2. Hb electrophoresis (Required) 3. DNA analysis for α and β Thalassemia Response Feedback: [None Given] • Question 13 0 out of 5 points After confirming the most likely diagnosis in the case above, what would your management plan be? Selected Answer: Correct Answer: Response Feedback: taking the iron suplement and vitamin C suplment because of increasing the iron absoprtion, taking the vegtables and foods with the high iron such as spinach, restriction the caffeein and also check the medication that she wants to take with her doctor because of being prgenant . Patients with thalassemia minor usually do not require any specific treatment. However, genetic counseling should definitely be planned for this case. [None Given] Wednesday, December 8, 2021 7:50:33 PM TRT