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A 35 – year old woman comes to the office because of an ulcer on the skin of her left ankle. She developed pigmentation in her left medial ankle several years ago and then developed a superficial, painless ulcer in the center of the pigmented area 2 months ago. She had been in excellent health prior to that. She works as a schoolteacher and is on her feet most of the day. She has been unable to heal it with local wound care and comes to see you for treatment. Which of the following diagnostic tests would be the most useful? 

During a typical May in St. Louis, it rains once every 2.6 days. Using the exponential distribution, calculate the probability that no rain ralls during the first week (7 days) in the month of May. (Hint: You can also think of this as the probability that the first rainy day happens after a week.)   You may any of use these values, if you think it would be helpful:  

1.       A 62 year old white female presents with increased abdominal distention over 3 weeks.  Patient has noticed a 14 lb weight loss over the last 4 months and increasing fatigue.   Patient has also noticed edema in his ankles over the same time frame.  She has history of mild hypertension, but is on no medications. On physical exam, patient is awake alert in no acute distress. Blood pressure is 100/60.  Respiratory 12, heart rate 73, temperature is afebrile.  HEENT is significant for no scleral icterus.  Skin exam has no jaundice.  Chest was clear to auscultation.  Heart was regular rate and rhythm. Abdomen is protuberant with some shifting dullness. Patient has 3+ edema bilaterally to the mid calf. Lab values are significant for a normal CBC, normal basic chemistry, creatinine of 1.5.  Albumin is 2.7, AST 33, ALT 43, total bili 1.2, LDH 458, alkaline phosphatase 337. Patient subsequently has a paracentesis of 4 L of cloudy fluid.   Fluid lab values: Albumin 1.8, total protein 3.2.  LDH 345.  Cell count 400 with 85% histiocytes.  Cultures of the fluid were sent. Urinalysis is significant for 2+ protein, SG 1.012, 1+glucose, with no cells on microscopy. What is the most likely cause of patient’s ascites?

1.       A 45 -year-old white female presents to your office with shortness of breath.  She has had a upper respiratory infection for the last 3 weeks. This initially began with a sore throat and rhinorrhea, and then progressed into a deep hacking cough productive of greenish sputum.  Patient has chills as well as subjective fevers. In addition patient has pleuritic chest pain. Past medical history is otherwise unremarkable. Allergies are none. Current medications are just oral contraceptives.  Social history patient occasionally smokes. On physical exam patient is an ill-appearing Hispanic female in mild distress. Temperature is 102.5, RR18, blood pressure is 115/76, heart rate of 96.  Physical exam reveals good air movement on the left, with diminished breath sounds on the right.  Patient is dullness to percussion on the right as well.  A chest x-ray was obtained which shows a right-sided infiltrate as well as a moderate right-sided pleural effusion. Lab values are significant for a white count of 15.5 with significant left shift. Patient had an LDH of 600, total protein of 7.3. Thoracentesis was performed: 1500 cc of a cloudy thick purulent fluid is obtained. Fluid lab values are WBCs 10,500 with a differential of 85% neutrophils, RBCs 4500, glucose 30, LDH 450, total protein 5.5, pH 7.33.  Gram stain of the fluid reveals many PMNs. What would be the correct diagnosis?

Which method of obtaining a bone biopsy is the most likely to cause a pathologic fracture at the biopsy site?

8. A 72 year-old black female presents with shortness of breath which has been progressive over the past 2 days. Patient does report having had a URI approximately one month ago.  On physical exam she is found to have decreased breath sounds on the left, suggesting a left pleural effusion, which is subsequently confirmed on chest x-ray.  Patient’s physical exam is otherwise significant for patient appearing moderately short of breath.  Patient has a past medical history of coronary artery disease, hypertension, diabetes and temporal arteritis, as well as recurrent pneumonia.  Allergies are none.  Current medications include Metformin 1000 mg po twice daily, metoprolol tartrate 50 mg po twice daily,  aspirin 81 mg po daily, simvastatin 40 mg po daily, Famotidine 40 mg po daily, and prednisone 50mg daily. Patient’s labs are significant for a white count of 14,000, with 75% neutrophils. Chemistries are significant for having a creatinine of 1.15.  LDH is 330, total protein is 7.2. Fluid analysis shows a cloudy turbulent fluid.  Thoracentesis fluid reveals :WBCs  500/ml-  neutrophils 60%, Lymphocytes 30%.  Glucose is 90.  LDH 100.  Total protein 3.3.  PH is 7.4.  Gram stain reveals occasional neutrophils and lymphocytes, but no bacteria.   What is the most likely cause of patient’s pleural effusion?  

A 56-year-old black female presents with shortness of breath which has been progressive over the last week. Patient does report having had a URI approximately one week ago. On physical exam she is found to have decreased breath sounds on the left, suggesting a left pleural effusion, which is subsequently confirmed on chest x-ray.  Patient’s physical exam is otherwise remarkable for patient appearing ill,  with shortness of breath. Vitals signs show pt to be afebrile, with HR of 112, BP 102/70 RR22.   Patient has a past medical history of rheumatoid arthritis, as well as recurrent pneumonia.  Allergies are none.  Current medications include Methotrexate 15 mg po weekly and prednisone 5 mg daily. Patient’s labs are significant for a white count of 14,000, with 75% neutrophils. Chemistries are significant for having a creatinine of 1.15.  LDH is 330, total protein is 7.2. Fluid analysis shows a cloudy turbulent fluid.  Thoracentesis fluid reveals :WBCs  20000/ml-  neutrophils 85%, Lymphocytes 10%.  Glucose is 20.  LDH 250.  Total protein 5.6.  PH is 7.1 Gram stain reveals large numbers of neutrophils with occasional gram positive cocci.   What is the most likely cause of patient’s pleural effusion?

Please choose all that apply. A minimum database in a young, healthy surgical patient may include:

A 25-year-old homeless man is transported to the emergency department by ambulance after bystanders called because he had been found lying unconscious for an unknown period of time.  According to the paramedics, the patient was found lying on the sidewalk and unresponsive to verbal or painful stimuli.  During transport to the hospital, the patient did experience a generalized tonic-clonic seizure lasting 30-45 seconds. The patient is unable to give any history. On examination, his blood pressure is 140/80 mmHg, pulse is 92 per minute, respirations are 14 per minute, and his temperature is 99.8 F. He is not responsive to verbal or painful stimuli. Examination of the chest, heart, abdomen, and extremities is unremarkable. The neurologic exam is without focal deficits. After placement of an indwelling catheter, visual inspection reveals dark, “coca-cola” colored urine. Blood alcohol level was 88 mg/dl. The serum creatine kinase level is 10,500 U/L. A urine sample was sent for drug screen showing the presence of cocaine.   Which of the following serum electrolyte abnormalities would be MOST LIKELY in this adult patient?   Answer Na K Ca2+ (8.5-10.5) PO4 (2.5-5.0) BUN creatinine Uric acid A. 125 5.8 12.1 2.4 44 2.4 Low B. 128 3.1 9.3 3.4 50 2.4 Elevated C. 130 5.8 8.1 5.8 60 2.4 Elevated D. 145 4.2 9.8 3.5 18 0.8 Elevated E. 145 4.2 9.8 3.5 18 0.8 Normal F. 155 4.5 8.1 5.8 40 1.5 Normal

 As-tu apporté des enveloppes ?  Oui, J’___ ai apporté.