IM: GIT
meduploader - 05-31-09 14:37

History of Present Illness: A 54-year-old female presents to the emergency department with the chief complaint of shortness of breath, blurred vision, vomiting and weakness for 2 days. Past Medical History: Bipolar mood disorder. Medications: Fluoxetine, diazepam. Allergies: None. Social History: Tobacco: 30 pack years; denies use of alcohol or drugs. Family History: Patient’s mother has rheumatoid arthritis and systemic lupus erythematosus Physical Examination: Well-developed, thin female, lethargic, oriented to name only. Vital Signs: Temperature 34oC, respiratory rate 34/minute, pulse 128/minute, blood pressure 92/50 mm Hg, pulse oximetry – 90% on room air. Skin: Warm and very dry with poor turgor. Head, Ears, Eyes, Nose Throat (HEENT): Normal cephalic atraumatic (NC/AT). Pupils 4 mm. Pupils equal, round, reactive to light and accommodation (PERRLA). Extraocular muscles intact (EOMI), no nystagmus.ormal hearing, tympanic membranes clear. Mucous membranes pale and dry with obvious cracking at the corners of the mouth and hyperemia of the posterior pharynx. Neck: Supple. No adenopathy or jugular venous distention (JVD). Chest: Decreased breath sounds with rhonchi in bases bilaterally. Cardiovascular Examination: Regular rhythm, normal S1 and S2, no murmurs, rubs or gallops. Abdomen: No scars. Soft, non-distended, hyperactive bowel sounds. No organomegaly noted. Diffuse tenderness to palpation, with positive Murphy’s sign. Rectal Examination: Normal tone, normal perianal sensation, guaiac-positive black stool. Neurologic Examination: Motor exam reveals 2/5 weakness bilaterally in the upper and lower extremities.Sensory exam shows no deficits in light touch, pinprick or position sense throughout. Deep tendon reflexes are symmetrically decreased 1+. Cerebellar exam is intact. Cranial nerves II-XII are intact. Initial Laboratory Test Results:ECG: Sinus tachycardia without ST or T-wave abnormality, QT lengthening or increase in PR interval. CBC: WBC 2,200 /m L, hematocrit 24%, hemoglobin 7 g/dL, platelets 16,000 /m L. Serum Chemistries:Na+ 149 mEq/L, K+ 4.3 mEq/L, Cl- 99 mEq/L, HCO3- 16 mEq/L, glucose 105 mg/dL, BUN 43 mg/dL, creatinine 3.8 mg/dL. Additional Studies: Ca++ 9.0 mg/dL, Mg++ 2.8 mg/dL, 3.7 mg/dL, INR 3.4, PTT 25 sec. 1. Which of the following toxic causes should be included in your differential diagnosis of this patient with stomatitis and gastrointestinal (GI) bleeding? A. 5-Fluorouracil, Golsalts, Methotrexate B. Phenytoin C. Gold salts, Methotrexate, Phenytoin D. Tetracycline E. Gold salts, Methotrexate 2. Methotrexate is structurally related to which of the following vitamins? A. Vitamin C B. Folic acid C. Vitamin B-12 D. Vitamin B-1 E. Pantothenic acid 3. What is the antidote to methotrexate? A. Pentahydrofolic acid B. Dihydrofolic acid C. Folinic acid (N5-methylene tetrahydrofolic acid) D. PABA + Pteridine precursors E. Trihydrofolic acid