A 65 year old man with a past history of

A 65-year-old man with a past history of bronchiectasis presents to the ER with
hemoptysis. He reports increased cough and sputum production over the last week.
There is often blood streaking his sputum, but on the last day he has noted that he is
coughing up tablespoons of clotted blood. PE shows normal vital signs, O2 sat of 98%
on room air. The patient is mildly dyspneic and has diffuse expiratory wheezing.
Radiography reveals findings consistent with bronchiectasis. What is the most likely
cause of the hemoptysis? *

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A 50-year-old male presents to the clinic for a routine health examination. A
comprehensive metabolic panel shows a serum Calcium level of 11.2 mg/dl. Serum
phosphate is 3.0 mg/dl. Serum creatinine is normal. He denies bone pain, lethargy,
weakness, or weight loss. What is the most common cause of hypercalcemia in
out-patients? *
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Vitamin D intoxication
Milk-alkali syndrome
Medications
Granulomatous disease
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Correct! Primary hyperparathyroidism and malignancy account for over 90% of cases of
hypercalcemia. Calcium is regulated in bone, the gastrointestinal tract, and the kidney. Other causes of
increased bone turnover include Paget's disease, immobilization, hyperthyroidism, hypervitaminosis A,
and adrenal insufficiency. Causes of increased GI absorption include vitamin D intoxication and
milk-alkali syndrome.
A 35 year old female undergoes a physical exam while obtaining new insurance
coverage. She reports 1 year of slowly progressive dyspnea on exertion and a change in
skin color. Her PE is notable for the the presence of cyanosis, an elevated JVP, a fixed
split loud loud S2, and peripheral edema. Arterial O2 saturation is 84% at room air. CXR
shows cardiomegaly and normal lung parenchyma. Ten years ago, at her last insurance
PE, her PE, O2 saturation and CXR were normal. Echocardiography most likely will
reveal: *
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Ebstein's anomaly
Ventricular septal defect
Tetralogy of Fallot
Truncus arteriosus

Atrial septal defect
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Correct! The patient is presenting with Eisenmenger's syndrome (shunt anomaly with predominant
right to left shunting) These shunts are initially left to right and therefore do not present with cyanosis.
Pulmonary hypertension develops over the years as the result of increased pulmonary blood flow,
increased vascular tone, and erythrocytosis. Atrial Septal defects are the most common in adults
presenting with Eisenmenger's syndrome. This patient had no evidence of pulmonary hypertension or
cyanosis 10 years ago.