Tommyk's posts: 501-523

[Anonymous]

501.
Q) HY Concept 500 spoke of croup from parainfluenza. NOW, there are exactly three other bugs/viruses within the same family. YOU MUST LUMP. What are they?

A) They are the same family, Paramyxovirus!! Measles, Mumps, and RSV. On my call last night, there were so many patients with RSV!! We will discuss the subtle difference between RSV and croup from parainfluenza next time if I am still alive. I am on call TONIGHT TOO! Coffee, anyone???

502.
To answer Sanaray's Question about the pictures and diagrams, I found that BRS Biochemistry, FA, and Kaplan all have good diagrams. The key to remembering diagrams..I say it again..is to stick to one source. I FOUND THAT WRITING OUT MY OWN BIOCHEMISTRY CHART WAS THE MOST HELPFUL. After referring to BRS, etc. I wrote out this GIANT BIOCHEMSITRY CYCLE WHERE EVERY SINGLE RELEVANT CYCLE INTERTWINED WITH THE OTHER. This way, you REALLY remember because you created your own chart. I wonder if there is a way to paste my own chart onto this site, but THERE ARE MANY biochem books that have this information. REMEMBER, EVERYTHING FEEDS INTO THE SUPERHIGHWAY of energy metabolism, that is Glycolysis and the TCA cycle. Know where every cycle "FEEDS IN". They are NOT isolated, but interconnected. Come to think of it, Lippincott's Biochem Review has some good "linking" diagrams. If you really understand how all the pieces fit together, it is SO MUCH EASIER to remember come test time. Also, people are asking about an atlas, etc...Webpath is great, but if you really study Netter's Anatomy and understand some of the basic anatomical relationships (eg. If I ask you to draw a cross section at C8 spinal cord level from a scratch paper, can you draw the MAJOR ARTERIES, NERVES/GANGLIA/TRACHEA, and the relationship to the other?) Everyone needs to know this, in the ER, for eg. I needed to know where the retropharyngeal space was on radiograph. It is stuff like that the NBME will want you to understand. Tommy..

503.
Q) Again, you will see this on tests and in clinics every second...patient will come in with signs of a "cold". But what are you most afraid of? A common coronavirus (Strucure? please? RNA or DNA?), will resolve without duress in a immunocompetent person. So the NBME/attendings will "pimp" you on whether the person is immunocompromised (HIV), or has a BAD Bacterial/Fungal infection and also if the virus could compromise the airway. So, moving along:
Case: You see a patient named Clarence Day who is a 6 year old female patient who looked like your previous patient with a "cold"...but you are ALARMED because in addition to tachycardia, she is leaning forward and slightly gasping for air..PLUS, she is DROOLING (Key!). Dx, and BUG, and Rx please?


A) Here, the disease is EPIGLOTTITIS, often caused by H. Flu, (but also S. pneumo and Group A Strep). This is a medical EMERGENCY b/c it can block the airway, so you call ETN and consider a CRICOTHYROTOMY and INTUBATE!

504.
Q) Case: You now have a patient named Edgar Poe who is six months old. His mother brings him in and your med student sees him. He comes out of the exam room and says that all the family had the "common cold" so he will send Edgar home with Tylenol only. But when YOU do your exam, you hear crackles and mild rhonci on lung exam, and the child seems to be gasping for breath. Your attending comes in and tells you this IS a virus, but in patients this young, it can cause deadly hypoxic events and infects the bronchioles and is VERY contagious. The month is December...
Bug and Drug and Structure of Bug please?

A) This is classic RSV virus infection, part of PARAMYXOVIRUS family with RNA, HELIX shaped, Enveloped, single stranded negative polarity. The drugs are ONLY given for serious hypoxia. You may be asked to do a trial of albuterol to rule out asthma (similar presentation), and a rapid antigen test for RSV. Some like to tx with ribarvirin (MOA please) and a monoclonal drug called synergin (an RSV antibody)

505.
Case: Similar presentation of a young child, female, named Edith Wharton. This patient has NOT had her immunization shots. Her mother is coming to you after her daughter has had fits of coughing that has waxed and waned for a year now. PE is notable for an extended stridor after taking a deep breath. Her CBC has marked elevated white count, and your attending tells you this is a serious NON-viral illness (you can R/O RSV) so that goes though phases. Bug and drug and dx please?

A) This is the famous "Whooping Cough". The INTERVALS AND PHASES of strong coughing differentiate it from the other common illnesses. Since she had no immunization shots, she did not get her Pertussis shot. The bug is Bordetella pertussis and is a gram neg bacteria. You need a two week course of ERYTHROMYCIN. (Note, a culture and fluorescent antibody staining can pinpoint your dx).

506.
Case: Well, I won't put one here except to say know the most common bugs of pneumonia, a favorite of clinics/boards due to its severity. But tell me, how can I tell the diff. between say, S. pneumoniae pneumonia and a viral pneumonia?

A) So key, LISTEN...both viral and bacterial bugs can cause pneumonia, but understand that a viral (or mycoplasma) source has USUALLY more BILATERAL, diffuse, crackles, rhonchi, wheezing of this LOWER respiratory tract infection(s). BUT...a bacterial source points to a more focal or UNILATERAL source, with dullness to percussion, absent breath sounds.
If you suspect a bacterial origin, treat with Penicillin or amoxicillin. But if you think you have S. aureus or H. flu, you need a second or third generation cephalosporin. Recall that "walking pneumoniae" from Mycoplasma needs different coverage like Erythromycin.

507.
Case: Regarding the pneumonia cases, what outcome are you most afraid of (don't answer death..)? And what is the treatment?

A) The most common complication of the pneumonias is a pleural effusion bad enough to compromise respiration. If you "drain" their lungs with pleurocentesis (you could get out a 1 liter or MORE), you can help with this outcome.

508.
Case: A female woman, Mrs. *******on comes running into your office with twins with signs and symptoms of meningitis. Both twins are male and four years old. One male, named Robert, had a prodromal stage that was not specific and included fever chills nausea. The other male, named Louis, had a very high fever throughout and missed a prodromal phase. He also has some mild seizures. Which one has the bacterial origin? And what is the bug most common? What is the most specific test? What drug will you grab?

A) The bacterial meningitis is life threatening while the viral is usually not. The bug most common depends on the age of the patient.. but cover/choose S. pneumoniae as a common cause. The bacterial etiology usually has an absent prodromal phase. Do a lumbar puncture to pinpoint bug. Tx with a 3rd gen. ceph. like ceftriaxone which moves into the CSF easily.

509.
Q) Really quick, you see a young patient with diarrhea, vomiting, and low grade fever. All bacterial cultures come back negative. There is no history of travel and the patient is taking no medications. The time of the year is February. What is the most likely VIRAL etiology? Structure?

A) Rotavirus. It is NOT enveloped, is square shaped, double stranded, and segemented.

510.
Case: You have a young patient who keeps returning to the clinics after all infectious etiologies for bugs are ruled out! Name a few NON-infectious causes of diarrhea in your young patient! VERY IMPORTANT!

A) IBD like ulcerative colitis, cystic fibrosis, anti bacterial meds, and conditions such as celiac sprue or gluten sensitive disease could do this.

Sincerely, tommy....


511.
Case: You see another young patient in your clinic. This time, she also has bad diarrhea. So after a history, your medical student grabs some Immodium (anti-diarrheal). There is blood and yellow sticky "goop" from the GI, and you see WBCs on wet mount.
1) Is this a good idea to give anti diarrheals?
2) Rapid Rotavirus Antigen Testing is Negative, and so is Clostridum difficile toxin detection for possible antibiotic use..NEGATIVE. Other baceterial cultures are negative. Hmm.. you sit there wondering... But then your attending says she she CYSTS in the stool sample. What bug and drug?

valuemd.com

A1) No, do NOT give antidiarrheals here, treat instead with oral hydration and replace and manage the electrolytes as necessary.

A2) Most commonly, this is Giardia. Treat with Metronidazole.


512.
Case: A young patient of yours comes in with diarrhea. All common bacterial and virla tests come back negative. So your attending says consider a paraiste like Camyplylobacter jejuni. What drug will you reach for?

A) Erythromycin

513.
Case: Still stickin' with diarrhea and stomach pains...now you see a young patient who was on Clindamycin therapy for a while...(what are your thoughts?)...your attending says he found Clostridium difficile TOXIN. DOC, please?

A) Meronidazole, given ORALLY

514.
Case: Now, you are still seeing diarrhea and stomach pains...but this time your patient is a young African American male who has associated symptoms of headache, fever, and muscle, and bone pain. What is the bug now?

A) Consider SALMONELLA.

515.
Case: Still going...another young patient wtih diarrhea and stomach pains. You get a good history and it does not seem like anything normally seen...there is some blood in the fecal material...he has isolated pockets of nerve damage, LOW platlets on a CBC, and hemolytic anemia. Bad, bad disease. Your attending hints this is caused by a TOXIN spills by a couple of different bacteria. What is the disease, bugs?


A) This is the infamous HUS, or hemolytic uremic syndrome. Very deadly. Two bugs..E COLI 0157:H7 and Shigella dysenteriae are seen to cause this in young patients.

516.
Case: Still diarrhea is facing you....you see another young male age 10 with fever, some blood in feces, diarrhea. You are thinking the answer choices/differentials...E coli, Shigella, Salmonella, Entamoeba...Hmm..hard one but the GI attending stops by and hints this is NOT parasitic, and the patient has a history of taking H2 blockers and he loves eating raw pork hot dogs. The labs come back and the bug is oxidase negative, non lactose fermenting. What is the bug and drug?

A) You are on your way to becoming a doctor if you got this one right.. this is Yersinia entercolitica (Y. pestis causes the PLAGUE!). As long as hypovolemic shock is avoided, you are in good shape. Give TMP-SMX as treatment since this bug is becoming resistant.

517.
Case: We move on briefly to hepatitis...since everyone in the US receives regular vaccines, you should not encounter HBV for example in your young patient population too often. But, please understand the HY facts which address when and where you see the different antigens and antibodies for each of the Hepatitis viruses...A, B, C, D and E. For Hep B, for example, understand that about 1 in 10 patients WILL have a chronic carrier state which IS INFECTIVE. They remain HBsAg (+), so they can infect others. Do you know the difference between HBV/HDV and HAV/HEV?

KNOW that anti-HB core antibodies are seen after HB surface antigen has been eradicated, and understand that this may occur before anti Hep B surface antigen antibodies appears! You must review Hep B core antigen/antibody detection!

518.
KNOW: That even though the attendings/NBME probably know that you are familiar that penicillin is the DOC for TREPONEMA PALLIDUM, and that you need VDRL and RPR for diagnosis, tell me...what is the specific test that is used for treponemal tests?

A) FTA-ABS test. Just understand that a patient who is young and has persistent jaundice, heptosplenomegaly and lymadenopathy is a classic presentation of syphillis obtained through "vertical" transmission, ie, from mother to child.

519.
Case: You have a young woman, say 21 years of age, which presents with a positive culture for Chlamydia and Neisseria. She is sadly...become infertile...
Q) What is the dx? What two bugs are commonly implicated? And what is the treatment? Can she have another common sequelae?

A) Since one in six or one in five with PID develop permanent infertility, you must be familiar with this. The two bugs (trick questions) ARE Chlamydia and Neisseria. The treatment for Chlamydia is Doxycycline or Azithromycin (Zithromax). For Neisseria, give a single dose of Ceftriaxone or a quinolone if you wish. The common bug Neisseria causes accompanied muscle pain in both males and females.

520.
Case: Your poor patient who has PID (pelvic inflammatory disease) is now coming back to you after two years with the triad of arthritis, red conjunctiva, and inflammation of the urethra. What is the disease?

A) Untreated PID can progress to Reiter's syndrome.

521.
Case: You see a 23 year old female patient with painless growths on her vulva. She has a sexual history with multiple partners. Diagnostic tests demonstrate that this is a VIRAL etiology. What is the bug and tx?

A) Among the MOST COMMON of the sexually transmitted diseases, you must know and understand all about HPV or human pap. virus. They can often cause these painless chancres that you can treat with CO2 laser ablation, scalpel excision, or laser therapy. MEDICAL pharmacotherapy consistents of interferon therapy, 5-FU, or Podophyllin (an anti mitotic). You must make this patient come for ANNUAL pap smears! Why??

522.
KNOW that for a young woman who comes to your clinic with vaginal itching, there are three USUAL SUSPECTS:

1) Bacterial Vaginosis from Gardnerella vaginitis, Mycoplasma hominis, and about 20 other vaginal flora. Sexual contact may or may not contribute... You will see these large "clue cells" on a slide. Tx is METRO.

2) Trichomonas...definitely you will see this, no question. This is easy to spot because you see these little oval creatures swimming around in wet mount...sexually transmitted. Treat with METRO.

3) Candida...you KNOW you will see this cottage cheese looking yeast with pseudohyphae on wet mount. They are often see increasingly with DIABETICS, PREGNANCY. Treat with NYSTATIN! KNOW this is NOT sexually transmitted.

523,
Case: ON NO!!! You have a patient with HIV, a young woman, who is with child!!! What drug will you give her for her baby since about 1/3 of the patients present with transmission eventually to their babies!

A) AZT can reduce the transmission to the fetus to less than 10%!!!!!

[nikki]

for your time and effort.

wish you lots of luck for your exam.....

nikki