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set of questions 3(Nasi)
1- 57 y/o male is on hemodialysis for CRF. Which of the ffg metabolic derangements can be anticipated?
A- hypercalcemia B- hypophosphatemia C- osteomalacia D- Vit. D excess E- Hypoparathyroidism 1- 57 y/o male is on hemodialysis for CRF. Which of the ffg metabolic derangements can be anticipated? A- hypercalcemia B- hypophosphatemia C- osteomalacia D- Vit. D excess E- Hypoparathyroidism Answer is c- osteomalacia. Kidneys failure to excrete phosphate-->hyperphosphatemia & fail to synthesize 1,25(OH)2D3. then Vit. D def. --> impaired intestinal ca absorption. Phosphate retention, defective intestinal absorption & skeletal resistance to PTH --> hypocalcemia --> secondary hyperparathyroidism --> worsens hyperphosphatemia by increasing the Ph. release from bone --> renal osteodystrophy 2,2- 50 y/o woman with a Hx of essential HTN, presents to ER with severe headache, nausea, vomiting and photophobia. On P/E, BP= 160/100 mmHg, she’s confused with nuchal rigidity without focal neurologic signs. ** What’s the Dx? A- hemorrhagic stroke B- ruptured cerebral aneurysm C- meningitis D- ischemic cerebrovascular accident E- TIA ** Dx is best confirmed with? A- LP B- Doppler US of carotid artries C- Head MRI D- Head CT followed by cerebral angiography E- EEG ** What’s the next most important step in Mx? A- urgent surgery with aneurysm clipping B- admission to ICU, close monitoring and Tx of HTN C- admission to ICU, close monitoring and IV antibiotics D- anticoagulation & antiplatlete therapy E- serial LP to drain CSF -ruptured cerebral anurysm, D-head CT followed by cerebral angio A-urgent surgery w/ anurysm clipping, most likley the pt. ruptured cerebral anurysm, as pt. is confused, no focal signs present and pt. has nuchal rigidity, could be and most likely due to the blood in the CSF--> meningeal irritation, etc.. although you also see nuchal rigidity w/ meningitis, here you have confusion as well although they give us a nice high B.P of 160/100, and we might want to choose stroke over cerebral anurysm, given the rest of the prez. here anurysm is more likly, as well as you would expect to see neuro focal findings w/ stroke, not present here ischemic cerebrovascular accident --> expect to see some focal signs as well as may not have nuchal rigidity TIA, usually transient and other symptoms present , not seen here 3.3- During an elective laparascopic cholecystectomy, the patient developes a sudden onset drop in BP, atrial desaturation and an increase in ventilatory pressure. What’s the most appropriate step of Mx? A- an IV fluid bolous B- decompression of the pneumoperitoneum C- inserting a chest tube D- re-evaluating the position of the endotracheal tube & portable CXR E- aborting the procedure & converting to an open cholecystectomy Answer is C, coz patient has developed tension pneumothorax 4.4- 2 wk old boy is brought for check up. He’s been doing well at home. Results of his newborn screen shows he has sickle cell dis. ** What’s the most important step in his Mx? A- avoiding heat exposure B- immunization with pneumococcal vaccine C- folic acid supplements D- iron supplements E- prophylactic penicillin ** Six months later, the same patient returns with a 3 day Hx of lethargy & fever with rhinorrhea and cough. On P/E, he is pale, tacchycardic with a LUQ mass. Hgb= 4, Plt= 100000, WBC= 15000 with 50% segmented neut. , reticulocyte count=15%. What’s the Dx? A- Acute chest syn. B- Acute splenic sequestration C- Aplastic crisis D- Intussusception E- Vaso-occlusive crisis Answer is E & B. because he’s at high risk of infection, especially with encapsulated organisms and penicillin will dramatically decrease this risk. Pneumococcal vaccine is not effective in neonates. It’s usually given at 2 yrs age. 5.5- A 52 y/o man receives a preoperative evaluation before an alective surgery. He is asymptomatic with a normal P/E, but he is noted to have a Hgb= 10.8, Hct= 33, MCV= 70, RBC= 6.1x1000/ microlit. What’s the most likely Dx? A- Sickle cell dis. B- Iron def. Anemia C- Alpha thalassemia major D- Beta thalassemia minor E- Anemia of chronic dis. D-beta thalassemia minor, pt. has hypocromic, microcytic anemia,..as well as increased retic. count--> increased RBC's, ..this last feature makes the better choice here to be thalassemia, as oposed to iron def. for example iron def. seems to be avery good choice, as one should think anemia in older MAN , is due to cancer-COLON ca , until proven otherwise..however you would expect to see low reticulocytes count w/ iron def. anemia. note- elevated retic. counts--> seen in thalassemia/hemoglobinopathy,..like SS anemia Follow Ups: D- Beta thalassemia minor microcytic anemia in an asympto pt with increased number of RBCs...>beta thalasemia minor 6.Patient of one of your colleague , comes to you and tells you that he has heard your colleague has aids.What should be your response: . Tell him that your colleague has aids . Tell him to ask your colleague himself whether he has aids or not . Refuse to tell him since he is not your patient . Tell him aids is not transmitted by person to person contact . Tell him to ask the incharge of the hospital Any comments? tell him to ask your colleague wheather he has aids or not,... this is the most appropriate response of this doctor , as this needs to be clarified b/n the pt. and his doctor. it would seem less appropriate for this doctor to discuss his colleague's issues of aids w/ his colleage's pt.- weather he has it or not. pt should be encouraged to ask his doctor , if pt. has concerns as this is the best way to find out and/or, plus discuss that or any other relavant issues or concerns the pt. might have in addition, reagarding his doctor having aids , for example and how this relates to him/her. telling the pt. weather aids is transmitted by person to pesron contact is irrelavant here, as well as asking the incharge of hospital is not necessary,.. 7.A patient who is being screened for vit b12 def undergoes a schilling test, 1mg of cobalamin im 1hr after administration of radiolabelled cobalamin. A normal schilling test ,excretion of >10mg% of the radiolabelled cobalamin in a 24hr urine specimen would be most likely in which of the following situations? A--Intrinsic factor def B--Surgically absent terminal illeum c Achlorhydria d Celiac sprue D Its celiac sprue--will have normal schilling test . it causes abnormal d-xylose test 8.wHICH OF THE FOLLOWING ENDOCRINOLOGIC ABNORMALITIES IS TYPICAL OF PATIENTS WITH ANOREXIA NERVOSA? A inc Gnrh B dec s cortisol C inc TSH d inc IGF levels e inc growth hormone Endocrine changes in A.N.: ** decrease in GnRH --> amenorrhea ** increase in serum cortisol and 24-h urine free cortisol ** euthyroid sick syndrome-like patthern ( T4 and free T4 levels in the low-normal range, T3 levels reduced, and rT3 elevated )TSH is normally or partially suppressed. ** increase in Growth hormone ** decrease insulin-like growth factor 1 (IGF-1) So answer is e- inc growth hormone 9.Thiazides ()—particularly indicated for hypertension in the elderly a contra-indication is gout; Beta-blockers )—indications include myocardial infarction, angina; compelling contra-indications include asthma, heart block; ACE inhibitors indications include heart failure, left ventricular dysfunction and diabetic nephropathy; contra-indications include renovascular disease ( and pregnancy; Calcium-channel blockers. There are important differences between calcium-channel blockers ( Dihydropyridine calcium-channel blockers are valuable in isolated systolic hypertension in the elderly when a low-dose thiazide is contra-indicated or not tolerated ). ‘Rate-limiting’ calcium-channel blockers (e.g. diltiazem, verapamil) may be valuable in angina; contra-indications include heart failure and heart block; Alpha-blockers a possible indication is prostatism; a contra-indication is urinary incontinence; Angiotensin-II receptor antagonists (section 2.5.5.2) are alternatives for those who cannot tolerate ACE inhibitors because of persistent dry cough, but they have the same contra-indications as ACE inhibitors. 10.Posted by epinephrine from IP 198.81.26.102 on August 07, 2003 at 08:11:31: In Reply to: Re: which is the antihypertensive contraindicated in elderly? posted by lahar on August 07, 2003 at 07:41:04: Beta blockers bcz they hav e low Renin when they get old just like Black ppl they dont respond to betablockers well bcz they have low renin so thats why in elderly and balcks we dont chooose beta blocker as ist drug...there r many others which r goood 11.A 13-year-old boy is brought to the hospital by paramedics because of possible poisoning. The father reports that his son has recently been drinking alcohol excessively. Over the past few days, the son had seemed very depressed and had been caught sneaking alcohol into the house on two occasions. The father tried confining the son to his bedroom, but later found him face down on the garage floor near a bottle of antifreeze. The patient's girlfriend confirmed that the patient did consume some liquid that she believed to be antifreeze. To rapidly assess this possibility, which of the following is the most appropriate initial step in management? A. Examine the patient's breath for a fruity odor B. Evaluate for hyperemia of his optic discs C. Obtain an ECG D. Evaluate his urine under a Wood's lamp E. Request a serum osmolarity measurement Wood's lamp examination of urine is the test for rapidly assessing the possibility of antifreeze ingestion. Manufacturers of ethylene glycol-containing antifreezes typically add fluorescein to the mix, which will fluoresce under a Wood's lamp. hyperemia of optic disc- methanol toxicity. breath for fruity odour- DKA ECG - not useful for this clinical history. serum osmolality - an elevated osmolar gap will be seen with ingestions of many osmotically active compounds, including ethanol. This measure is therefore not specific for ethylene glycol. 12.Early Lyme Disease: fatigue chills and fever headache muscle and joint pain swollen lymph nodes erythema migrans Late Lyme Disease: Arthritis . Nervous system abnormalities can include numbness, pain, Bell's palsy (, and meningitis Less frequently, irregularities of the heart rhythm occur 13.absolute indications of open breast biopsy..... positive FNA....cytology cystic mass with a solid component or bloody aspirates.masses with nipple discharge, suspiciou smamogram changeswithout a dominnet nodul eor discrete thickning... for fibrocystic breast pain danazol is the best drug other useful advise is dont smoke dont take caffeinated drink ocp bcz this is premelig condition... monthly self breats exam after age 20 soon after cessation of menstural cycle.. best exam is when they r in shower...doctor must demonstarte with proper demonstration ..bcz 80% of breats ca r dected by women on their own.... if fibroadenomaa.....fna is done if cyst reappera or bloody nipple d/c then open biopsy basal mamo at the ages bet 35 and 40 women at high risk of breast ca ..shoul dhav e mamo gram early and annuly.. on fibroadenoma is fluid reacumulate again or if d/c is bloody then biopsy. fibroadenoma is most comon sinle mass freely moveable rubbery inconsistancy...commonbet 25 to 30 yrs of age... for fibrocystic dieases f/u pt in 6 wk since its hormone dependent so usuallly resolved after menses.. any ovarian mass over 35 yr is imp bcz it could b ca so pelvic ultrasoun d and if adnexal mass is morethan 6 cm laprotomy or laproscpic removal is madantory .. ca in situ in ca cx can b treated by... excition with col d knife laser conization hystrectomy norplant is low dose of progestin which ac t by supressing the lh surge and since its progestron most comonside efect is viginal spotting.. the most c sid eefect of estrogen pilll is nause an d vomitting norplant also thicken the cervical secretions. rolaxefen is much better choice for who has h/o endometrial ca or breast if menopausal to prevent osteoporosis bcz it potect from both.. most comon cause of dysmenorrhea and dyspurinia in awomen less than 35 is endometriosis and more than 35 its adeno myosis...where utral ling is in the myometrium .. chroniac villus samplin can b done at 10 ..12 wks but more risky than aminocentesis remmber it cant detect neural tubed defect... if MSAFP is positive then next step is amino centesis and if it is showing ntd then next step is ultrasound.... chalmydia trachomatus is most c sexual transmitted diease in women... when u treta gonorreha always give doxy 100mg bid fo 10 days for chalmydia..but if u r treating chalmydia no need to give treatment for gonoreha.. ocp dec the chance of PID and iud inc it ocp dec the chance of ovarian ca ocp is goood an dist drug of choice for polycystic ovarian syndrome... no ocp if coronary herat diease or sickel cell disease liver disease, thromboemolic diease.dub.smoker s over 35 yrs of age.. if woman has syphlis in preg desenstize her if allergic to pencilline... if hiv has any stage of syphylis terat with pcn an d always iv jus t manage everystage like its neurosyphilis if pt is hiv positive itp is most comon these days bcz hiv is common. GIFT involve transfering both ovum and sperm into follapian tube..so fertilization occur in follapian tube.....these woemnmust hav e one normal functioning f tube preg rates r 17% with in vitro and 26 % with GIFT 14.A 56-year-old woman had normal menses until undergoing menopause at age 51 years and has received no postmenopausal hormone replacement therapy (HRT). She is in good health and walks 15 miles per week for exercise. She does not smoke or drink alcoholic beverages and has never fractured a bone. Her estimated calcium intake is 600 mg per day. She has no contraindications to HRT. She has read about osteoporosis and wishes to evaluate her fracture risk and discuss possible preventive therapies. The next best step in the management of this patient is: (A) Measure parathyroid hormone (PTH), thyroid- stimulating hormone (TSH), and 25-hydroxyvitamin D levels. (B) Measure sedimentation rate and perform serum protein electrophoresis. (C) Recommend appropriate calcium and vitamin D intake and HRT. (D) Reassure the patient that there is no increased risk of breast cancer with HRT. (E) Measure bone density. C This patient has no risk factors for osteoporosis other than the postmenopausal state. Testing to screen for secondary causes of osteoporosis is unnecessary in the absence of evidence of osteoporosis. She may benefit from hormone replacement therapy (HRT) with regard to general well-being, cardiovascular risk, or osteoporosis, and a discussion of the risks and benefits of HRT is appropriate. Provision of an adequate calcium intake reduces the loss of bone mineral and reduces the risk of fracture. With an estimated daily calcium intake of 600 mg, she requires an additional 600 mg to 900 mg of elemental calcium to optimize her intake, and this can be provided in the form of a supplement (for example, calcium carbonate, 500 mg [200 mg elemental calcium] three times daily with meals). Exercise is an important part of the treatment, but this patient walks 15 miles a week and is therefore already exercising sufficiently. Although studies of cost-effectiveness suggest that in women without additional risk factors for osteoporosis, it is most cost effective to defer screening bone densitometry and treatment until age 65 years, a bone density study is reasonable in younger women if they desire it, and a determination of bone mineral density by dual-energy x-*** absorptiometry (DXA) or other methods may be helpful in their decision-making process. 15.A 66-year-old woman presents because of the sudden onset of severe low back pain. On physical examination, there is tenderness in the upper lumbar spine and spasm of the paraspinous muscles. A plain radiograph shows a compression fracture of L1. The serum calcium level and serum protein electrophoresis are normal. Despite educational efforts on the benefits of hormone replacement therapy, the patient has declined treatment with estrogen and is taking no medications. What is the next best step in this patient’s management (A) Vitamin D supplementation (B) Alendronate (C) Calcitonin (D) Biweekly physical therapy and weight training B Having sustained one fracture, this patient is at high risk for subsequent fractures, even without additional risk factors, and she is therefore a candidate for treatment. A bone density study could be obtained to define her baseline for subsequent treatment, but it is unnecessary for risk stratification. She would benefit from hormone replacement therapy to maintain bone mass, even though she has already experienced the most rapid period of postmenopausal bone loss. However, because she refuses hormone replacement therapy, alendronate is the best choice. A reasonable alternative therapy is raloxifene. She should also receive a vitamin D supplement and an oral calcium supplement if her dietary intake of calcium is inadequate, but treatment with vitamin D and calcium will only slow the rate of bone loss, not restore bone mass. Physical therapy may provide symptomatic benefit, but weight training should be undertaken cautiously, if at all, in a patient at risk of additional osteoporotic fractures. 12.A 40-year-old woman has recently been treated for a node-negative, estrogen–receptor-negative breast cancer. Her oncologist has recommended she undergo four cycles of chemotherapy consisting of doxorubicin and cyclophosphamide followed by four cycles of paclitaxel at standard doses. She was premenopausal at diagnosis but has not had a period since the second cycle of chemotherapy. She and her partner deferred having children but had begun to discuss having a child before her diagnosis. She comes to you for information about her chance of remaining fertile and the long-term complications of early menopause. Which of the following would NOT be appropriate management for this patient? (A) Referral for bone density scanning; therapy with calcium, 1 g/d orally (B) Counseling about appropriate use of vaginal lubricants (C) Therapy with raloxifene, 60 mg/d orally (D) Screening for hypertension and hypercholesterolemia (E) Counseling that if her menses recommence, she can become pregnant safely C A diagnosis of breast cancer is a life-changing event. The risk of recurrence and its subsequent morbidity and mortality can be psychologically traumatic, and if cancer does occur, most patients have difficulty maintaining a normal lifestyle. However, most patients with nonmetastatic, early-stage breast cancer have a good chance of being cured and returning to normal function following adjuvant treatment. These patients may suffer long-term anatomic and physiologic consequences of therapy, including cosmetic deformities from surgery and radiation and the risk of second malignancies from surgery, radiation, and systemic therapies. One of the most common concerns is the risk of premature menopause in young women with the disease or difficulty in treating the complications of menopause in older women. The four major complications of menopause are postmenopausal symptoms (hot flushes, moodiness, vaginal dryness/dyspareunia), osteoporosis>, coronary artery disease, and memory loss. Hormone replacement therapy (HRT) with estrogen and progestational therapy (to reduce the elevated risk of endometrial cancer) is indicated for most women who have these conditions but who have not had breast cancer. HRT decreases postmenopausal symptoms by as much as 90% and the risk of osteoporotic fractures by as much as 50%. Although not so well established, the benefits of HRT for reducing the risk of coronary artery disease and memory loss also appear to be substantial. The risk of breast cancer is increased in women who are exposed to exogenous estrogen, and one of the mainstay therapies for women with established breast cancer is antiestrogenic therapy (ovarian ablation and/or tamoxifen in young women, tamoxifen or aromatase inhibitors in older women). Therefore, in the past, HRT was felt to be contraindicated in women with prior breast cancer. Although recent authorities have questioned this absolute approach, most physicians continue to advise their patients to reduce the risks of these complications by nonhormonal means, such as avoiding tobacco, moderate exercise, careful control of hypertension and hypercholesterolemia, and nonestrogen prophylaxis against osteopenia. Although tamoxifen therapy has antiestrogenic properties in breast tissue, it is an estrogen receptor agonist in bone and liver. Therefore, in addition to being an effective treatment for breast cancer, tamoxifen therapy also appears to decrease osteopenia and hypercholesterolemia, especially in postmenopausal women. Because of this mixed agonist/antagonist activity, tamoxifen and other drugs like it are now known as selective estrogen receptor agonists (SERMs). A second-generation SERM, raloxifene, has been approved by the Food and Drug Administration for treating in postmenopausal women. Tamoxifen has estrogenic agonistic activity in the uterus, and therefore, its use is associated with a two- to threefold increase in the risk of endometrial cancer. Early clinical trials of raloxifene in the treatment of However, such an approach must be taken cautiously. The effects of raloxifene in preventing breast cancer recurrence have not been studied extensively. Furthermore, in this patient’s case, SERM therapy may be contraindicated. In one large prospective clinical trial, node-negative patients for whom chemotherapy was appropriate were all randomly assigned to postchemotherapy tamoxifen or observation regardless of their estrogen-receptor status. As expected, estrogen receptor–positive women who received tamoxifen therapy had significantly lower recurrence and mortality rates, but estrogen receptor–negative patients had a statistically significant increased risk of recurrence and death if they were assigned to tamoxifen therapy. Therefore, at present, SERM therapy for estrogen receptor–negative patients who are treated with adjuvant chemotherapy is not advised. Sexuality and fertility are complex problems after diagnosis and treatment of breast cancer. However, many women return to normal sexual activity. Vaginal dryness and dyspareunia are frequent problems. Several nonhormonal vaginal lubricants are available commercially and should be recommended. Eventually, the problem may be so severe that vaginal hormonal creams containing estrogen or testosterone may be indicated, although these are absorbed and provide low levels of systemic estrogen. Several studies suggest that becoming pregnant after breast cancer treatment does not increase a patient’s risk of cancer recurrence or death. Of course, the patient’s ability to become pregnant may be decreased because of ovarian failure after chemotherapy. The odds of becoming permanently amenorrheic after chemotherapy are age-related. A woman in her early 40s has a 50% to 75% chance of becoming postmenopausal. Patients who are taking SERMs should be advised to use barrier contraceptives even if they are amenorrheic. These agents may prevent menses but they may not prevent ovulation and appear to be teratogenic. Although women should also use barrier contraceptives during chemotherapy, there appears to be no increase in spontaneous abortions or birth defects in women who conceive following completion of chemotherapy. 14.Hyperlipoproteinemia- notes [ Follow Ups ] [ Post Followup ] [ Forum 2 ] -------------------------------------------------------------------------------- Posted by ACE from IP 65.81.153.248 on August 07, 2003 at 09:37:49: 4TYPES: familial hypertriglyceridemia, familial lipoprotein lipase deficiency, familial apoprotein C-II deficiency, and hepatic lipase deficiency. Familial hypertriglyceridemia is an autosomal dominant disorder with both overproduction and reduced catabolism of VLDL particles. Fasting triglycerides range from 200 to 750 mg/dL ...the disorder is NOT implicated as a risk for coronary artery disease. TRT: NICOTINIC ACID AND GEMFIBRIZOL. Familial lipoprotein lipase (LPL) deficiency : autosomal recessive disorder in which chylomicrons accumulate in infancy..PANCREATITIS and the other clinical manifestations of hyperchylomicronemia are present. ATHEROSCLEROSIS is NOT a feature of this defect. Because apo C-II is needed for the effectiveness of LPL, the clinical manifestations of the rare defect of familial apoprotein C-II deficiency are similar to those of LPL deficiency. Note from Merck Manual: Type I Hyperlipoproteinemia :A relatively rare inherited deficiency of either lipoprotein lipase activity or the lipase-activating protein apo C-II, causing an inability to effectively remove or "clear" chylomicrons and VLDL triglycerides from the blood. Symptoms, Signs, and Diagnosis This disease is manifested in children or young adults by pancreatitis-like abdominal pains; pinkish yellow papular cutaneous deposits of fat (eruptive xanthomas), especially over pressure points and extensor surfaces; lipemia retinalis; and hepatosplenomegaly. Symptoms and signs are exacerbated by increased dietary fat that accumulates in the circulation as chylomicrons.TRT- DIET DEC FAT INTAKE Hepatic lipase deficiency is a rare autosomal recessive defect that alters the final stages in the remodeling of small VLDL and IDL particles. VLDL remnants and HDL levels are INC. Familial hypercholesterolemia caused by a mutation in the gene responsible for the LDL receptor. Plasma cholesterol levels are high at birth, and values in adults range from 275 to 500 mg/dL. Tendon and tuberous xanthomas as well as xanthelasmas are features of this disorder. Coronary artery disease presents in the 30s or 40s. High doses of a “statin” combined with a bile acid sequestrant are initial therapies for both the homozygotic and heterozygotic form of familial hypercholesterolemia. If these agents are not effective in lowering LDL cholesterol by 15% in 3 months, nicotinic acid should be added. Neomycin and probucol are additional drugs that have been used in refractory cases. When pharmacologic treatment is unsuccessful, several surgical procedures have been tried, with mixed results: these include ileal bypass, portocaval anastomosis, and liver transplantation. LDL apheresis is another approach reserved for patients refractory to pharmacologic regimens. TRT: COLESTIPOL,CHOLESTRYRAMINE, LOVASTATIN, NICOTINIC ACID ( ACC TO KAPLAN ) Familial defective apo B-100 is caused by a mutation in the gene responsible for apo B-100; with a decreased affinity of LDL for its receptor, the clinical picture resembles that of familial hypercholesterolemia. Polygenic hypercholesterolemia is a result of multiple genes interacting with environmental factors to cause both overproduction and reduced catabolism of LDL and result in plasma cholesterol levels of 240 to 350 mg/dL. The hypercholesterolemia is often not detected until vascular disease develops. Familial combined hyperlipidemia is an autosomal dominant defect that may present variously as a combined hyperlipidemia, isolated hypertriglyceridemia, or isolated hypercholesterolemia. In affected patients, the lipoprotein phenotype may change with time because the underlying defect is probably polygenic and involves the metabolism of VLDL. Oversecretion of VLDL is the basic root for the multiple biochemical manifestations of a disorder that is the most common familial lipid defect in survivors of myocardial infarctions. It occurs in 0.5% to 1% of the population of the United States and is often influenced by environmental variability as well as additional genetic heterogeneity. Atherosclerosis is accelerated by the presence of small particles of VLDL, IDL, and LDL. Patients with plasma triglyceride levels greater than 500 mg/dL and a moderate cholesterol elevation respond best to gemfibrozil or nicotinic acid Dysbetalipoproteinemia is due to homozygosity for apo E-2 and the failure to catabolize chylomicrons and VLDL remnants normally. Tuberous xanthomas and deposits of cholesterol in the palmar creases may be present. The ratio of triglyceride to total cholesterol approximates 1, whereas that of VLDL cholesterol to VLDL triglycerides is greater than 25. Coronary artery and peripheral artery atherosclerosis is accelerated. Conditions Associated with secondary Hyperlipoproteinemia Hypercholesterolemia Hypothyroidism Nephrotic syndrome Anorexia nervosa Biliary cirrhosis (lipoprotein x) Acute intermittent porphyria Hypertriglyceridemia Diabetes mellitus Acute hepatitis Obesity Systemic lupus erythematosus Chronic renal failure Pregnancy Monoclonal gammopathy Sepsis Stress Drugs: alcohol, glucocorticoids, estrogens, isoretinoids, thiazides, b-blockers TRT: In men younger than 35 years without known cardiovascular disease and in premenopausal women, pharmacotherapy is not started unless the LDL cholesterol exceeds 190 to 220 mg/dL. On the other hand, in patients with known coronary artery disease, pharmacotherapy should start when the LDL cholesterol is greater than 130 mg/dL. primary prevention: Lowering cholesterol with pravastatin in middle-aged men without CAD and a plasma LDL cholesterol above 150 mg/dL reduced both the number of coronary events and coronary mortality. aggressive measures to lower cholesterol are required in patients with existing CAD. Benefits are most pronounced when plasma LDL cholesterol levels are reduced to 100 mg/dL, a level that has become the goal in all secondary prevention studies. Follow Ups: Re: Hyperlipoproteinemia- notes - monztree 10:05:11 08/09/03 (0) Wow... Great job ACE.... Thanks alot... - SN 10:00:34 08/07/03 (0) 15.A 40-year-old woman consults a physician about lesions on her neck that she finds cosmetically unattractive. On examination of the neck, multiple lesions that seem to be hanging off the skin are seen. Each lesion is small, soft, and pedunculated. The largest lesion is about 4 mm in diameter. The color of different lesions varies from flesh colored to slightly hyperpigmented. Which of the following is the most likely diagnosis? A. Acrochordons B. Lentigos C. Lipomas D. Seborrheic keratoses E. Spider angiomas These lesions are skin tags, more formally known as acrochordons. They are very common benign lesions that can occur at any skin site, but have a predilection for the neck, axilla, and groin. Multiple lesions are common, and the lesions tend to increase in number with age. They are usually asymptomatic but can be irritating. Microscopically, an acrochordon consists of a fibrovascular core, sometimes also with fat cells, covered by an unremarkable epidermis. Asymptomatic skin tags are usually not treated. Many methods can be used to remove disfiguring or irritated skin tags, including freezing with liquid nitrogen, light electrodesiccation, or excision with scalpel or scissors. 16.A 35-year-old woman presents to a clinician because of an itchy a patch of skin near her knee. 6 months previously, she had had several mosquito bites in the relatively small area. The mosquito bites eventually resolved, but the area had continued to be itchy, and she had continued to scratch it periodically. The well-defined 6-cm diameter patch of skin is now dry, scaling, hyperpigmented, and thickened. A ring of discrete brownish papules can be seen at the periphery of the lesion. Which of the following is the most likely diagnosis? A. Lichen simplex chronicus B. Pompholyx C. Psoriasis D. Seborrheic dermatitis E. Stasis dermatitis lichen simplex chronicus. this lesion can occur following mosquito bite. papule will cause severe itching. scratching the lesion makes it spread and recur(cycle repeated) aim in therapy is to arrest the cycle of itching scratching and paules formation. 17.A patient has a wedge pressure of 22 mmHg, pulmonary artery pressure of 48/24 mmHg and right atrial pressure (CVP) of 4 mmHg. Likely diagnostic possibilities include all the following except: a. coronary artery disease b. aortic stenosis c. mitral regurgitation d. pulmonary embolism e. aortic insufficiency 18.A 27 yo woman HIV+ presents with severe headache,nausea,vomiting,stiff neck.T:39C. Her CD4 count is likely to be: A:<100 B:100-150 C:150-200 D:200-250 <100, this pt. most likely has meningitis ( headache, other symptoms + stiff neck), which here, given the HIV+ Hx would be due to cryptoccocus, cryptococcus and for that matter toxo as well will be opportunistic when the count of CD falls to less than 100,... fungal and /or firal infection are commonplace in HIV+ compromised pt.'s , w/ low count.. Follow Ups: 19.A 54 yo coal miner presents with a history of severe pain in the left knee.He doesn't have a history of direct trauma,but has had episodes of pain in the left knee in the past,especially behind the knee.Ph.E shows fluctuant swelling.The knee is nontender,but tenderness is noted along the medial joint line,especially in the post.aspect. The most likely Dx? Tear of the medial meniscus high incidence among miners,bcoz they constantly move from a crouched position to a standing position and remain crouched for prolonged periods,transmitting considerable weight to the menisci 20.Psychodynamic psychotherapy indicated in: a:autistic disorder b:borderline personality disorder c:major depression,single episode with melancholic features d:schizophrenia e:social phobia,generalized type f  bsessive-compulsive disorder21. 37yo female presents to the ER after her car skidded on the freeway and struck a pillar.PR:88,RR:20,BP:100/70mmHg. On Ph.E jugular neck veins not prominent,cyanosis absent,breath sounds symmetric.The most likely Dx? a:dissection of the thorasic aorta b:Myocardial contusion c  ulmonary contusiond:cardiac tamponade e:ruptured aortic aneurysm a:dissection of the thorasic aorta thorasic distruption of aorta after a DECELERATION injury Follow Ups: 22.A 3mo infant is brought to the ER by his mother bcoz of a firm inguinal bulge.For 2wk the mother had noted this bulge when he cried,but it always disappeared when she calms him.The bulge has now remained for 3hr.The infant is crying and has a firm inguinal mass that's not discolored.The infant T:37.5C. What's the most appropriate first step of Mx? Follow Ups: incarcerated inguinal hernia an attempt of reduction is appropriate with administeration of a muscle relaxant and barbiturate and placement in the Trendelenburg position 23.The patient has a wedge pressure of 8 mmHg, pulmonary artery pressure of 40/10 mmHg and right atrial pressure of 16 mmHg. The cardiac index is 1.8 L/min/m2. Likely diagnoses include all the following except: a. right ventricular infarct b. pulmonary embolism c. pulmonary stenosis d. complete obstruction of left anterior descending coronary artery e. right ventricular dysfunction D The least likely diagnosis is obstruction of the left anterior descending coronary artery. This patient has a normal wedge pressure indicating normal left sided cardiac function, but the pressures in the right heart are elevated including the right atrial pressure and the pulmonary artery pressure. Therefore, the hemodynamic abnormality resides in the right heart. Possibilities include RV dysfunction, pulmonary embolism, pulmonary stenosis, and RV dysfunction. Follow Ups: 24.A homeless, alcoholic male is brought to the ED with a mildly altered level of consciousness. Although there is no history or external signs of trauma, a head CT is obtained and it shows a large collection of blood, with slight midline shift. Which of the following statements is TRUE regarding this patient’s most likely diagnosis? (A) It is usually caused by tearing of the middle meningeal artery (B) The patient should show signs of elevated intracranial pressure immediately after the injury (C) Brain atrophy associated with alcoholism makes him less susceptible to this type of bleed (D) Immediate surgery may not be necessary (E) Morbidity and mortality are much lower than for other intracerebral bleeds The answer is D.This patient likely has a subdural hematoma, a collection of blood beneath the dura and overlying the arachnoid and brain. It results from tears of bridging veins that extend from the subarachnoid space to the dural venous sinus. Patients with brain atrophy due to either aging or alcoholism are particularly susceptible to developing subdural hematomas. Acute subdurals are usually symptomatic within 24 h. Subacute subdural hematomas are symptomatic between 24 h and 2 weeks after injury, and chronic subdurals become symptomatic 2 weeks or more after the injury, when the blood clot liquefies. On CT, most acute subdurals appear hyperdense, subacute bleeds are isodense or mixed density, and chronic subdurals are hypodense. Immediate surgery may not be appropriate for chronic subdural bleeds. The morbidity and mortality of subdurals exceeds that of epidurals because of the greater severity of underlying brain injury. Epidural bleeds are associated with a tear of the middle meningeal artery. 25.A 45-year-old male unrestrained driver is brought to the ED with cervical spine precautions by an EMT unit after a high-speed MVA. He has a Glasgow Coma Scale (GCS) score of 6 and no obvious signs of trauma. His shallow respirations are being inadequately assisted with a bag-valve mask. Radial pulse is thready, and the extremities are cool. Which of the following should be performed before rapid sequence intubation (RSI)? (A) A brief neurologic examination including a check of rectal tone (B) An immediate chin lift to clear the airway from any obstruction (C) A full set of vital signs (D) A lateral cervical spine x-*** (E) Four quick tidal volume breaths with 100 percent oxygen using a bag-valve mask device The answer is E.This patient clearly requires immediate intubation and ventilation. Gaining control of the airway must not be delayed to obtain x-rays, perform a neurologic examination, or even measure a full set of vital signs. A “normal” lateral cervical spine x-*** does not rule out an unstable cervical spine injury. Irrespective of x-*** findings, the same precautions (inline stabilization) must be taken during RSI. A jaw-thrust maneuver could help clear an airway obstruction, but a chin lift would be contraindicated because of a possible cervical spine injury. Follow Ups: 26.A 28-year-old male sustains a gunshot wound to the back, just medial to the left scapula. Field blood pressure is 98/p, pulse is 101, and respiratory rate is 38. En route to the ED, he received high-flow oxygen and 1 L normal saline. He is agitated and diaphoretic on arrival. You are unable to hear heart sounds because of ambient noise, but the neck veins appear normal. Blood pressure starts to decrease and respiratory status worsens over the next few minutes, but he is still conscious and oriented. Given that all of the following interventions are available, what is the MOST appropriate next step? (A) Emergent bedside cardiac ultrasound (B) Emergent thoracotomy (C) Immediate needle decompression of the left chest (D) Immediate blood transfusion (E) Immediate chest x-*** The answer is A. It is unclear whether this patient has cardiac tamponade, a tension pneumothorax, or hemorrhagic shock. Cardiac tamponade is diagnosed clinically by Beck’s triad (hypotension, muffled heart sounds, and elevated neck veins). However, in a hypovolemic patient, clinical assessment may be difficult. Pericardial fluid detected by bedside ultrasound confirms the diagnosis of pericardial tamponade. If present, immediate pericardiocentesis is indicated and can be lifesaving. 27.An 83-year-old female fell while walking to the bathroom. She complains of severe pain and will not tolerate any movement of the left leg. The leg is externally rotated and shortened. Which of the following is the MOST likely location for the fracture? (A) Intertrochanteric (B) Transcervical (C) Subcapital (D) Subtrochanteric (E) Acetabular The answer is A.Falls in the elderly are associated with high morbidity and mortality. They are the most common cause of accidental injury in patients older than 75 years and the second most common cause between the ages of 65 and 74 years. The most likely area of hip fracture is the intertrochanteric region. Pain coupled with external rotation of the leg is a classic presentation. The second most likely place for a fracture of the hip is the transcervical region. 289.A 6-month-old child falls and hits his head. Which of the following signs would be the MOST indicative of serious neurological injury? (A) The parent states the child was pale and sweaty for a few minutes after the fall (B) A single post-fall episode of emesis (C) Lethargy immediately after the head injury (D) Hypotension (E) A single grand mal seizure immediately after the fall The answer is D. Infrequently, infants become hypotensive from blood loss into either the subgaleal or epidural space after head trauma. Hypovolemia can occur because of open cranial sutures and fontanelles. Transient paleness, lethargy, diaphoresis, and emesis are common after minor head trauma and do not necessarily signify significant neurological injury. Persistence of any of these signs or symptoms, or change in mental status is concerning. Seizures may occur shortly after head injury and are usually self-limited. However, about 50 percent of patients with posttraumatic seizures have positive findings on head computed tomography (CT). Children with two or more seizures or a GCS 8 should be strongly considered for anticonvulsant therapy 30.A 36-year-old female comes to the ED complaining of headache and nausea. She had a negative head CT 5 days earlier after a brief lapse of consciousness after an MVA. She is amnestic to the event. Which of the following statements is FALSE? (A) The mortality rate for patients with head injury and a negative head CT approaches zero (B) Retrograde and antegrade amnesia is common with this type of injury (C) The patient is not at risk for significant injuries because she is 5 days out from the initial trauma and relatively asymptomatic (D) The patient may have alterations in thinking, sleeping, or concentration abilities (E) A new sensitivity to alcohol is normal and will probably resolve within a few weeks The answer is C. This patient is suffering from postconcussive syndrome after minor head injury. Patients with minor head injury represent 80 percent of the population of patients presenting to the ED with head trauma but suffer neurological deterioration less than 2 percent of the time. Symptoms are subtle and may only be brought out by formal neuropsychological testing. Insomnia, amnesia to the event, sensitivity to alcohol, difficulty concentrating, depression, and visual changes are common. Most symptoms resolve within the first few weeks, but patients should be warned that they can persist for up to 6 months postinjury. No focal motor weakness or sensory loss has been described with this syndrome, and anyone with these signs after an accident should be further evaluated. Intracranial bleeds and posttraumatic seizures can present as late as 1 to 2 weeks after minor head trauma. 31.After a moderate-speed MVA, a 32-year-old male restrained driver has a normal upright anteroposterior chest x-*** but a 2-mm pneumothorax on CT. Which of the following is the BEST indication for placement of a thoracostomy tube? (A) One or more rib fractures (B) Need for intubation and mechanical ventilation (C) Pulmonary contusion (D) Cardiac contusion (E) PaO2 100 The answer is B. An “occult pneumothorax” is a small pneumothorax that is seen on CT but not on chest x-***. Patients with occult pneumothoraces can be observed without a chest tube unless they need to be intubated. Positive pressure ventilation postintubation carries the risk of converting an occult pneumothorax into a tension pneumothorax if a thoracostomy is not performed. 31.A 64-year-old woman who has had diabetes mellitus for 8 years presents with fatigue and irritability. She has been taking combination therapy with glyburide and metformin, and her two most recent hemoglobin A1C measurements were 6.8% and 7.2%. She cannot sleep at night because of severe pain in both feet and ankles; the pain is aggravated when the bed sheets touch her feet, and on occasion the foot pain is accompanied by lancinating pains in both legs. Exercise or movement sometimes eases the pain. On physical examination, both ankle reflexes are absent, and decreased vibratory sensation is noted in both feet. Her femoral and popliteal pulses are strong, but dorsalis pedis and posterior tibial pulses are present but diminished. What should you do next in this patient? (A) Order noninvasive Doppler studies of the lower limbs. (B) Start gabapentin therapy. (C) Start aspirin and dipyridamole therapy. (D) Order magnetic resonance angiography. B Painful peripheral neuropathy is often worse at night and the cause of sleeplessness with consequential fatigue. Recent trials with gabapentin demonstrate its effectiveness in decreasing pain and improving sleep. The presence of femoral and popliteal pulses and the improvement of the pain with exercise make it less likely that the pain is secondary to vascular insufficiency. 32.A previously healthy 55 yo woman c/o diplopia since 3 days, temp-N Extraocular movts limited in all direction s except laterally right pupil is larger than the left and poorly reactive to light. Examination reveals drooping of rt eyelid and slight deviation laterally.which is the most likely cause DM Giant cell arteritis Syphilis HTN Aneurysm of post. communi.. artery carcinoma of rt lung apex This patient displays signs of oculomotor palsy, with restriction of the eye movements in all directions (except laterally, due to preservation of the sixth cranial nerve, the abducens), and ptosis. Dilatation of the pupil, which fails to react to light, is a sign of intracranial compression of the third, or oculomotor cranial nerve. This should prompt search for an underlying surgical cause of oculomotor palsy. Uncal herniation and aneurysm of the posterior communicating artery are the two most common surgical conditions leading to oculomotor palsy. In the absence of clinical evidence of increased intracranial pressure, it may be assumed that the patient has an aneurysm of the posterior communicating artery until proven otherwise. Cerebral angiography is the investigation of choice to confirm the diagnosis. All of the most common medical causes of oculomotor nerve palsy result in paresis of extraocular movements and ptosis, but the pupillary light reflex is preserved. These conditions include diabetes mellitus giant cell arteritis syphilis and systemic hypertension Carcinoma of the right pulmonary apex may result in Horner syndrome (miosis, ptosis, enophthalmos, and loss of sweating on the affected hemiface) due to infiltration of the cervical autonomic ganglia. 33.The patient is a 16 year-old male who recently traveled to Sudan for two weeks. He forgot the fourth dose that he was scheduled to take. Two weeks later, he began to experience fatigue, diarrhea, nausea and vomiting. These symptoms came and went without any specific patterns. Hematologic analysis did not reveal any hematologic abnormalities at that time. Two weeks later his symptoms worsened. He developed fever, orthostatic hypotension and a weight loss of 15 pounds. He was admitted to the hospital for treatment. LABORATORY AND MICROSCOPIC EXAMINATION: Table 1. Laboratory values at admission Complete Blood Count Cell Type Value Reference WBC * 2.6 4.5-13 (x109/L) RBC * 3.06 4.5-5.3 (x109/L) Hgb * 9.0 13.5-17.5 (g/L) Hematocrit (HCT) * 25.8 37.0-49.0 % MCV 84.2 78-98 fL MCH 29.5 24-30 pg MCHC 35 32-36 g/dL RDW * 16.7 11.8-15.2 % Differential Neutrophils * 21 31-61 % Absolute Neutrophils * 0.55 1.80-8.00 (x109/L) Lymphocytes * 61 28-48 % Absolute Lymphocytes 1.58 1.40-5.90 (x109/L) Monocytes * 15 3-9 % Absolute Monocytes 0.39 0.00-0.80 (x109/L) Eosinophils 1 0-3 % Absolute Eosinophils 0.03 0.00-0.60 (x109/L) Basophils 0 0-2 % Absolute Basophils 0.00 Bands 2 2-8 % Absolute Bands 0.05 Platelets * 111 156-369 (x109/L) Dx?? Dx?? Follow Ups: Re: Q13 - Giri 19:15:05 08/07/03 (0) Re: Q13 - DAFFODIL 19:11:01 08/07/03 (0) was he taking prophylaxis for malaria??? - prep 18:52:13 08/07/03 (1) BINGO- RIGHT ANS!! - ACE 20:09:21 08/07/03 (0) Re: Q13 - Gi 18:18:28 08/07/03 (0) ignore that sentence ( what is his most likely dx ) - ACE 18:15:54 08/07/03 (0) Re: Q13 wut fourth dose? - saima 18:13:01 08/07/03 (0) 53-year-old man comes to the office complaining of severe right toe pain. The patient was awakened in the middle of the night by a sharp, burning pain localized to the first metatarsophalangeal joint. It is noted to be warm, painful to touch, and edematous; the patient cannot move the joint in any direction without extreme pain and will not allow the toe to be covered. The patient's medical history is significant for hypertension for which he takes a thiazide diuretic. He consumes about 3 pints of beer per day. Which of the following is most likely to confirm the diagnosis in this patient? A. Aspiration of fluid from the affected joint B. Determination of serum urate concentrations C. Determination of urine urate concentrations D. Radiologic examination of the affected joint E. Response to intravenous corticosteroids 53-year-old man comes to the office complaining of severe right toe pain. The patient was awakened in the middle of the night by a sharp, burning pain localized to the first metatarsophalangeal joint. It is noted to be warm, painful to touch, and edematous; the patient cannot move the joint in any direction without extreme pain and will not allow the toe to be covered. The patient's medical history is significant for hypertension for which he takes a thiazide diuretic. He consumes about 3 pints of beer per day. Which of the following is most likely to confirm the diagnosis in this patient? A. Aspiration of fluid from the affected joint B. Determination of serum urate concentrations C. Determination of urine urate concentrations D. Radiologic examination of the affected joint E. Response to intravenous corticosteroids A. Aspiration of fluid from the affected joint of course clinicallly we r sure that its gout bcz alcohal ppt the attack of gout..but to make sure we have to do aspiration and see what kind of crystal these r..negatively bifrengent polarized needle is gout..and wkly posive on e is psudo gout...uric acid in urin e we will check if gout needle r confirmed to giv e therapy to see pt is over excretor or under....plasma uric can b normal....so it s not relible it could b high like many clinical condition like preeclemsia its high...and som etim eits dec like in siadh...so its not accurate..xray will not help..bcz we knowaspiration will decide the managment...this is what i think.. Follow Ups: 1.A 10-year-old boy complained of leg cramps and clumsiness. His motor development was normal. He was in the fifth grade and was performing well academically. At age seven, he had begun to walk on his toes. He had sprained his right ankle twice in the last year and had also complained of hand cramps after long periods of writing. His maternal grandfather had "weak feet" and his maternal uncle had leg braces. His mother had no complaints, except for occasional leg cramps after long walks. Two younger siblings had no neurological complaints. He appeared healthy, and his gait showed toewalking and, that he was unable to walk on his heels. His heel cords were tight and there was weakness (4/5) of the dorsiflexors of both feet. The legs showed mild atrophy of the anterior tibialis and peroneal muscles. There was no atrophy or weakness of the intrinsic hand muscle. The stretch reflexes were absent in the upper and lower limbs. The plantar responses were flexor. There was decreased pricking sensation distally in stocking distribution. The great auricular nerves were enlarged on both sides, but the left was more visible. When palpated, the ulnar and peroneal nerves were found to be enlarged. He had mild pes cavus deformity. Motor nerve conduction velocities were performed: the motor NCV of the right peroneal nerve,the left ulnar nerve&the right median nerve were decreased. He had motor distal latencies that were proportionately prolonged and absent sensory nerve action potentials. There was no electrophysiological evidence of motor conduction blocks. What's the most likely diagnosis? a case of Charcot-Marie-Tooth it's very HY!i had similar case in step1 exam!!!! 2.Post subject: q286 Posted: Thu Jul 24, 2003 12:01 pm -------------------------------------------------------------------------------- Decrease in all hemodynamic parameters:JVD,CO,PCWP,SVR is seen in which kind of shock? A:hypovolemic B:cardiogenic C:septic(early phase) D:septic(late phase) E:neurogenic neurogenic shock 3.Which of the following scenarios would be most suspicious for possible child abuse? a. A 2 year old who presents with a tibial fracture after reportedly fa,lling down a few steps. b. A 1 year old who presents with a forehead hematoma after reportedly fa,lling out of a stroller. c. A 3 month old who presents with a nondisplaced femur fracture after reportedly rolling off the changing table. d. A 3 year old who presents with a spiral fracture of the tibia after reportedly getting his leg twisted while fa,lling off a tricycle. the answer is C the injury in this option is incompatible with the infant's development,as he can't roll off at this age! 4.A 24 yo old motorcyclist presents to ER with BP:90/60mmHg after hiting by car.He’s anxious, confused, skin is warm and well perfused, breathing rapid and shallow, pulse slow but weak,he’s unable to move arms or legs.management? case of neurogenic shock,he has paralysis may be due to cervical vertebral Fx,do ABC,stabalize neck,do xrays of head&neck... for Rx of shock:the initial intervention is volume infusion,if hypotension is refractory to volume infusion alone,a peripheral vasoconstrictor like phenylephrine or norepinephrine is administered.bcoz spinal shock pts tend to equilibrate body T with their environment,fluids&ambient room T must be kept warm(washington) 5.CARCINOGENIC BACTERIA CAN CAUSE WHICH OF THE FOLLOWING MALIGNANCIES..? 1) TRANSITIONAL CELL CARCINOMA AND SQUAMOUS CELL CARCINOMA 2) LYMPHOMA AND ADENOCARCINOMA 3) LEUKEMIA AND SQUAMOUS CELL CARCINOMA 4) SARCOMA AND SQUAMOUS CELL CARCINOMA 5) ADENOCARCINOMA AND LEIOMYOSARCOMA Is it B----lymphoma & adenocarcinoma??????? And the bacteria i have on my mind is......Helicobacter pylori..... It causes MALT(Mucosa associated lymphoid tissue) lymphomas and also chronic atrophic gatritis which leads to gastric adenoca........... Iam not very sure though............ THAT WAS WONDERFUL AGAIN SMITHA..... YOU ARE MARVELLOUS....... IT'S DEFINITELY HELICOBACTER PYLORI..... IT'S RECENTLY BEEN CLASSIED BY WHO AS CLASS IV CARCINOGEN.... AND IT CAUSES MALT LYMPHOMAS(LOW GRADE) AND GASTRIC ADENOCARCINOMA........ 6.A YOUNG MAN OF 30 YEARS OLD CAME TO THE EMERGENCY DEPARTMENT WITH A HISTORY OF ANXIETY , PALPITATIONS AND HYPERSALIVATION. THE PATIENT WAS VERY WELL ORIENTED TO THE PERSON, PLACE AND TIME. HE ANSWERED ALL THE QUESTIONS BY PHYSICIANS SATISFACTORILY. THE PATIENT SUDDENLY DIED AFTER 2 HOURS OF ADMISSION DUE TO CARDIORESPITARY ARREST. WHAT WILL THE BRAIN BIOPSY OF THIS PATIENT REVEAL...? 1) INTRACELLULAR EIOSINOPHILIC INCLUSION BODIES 2) INTRANUCLEAR BASOPHILIC INCLUSION BODIES 3) GIANT CELLS WITH BIZZARE NUCLEI 4) MULTINUCLEATED GIANT CELLS 5) MULTIPLE VASCULAR HEMORRHAGIC SPOTS WHAT IS THE VECTOR MOST LIKELY RESPONSIBLE FOR THIS PATIENT'S DISEASE...? 1) DOG 2) BATS 3) BIRDS 4) MOSQUITO 5) SKUNK Is this a case of RABIES, shirish?Coz, this early/drastic involvement of brain stem and leading to cardiorespiratory arrest.......this is wat actually distinguishes it from other viral encephalitides........ If so, then i'd go for........A...intracellular eosinophilic inclusion bodies/Negri bodies, which r bullet shaped .......found in neurons infected by rabies virus. And the vector.........I'd go for 5......skunk, coz that's more common in USA than dog bites 7.A 73yo man with a h/o HTN complains of a ten minute episode of left sided weakness and slurred speech. On further questioning, he relates 3 brief episodes in the last month of sudden impairment of vision affecting the rt. eye.His examination now is normal. 1. Which of the following wud be the most appropriate next diagnostic test? a.CPK b.Holter monitor c.Visual evoked responses d.Carotid artery Doppler ultrasound e.Conventional cerebral angiography 2.The episodes of visual loss are most likely related to a.Retinal vein thrombosis b.Central retinal artery ischemia c.Posterior cerebral artery ischemia d.Middle cerebral artery ischemia e.Posterior ciliary artery ischemia yes, perrrrrrrfect all of u r rite & ya shirish it is amurosis fugax......... answers r........carotid doppler & central retinal a. occlusison.......... This pt. is xperiencing classical symptoms of xtracranial internal carotid artery ds.,which includes episodes of ipsilateral transient monocular blindness or amaurosis fugax,and contralateral TIAs consisting of motor weakness.These symptomatic pts. have a high likely hood of developing strokes...the appropriate test to confirm the suspicion of carotid artery stenosis is a doppler ultrasound test of carotid arteries.... The presumed mechanism is transient monocular blindness in carotid artery ds. is embolism to the central retinal artery or one of the branches. Although classic teaching has emphasized the role that cholesterol emboli play in causing this blindness, maybe seen on fundoscopic examination even of asymptomatic individuals.... Retinal vein thrombosis.....produces more rapid loss of vision,with hemorrhages in retina, not asso. with TIAs described here..... Although both posterior and middle cerebral artery ischemia can cause visula loss, thye wud not be xpected to cause the monocular blindness described here. Post. ciliray artery ischemia.....acute,painless,not asso. with preceedingtransient monocular blindness or TIAs...... Hope iam clear again............. Now, coming to shirish's q........wat wud be the immediate step of management......... THIS IS AN EMERGENCY & shud be referred to an opphthalmologist basically, but as an emergency t/t following can be done........ 1.laying the pt. flat 2.ocular massage 3.high concentrations of inhaled oxygen 4.IV acetazolamide 5.Ant. chamber paracentesis Thrombolyis within 6 hrs of presentation,particularly intraarterial but also IV, is being used, but maynot improve overall outcome???? And in this, the main management problem lies in identifying any treatble underlyying disorder like.........1.Giant cell arteritis in older pts(high dose corticosteroid & bilateral temporal artery biopsy done); 2. if asso. head & neck pain with CRA occlusion , suspecting carotid & cardiac sources, then internal carotid artery dissection shud be considered. 8.case: A 17 yo girl comes to the office that her skin is “breaking out”.She has not prior h/o skin problems but has noticed that during the week before each menstrual cycle she develops red pustules on her cheeks , chin, and back.These changes improve over the course of the month , only to return prior to her subsequent menses.she has no other significant past medical history and never taken OCPs.She is thin and in no acute distress.All of her VS are normal and her PE is unremarkable xcept for numerous comedons around the cheeks and chin and scattered erythematous pustules on her cheeks & upper back. Wat’s the appropriate treatment ……… .1.topical metronidazole 2.topical corticosteroid tx. 3.topical benzoyl peroxide 4.topical clindamycin 5.oral tetracycline 6.oral isotretinoin YESSSSSS, DPS, U THOUGHT IT OUT GOOOOOD.......... ANSWER IS….4 , topical clindamycin This pt. Clearly has acne vulgaris. If this pt. Had NO COMEDONS, it can be called a rosacea case.And out of the options listed here, 3,4,5,6 can be used in acne vulgaris, but when????? For comedons ONLY-----benzoyl peroxide or Retin-A When inflammatory lesions present----topical clindamycin and erythromycin Oral antibiotics/tetracyclins r less preferred given the frequency of it’s s/es. Oral isotretinoin is highly effective in severe cystic cases of acne.However this drug is highly teratogenic and shud be cautious in using it……… NOTE: ----------------.Females of child bearing age shud be instructed to use 2 forms of contraception 1 month prior to starting isotretinoin, while taking the medication, and for 1 month after isotretinoin has been stopped. Pregnancy tests must be negative before a prescription is given and monthly preganancy tests must be negative before prescriptions are renewed. 9.A 16 yo girl has had fever , vomiting, and watery diarrhea for the past 24 hrs. She also complains of intermittent abdominal pain and generalized myalgia.OE…slightly lethargic, T—103 F, BP—75/50mm Hg, P—150/min. Her conjunctivae and pharynx are hyperemic.She has a generalized erythematous maculopapular rash that spares the wrists. Which of the following will be the most appropriate treatment? a. Amanatidine b. Gentamicin c. Ketoconazole d. Nafcillin e. Prednisone. The clinical presentation is consistent with TSS and IT DOES SPARE wrists....... It is caused by Staph. aureus and ususally occurs in women using highly absorbent tampons. The pt.s systemic and other symptoms r due to it's toxic nature. In a YOUNG GIRL, TOXIC, RASH SPARING WRISTS, ALWAYS THINK OF TSS FIRST!!!!!!!!!!! 10.65 year old male patient with COPD presents with pain in the wrist of 5 week duration. This pain has been more prominent at night . O/e the patient has tenderness around the wirst region... His physical exam was othersie normal other than the findings of COPD. X-*** wrist reveals peri-osteal thickening sugeestive of "osteomyelitis" What is your next step in managemenet? Yeahhhhhh, always keep in mind MALIGNANCY in a smoker........ Perfect ....excellent Smitha.... This is a Paraneoplastic feature...... Hypercalcemia.....Yes it cld be but cld also be Hypertrophic osteoarthroathy ..even though clubbing isn't mentioned And the secoond is definitely Eaton Lambert.... has nothing to do with Horner's syndrome I didn't mention ...miosis, anhydrosis....(U can't just rely on drooping of the eye lid fri Horner) Plus Eaton Lambert....the features are out there...a paitient complaining of fatigue and drooping of eyelids that imporves on activity...... Therefore the correct answer to the case is go get a CXR This is Hypertrophic Pulmonary Osteoarthropathy (HPO) that presents with periosteal thickening. esp in a pt who has been a chronic smoker, think always of Squamous cell Ca as HPO is usually associated with malignancy in real life (and always in USMLE). First thing - do a CXR or Chest CT scan. Then bronchoscopy with biopsy OR sputum study for cell cyto 11.47 year old female patient presents with hypertension and is begun on treatment with Atenolol 50 mg/day (dose not so important) hehe She has failed thought to inform you that she is ASTHMATIC or you have been too busy to ask about it and next day ...the poor lady comes to the ER where you also happen to be.... with an acute asthmatic attack.......Wheeze and difficulty breathing.... Tell me how wld u treat this poor lady ...... and explain Wh     
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