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03-31-2005, 02:01 AM
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set 7(Nasi)
Q. A 31yo man with diabetic nephropathy undergoes an uneventful renal transplant from his sister.his immunosuppressive regimen includes azathioprine,steroids&cyclosporine.on postoperative day3 the pt is doing well,but u notice on his routine lab tets that his WBC is 2000.What's the most appropriate next step of management?
a:start gancyclovir b:start broad-spectrum Antibiotics c:Administer filgrastim d:Administer FK50 e:decrease cyclosporine f:increase cyclosporine g:decrease azathioprine h:increase azathioprine i:withhold stroids j:administer stroid boost k  btain renal USA. the answer is g:the major side effect of azathioprine is BM toxicity,both WBC&plts should be monitored in the immediate posttransplant period.the pt’s decrease in WBCs is secondary to azathio toxicity and the most appropriate step is to decrease its dose. Q. A 43-year-old male heavy smoker with a 2cm,asymptomatic poplitel aneurysm found accidentally on an aortogram done to evaluate the abdominal aneurysm.what’s the next step of management? A. Bcoz of the risk of the embolization and thrombosis with resultant gangrene,as well as the lesser risk of rupture(all of which lead to substantial likelihood of limb loss)even relatively small,asymptomatic aneurysms should be excised when discovered.(source:Schwartz) But according to NMS those asympto>2cm should be repaired. I think Schwartz more reliable. Another point:as popliteal aneurysms r associated with AAA in 60% of cases,always look for AAA in any case with popliteal aneurysm Q. 3days after resection of a ruptured abdominal aneurysm in a 74yo woman who presented with back pain&hypotention,she complains of severe,dull left flank pain&passes bloody mucus per rectum.what’s the most likely diagnosis? A. Ischemia of left colon The incidence of ischemic colitis following abdominal aortic resection is about 2%.the IMA is usually ligated at the time of aneurysmorrhaphy.pts who suffered an episode of hypotension following rupture of an aneurysm at high risk for diminished flow through collateral vessels. Q. For the first 6hr following surgical repair of a leaking abdominal aortic aneurysm in a 70yo man oliguria(total urinary output of 25cc since the operation)has become a concern.what’s the most appropriate diagnostic test for this pt? a:abdominal US b:renal scan c:left heart preload pressures d:urinay Na concentration e:Cr clearance f:abdominal CT A. c:left heart preload pressures The most likely coz of oliguria observed in this pt is hypovolemia.pts who had a leaking aneurysm&then a long,usually difficult operation with large surgical fields that collect third-space fluids may be intravascularly depleted despite large volumes of IV fluid&blood replacement. Volume status would be best assessed by floating a Swan-Ganz catheter to measure the preload pressures in the LA,titrate the CO by providing as much fluid as necessary to keep the wedge pressures near 15mmHg. Q. a 55yo man with recent onset of AF presents with a cold,pulseless left lower extremity,he complains of left leg paresthesia&is unable to dorsiflex his toes.following a successful popliteal embolectomy with restoration of palpable pedal pulses,the pt is still unable to dorsiflex his toes,what’s the next step of management? A. Inability to dorsiflex the toes is a grave sign of ant.compartment ischemia. There r 2 conditions in this case that lead to the ant.compartment syndrome:acute arterial occlusion &rapid reperfusion of ischemic muscle Rx  rompt fasciotomyQ. 5mo after exposure to a household case of active pulmonary TB,a 27yo HIV+ man presents with fever,chills,rash,weight loss,and nonproductive cough for 2weeks.A CD4 count 3mo ago was 380cells/mm3.A Cxray reveals basilar interestitial infiltrates without cavities,adenopathy or pleural effusion,A PPD test with controls reveals cutaneous anergy.what's the most likely diagnosis? a:M.TB b:toxo c:CMV d:P.Carinii e:strep.pneumoniae A. a:M.TB the pt is mod immunocompromised but CD4 not in a range(<200)that’s typical for pts with classic opportunistic infections in AIDS,So P.Carinii,CMV,toxo r unlikely pathogens.His recent exposure to a household contact with pulmonary TB,the subacute nature of his illness&radiologic findings r quite consistent with pulmonary TB in an HIV-infected pt.So the best appropriate management for this pt is begin 4drug anti-TB treatment&schedule bronchoscopy with BAL(to show acid-fast bacilli)if pt unable to produce sputum Q. A mother brings her 14yo boy&6yo girl to ur office for a routine visit.They have no history of chickenpox and no history of varicella immunization .The mother asks if it’s necessary to do vaccination against varicella,u recommend to do vaccination: A:at initial visit for both B:at initial visit only for boy C:at initial visit only for girl D:at initial visit and repeat 4-8wks later for both E:at initial visit for both and repeat 4-8wk later for girl F:at initial visit for both and repeat 4-8wk later for boy G:at initial visit for both and repeat 8-12wk later for girl H:at initial visit and repeat 4-8wk later only for boy A. F:at initial visit for both and repeat 4-8wk later for boy Q. Do u recommend varicella vaccine to an asymptomatic HIV+ infant? A. in general it's CONTRAINDICATED!learn this without details for exam!! BUT! Varicella vaccine should be considered for asymptomatic or mildly symptomatic HIV-infected children in CDC class N1 or A1 with age-specific CD4+ T-lymphocyte percentages of 25%. Eligible children should receive two doses of varicella vaccine with a 3-mo-interval between doses.(www.cdc.gov,Nelson textbook) but i think it's not necessary to learn details for exam,like CDC class... *MMR vaccination is recommended for all asymptomatic HIV-infected persons who do not have evidence of severe immunosuppression and for whom measles vaccination would otherwise be indicated MMR vaccination should be considered for all symptomatic HIV-infected persons who do not have evidence of severe immunosuppression or of measles immunity. Q. Increased risk of varricella infection may be seen in  may be more than one ans)a:a child who received varicella vaccine 3wk following MMR vaccine b:a child who received varicella vaccine 4wk following MMR vaccine c:a child who received varicella vaccine at the same time of MMR vaccine d:a child who received varicella vaccine 5wk following MMR vaccine A. a:a child who received varicella vaccine 3wk following MMR vaccine b:a child who received varicella vaccine 4wk following MMR vaccine Risk of breakthrough varicella 2.5 times higher if varicella given<30 days following MMR no increased risk if varicella given simultaneously or >=30 days after MMR. Q. U visit a 25 yo male pt who just received BM transplantation,which statement is correct about immunization in this pt? a:influenza vaccine at 4mo following transplant and annually thereafter b:MMR at 24mo following transplant c:varicella at 6mo following transplant d:HBV at 12 mo following transplant e:Td at 6mo following transplant A. d:HBV at 12 mo following transplant Pts who recieved BMT,should be revaccinated,the schedule for this pts: 1-influenza vaccine>6mo following transplant&annual therafter 2-inactivated vaccines like Td,IPV,HBV,PPV after 12mo 3-MMR after 24mo,if he's immunocompotent 4-varicella not recommended Q. A 12mo infant with PPD+ brings to ur office for routine immunization,which vaccines r contraindicated in this pt? A. no vaccine is contraindicated in a PPD+ status,so follow an immunization shedule for normals A theoretical basis exists for concern that measles vaccine might exacerbate tuberculosis. Consequently, before administering MMR to persons with UNTREATED ACTIVE tuberculosis, initiating antituberculosis therapy is advisable Q. A 15mo male infant with diagnosis of Kawasaki disease just received IVIG therapy,his last immunization was at 6mo(DTP,Hib,HBV,OPV),now what’s the schedule for his immunization at this age? A. According to the history of last immunization&his age:he should recieve Hib(4th dose),MMR&varicella(first dose)BUT as he recieved IVIG before he can't recieve live vaccines:MMR,varicella,persons who recieve Ab products should wait more than 3mo before recieving a live vaccine(for IVIG:at least 7-11 months!) so he just can get Hib vaccine now Q. which vaccines r contraindicated in premature infants? A. yes,do routine vaccination,JUST:If an infant weights less than 2 kg at birth,and the mother is antigen-negative, delay the first dose of hepatitis B vaccine until the infant weighs at lease 2 kg or is 2 months of age (or at hospital discharge, if there is concern that the infant may not begin the vaccine series as an outpatient). Q. A premature newborn(weight at birth 1850gr)to a mother with HBs Ag+,which vaccines r recommended at birth? A. If an infant weights less than 2 kg at birth, and the mother is antigen-negative, delay the first dose of hepatitis B vaccine until the infant weighs at lease 2 kg or is 2 months of age (or at hospital discharge, if there is concern that the infant may not begin the vaccine series as an outpatient). If the mother is antigen-positive or if her antigen status is unknown, use the vaccine schedule in which the first dose, plus HBIG, is given within 12 hours of birth, regardless of the infant's birth weight. But when these infants weigh less than 2 kg, do not count this dose as part of the 3-dose primary series Q. varicella vaccine is contraindicated in a child MAY BE MORE THAN ONE ANS)a:whose mother is 8wk pregnant b:whose father is receiving chemotherapy for Rx of lymphoma c:with diagnosis of ataxia-telangiectasia from birth d:with diagnosis of Bruton’s agammaglobulinemia from birth A. c:with diagnosis of ataxia-telangiectasia from birth varicella vaccine: Contraindications 1-Severe allergic reaction to previous dose or vaccine component 2-Substantial supression of cellular immunity 3-Pregnancy Precautions 1-Recent (<11 months) receipt of antibody-containing blood product (specific interval depends on product) 2-Moderate or severe acute illness with or without fever Safe in: 1-Pregnancy of recipient's mother or other close or household contact 2-Immunodeficient family member or household contact 3-Humoral immunodeficiency (e.g., agammaglobulinema) Q. A 2yo girl&5 yo boy present to ur office for a well-child visit.Their mother is under treatment for pulmonary TB.After doing PPD test,the tuberculin reaction is 7mm for girl and 4mm for boy.what’s the best management for these children? A. 1-girl with skin test+(>5mm): INH therapy should be given to any child with a positive tuberculin skin test but no clinical or radiographic evidence of disease. The currently recommended regimen is 9mo of daily INH therapy. 2-boy with skin test-(<5mm): INH therapy should be started for children <6yr of age with a negative tuberculin skin test who have had recent exposure to an adult with infectious TB including infection of mother.These children may already be infected with M.TB but have not yet developed delayed hypersensitivity.In exposed children, tuberculin skin testing is repeated 3mo after contact with the adult source case has been interrupted. If the repeat tuberculin skin test is negative, INH can be discontinued; if the second skin test is reactive (>5mm), the child has TB infection and a full course of INH therapy can be administered. BUT in this case there was NO NEED to do skin test,treatment should be started for both at presentation&reevaulation should be done after 2-3mo for adulats SKIN TEST considered positive if reactive>5mm in close contacts with TB pts. Q. A 65 yo woman with several syncopal episodes.A holter monitor shows episodes of sinus arrest&SVT.management? A. SSS implantaion of permanent pacemaker+beta blockers to control tachyarrythmia Q. A 26yo man presents to ur office with urethral discharge.A Gr stain shows gram- diplococci.His PMH is positive for severe allergic reaction to penicillin.what’s the most appropriate management for this pt? a:azithromycin 1gr PO single dose b:spectinomycin 2gr IM single dose c floxacin 400mg PO bid for 7daysd:ciprofloxacin 500mg PO single dose e floxacin 400mg PO bid for 7days followed by doxycycline 100mg PO bid for 7daysf:ceftriaxone 125mg IM single dose followed by doxycycline 100mg PO bid for 7days A. c floxacin 400mg PO bid for 7daysa:azithromycin 1gr PO single dose:azithro effective against both gonorrhea&chlamydia BUT SINGLE dose administeration associated with 93% failure rate in treatment of GONORRHEA b:spectinomycin 2gr IM single dose:it's not effective against chlamydia,for pts who allergic to penicillin&can't tolerate quinolones,it should be prescribed WITH doxy to cover chlamydia c floxacin 400mg PO bid for 7days:the only FDA approved quinolone that's effective against BOTH gonorrhea&chlamydia is ofloxacin,so u can prescribed it as a single drug!but according to harrison only 7DAYS treatment effective against chlamydia not single dose!!!d:ciprofloxacin 500mg PO single dose:this one only effective against gonorrhea,add doxy to cover chlamydia e floxacin 400mg PO bid for 7days followed by doxycycline 100mg PO bid for 7daysflox alone for 7days efficient treatment in this case,no need to add doxy!f:ceftriaxone 125mg IM single dose followed by doxycycline 100mg PO bid for 7days ts who allergic to penicillin,usually allergic to cephalosporins too,so start Rx with other drugsQ. a Cxray of a 31yo miner reveals hilar adenopathy&numerous tiny round opacities predominately in the upper lung fields,he’s quite asymptomatic.PPD skin testing shows 12mm tuberculin reaction.Mangement? A. Any pt with silicosis&PPD+ should be treated for TB according to a table in harrison:in persons with high risk medical conditions tuberculin reaction>=10mm should be considered+,i think silicosis>10mm too(in this category)but not sure,any idea from other sources? Q. A child with IDDM,which vaccine(s) r contraindicated from the list below? A  TaP(or Td)B:OPV C:IPV D:MMR E:Hib F:HBV G:varicella H:rotavirus I neumococcusJ:influenza A. DTaP(or Td),OPV,MMR,Hib,HBV,pneumococcus,influenza: recommended IPV,varicella,rotavirus:use if indicated source:Nelson Q. A child with renal failure,which vaccines r contraindicated from the list below? A TaP(or Td)B:OPV C:IPV D:MMR E:Hib F:HBV G:varicella H:rotavirus I neumococcusJ:influenza A. DTaP(or Td),OPV,MMR,Hib,HBV,pneumococcus,influenza: recommended IPV,varicella,rotavirus:use if indicated source:Nelson Q. A 23 yo woman who’s 15 wk pregnant presents with her 2yo daughter, who has developed a vesicular rash the previous day. The rash appears typical of early chickenpox. The woman has no past history of chickenpox, and her mother can’t recall her having been infected.What’s the management? A. VZIG Women who have close contact with chickenpox during pregnancy and no previous history of the disease should be tested as soon as possible for varicella antibody (most are seropositive, even in the absence of a past history).ZIG should be given as soon as possible after contact. Although its effectiveness diminishes if given more than 72 hours after contact, it may modify the severity of the rash, if it occurs. However, the risk of fetal infection is unrelated to the severity of maternal illness. The most common clinical manifestation of fetal varicella infection is herpes zoster in the first year of life, which is usually benign. The role of intrauterine diagnosis of fetal varicella infection by amniocentesis and PCR of amniotic fluid is not yet established. Q. All may aggravate psoriasis except: a:hepatitis C b:strep.pharyngitis c:lithium d ropranololA. the answer is hepatitis C Q. A 34 yo male presents with somnolence,incoordination,gait difficulty,tremor&impaired speech.Prior to this he was healthy.He’s not taking any prescribed medication.which one is the least likely explanation? a:He’s a user of street drugs b:He’s a dry-battery manufacturer c:He’s a smelting worker d:He’s a arc welder e:He’s a plumber f:He’s a miner A. the answer is e:He’s a plumber(exposure to lead) Exposure to manganese during mining,smelting,arc welding&dry battery manufacturing may cause injury to the basal ganglia&result in Parkinsonism.MPTP in street drugs can cause the same clinical picture Q. A 24yo woman complains of a red,scaling plaque under her ring but not under the watchband,the most likely diagnosis? a:atopic dermatitis b:allergic contact dermatitis c:irritant contact dermatitis d:seborrheic dermatitis A. the answer is c:irritant contact dermatitis dermatitis under a ring often results from soap&water that get trapped,causing an irritant contact dermatitis. Q. A 32yo man presents with a facial rash which has been present for approximately 18 mo. He’s been seen and treated many times in the past with differing amounts of success. Record review shows two 10-day courses of the oral antibiotics dicloxacillin and cephalexin. Both drugs produced improvement during the course of treatment, but the rash returned when treatment was discontinued. Application of the topical antibiotic mupirocin worsened the condition.The patient reports that the lesions tend to wax and wane, but continue to affect the same area.The patient has no other symptoms and is otherwise healthy. FH is negative.On Ph.E:the lesions appear on right face as 2 fairly well-circumscribed, edematous, deeply erythematous, almost violaceous plaques. Multiple telangiectasias r visible within both lesions, and 1 lesion has several pustules. The lesions blanch incompletely with pressure. The lesions r negative for spores and hyphae(with KOH10%), but something assumed to be the head of a Demodex folliculorum mite is seen on the slide.HIV test negative.The biopsy of lesions show a superficial perivascular and periadnexal lymphoplasmacellular infiltrate with telangiectases and focal widening of follicular infundibula. No granulomas r seen.What is your diagnosis?and management for this pt? A) Cellulitis B) Rosacea C) Cutaneous lymphoma D) Majocchi's granuloma E) Demodicidosis F) Acne vulgaris A. the answer is: B) Rosacea A facial cellulitis would have cleared with systemic antibiotic treatment, or would have continued to worsen. A fungal infection of the skin with deeper involvement of the hair follicles (Majocchi's granuloma) would have shown hyphae in the skin scraping or biopsy specimen. A cutaneous lymphoma would have had a different histologic appearance, but these have been mistaken for rosacea in the past.Demodicidosis, a disease due to overgrowth of the Demodex folliculorum mite, usually occurs in patients with a lowered immune status, but the lesions are often similar to the lesions of rosacea.This patient had a negative HIV test, no history of other disease, and no other complaints. Also, one would have expected to have seen multiple mites on the biopsy specimen. Acne vulgaris, while having the papules and pustules associated with rosacea, does not usually have the telangiectasia and generalized erythema associated with rosacea. Rosacea usually appears as clusters of papules and pustules on erythematous, edematous, telangiectatic skin. The condition usually involves the cheeks, forehead, and nose in the aforementioned symmetric pattern. The eyes are often involved as well; as many as 58% of persons with rosacea have ocular involvement. Rosacea usually occurs after the age of 30, and most commonly affects persons of Celtic origin. There is an association between increased counts of Demodex folliculorum and rosacea. Rosacea progresses through 4 general stages. The first stage is referred to as prerosacea. Patients complain of increased facial flushing and blushing, which often occurs in response to certain triggers. These triggers include sun exposure, hot or alcoholic beverages, spicy foods, caffeine, stress, and strenuous exercise. Stinging, burning, or redness may occur after the application of topical skin-care products. In the second stage, erythema becomes more persistent and fine telangiectases appear. Papules and pustules develop in the third stage of disease; telangiectases become larger and increase in number, and erythema deepens and becomes permanent. The third stage also may be characterized by ocular involvement. The patient may complain of burning, dryness, or a gritty feeling in the eye. Blepharitis may be present, and erythema may spread to the conjunctivae and lids. Approximately 20% of patients will develop ocular symptoms prior to skin lesions. The fourth stage involves hyperplasia and edema of the affected areas. Irreversible hypertrophy of the sebaceous glands of the nose results in rhinophyma. Ocular involvement may progress to keratitis and permanent blindness. Treatment RX ral tetracycline 250-1000mg/day.topical metronidazole or sodium sulfacetamide r also effectiveIn resistant cases, isotretinoin 0.5 mg/kg per day for 20 weeks has been used with success. For those suffering irreversible hypertrophy, edema, and telangiectasia, carbon dioxide lasers and intense pulsed light sources are being used to reshape the nose and destroy the vascular lesions caused by this disease. As with most conditions, prevention remains the key. Patients diagnosed at an early stage of disease should be cautioned to avoid triggers, use sunscreens with an SPF of at least 15 year-round, cleanse skin daily with a mild water-soluble cleanser, and always use noncomedogenic skin-care products that don't cause skin irritation Q. what's the follow up for a pregnant women with diagnosis of acute pyelonephritis after completing IV Ab therapy&hospital discharge? A. Oral Ab r continued for 7days after discharge.periodic U/C helps detect any recurrence,pts should be given long-term prophylactic Ab therapy with a single daily dose of nitrofurantoin. Q. A 2yo boy refuses to use his arm after being lifted up by his outstretched arms.He holds his arm slightly flexed&pronated.What's the most appropriate next management for this pt? A. Radial head dislocation or subluxation(nursemaid’s elbow)can usually be reduced by supination of the forarm while feeling the head of the radius&in a continuous motion,flexing the elbow(with usually a palpable click over the radial head).Xrays r usually normal. Q. A 22yo female college student comes to ur office bcoz of exercise-induced cramping in the left calf that began suddenly after playing 3sets of tennis.On exam of the left leg,the femoral pulse is normal.The popliteal pulse is palpable but week&a weak pedal pulse is present.The latter 2 pulses disappear with passive dorsiflexion of the foot.The right leg has normal arterial pulses.what’s the most likely diagnosis and next step of management? A. Popliteal artery entrapment syndrome,angio,surgery With passive dorsiflexion of the pt’s foot,tensing of the gastrocnemius muscle compresses the femoral artery causing obliteration of pulses. Q. A 25yo woman with history of IDDM comes to ur office for contraceptive advice(effective one!),what do u recommend? A. DM without vascular disease:all methods can be used DM with vascular disaese or DM>20yr:the copper IUD a good contraceptive choice progestine-only pills,norplant&LNg-IUDs second choice OCs&combined injectables either r contraindicated or usually undesirable methods of choice DMPA:undesirable method of choice female sterilization:incraesed risk of hypoglycemia,ketoacidosis or postoperative infection:should be done with precautions Q. A 21yo female who recently found she’s pregnant comes to ur office and asks when will it be necessary for her to start taking supplemental iron,what do u say? A. It’s not usually necessary for a pregnant woman to take supplemental iron during the first 4mo,bcoz iron requirements r only minimal during this time.Giving iron during this time could aggravate nausea&vomiting.its’ usually recommended during the last half of pregnancy. Dose:single dose of 60mg elemental iron per day(325mg FeSO4) Q. 10yrs after radical mastectomy for breast carcinoma,a 55yo woman returns to her doctor with visual complaints,she has otherwise feeling well.Skull Xrays reveal an area of destruction of the se,lla turcica,with small calcifications throught the lesion.The most likely diagnosis is: a ituatry adenmab:craniopharyngioma c:chordoma d:granular cell tumor e:metastatic breast carcinoma A. the answer is craniopharyngioma:focal calcification is present in almost all cases,in 75% of cases prominent enough to appear on xray.metastases to the pituatry&se,lla from breast which r mainly autopsy findings,may occasionally cause DI. Q. A 18yo woman with tetralogy of Fallot has an acute onset of fever,vomiting&seizure.What's the next step of management for this pt? A. CT Scan&surgical drainage of brain abscess. Q. What’s the most sensitive serologic test in all stages of syphilis? A. FTA-ABS Q. A 68 yo retired man comes to ur office bcoz he has had a stuffed ear for about 6wk.He reports no recent cold or allergy symptoms but has right facial pain&decreased hearing.He&his wife have not been traveling.Exam of the left tympanic membrane&air canal is normal.The right tympanic membrane is dull&immobile.The Weber test lateralizes to the right side.what’s the best next step of management for this pt? A. 1. Open Eustachian tubes with air douche or catheder. 2. Check for nasopharyngeal carcinoma. Three causes of tube dysfunction: Enlarged adenoids (he's too old) Upper airway infections (it's lasted too long) Tumor (carcinomas, he's get the age for it) Complete visualization of the oronasopharynx. In an elderly person with gradual onset of otitis media with effusion&no history of allergies,recent colds,or previous surgery the physician must suspect the possibility of a nasopharyngeal tumor. Q. Treating a case of gonorrhea is an example of: a rimary preventionb:secondary prevention c:tertiary prevention d rimary&secondary preventione rimary,secondary&tertiary preventionA. d,treating a case of gonorrhea:both secondary.p:Rx of disease&primary.p reventing other ppl from getting the diseaseQ. What’s the most appropriate management of a face presentation with no fetal distress&an adequate pelvis as determined by digital exam? A. Allow spontaneous labor with vaginal delivery In the presence of a face presentation,successful vaginal delivery will occur the majority of the time with an adequate pelvis.spontaneous internal rotation during labor is required to bring the chin to the ant.position which allows the neck to pass beneath the pubis. forceps may be associated with injury to the face,so it's not used in case of face presentation Q. A 45 yo pt who had menorrhagia for 6mo underwent a dilation&curettage.The uterus was normal in size.the cavity felt smooth&the pathology report was a secretory epithelium.what’s the best management for this pt? A. prescribe cyclic medroxyprogestrone acetate to effect an orderly withdrawal bleeding each mo. Q. A 23yo man presents to the ER after swallowing 2open safety pins 6hrs ago.Xrays show the pins r located in the small intestine now.What’s the most appropriate management for this pt? A. follow up with serial Xrays&abdominal exam Q. A 25 yo woman presents at 8wk of pregnancy with a PMH of pulmonary embolism 7yr ago during her first pregnancy.She was treated with IV heparin followed by several mo of oral warfarin&has had no furthur evidence of TE diz for over 6yr.Now what’s the the most appropriate management for this pt? A. because of the presence of past medical history of PE this patient can be considered as at risk for PE during this pregnancy because pregnancy predisposes for DVT because of venous stasis, so prophylactic measures should be taken like for eg. mechanical things like elevating the leg while sitting and calf muscle flexion exercises medical management with low dose heparin is especially helpful not only to decrease the incidence of DVT but also PE the pt should be placed on low dose heparin therapy throughout her pregnancy&the puerperium. Q. A 14 yo high school student is referred for evaluation of primary amenorrhea.She’s an excellent athlete&runs almost 5 miles daily.On exam it’s noted that her breasts r Tanner stage 1&pubic development:stage2.The reminder of the exam is within normal limits.Appropriate evaluation should include: a regnancy testb:karyotype c:serum estrogen levels d:serum FSH levels e:serum testosterone levels A. d:serum FSH levels although exercise-induced amenorrhea is relatively common in this age group,this young woman hasn’t begun her sec.sexual development&requires complete evaluation.The absence of breast development indicates lack of estrogen production,high serum FSH levels shows a gonadal failure(like Turner),low FSH levels suggests a hypothalamic disorder. more from BRS: defenition of primary amenorrhea:no menses by age 14 and absence of secondary sex characteristics in evaluation of primary amenorrhea:if breasts absent&uterus present: absence of breasts shows:no estrogen is being produced by the gonads bcoz of: 1-lack of 2 functional X chromosomes 2-nonfunctional hypothalamic-pituitary axis 3-absence of ovarian follicles presence of uterus shows: normal mullerian development&absence of a Y chromosome diff.diagnosis:gonadal dysgenesis(Turner),hypothalamic pituatry failure(in this case FSH measurment can diff these 2conditions from each other) evaluation:FSH level,GnRH stimulation test,karyotype Q. A 27 yo marathon athlete asks for ur advice regarding her menstrual cycles.In the past 4yr she has menstruated only once,the exam normal. Appropriate advice would be to ask the woman to: a:reduce physical activity to a minimum b:increase caloric intake&gain weight c:take OCPs d:await the result of a progestin withdrawal test A. the answer is d amenorrhea by itself is not harmful for the pt,but as it reflects a hypoesterogenic state,makes the pt suspectible to developing osteoprosis.So a progestin withdrawal test is done,if bleeding occurs,the pt produce adequate amount of estrogen and ERT not required,if test negative ERT recommended for prevention of osteoprosis. Q. You care for a 32-year-old school teacher who is in the second half of her pregnancy. A 6-year-old boy came to class on the first day of school with "an infection with 'slapped cheeks' and a lace-like rash." His mother told your patient that the boy became sick with a high fever, muscle aches, and a headache 10 days before school started. When these symptoms subsided, this rash suddenly appeared 1 day ago. A doctor examined the boy and told the mother that all of his "blood work" was normal. Since this boy did not want to miss the first day of classes and he "felt fine" his mother allowed him to attend school. Even though your patient is asymptomatic, she is worried about her health and the health of her unborn baby. The best next step is to A. administer intravenous immunoglobulin therapy to prevent infection B. advise her to have an amniocentesis to evaluate the unborn baby's health C. advise her to stay home from school until the boy's rash disappears D. ask her to return for reexamination in 1 week E. reassure her of the relatively low potential risk to her and her unborn baby A. The correct answer is E. The boy in this patient's class has the classic symptoms of erythema infectiosum (Fifth disease), which is an infection caused by Parvovirus B19. Patients with this disease are only infectious before the onset of the rash, during the period with the nonspecific febrile illness. The virus typically only causes a significant, severe illness in individuals with sickle cell disease and other hemoglobinopathies. In rare cases, parvovirus contracted during pregnancy has been associated with fetal hydrops and death. But as stated earlier, the boy in this pregnant patient's class was contagious before school started, and since he is no longer contagious, she should be reassured of the relatively low potential risk to her and her unborn baby. If she was in contact with him during the phase of the illness before the onset of the rash, she should have serologic testing and a fetal ultrasound to evaluate the health of her and the baby. It should be mentioned that the complications of parvovirus in pregnant women typically occur during the first half of pregnancy. Q. A 79yo woman presents with an indwelling Foley catheter&pyuria.What’s the best management for this pt? A. Asympto bacteriuria or pyuria the rule in pts with chronic indwelling Foley catheters,Rx should be reserved for symptomatic episodes only! Q. A 43 yo woman presents with closed,nondisplaced Fxs of the right tibia&fibula in a skiing accident associated with loss of sensation over the later aspect of the affected calf&foot.The pt’s leg is casted&the Fxs heal without complication.6mo after the injury,the pt develops intense burning,hyperesthesia&cyanosis of the right foot.What’s the best management for this pt? A. reflex sympathetic dystrophy paravertebral sympathetic block with local anesthesia ASA the diagnosis is made.repetitive blocks or sympathectomy for recurrent pain. Q. A pt in 34wk of pregnancy complains of focal pain&tenderness on palpation of the ant uterine wall at the site of uterine fibroid.The most appropriate treatment for this pt is: a bservation with antibioticsb bservation with analgesicsc:myomectomy d:laparotomy to rule out a uterine rupture e:cesarian section A. b bservation with analgesicsred degeneration of fibrinoids:is a hemorrhagic infarction causing local pain&tenderness,symptoms&signs usually subside within a few days. Q. A 27yo woman has recent onset of fever,fatigue,night sweats,mild anorexia,abdominal pain&low volume bloody diarrhea(heme+).Her CD4 cell count is 24. what's the most likely diagnosis? a:cryptosporidiosis b:MAC disease c:CMV d:Non-hodgkin's lymphoma e:histoplasmosis A. c:CMV CD4<50 constitutional symptoms in the presence of abdominal pain&heme+diarrhea:CMV colitis cryptospoidiosis may cause abdominal pain&diarrhea,but usually is not associated with blood in the stool.MAC diz possible,but abdominal pain is much more common in pts with CMV colitis. Q. A 45yo man presents with fever,nigh sweats,anorexia,weight loss&intermittent large-volume diarrhea.His CD4 cell count:15,CT scan shows periaortic lymphadenopathy what's the most likely diagnosis? a:cryptosporidiosis b:MAC disease c:CMV d:Non-hodgkin's lymphoma e:histoplasmosis A. b:MAC disease CD4<50+constitutional symptoms+diarrhea+LAP MAC most likely bcoz of periaortic LAP,lymphoma not with diarrhea Q. A 26yo man presents with daily fever,night sweats,fatigue,small bowel obstruction&weight loss.His CD4 count:230 what's the most likely diagnosis? a:cryptosporidiosis b:MAC disease c:CMV d:Non-hodgkin's lymphoma e:histoplasmosis A. d:Non-hodgkin's lymphoma constitutional symptoms+obstruction due to tumor looking at the cd 4 count wat u can find below 200 is cryptosporodiosis so its out.......next below 50 cd4 count is mac disseminated and histoplasmosis ,so they r out tooo from the rest two of em above 200 cmv and nonhodgkin lymphoma best guess is non hodgkin lymphoma as pt present with obstructive signs and symptoms Q. A 34yo HIV+woman has a CD4 cell count of 270,oral thrush&a history of herpes zoster.Reaction to tuberculin skin test is negative&Cxray is normal. What's the most appropriate management for this pt? a:start TMP-SMX prophylaxis b:start dapsone prophylaxis c:start INH prophylaxis d:start rifabutin prophylaxis e:both a&d f bserve&re-evaluate in 3-6moA. A She has symptomatic HIV disease bcoz of her history of oral thrush.PCP prophylaxis indicated even with CD4>200 in this case,for asympto pts prophylaxis when CD4<200.prophylaxis for MAC when CD4<75 with rifabutin,dapsone alternative Rx with allergic reaction to tmp-smx,PPD negative so with normal xray and no previous history of TB or close contact to TB cases,no need to INH prophylaxis Q. Which of the following statements about pheo is incorrect? a:Hct is increased b:the impaired glucose tolerance rarley required treatment with insulin c:hypercalcemia has been attributed to the ectopic secretion of PTH-related protein d:in pts with MEN2,pheo should be excluded&removed before thyroid or parathyroid surgery e:After successful surgery,cathecholamine excretion returns to normal in about 4weeks&should be measured to esure complete tumor removal A. e:After successful surgery,cathecholamine excretion returns to normal in about 4weeks&should be measured to esure complete tumor removal it returns to normal in about 2wk,the impaired glucose tolerance rarley required treatment with insulin and it's treated by tumor removal,in pheo ALONE(not with MEN II)hypercalcemia has been attributed to the ectopic secretion of PTH-related protein Q. A 32yo male presents to the physician at his place of work,complaining of testicular enlargement.The physician confirms the finding&refers him for surgical Rx.The mass is discovered to be a seminoma.Appropriate Rx is given.A similar case occured in this factory earlier in this yr.The company physician should: a:inform the employer of the man's diagnosis b reserve the man's anonymity but indicate to management that this was the second case to occur in the past yrc:advise both management&the workers that 2 cases of testicular cancer have occured in the past yr d:quietly begin a search for possible carcinogens but inform neither workers nor management e:insist that information about the RFs for testicular cancer be released to management&workers A. d:quietly begin a search for possible carcinogens but inform neither workers nor management physician should treat as confidential.information should be released only when required by law or bcoz of overiding public health considerations.the occurrence of 2 similar cases of an illness in a yr could be attributed to chance&doesn't at this stage indicate the risk of an overiding public health problem Q. A 16 mo girl is admitted to the hospital with H.influ meningitis.social history reveals that she lives at home with her parents&a 3yr old boy.She attends a day care center 2 mornings a week.U're asked to advise about appropriate prophylaxis for contacts. Each of the following should recieve rifampin prophylaxis except: a:the pt b:the sibling c:the parents d:all children less than 4yo who attended the day care center with the pt during the past wk A. d:all children less than 4yo who attended the day care center with the pt during the past wk children with H.influ meningitis can continue to be carriers of the organism despite a full course of Ab therapy,so an effective prophylactic Ab should be given to an affected child before discharge home.The sibling&any other children less than 4yr who have had CLOSE contacts with the pt should receive prophylaxis.(close contact usually defined as >=4hr of contact on 5 of the preceding 7days).The parents of the pt should receive rifampin prophylaxis to help prevent the spread of infection to other children living in the home. Q. A 5200 gm newborn infant of a diabetic mother has Apgar score of 4,7 at 1&5minutes.At 2hr of age,the infant has a serum glucose 24&Hct 68%.At 24hr of age,the infant has a serum Ca level of 6.8,Appropriate therapy is started.At 30hr of age,the infant has bilious vomiting&abdominal distention.Rectal exam reveals a small amount of meconium in the ampula.A plain abdominal xray shows dilation of the small bowel. what's the most likely diagnosis&management for this pt? A. neonatal small left colon syndrome: a frequent association with gestational DM of mother usually this condition is transient and requires only conservative management,seldom requires surgical intervention Q. A 32yo woman with brief throbbing headaches,truncal sweating&palpitations has become much worse when she became pregnant.Exam of the pt also shows skin lumps&some unusual pugmentation.It's difficult during these attacks to hear the BP sounds.u do a spot test of urine&make the diagnosis,u're looking for: a orphyrinsb:metanephrine c:bilirubin d:sugar e roteinA. b:metanephrines case of pheo with NF bcoz of vasoconstriction,peripheral pulses may be diminished&the BP hard to hear. Q. A 26yo man presents in the ER with the complaint of recurrent coliky,mid-abdominal pain.On Ph.E he has a palpable abdominal mass&several areas of increased pigmentation on his lips,palms&soles.He states his father had a colon polyp removed several yrs ago. What's the most likely diagnosis? A. A case of puetz-jeghers syndrome who presents with intussuspection Q. A healthy full-term newborn infant has bilateral talipes equinovarus(clubfoot),ur best treatment recommendation is to: a:cast the feet on the first day of life b:consult a pediatric orthopedist when the child is 2wk old c:decide about treatment during the infant's first office visit d bserve the infant for 72hr&then cast the feet if no spontaneous improvement occurse lan to have the child undergo defenitive surgical repair at 9mo of ageA. a:cast the feet on the first day of life Q. U r caring for a 6yo boy with PKU whose blood phenylalanine level is 10mg/dl.The parents have asked ur advice about discontinuing the child’s phenylalanine-restricted diet.ur best advice to them would be: a:continue the diet indefinitely b:discontinue the diet at this time c: discontinue the diet at this time,but resume the diet if the blood Phe level increases d:have psychologic testing performed&adjust the diet in accordance with the results A. a:continue the diet indefinitely The goal of the phe-restricted diet is to facilitate normal brain development by maintaining the blood phe level between 2&10mg/dl.for many yrs,most Rx centers recommended discontinuation of the diet at 5-6yr old.recent studies have suggested that some children who discontinued the diet at 5-6yo have had a slightly lower IQ&poorer academic achievement than those who continued the diet.So,it’s now recommended that children with PKU follow the restricted diet continuously&indefinitely. Q. A 26yo truck driver increasingly irritable for the past 3mo,moods have become unpredictable,now is accusing wife of infidelity.What’s the most likey diagnosis? A. Amphetamine psychosis Chronic amphetamine use&abuse as seen in some long distance truck drivers who use the stimulant drug to stay awake,may coz a psychotic paranoid syndrome that’s very similar to paranoid schizo. Q. A worried mother asks u how to manage her 5yr son who she says is stealing.Apparently,he keeps bringing home toys that belong to other children. U should advise her to: a:take the toys back herself,without any fuss&bu,y him similar toys b:tell him that if he stops stealing,he will have a reward every weekend c oint out that this is stealing&spank himd:make sure he has enough toys&see that he returns the toys to the owners e:ignore the whole affair,this is a developmental phase that will soon pass A. I don't think that positive reinforcement would be efficient in a five year old. D might be better because it involves teaching him the undoing behavior (see that HE HIMSELF returns toys to owners), while making sure to address the possible reason for this behavior. E is partly correct, because this is NORMAL behavior in a 5 year old. It is a resolving phase since while 3 yo don't feel it's wrong, 5yo have planned for it, but haven't internalized the "wrongness" of it. Ignoring it will likely send the wrong message, that it's ok to steal. Q. A teenage boy in psychotherapy says to his psychotherapist,”nobody cares for me”. The therapist knows the adolescent is receiving at least the usual family love&attention. The doctor should respond: a:”of course ur family cares for u” b:”I wonder why that should be so” c:”I care for u” d:”how much caring do u need?” A. b:”I wonder why that should be so” In psychotherapy relationship,especially with an adolescent,the response of the psychotherapist is often factual&direct. Q. A 6yo girl was scratched on the left hand by a cat.10days later she had a tender,left axillary node,T:37.8,a red left eye without any pain&discharge&a left preauricular lymphadenopathy.Aspiration of the axillary node recovered pus,from which no organism was grown on routine culture.She developed erythematous nodules and plaque over both shins 1 wk later. Which of the following statements regarding the most likely diagnosis,is not correct? A:A scratch by a kitten is more likely to cause the disease than a scratch by an adult cat B:the presentation of skin nodules is a self-limited condition&corticostroids r not recommended C:boys r affected more often than girls D:Warthin-Starry silver stain useful to show the organisms E:azithromycin decreases the duration of disease in 50% of patients if prescribed during the first 30 days F:Incision and drainage of nonsuppurative nodes should be avoided because chronic draining sinuses may result A. E:azithromycin decreases the duration of disease in 50% of patients if prescribed during the first 30 days A case of CSD with erythema nodusom(which is self-limited&corticostroids have no effect)&Parinaud's occuloglandular syndrome:the most common atypical presentation,noted in 2–17% of patients,which is unilateral conjunctivitis followed by preauricular lymphadenopathy.Direct eye inoculation as a result of rubbing with the hands after cat contact is the presumed mode of spread. A conjunctival granuloma may be found at the inoculation site. The involved eye is usually not painful and has little or no discharge, but it may be quite red and swollen. A small prospective study of azithromycin shows decrease in initial lymph node volume in 50% of patients during the first 30 days, but after 30 days there was no difference in lymph node volume. No other clinical benefit was found. It is clear that for the majority of patients, the disease is self-limited, with resolution occurring over weeks to months, and that treatment affords minimal, if any, clinical benefit. Suppurative lymph nodes that become tense and extremely painful should be drained by needle aspiration, which may need to be repeated. Incision and drainage of nonsuppurative nodes should be avoided because chronic draining sinuses may result. Q. A 56yo man complains of fatigue,dyspnea on exertion&palpitations.He has had a murmur since childhood.Exam reveals a grade3/6 midsystolic pulmonic murmur&a 1/6 mid diastolic tricuspid murmur at LLSB.Cxray shows RV enlargement&prominent pulmonary arteries.ECG shows AF with a RBBB.What’s the most likely diagnosis? A. ASD in the more common ostium secondum type of ASD there's often R-axis deviation,but the ostium primum type has a left-axis deviation Q. A 65yo obese man with recurrent coughing attacks(especially marked while asleep)slight horseness&no cardiorespiratory dz,there’s no history of allergy.Cxray is normal. Procedure most likely to help diagnosis is: A:barium imaging of the esophagus B:24-hr PH monitoring C:esophageal manometry D:esophagoscopy E:acid perfusion test(Bernstein test) A. B:24-hr PH monitoring COMPLETE EXPLANATION BY Hassan......no need to add more Q. A newborn infant girl has myelomeningocele.Which of the following studies would identify the most common associated anomaly? a:CT of the head b:cardiac echo c:Xray of the hips d  *** of the spinal columne:VCUG f:abdominal US A. a:CT of the head the most common asso anomaly is hydrocephalus,xray should be done to determine the need for placing a ventriculoperitoneal shunt Also the bladder may be small&spastic or large&hypotonic,so VCUG should be done before discharge,hips may dislocate overtime esp.with paresis or paralysis involving lumbar segments so xray should be done for pts at risk(but these 2 conditions r not as common as hydrocephalus!) Q. A 25 yo woman complains of 3mo of postprandial abdominal distention,bloating&nausea that’s partially relieved by vomiting of ingested food.although symptoms were intermittent at first,they now appear about 15min after each meal&last 1-2hr.Symptoms r diminished by eating very small meals.The pt has lost 25kg in the past 6mo,however she was on a weight-loss diet for the past 7mo&at least 20kg were lost prior to the onset of symptoms.Recently she has noted partial relief of symptoms if she assumes a “hands&knees”position after eating.Ph.E reveals a thin woman with evidence of recent weight loss.No other abnormalities r noted.What’s the most likely diagnosis? A. This case with typical history of: *sup.mesentric artery syndrome* a reversible obstruction of the third portion of the duodenum as it passes between the SMA&the fixed retroperitoneal structures.It’s seen in pts with recent substantial weight loss.Characteristically symptoms improve with a “hands&knees”position or prone position as the SMA tends to fall away from the duodenum under the influence of gravity. Q. A 9mo-old otherwise healthy boy has had chronic constipation since birth.Although the mother has given the infant enemas&mild cathartics on many occasions,he still seems to retain stool&has difficulty with bowel movements.A barium enema done recently failed to show a transition zone between dilated&normal rectum or colon.What’s the best next step of management for this pt? a:repeat the barium study b rescribe daily enemas with mineral oil for 1moc:evaluate the infant for hypothyroidism d btain a biopsy of the rectumA. e btain a biopsy of the rectumA history of chronic constipation since birth suggests the diagnosis of Hirschsprung dz.the definitive test for Hirschsprung dz is an adequate biopsy of the rectum in search of ganglion cells.In as many as 20% of barium enema studies,proven cases of Hirschsprung dz fail to demonstrate the usual transition zone. Q. A 30 yo man on vacation has had symptoms of URI for 1 wk&persistent headache for 3days.He received a cadaveric renal allograft 1 yr ago&is now taking prednisone,azathioprine&cyclosporine.T:37.8,bu t Ph.E shows no abnormalities.The allograft is not enlarged or tender,there’s no nuchal rigidity&there r no focal neurologic findings.Serum Cr:1.5mg/dl,WBC:5000. Which test should u do next to evaluate the pt’s condition? A:CT scan of the head B:LP C *** of skull sinusesD:U/A E:Cxray F:serum cyclosporine measurement A. B: doing LP to rule out cryptococal meningoencephalitis Chief complaint is heacache Q. In the age group 35yr&older,yearly death rates per 1000 persons from lung cancer r 0.07 for nonsmokers&0.96 for cigarette smokers. Which of the following statements is true concerning interpretation of this finding? A:cigarette smokers r 14.7 times as likely to develop lung cancer as r nonsmokers B:The attributable risk measures the incidence or rate of recurrence C:The attributable risk measures the strength of an association,high attributable risk leading to conclusions about etiology or causality D:The attributable risk of lung cancer due to cigarette smoking is 93% E:in smokers,the overall rate of lung cancer death linked to cigarette smoking is 0.96 A. D:The attributable risk of lung cancer due to cigarette smoking is 93% Relative risk is the ratio of the incidence rate of those persons exposed to a certain condition or factor to the incidence rate of those persons not exposed.Here the relative risk is 0.96/0.07=13.7 Attributable risk measures the impact that removal of a certain factor may have on the incidence of the dz.Incidence or rate of recurrence is measured by the absolute risk.Relative risk measures the strength of an association,whereas absolute risk is used in in actuarial situations.In the figures given,the overall rate of deaths from lung cancer in cigarette smokers is 0.96, of which 0.89(0.96-0.07)is attributable to cigarette smoking.Thus the percent attributable risk is 0.89/0.96*100=93% Q. Electrical current burns to the lips of young children require close observation of which of the following? A:brain injury from the electrical current B:child abuse C:delayed massive bleeding D:the need for plastic reconstruction E:all of the above A. the answer is:C:delayed massive bleeding Children with burns of the lips should be observed carefully for subsequent rupture of the labial artery 3-5days post injury. Q. A stage Ib SCC of the cervix is diagnosed in a pregnant pt at 22wk of gestation.Recommended management for this pt is: a:expectant therapy until fetal maturity b:immediate external radiation therapy c:intracavitary cesium before external radiation therapy d:induction of labor with anticipated vaginal delivery e:immediate radical hysterectomy with pelvic lymph node resection A. e:immediate radical hysterectomy with pelvic lymph node resection staging of invasive cervical cancer in pregnancy is complicated by edema&softening of the cervix,paravaginal& parametrial tissues&the bulkiness of the growing uterus.So the liklihood of understaging is increased.Management is influenced by the stage of the dz,fetal viability at the time of diagnosis,effect of therapy on the fetus&the pt's&her family views on her dz.Pregnant women with stage Ib cervical cancer r best advised to undergo Rx IMMEDIATELY!this may be either with surgery or irradiation,but there's a tendency to prefer definitive primary surgery(abdominal hysterectomy& regional lymphadenectomy)bcoz of the overall good results,good cure rate,ovarian preservation,improved sexual function&elimination of delay in Rx. Q. A 23 yo woman who has been taking insulin for control of DM for 7yr is found during a routine exam to have a firm nodule in the left lobe of the thyroid gland.The right lobe is easily palpable&possibly enlarged. Serum thyroxine:6.2(N=5-11) Resin T3 uptake:0.60(N=0.85-1.15) TSH:42(N=0-6) Thyroidal uptake of radioiodine at 24hr:40%(N=5-30),radioisotope thyroid scan shows all uptake confined to the palpable nodule(reported as a hot nodule).What’s the most appropriate action? A:administration of L-thyroxine to suppress the nodule B:measurement of serum T3 to detect T3 toxicosis C:radioiodine ablation of the nodule D:administration of PTU E:needle aspiration of the nodule A. the answer is A:administration of L-thyroxine to suppress the nodule case of Hashimoto thyroiditis,sometimes associated with normal or even elevated radioiodine uptake,which has destroyed most thyroid tissue leaving only a single island of function:the hot nodule Q. a 15 yo boy is brought to ur office by his friends who say he’s”high on drugs”.They r scared of him.As u look at the teenager,u note his sallow complexion&his generally thin appreance.He’s constantly restless as he sits in the chair.He grinds his teeth periodically&his eyes shift rapidly as he scans ur office.When he talks,his voice sounds thick.U can find no signs of self-injection on Ph.E.He admits he’s taking “dope”.With some resistance,the adolescent pt responds to ur questioning.He reveals a wide range of paranoid thinking&tells how he’s planning to get those ppl who’re making his life difficult.When u try to sway his ideas by pointing out his lack of logic,he stares suspectiously at u. ur likely diagnosis is: a:schizophrenia,paranoid type b:hallucinogen abuse c:amphetamine abuse d:heroin abuse A. c:amphetamine abuse LSD intoxication may produce a paranoid syndrome&chronic drug ingestion can produce this debilitated state,but LSD toxicity usually leads to greater distruption of reality contact. When an adolescent presents with a florid paranoid psychosis,amphetamine abuse is the most likely diagnosis&must be excluded first! Q. The psychiatrist is called to see a 26yo former medical hospital pt.2days previously the pt was involved in a motorcycle accident.Though he was probably drunk at the time,he was only dazed&shaken up by the crash.His neighbors have now brought him to the ER bcoz they found him wandering around his yard,confused&half-naked.His previous hospital history is not available.He’s disoriented as to time&place.His speech is slow&rather slurred.He’s annoyed by all this “fussing”&wants to fo home,hough he can’t say where his home is.The typical exam is unremarkable apart from superficial skin abrasions from his accident. What’s the most appropriate next step of management? A. case of subdural hematoma,order CT Q. A 32 yo man received an allogenic renal transplant 50 days ago&has been taking TMP-SMZ.he now has a fever,malaise&evidence of hepatitis followed by progressive dyspnea&hypoxemia with a diffuse interstitial pulmonary infiltrate developing over 5-7days.What’s the most likely diagnosis? A. CMV pneumonia Q. A 7wk old infant develops a progressive staccato cough,wheezing&tachypnea,without fever.Cxray shows hyperinflation.Which of the following sentences is incorrect about the most likely diagnosis? A:A distinctive lab finding is the presence of peripheral eosinophilia B:The recommended treatment regimen for this condition is erythromycin C:Immunoprophylaxis reduces the frequency and total days of hospitalization in high-risk infants D:Long-term pulmonary abnormalities r common A. C,Pneumonia due to C. trachomatis develops in 10–20% of infants born to women with chlamydial infection. Only about 25% of infants with nasopharyngeal chlamydial infection develop pneumonia. C. trachomatis pneumonia of infancy has a very characteristic presentation. Onset usually appears between 1 and 3mo of age and is often insidious, with persistent cough, tachypnea, and ABSENCE of fever. Auscultation reveals rales; wheezing is uncommon. The absence of fever and wheezing helps to distinguish C. trachomatis pneumonia from RSV pneumonia.(although this pt has wheezing but most data suggests C.pneumonia including lack of fever).A distinctive lab finding is the presence of peripheral eosinophilia (>400cells/mm3 ). The most consistent finding on chest radiograph is hyperinflation accompanied by minimal interstitial or alveolar infiltrates. choice C correct for RSV infection! Q. A 27yo primigravida at term is admitted to the delivery suite having 5-min contractions.She’s found to be 3cm dilated.When examined 5hr later,she has only progressed to 4cm&75%effaced.The station is at station 0.Her contractions r mild to mod&have become more irregular during the past 3hr.She has been up walking around,but this has not helped.Her membranes r intact&bulging.The FHR tracing is reactive.The most appropriate course of action at this time would be: a erform an amniotomyb:begin oxytocin stimulation for hypotonic labor c:call the anesthesiologist to administer an epidural anesthetic d:reassure the pt that her contractions will eventually pick up A. the answer is:a erform an amniotomythe pt with active labor followed by hypotonic uterine dysfunction&head engaged:if membranes r intact:do amniotomy as it may augment&shorten labor. oxytocin administration should ONLY be considered after the membranes have been ruptured&there's still no progress in labor! Q. A 22 yo Hispanic man recently discovered changes in his skin that he describes as "ugly spots with terrible itching". He has a history of a short-lived substance abuse problem when he was 18 years old, which he got help for immediately. Although he is now "clean" he wonders if this may be the cause of all his skin problems. The pt's father, who presently has a drug& alcohol problem, has the same spots on his skin which come& go. On Ph.E, there r 2 scaly plaques on the left temporal scalp, his ears r scaly throughout the external auditory canals bilaterally, there r pink, scaly well-defined plaques on his elbows, and distal onycholysis. What’s the most likely diagnosis& the most appropriate next step of management for this pt? A. Although this pt is presenting with many of the classic signs of chronic plaque PSORIASIS,it's best to document it clearly in the chart with a representative BIOPSY at least once in a patient with this chronic disease.The easiest place to do a biopsy in this patient is either the scalp or the elbow. The classic signs of chronic plaque psoriasis are silvery or pink well-defined plaques, which can span the whole body from the scalp to the feet. The most classically involved areas include the scalp, ears, elbows, knees, sacrum and ankles.. Psoriasis is an inherited disease whose exact chromosomal location and mechanism is still under debate. Psoriasis has not been directly linked to substance abuse problems. This patient most likely inherited the psoriasis and perhaps even the substance abuse problems from his father,separately. Q. A 2yo girl was found sucking on the cap of a bottle of drain cleaner.Ph.E reveals mild erythema of the lips&tongue but no evidence of respiratory distress or drooling.The best management for this pt is: a:barium swallow if dysphagia or fever develops b:barium swallow immediately c:barium swallow within 48hr d:esophagoscopy if dysphagia or fever develops e:esophagoscopy within 48hr A. e:esophagoscopy within 48hr ingestion of liquid alkali can produce liquefaction necrosis,which can extend to deep layers of the esophagus.Even small amounts of caustic material can cause significant damage.minimal findings on exam of the oral cavity&oropharynx r not reliable indicators that damage in the esophagus also is minimal.If esophagoscopy is performed too early(within 24hr after ingestion)a small but developing lesion may be overlooked. A barium swallow performed too early probably won't be diagnostic&may interfere with direct visualization later.Also antibiotic therapy should be initiated ASA the pt is examined.The efficasy of corticostroids to reduce the formation of strictures is controversial. Q. A 70 yo man presents 8mo after placement of a Dacron graft for an AAA&complains of coffee-ground emesis&decreased urinary output.On exam,he smells of alcohol&has a low grade fever,hypotension&abdominal tenderness.Lab values include:Hct:20%,WBC:21000 with a shift to left.Nasogastric aspirate is clear but guaiac+.What’s the most likely diagnosis? A. aortoduodenal fistula fever&increased WBCs in a pt with a synthetic graft:consider graft as a source of infection!!infection of an intraabdominal graft may present with fever,abdominal tenderness&ureteral obstruction or hydronephrosis.An aortoduodenal fistula may develop between an infected aortic graft&the duodenum&presents with hematemesis or circulatory collapse Q. A 72yo smoker is admitted to the hospital for COPD exacerbation. Admission vitals r RR:18/min, with a BP:180/100 mm Hg, and an O2 saturation of 91%. He is started on nebulized albuterol & ipratropium bromide, as well as prednisolone IV. Admission Cxray reveals flattened hemidiaphragms, increased retrosternal clear space & hyperlucent lungs. Given a suspicion of pulmonary embolus, a V/P scan is performed demonstrating nonsegmental perfusion defects of the left upper lobe, with a small left lung and a complete absence of perfusion&ventilation of the entire right lung. The patient becomes acutely short of breath. His RR r:30/min with otherwise normal vital signs. After supplemental oxygen (4 L/min by nasal cannula)& nebulizers r administered, the RR becomes 29/min, with a BP of 80/40 mmHg, and an O2sat of 82%. A repeat Cxray is pending.What’s the most appropriate management for this pt? a:administer heparin,IV b:start thrombolytic therapy immediately c:insert a chest tube on the left side d:insert a chest tube on the right side e btain a surgical consult for emergent lung volume reduction surgeryf btain a surgical consult for emergent embolectomyg:send him for coronary artery catheterizat     
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