set 8 (Nasi)

[cyrus1345]

1.An 18-year-old female high school senior presents with amenorrhea. She has never had a menstrual period. She had multiple ear infections as a child but has had no medical problems recently. She walks to school but does not participate in sports. She is otherwise healthy and takes no medications. She is 130 cm (59 in) tall and weighs 54.5 kg (120 lb); her blood pressure is 140/90 mm Hg. Her skin is clear, without acne, hirsutism, or striae. She has a short neck and low-set ears, as well as wide-spaced nipples and no breast development. She has a few axillary and pubic hairs, and a small uterus on bimanual examination. You cannot feel her ovaries.

What is the most likely diagnosis?


(A) Kallman’s syndrome


(B) Turner’s syndrome


(C) XY gonadal dysgenesis


(D) Congenital adrenal hyperplasia


(E) Delayed puberty





B


2.A 30-year-old woman presents because of 6 months of amenorrhea. She had regular menses starting at age 13 years and is otherwise healthy. Menses gradually became irregular over the past 5 years, in spite of relatively stable weight and activity. She has no acne or hirsutism. The results of recent laboratory tests included normal serum thyroid-stimulating hormone and prolactin levels and a negative serum pregnancy test.

What is the next most useful diagnostic test for the evaluation of secondary amenorrhea in this patient?


(A) Measurement of serum luteinizing hormone


(B) Measurement of serum follicle-stimulating hormone


(C) Pelvic ultrasound


(D) Measurement of serum estradiol


(E) MRI of the pituitary gland





In this patient, the negative pregnancy test, and normal serum TSH and prolactin levels exclude the most common causes of secondary amenorrhea. The remaining causes include hypothalamic amenorrhea and ovarian failure. Of the tests listed, serum FSH is the most likely to be diagnostic of a reproductive endocrine abnormality, as it has a longer half life than luteinizing hormone and becomes elevated relatively early in the process of ovarian aging. Luteinizing hormone is less useful because of its greater variability across the normal menstrual cycle (including the dramatic, often 10-fold, increase at the midcycle surge), its more striking 1 to 2 hourly pulsatility, and its elevation in polycystic ovary syndrome as well as ovarian failure. Serum estradiol is frequently in the normal range in various reproductive disorders and therefore rarely useful. MRI of the pituitary gland is not indicated unless other tests are normal and a hypothalamic cause of needs to be ruled out. Finally, pelvic ultrasound can show the presence of ovaries, their size, and the uterine morphology and endometrial thickness, but cannot diagnose the cause of secondary amenorrhea. It may be more useful in the evaluation of primary amenorrhea, if the physical examination is inadequate to confirm the presence of intact ovaries and a uterus, or in the evaluation of excessive menstrual bleeding, when it can identify endometrial thickening, polyps, and/or uterine leiomyomas. A medroxyprogesterone challenge test can show that the uterine anatomy and vaginal outflow track are normal, which is suggested by the history of previously normal menstrual cycles. In addition, the challenge test provides some information about recent estrogen exposure. However, it cannot be diagnostic in estrogen deficiency.



3.A 28-year-old woman presents because of nipple secretion that she detected on breast self-examination. She had normal menarche at age 13 years, followed by regular menses until 1 year ago when her periods ceased. She has no significant medical history and is taking no medications. Review of systems reveals fatigue, which she attributes to working two jobs, and a recent 2-kg (4.4-lb) weight gain. She does not have hot flushes. The family history includes diabetes mellitus and early coronary artery disease. On physical examination, she has bilateral galactorrhea but otherwise appears healthy.

Which of the following tests would you order initially to evaluate this patient?


(A) Medroxyprogesterone (Provera®) withdrawal challenge


(B) Measurement of serum prolactin, estradiol, and luteinizing hormone


(C) Measurement of serum prolactin and thyroid-stimulating hormone, and urine pregnancy test


(D) Measurement of serum prolactin, thyroxine, and follicle-stimulating hormone



C

4.A 23-year-old female graduate student presents for evaluation of hirsutism. She has noted the gradual development of facial hair over the past 4 to 5 years. She had menarche at age 14 years, and her menses have been irregular ever since. Her most recent menstrual period was 3 months ago, about the time she entered graduate school. She took oral contraceptive pills for birth control from age 16 to 18 years, but stopped when the relationship ended. She is otherwise healthy and takes no medications. Her parents are both Irish. On physical examination, she is 168 cm (66 in) tall and weighs 68.2 kg (150 lb). She has a few acne cysts on her chin. She has terminal hair on her upper lip and areolae. The rest of her examination, including her pelvic examination, is normal.

What is the most likely diagnosis?


(A) Stress-induced amenorrhea


(B) Polycystic ovary syndrome


(C) Late-onset congenital adrenal hyperplasia


(D) Ovarian androgen-secreting tumor


(E) Idiopathic hirsutism





B
The peripubertal onset of irregular menstrual cycles and hyperandrogenic symptoms such as acne and hirsutism are most commonly caused by the ovary syndrome, which affects up to 5% of adult women. In this patient, hypothalamic amenorrhea is unlikely because of the hirsutism. Late-onset congenital adrenal hyperplasia is much less common than ovary syndrome, especially in someone of Irish descent. An androgen-secreting tumor is unlikely because the course began slowly at puberty, there is no evidence of hyperandrogenic symptoms (balding, clitoromegaly, and muscle virilization), and there are no other associated symptoms such as hypertension or evidence of cortisol excess. The diagnosis of idiopathic hirsutism requires regular menstrual cycles. Given the clinical presentation, the most efficient evaluation would be to measure serum thyroid-stimulating hormone, prolactin, and follicle-stimulating hormone to rule out impending failure, and urine human chorionic gonadotropin to rule out pregnancy before initiating therapy. If the clinical suspicion of an androgen-secreting tumor were higher, measurements of serum testosterone and DHEA-S would be helpful.

This patient has both cosmetic concerns and menstrual dysfunction. Whereas the clinician may be most concerned about preventing endometrial hyperplasia, the patient may be most concerned about her appearance. Since there are safe and effective medications for both concerns, a medical therapy should be offered if the patient desires and does not have significant risks. Oral contraceptive pills are the single best therapy for benign ovary syndrome. They suppress androgen production by suppressing gonadotropin secretion and increasing sex hormone binding globulin, control irregular menstrual bleeding (thereby preventing endometrial hyperplasia and cancer), and slightly suppress adrenal androgen secretion. The doses of estrogen and progestin in standard hormone replacement therapy are generally insufficient to suppress gonadotropins enough to suppress androgen production. Spironolactone can be effective therapy for hirsutism, but in general it does not control menstrual irregularity and therefore does not consistently protect the endometrium. Because of a potential teratogenic effect, spironolactone should be given in combination with an oral contraceptive pill in women who are sexually active. Dexamethasone is no more effective than the other therapies but has significantly more side effects (weight gain, mood changes) making it an undesirable choice. Although insulin-sensitizing medications such as metformin and troglitazone have been shown to reduce serum androgen levels, they have not been proven to be effective in the treatment of hirsutism or in comparison with conventional therapies, and may also have side effects.





5.Idiopathic hirsutism (regular ovulatory menstrual cycles, no other disorder)
Polycystic ovary syndrome (oligoovulation and hyperandrogenism, no other disorder)
Nondisease states (for example, hypertrichosis)
Factitious/iatrogenic
Neoplasms
Pituitary (prolactinoma, Cushing’s disease)
Ovary (Sertoli-Leydig cell tumors, hilus cell tumors)
Adrenal (adrenal adenoma, adrenal carcinoma)
Late-onset congenital adrenal hyperplasia (adrenal enzyme defects)
Other medical conditions
Adult hypothyroidism
Medications causing androgenic hirsutism (synthetic glucocorticoids)
Adrenocorticotropic hormone
Metyrapone
Anabolic steroids
Maternal use of synthetic progestational agents (fetal virilization)
Medications causing hypertrichosis
Phenytoin
Glucocorticoids
Penicillamine
Diazoxide
Streptomycin
Hexachlorobenzene
Psoralens
Cyclosporine
Juvenile hypothyroidism
Acute intermittent porphyria
Malnutrition
Anorexia nervosa
Dermatomyositis
Epidermolysis bullosa
de Lange’s syndrome
The postencephalitis period
The onset of multiple sclerosis
Nevoid hypertrichosis
Severe insulin resistance
Type B insulin resistance
Rabson-Mendenhall syndrome
Lipodystrophy syndromes


6.Laboratory studies in hirsutism serve both to confirm the clinical impression of hyperandrogenism and to identify the source of excess androgens, either adrenal or ovarian. The workup recommends 2 visits, a baseline evaluation followed by a 2-week dexamethasone treatment period. Specific discussion of the testing is below.
Testosterone: The most important assay is of serum testosterone, the major circulating androgen. If the results from testing the total serum testosterone level are normal, measure the free serum level because hyperandrogenism (and insulin resistance, if present) decreases sex steroid–binding globulin, such that the unbound, biologically active testosterone moiety may be elevated even if the total level is unremarkable. Extremely high testosterone levels are likely to be associated with adrenal or ovarian tumors, whereas very mild elevations are found in idiopathic and benign etiologies. Indeed, in idiopathic hirsutism, the results from testing androgen levels are often normal. In some of these women, hirsutism is thought to be caused by increased skin sensitivity to androgen or by increased skin 5 alpha-reductase activity. This enzyme is located in the skin near the hair follicle, and it converts plasma testosterone into the androgen metabolite dihydrotestosterone.
Dehydroepiandrosterone sulfate: Because testosterone can originate in either the adrenal cortex or the ovary, an elevated testosterone level does not indicate the gland of origin. Accordingly, measurement of elevated plasma levels of DHEAS, an androgen synthesized almost exclusively by the adrenal cortex, can indicate excess adrenal function. Elevations in both testosterone and DHEAS suggest an adrenal origin, whereas an isolated testosterone elevation indicates an ovarian source.
Dexamethasone suppression : Laboratory testing of testosterone (free or total) and DHEAS can be performed on the initial visit. At the same time, a diagnostic trial of dexamethasone therapy for 7-14 days can be initiated to help exclude ACTH-dependent hirsutism. When the patient returns, free testosterone, DHEAS, and plasma cortisol levels are measured. Dexamethasone-mediated suppression of androgens is observed in healthy women who do not have hirsutism and in those with CAH and idiopathic hirsutism.
Adrenocorticotrophin stimulation: An ACTH-stimulation test (250 mcg for 30 min) can help differentiate between CAH and idiopathic hirsutism because CAH produces abnormal findings (elevations in metabolic precursors of cortisol).

CAH causing hirsutism is due to 1 of 3 cortisol biosynthetic defects, ie, 21-hydroxylase deficiency, 3 beta-hydroxysteroid dehydrogenase, or 11 beta-hydroxylase deficiency.

Because 21-hydroxylase deficiency accounts for the vast majority of cases of CAH (approximately 90%), the discussion is focused on this diagnosis. Investigate possible 21-hydroxylase deficiency by measuring plasma 17-hydroxyprogesterone levels obtained between 0700 and 0900 hours. Values less than 7 nmol/L exclude the diagnosis, and values greater than 45 nmol/L (in women who are nongestational) confirm 21-hydroxylase deficiency. When basal values of 17-hydroxyprogesterone are between 7 and 45 nmol/L, an ACTH-stimulated concentration of greater than 45 nmol/L is also diagnostic.

Although elevated basal plasma 17-hydroxyprogesterone levels (as high as 17 nmol/L) may be present during the luteal phase of the menstrual cycle and in PCOS, ACTH-stimulated increments are blunted.

Cortisol suppression: Investigation of subnormal dexamethasone suppression of androgens can be guided by the patient' s cortisol level, without the need for an ACTH-stimulation test. PCOS and adrenal and ovarian tumors are associated with normal suppression of cortisol by dexamethasone, whereas cortisol levels in patients with Cushing syndrome are not suppressed.

Other lab tests
Serum prolactin or FSH: Women with hirsutism and amenorrhea of unknown cause should have a serum prolactin or FSH test to evaluate for either a prolactinoma or ovarian failure.

Diabetes screening: Women with hirsutism, PCOS, obesity, or acanthosis nigricans may have insulin resistance, and screening for diabetes and hyperlipidemia is warranted.

Imaging Studies:


If indicated by the findings from the clinical evaluation and laboratory testing, perform ovarian ultrasonography and adrenal computed tomography scanning or magnetic resonance imaging to evaluate for either ovarian or adrenal sources of androgen production.



7.phenobarbital is safer in pregnancy,

phenytoin and/or valproic acid are both teratogenic,..

phenytoin-multiple abnormalities, inc. hypoplasia of distal phalanges,..cleft lip/palate

valproic acid- fetal anticonvulsive syndrome, neural tube defects, etc..

advice abortion- is not necessary, thus not the best option,..


8.A 29-year-old previously healthy hospital phlebotomist presents because of several months of fatigue, malaise, and weakness. Formerly overweight, she is surprised that she has lost 7 kg (15 lb) without dieting, noting that she has been eating “a lot of junk food, like chips and pickles.” Friends have told her that she looks good, with the weight loss and a dark tan.

On physical examination, she is 158 cm (62 in) tall and weighs 50 kg (110 lb); her pulse rate is 80/min supine and 98/min standing, and her blood pressure is 118/80 supine and 100/70 standing. Her skin is tan, with freckling of the nose and lips; she has dark nipples and palmar creases. The maximum serum cortisol concentration after administration of cosyntropin is 2.1 µg/dL at 60 min (normal > 18 µg/dL). Serum adrenocorticotropic hormone level is 453 pg/mL (normal 9 to 52 pg/mL).

Which of the following would be optimal management for this patient?


(A) Administer glucocorticoids and mineralocorticoids, and order adrenal imaging.


(B) Administer glucocorticoids and order head imaging.


(C) Administer mineralocorticoids and measure serum ferritin.


(D) Administer glucocorticoids and mineralocorticoids, and order head imaging.





A
This patient’s presentation is classic for primary adrenal insufficiency, with features such as weight loss, salt craving, and hyperpigmentation. The diagnosis is confirmed with a flat cosyntropin test. The adrenal source of her hypoadrenalism (as opposed to pituitary) is confirmed with a markedly elevated serum ACTH. Treatment must include both glucocorticoid and mineralocorticoid replacement as primary adrenal insufficiency is associated with failure of both cortisol and aldosterone secretion. Imaging of the adrenal glands is required to determine whether this patient has autoimmune adrenalitis, in which case the adrenal glands will be atrophied, and which is the most frequent source of hypoadrenalism in industrialized countries. In contrast, large adrenal glands would be consistent with tuberculosis or other infectious and infiltrative causes of hypoadrenalism and would mandate further diagnostic evaluation. In this patient who works in a hospital, tuberculosis and other infections are possible. Although hemochromatosis is a rare cause of adrenal failure, a work-up for this disorder would be necessary only if the adrenal glands were found to be enlarged. In this patient, adrenal imaging revealed bilateral atrophic adrenal glands, confirming the diagnosis of autoimmune adrenalitis and no further diagnostic investigation was needed. The patient felt well within 2 days of replacement therapy, and noted fading of her hyperpigmentation over the subsequent 6 months. She will need monitoring for other autoimmune disorders.


Follow Ups:


9.A 38-year-old woman presents with fatigue, nausea, and headache. She has had severe asthma for 6 years but discontinued her asthma medications 1 week ago because she was feeling well. Her medical history includes a seizure disorder that she has had for 20 years and that is stable on pheno-barbital therapy. On physical examination, her temperature is 37.7 °C (100 °F), her pulse rate is 92/min, her respiration rate is 16/min and breathing is unlabored, and her blood pressure is 110/70 mm Hg. The rest of the examination is unremarkable.

The most likely cause of this patient’s symptoms is:


(A) Phenobarbital toxicity


(B) Pulmonary infection with Pneumocystis carinii


(C) Hypoadrenalism due to hypothalamic–pituitary–adrenal axis suppression


(D) Hepatitis A





C


10.A 53-year-old postmenopausal woman presents with new-onset hirsutism, fatigue, a 4.6-kg (10-lb) weight gain, and several months of vague abdominal pains. Her medical history includes hypertension for the past 6 months, and for which she is taking a calcium channel blocker.

On physical examination, she is 160.5 cm (64 in) tall and weighs 72.7 kg (160 lb); her pulse rate is 80/min, and her blood pressure is 160/90 mm Hg. She has moderate abdominal obesity, normal extremity size, and mild to moderate hair growth on the chin, chest, and linea alba. There is slight fullness in the left lower abdomen and slight clitorimegaly. Neurologic examination is normal, except for 3/5 strength of the proximal leg muscles.

Laboratory studies
Serum chemistry panel Normal
Baseline morning serum cortisol 18.9 µg/dL (normal 8 to 20 µg/dL)
Urine free cortisol 435 µg/24 h (normal < 90 µg/24 h)
Morning serum cortisol after 8 mg of dexamethasone at midnight 12.5 µg/dL (normal < 5 µg/dL)
Serum ACTH Less than 10 pg/mL (normal 9 to 52 pg/mL)


What is the appropriate next step in the evaluation of this patient?


(A) Adrenal imaging (CT or MRI)


(B) Head imaging (CT or MRI)


(C) Chest imaging (CT or MRI)


(D) Bilateral inferior petrosal sinus sampling for ACTH




A

10.45-year-old woman undergoes emergent abdominal imaging after an automobile accident in which she sustained multiple injuries; although no acute surgical problems are noted, the radiology report notes the presence of a 6.3-cm right adrenal mass. The results of chemistry and hematology tests are normal.

Which of the following is the best evaluation plan for this patient?

(A) Chest CT, 4 PM serum cortisol, repeat imaging in 3 months


(B) 24-Hour urine free cortisol, 24-hour urine catechol-amines and metabolites, surgical consultation


(C) Paired plasma renin and aldosterone, 8 AM serum cortisol, repeat abdominal imaging in 6 months


(D) Serum testosterone, fasting serum epinephrine and norepinephrine, surgical consultation



11.Q516-A 33yo woman HIV+,complains of fever& persistent diarrhea since her last visit 6wk ago.Lab:
AST:43,ALT:40U/L,Albumin:3.1g/dL,ALP:228U/L,Total bilirubin:1.4g/dl
Her CD4 count is likely to be:
A:<50
B:50-100
C:100-150
D:150-200
E:>200
>>ANSWER:A:<50
MAC:the most common cause of fever in a pt with AIDS without other overt symptoms,is most often associated with the symptoms of fever with or without diarrhea.
Lab findings:involvement of the biliary tract&BM:increased ALP&pancytopenia.
At a CD4<50:HIV-associated dementia,CMV and MAC develop.
cryptosporidium may have biliray tract involvement but is usually with RUQpain

*Q517-A 13yo female complains of low back pain for the past 3wk.Since 7yo she's been competing in gymnastics.Her pain is localized to the lower back and is usually relieved with rest.On Ph.E the pain is aggravated with hyperextension of the lumbosacral spine.Sciatic tests&neurologic exam r normal.Plain xray shows a lucency at the pars interarticular.
The most likely Dx?
>>ANSWER:Spondylolysis
Spondylolysis is a defect seen in the pars interarticularis portion of the lamina. On oblique radiographs, the posterior elements form the appearance of a Scottie dog. A break in the pars interarticularis can have the appearance of a collar around the neck.Spondylolysis is 2-4 times more common in men than in women.
Spondylolysis is believed to be caused by repeated microtrauma, resulting in stress fracture of the pars interarticularis. Heredity also is believed to be a factor. Patients with spina bifida occulta have an increased risk for spondylolysis. Approximately 95% of cases of spondylolysis occur at the L5 level
Spondylolysis commonly is asymptomatic. Symptomatic patients often have pain with extension and/or rotation of the lumbar spine. Approximately 25% of individuals with spondylolysis have symptoms at some time. Athletes who participate in sports, such as soccer, baseball, football, wrestling, gymnastics, and tennis, are more likely to have symptomatic spondylolysis at some point(with hyperextension maneuvers)
Patients with suspected spondylolysis should be evaluated initially with plain radiography, consisting of anteroposterior, lateral, and oblique views of the lumbar spine. The lateral views are most sensitive for detection of pars fractures, and the oblique views are most specific.

*Q518-A 5yo boy presents with a history of social withdrawal and a failure to develop friendships with other children.He’s preoccupied with ensuring that all the toys in his room r placed in exactly the same spots each day&he eats exactly the same food for breakfast each morning.His language ability is appropriate for his age when he makes requests or answers direct qs.He’s able to read simple books,dresses himself and can operate the household TV&streo.The most likely Dx is:
a:Asperger disorder
b:Autistic disorder
c:Childhood disintegrative disorder
d:Ret disorder
e:Social phobia
>>ANSWER:a:Asperger disorder
it's characterized by defecits in interpersonal development,restricted patterns of interest&behaivior,and normal cognitive and speech development.

*Q519-A pt presents to the ER with a profuse bleeding from a knife wound in the right side of the chest,which didn't penetrate the ribs.It happened 30min ago.Which of the following lab parameters is most likely to be abnormal?
a:arterial PH,PaO2,PaCO2
b:CVP
c:Hgb,Hct
d:O2 saturation
e:MCV
>>ANSWER:b:CVP

*Q520-Which of the following diseases is least associated with increased risk of breast cancer?
Avarian cancer
B:endometrial cancer
Crostate cancer
D:melanoma
E:lung cancer
>>ANSWER:E:lung cancer
BRCA1,BRCA2 genes r associated with breast cancer,ovarian cancer,prostate cancer and melanoma.
The tumor suppressor gene P53 is associated with breast cancer,brain cancer,sarcoma,laryngeal cancer,vascular tumor,and adrenal cortex cancers.
Cowden disease is associated with colon cancer,thyroid cancer&breast cancer.
Endometrial cancer,ovarian cancer&other GI cancers r seen in HNPCC(Lynch syndromeII)
Currently there's no well-supported genetic association between lung cancer&breast cancer.

*Q521-A 47yo Caucasian man complains of weight gain.In the past mo he has noticed difficulty buttoning his pants.He works as an accountant for an automotive company that manufactures brake systems.His social history is significant for 20pack-yr of tobacco abuse.He doesn’t use alcohol.He’s married with 2 healthy children.His FH is notable for an uncle who died of liver disease and an aunt who had breast cancer at 48yo.On Ph.E he has shifting dullness.Paracentesis result:Total protein:2mg/dl,Albumin:2.3mg/dl,Cell count:230/mm3
Serum albumin:3.8mg/dl,WBC:8100
Which of the following Dx is least likely?
A:hepatitis C
B:Budd-Chiari syndrome
C:Veno-occlusive disease
D:Portal vein thrombosis
E:Peritoneal carcinomatosis
>>ANSWE:E:Peritoneal carcinomatosis
SAAG=1.5mg/dl(3.8-2.3),it's greater than 1.1 so correlates well with portal HTN as a cause of ascite in this case.Peritoneal carcinomatosis causes ascites exclusive of portal HTN and it's associated with a SAAG<1.1.other options r *** with increased portal HTN(Hepatitis C causes ascites secondary to cirhosis,wich increases portal pressure)

*Q522-A 27 yo woman presents with a right cervical LN which reveals well-differentiated,branching structures and blue-staining concretions.The most likely Dx?
>>ANSWERapillary adenocarcinoma(blue-staining concretions:PSOMMA BODIES)

*Q523-During a 6mo course of psychotherapy a psychotherapist and her pt gain insight about the implications ofearly memories the pt has of several unexpected separations from her parents and the resulting emotional turmoil.Which of the following disorders is most likely successfully treated with this intervention?
A:dysthymia
B:enuresis
Cbsessive-compulsive disorder
D:schizophrenia
E:social phobia
>>ANSWER:A:dysthymia
Psychodynamic psychotherapy

*Q524-A 24yo male was going down a ski slope and decided to suddenly change direction.He heard a sudden pop and felt pain in the left knee.There's a fluctuant swelling of the left knee.Whch of the following is most likely injured?
a:ant.cruciate ligament
bost.cruciate ligament
c:medial collateral ligament
d:lateral collateral ligament
>>ANSWER:a:ant.cruciate ligament

*Q525-A 19yo Caucasian teenager has a routine sports physical.He’s a runner on the track team at college.U/A shows 5 RBCs/HPF.The adolescent has no known trauma and has no history of previous hematuria.The most appropriate next step of Mx is:
A:IVP
B:cystoscopy
C:radiographic exam of kidneys,ureters,bladder
D:CT scan
Ebservation
>>ANSWER:C:radiographic exam of kidneys,ureters,bladder
case of microscopic hematuria(>3RBCs/HPF)
To rule out a significant stone or a GN,only radiographic exam of kidneys,ureters,bladder and measurment of serum Cr is necessary.If radiographic exam is positive,next step wil be IVP.if radiographic exam is negative,follow up is reasonable.




12.50 yr refered for evaluation of Type II Dm which was discovered during preop for carpal tunne. PMH: HTM ROS reveals nocturia, polyuria, heavy snoring, joint pain, weight gain, generalized weakness, new onset impotence. he also mentions shoe size has increased. on PE he has numerous skin tags, coarse facial features and fleshy hands...

NEXT STEP SHOULD BE TO
A- measure early am GH
B- perform insulin tolerance test, measure GH at 0, 30, 60 ,90 and 120m
C- meaure 24hr cortisol urine
D- measure IGF- 1
E- meausure IGF-1 after administration of dexamethasone at midnight.


Follow Ups:


D
acromegaly, the best screening test for which is measurement of serum insulin-like growth factor 1 (IGF-1), which provides an integrated measure of growth hormone levels over a several day period. The confirmatory test is an oral glucose suppression test, measuring growth hormone, which is less than 1 ng/mL in normal persons. Single measurements of serum growth hormone (such as a fasting or random level) are not helpful because it is secreted in a pulsatile manner with a short half-life and its concentration also varies diurnally. Insulin tolerance testing measurement of growth hormone is used to make the diagnosis of growth hormone deficiency, not growth hormone excess, and there is not an IGF-1 suppression test. This patient had a serum IGF-1 concentration of 1532 ng/mL, and an oral glucose-suppressed growth hormone which failed to suppress at 11 ng/mL. MRI of the head showed a 1.7-cm pituitary mass. He was referred for transsphenoidal surgery, which is the first line of therapy for acromegaly.

13.A 25-year-old man presents because of several months of episodic sweating, headaches, and palpitations. He is unsure whether these symptoms are associated with stress; but on detailed questioning, he appears to have no major life stresses. His medical history includes surgical repair of ankle injuries sustained in a fall while rollerblading 6 months ago; the anesthesiologist noted that the patient’s blood pressure fluctuated during the procedure and advised him to be evaluated for possible hypertension, but he had not done so.

On physical examination, he is 180 cm (71 in) tall and weighs 72 kg (158 lb); his pulse rate is 80/min, and his blood pressure is 135/80 mm Hg. He has no goiter, lid lag, or tremor. Plasma glucose and thyroid function tests are normal during an episode of palpitations.

Which of the following is the best next step in the evaluation of this patient?

(A) Measurement of serum insulin and insulin-like growth factor 1


(B) Return on 3 consecutive days for measurement of blood pressure in a sitting position


(C) Measurement of serum epinephrine and norepinephrine at 6 pm


(D) Measurement of catecholamines in a 24-hour urine sample


(E) Referral for stress management




D
Classic case of pheochromocytoma


14.healthy 52-year-old woman presents for her routine annual physical examination. She has been healthy and currently feels well. On PE, she is 162 cm (64 in) tall and weighs 60 kg (130 lb); her pulse rate is 80/min, and her blood pressure is 160/100 mm Hg. On 2 subsequent days, she has her blood pressure measured and the results are in the same range. Laboratory studies
Serum sodium 140 meq/L
Serum potassium 3.3 meq/L
Serum creatinine 0.8 mg/dL
Blood urea nitrogen 12 mg/dL
Plasma glucose 78 mg/dL
Serum calcium 8.5 mg/dL
Serum phosphorus 3.0 mg/dL

Dx?

A.Adrenal insufficiency
B.primary hyperaldosteronism
C.11 OH deficiency
D.Cushings disease
E.normal healthy patient




B-primary aldosteronism


15.A 41-year-old woman presents with proptosis, palpitations, amenorrhea, and a 9-kg (20-lb) weight loss. Her evaluation led to a diagnosis of Graves’ disease, with a radioactive iodine uptake of 89% at 24 hours that was diffusely distributed in her mildly enlarged gland.

Laboratory studies
Serum T4 18.8 µg/dL (normal 5 to 12 µg/dL)
Serum thyroid-stimulating hormone <0.01 µU/mL (normal 0.5 to 5.0 µU/mL)


She was started on a b-blocker and methimazole, 10 mg three times a day. After 6 weeks of treatment she is feeling considerably better.

Which of the following is the best test to use to follow her clinical course and to adjust her dosage of methimazole?
(A) Pulse rate


(B) Serum T4 level


(C) Serum TSH level


(D) Serum thyroid stimulating immunoglobulin


(E) Radioactive iodine (123I) radioactive uptake and scan





B
Although pulse rate is very sensitive to abnormal levels of thyroid hormone, it is not as reliable as other measures. The serum TSH level may remain suppressed for an extended period of time after it has been suppressed, especially in patients with Graves’ disease. TSH levels are therefore very helpful in confirming the diagnosis of the hyperthyroid state, but are not the best parameter to follow in patients undergoing treatment for thyrotoxicosis. TSI levels may rarely be helpful in the evaluation of patients with Graves’ disease but are not helpful in their ongoing management. Since TSI can cross the placenta and can cause neonatal thyrotoxicosis, it may be useful in the management of patients with thyrotoxicosis who are pregnant.

Similarly,123I uptake and scanning are helpful diagnostically but would not be very helpful for ongoing management. Serum T4 levels are the best parameter to follow; they are readily available and relatively inexpensive, and allow for careful monitoring of the effects of antithyroid drug therapy.



16.A 22-year-old woman presents with weight loss, hyperdefecation, amenorrhea, heat intolerance, and dry irritated eyes. Her medical history is unremarkable and she takes no medications.

On physical examination, she appears anxious; her pulse rate is 108/min, and her blood pressure is 144/60 mm Hg. Examination of the head, eyes, ears, nose, and throat reveals proptosis with lid lag and stare. Her thyroid gland is about three times normal size, is firm, and has a loud bruit.

Laboratory studies
Serum thyroid-stimulating hormone <0.01 µU/mL (normal 0.5 to 5.0 µU/mL)
Serum T4 16.8 µg/dL (normal 5 to 12 µg/dL)


What is the best study to establish the diagnosis in this patient?

(A) Measurement of serum antithyroid antibodies


(B) Measurement of serum thyroglobulin level


(C) Measurement of serum thyroid-stimulating immunoglobulin


(D) Radioactive iodine (123I) uptake and scan


(E) Needle aspiration and biopsy of the thyroid gland





D
Appropriate treatment of thyrotoxicosis requires a clear understanding of the mechanism underlying thyroid hormone excess. Exogenous sources of thyroid hormone and thyroiditis do not respond to antithyroid drugs, surgery, or radioiodine ablation.

This patient presents with classic Graves’ disease. She has clinical and chemical thyrotoxicosis. The presence of proptosis strongly suggests Graves’ disease, as do the goiter and bruit. Although some clinicians would argue that the scan and uptake are not necessary, they are the best way to confirm the diagnosis. The scan should rule out thyroiditis and exogenous T4 as the cause. The scan would confirm that antithyroid medications or thyroid destruction would be appropriate forms of therapy and also help estimate the dosage of radioactive iodine. Although antithyroid antibodies and thyroid-stimulating immunoglobulin may be present in patients with Graves’ disease, the results of these antibody tests would not alter therapy and if negative would not rule out Graves’ disease. A needle biopsy would only add confusion to the diagnostic process. Thyroglobulin levels would be high because the source of the excess thyroid hormone is endogenous. Thyroglobulin levels would be low if the T4 source were exogenous.


17.A 32-year-old woman presents with a 3.7-kg (8-lb) weight gain, dry skin, decreased energy, and 6 to 8 months of oligomenorrhea. She is gravida 2 para 2, and her youngest child is now 8 years old. A review of systems reveals some increasing constipation, mild frontal headaches that are relieved by aspirin, and some vaginal dryness.

On physical examination, she appears mildly lethargic; her pulse rate is 58/min, and her blood pressure is 168/78 mm Hg. There is no palpable thyroid enlargement. Her chest is clear and her cardiac examination is normal. Her deep tendon reflexes are “hung-up” at the ankle.

Laboratory studies
Serum thyroid-stimulating hormone 4.5 µU/mL (normal 0.5 to 5.0 µU/mL)
Serum follicle-stimulating hormone 5.5 mU/mL (normal 5 to 20 mU/mL, follicular or luteal phase)
Urine pregnancy test Negative


What is the best next step in the evaluation of this patient?


(A) Medroxyprogesterone challenge (10 mg/d for 5 days)


(B) Overnight dexamethasone suppression test (1 mg of dexamethasone at midnight, measure serum cortisol at 8 am)


(C) Radioactive iodine (123I) uptake and scan


(D) Thyrotropin-releasing hormone (TRH) stimulation test (1 vial of TRH at time 0 with TSH measured at 0, 30, and 60 min after administration of TRH)


(E) Measurement of serum free T4 and serum prolactin





E
When the history and physical examination suggest hypothyroidism, an elevated serum TSH level confirms the diagnosis of primary hypothyroidism and the next step is treatment with thyroid hormone. A “normal” or low TSH in the face of hypothyroid findings should lead to additional testing. A normal serum free T4 level or some other measure of circulating thyroid hormone levels (total T4 or T3) that is normal would suggest that thyroid function is indeed normal and that another cause for the patient’s findings should be sought.

A low level of one of the circulating forms of thyroid hormone in the face of a “normal” or low TSH suggests central or secondary hypothyroidism (or possibly tertiary hypothyroidism). Pituitary failure due to tumor infiltration or autoimmune disease can result in hypothyroidism, although thyroid failure is usually not the first sign or symptom of the process. Dysfunction of the reproductive axis in both males and females is often the first manifestation of pituitary gland failure. This patient has evidence of reproductive axis failure in addition to symptoms and findings of hypothyroidism. Since hypermenorrhea or menometorrhagia is the most common menstrual manifestation of hypothyroidism, this patient’s oligomenorrhea, along with her “normal” TSH, suggests a central lesion. A prolactin level will help identify a pituitary lesion. It is often elevated when a pituitary tumor is present. Prolactin concentration can also be elevated in primary hypothyroidism. If a thyroid hormone level confirmed the presence of thyroid hypofunction, a CT or MRI scan of the pituitary would be the next step. In addition when pituitary failure is suspected, evaluation of the adrenocortical axis should be undertaken promptly and prior to thyroid hormone replacement.

A progestogen challenge would assess uterine function and estrogen production but would not lead to a unifying diagnosis. Cushing’s syndrome seems unlikely.123I imaging would not provide helpful information. TRH testing might show decreased TSH responsiveness but would not lead to a more specific diagnosis.



18.wht is th e drug of choice for neurocardiogenic sycope
A)BENZODIAZEPINE
B) BETA BLOCKERS
C)SSRI,S
D)NITRO
E)CA CH BLOCK



B


19.A 50 yr old female c.0 seeing rooom spinwhen ever she looks to th e left.it last for sev minutes and then goes away on its own...no other s/s what u thing she has?
A)MINIERES DISEASE
B)ACOUSTIC NEUROMA
C)ACUTE LABYRINTHITIS
D)BENIGN POSITIONAL VERTOGO
E)VESTIBULAR NEURITIS

q,3...WHICH ON EOF TH E FOLOOWING IS NOT A RISK FACTOR FOR CORONARY ARTERY DISEASE...
A)OBESITY
B)HYPETRIGLYCERIDIMA
C)HTN
D)SMOKING
E)DIABETES MILLITIS

q4.. PT WITH H/O BCG VAC SHOULD HAVE THEIR TB SCREENING ALTERD IN TH E FOLLOWING WAY...

.
A)THEY SHOULD NEVER HAVE A PPD,THEY SHOULD HAVE SREENING CXR INSTEAD WHEN THEY SYMPTOMATIC
B)TH E CUT OFFF FOR POSITIVE PPD ISGREATER THAN 15 MM IN PT WITH PRIOR BCG
C)TH EBCG HISTORY SHOULD B IGNOREDUNLESS IT WAS GIVEN WITH IN I YR OF SCREENING PPD
D)IF BCG FOR GIVEN MORE THAN 10 YRS PEOR THEY CAN B SCREEN AS NORMAL
E) IF BCZ WAS GIVEN 15 YR PRIOR U CAN SCREEN THE PT WITH CERTAIN CERTAINITY WITH PPD



D A C


20.THE entire house hold has ppds placed.the pts(recent converter) daughter age 18 who is asymptomatic has also positive ppd 14 mm..what intervention does she need if she is living with a recent converter


A)SPUTUM INDUCTION A ND 4 DRUG THERAPY UNTIL CULTURE IS NEGATIVE
B)CXR AND INH FOR 6-9 MONTHS
C)AN HIV TEST AND 12 MONTH OF INH
D)CXR AND REPEAT PPD IN 6 MONTHS
E) NO INTERVENTION SINCE SHE IS ASYMPTOMATIC

Q6...
WHICH OF TH E FOLLOWING PTS TAKING INH DONT REQ BASELINE AND MONTHLY LIVER FUNCTION TESTING....

A)PREG PT
B)HIV INFECTED PT
C)PT OVER 35
D)POSTPARTUM WOMEN OF COLOR
E)PT WHO R UNDER 35

Q7..WHICH OF THE FOLLOWING DOESNT NOT INDICATE AN EARLY CARDIOVERSION...

A)40 YR OLD FEMALE WITH IST EPISODE OF A FIB TOTAL OF 24 H DURATION SH EHAS NO SIGF PAST MED HISTORY
B)A 65YR OLD MALE WITH PAST MED H/O CAD CAME TO ER WITH ANGINA AND NEW ONSET OF A/ FIB AS CPMARE TO OLD EKG SHOWING ALL NSR
C)A 70 YR OLD MALE IN A FIB WITH RAPID VENT RESPONSE WITH RATE OF 140 AND HE IS DIZZTAND WK AND POOR PERIPHRAL PULSES ON EXAM
D)A 77 Y OLD F WITH 2 WK H/O A FIB ON COUMADIN FOR I WK WITHOUT EVIDENCE OF ATRAIL THROMBUS ON TEE WHO IS RATE CONTROL WITH METOPROLOL

Q8...ALL OF TH E FOLLOWING R S/S OF NICTIN WITHDRAW; EXCEPT...
A)WT LOSS
B)BRADYCARDIA
C)IMPAIRED CONCENT
D)DEPRESSION

B , C , D , A


20.A 2-year-old girl is brought to the emergency department because she looked "unwell" and has not wanted to get out of bed for 24 hours. She had a diarrheal illness 1 week ago marked by fever and bloody diarrhea, from which she had recovered. However, 2 days ago she developed reduced appetite as well as lethargy. She has had only two wet diapers in the last 36 hours. She was previously a well child and at the regular clinic visits normal growth and development were noted. Examination shows an irritable, pale child with petechiae and edema. Vital signs are: pulse 136/min, respirations 26/min, and blood pressure 102/74 mm Hg. Lung and abdominal examinations are normal. Laboratory studies show:

Which of the following is the appropriate next step in management?

A. Administer methylprednisolone

B. Administer a normal saline bolus of 20 mL/kg

C. Begin peritoneal dialysis

D. Begin plasmapheresis

E. Transfuse red blood cells



Explanation:
The correct answer is C. This patient has presented in acute renal failure, which is manifested by oliguria, elevated blood urea nitrogen and creatinine, and hyperkalemia. Given the clinical picture, the most likely etiology is hemolytic uremic syndrome (HUS). HUS is the most common cause of acute renal failure in young children and most frequently follows an episode of gastroenteritis caused by enterohemorrhagic strain of E. coli (0157:H7). Endothelial injury to the kidneys leads to renal failure, whereas damage to red cells and platelets in the kidneys leads to the thrombocytopenia and microangiopathic hemolytic anemia. The management is supportive care of the renal failure, which is self-limited in most cases. Given the marked elevation of creatinine as well as hyperkalemia in this patient, the most appropriate choice would be to initiate peritoneal dialysis.
Steroids such as methylprednisolone (choice A) are used for renal diseases such as lupus nephritis and nephrotic syndrome. They have no role in the treatment of HUS.
Children who present with oliguria may benefit from a normal saline bolus (choice B) if the intravascular volume is depleted. However, the patient in this vignette demonstrates signs of fluid overload, and a bolus of intravenous fluids is inappropriate in this setting.
Plasmapheresis (choice D) is useful in adult patients who have thrombotic thrombocytopenic purpura, but not in children with HUS.
Due to the presence of fluid overload and hyperkalemia, red blood cell transfusion (choice E) is not safe in this patient until peritoneal dialysis has been instituted.



Follow Ups:


21.A 50-year-old man comes to the clinic with a year long history of having difficulty holding and using a writing instrument. He reports that he develops right hand and forearm spasms when writing, so that he cannot "bend his wrist the right way". He has been healthy all his life and is on no medications. He denies any dizziness or loss of consciousness or any history suggestive of a seizure. He uses a computer approximately 3 hours a day at work. Which of the following is the most likely diagnosis?

A. Benign essential tremor

B. Carpal tunnel syndrome

C. Cervical radiculopathy

D. Focal dystonia

E. Parkinson Disease



FOCAL DYSTONIA is the ans

Explanation:
The correct answer is D. Such a writing cramp would be an example of focal dystonia of unknown cause. In this condition, the patient develops cramps with altered hand and arm posture when attempting a specific task such as writing. The other conditions may cause problems with writing as well but are usually not seen in isolation.
Benign essential tremor (choice A) features a distal upper extremity tremor during a task.
Carpal tunnel syndrome (choice B) is caused by median nerve compression and leads to hand weakness, which may affect writing.
Cervical radiculopathy (choice C) can lead to hand numbness and hyporeflexia.
Parkinson disease (choice E) presents with micrographia, bradykinesia, and often, a slow, "pill-rolling" tremor.



1.19 yr old woman had beeen wheel chair bound since age 12 with kyphoscoliosis cerebellar signs and pigmentary retinopathy.diagnosis?

fredirichs ataxia
at 10 yrs have ataxia a nd dev lower limb weakness with skeletal problems


Follow Ups:


2.diabetic 65yr old pt dev rt facial palsy with c/l hemiplegia. o/e there is rt abduction defect.lesion and syn?


millard gubler syn
pons lrsion here rt side


Follow Ups:


3.60 yr old man with htn dev sudden onset 3rd nerve palsy and left hemiplegia?lesion and diagnosis
weber syn
midbrain lesin .here its on rt side


4.50 yr old with htn dev sudden onset of slurring of speech , vommitting and rt horners syndrome.he had a problem standing staight.o/e horizontal jerky nystagmus.where is the lesion? and diagnosis?


lat medullary syn namely wallenburg syn
lesion at inf cerebellar peduncle


5.32 yr old female dev pain in right eye and propptosis. o/e normal vision ,decreased movement and loss of pain sensation to touch and pain.left eye is normal.where is the lesion?


at sup oblique fissure.
there is no proptosis in cavernous sinus lesion except in fistula and its usually bilateral

6.pt has occulomotor palsy and left involuntary trmor.where is the lesion?
red nucleus
i know answer but dont know explanation



7.young asian women with problems in both hands and complains of blurred vision on exercise.diagnosis?


takayasu arteritis
giant cell artetitis of aortic arce
hand problems like raynayds phen
blurred visio id due to steal phenomenon similar ti sc steal syn where there is loss of conciousness on exercise


Follow Ups:


8.young pt with bilateral cataracts and epilepsy.what is the next step in management?

do serum calcium tests
both hypoparathyroidism and pseudohypoparathyroidism present similarly
do serum parathyriond lev to diff them


9.pain in ear and cannot shut eye on same side. diagnosis?


Follow Ups:


ramsay hunt syn due to herpes zoster

10.how do u diff bet marfan syn and homocystinuria based on eyefindings?


lens up and out in marfan
lens down in homo
to diff bet alport and nf based on eye is
coast of maine pigmentary change in alport
coast of california pigmentary change in ny
both have cafeulait spots and neurofibromas



its mccune albright not alports
albright with fibrous dysplasia cafe lait spots and precocious puberty
alport with heriditary nrphritis deafness and ocular problems


11.The most common causes of monoarthritis are crystals (i.e., gout and pseudogout), trauma, and infection. Gonococcal arthritis is the most common type of nontraumatic acute monoarthritis in young, sexually active persons in the United States. At first the patient came in with ankle swelling for the first time. It is red and inflamed. No h/o of trauma. If there was one, X-*** would be the first step. It is monoarticular. No fever (which would have clearly indicated the possibility of septic arthritis). There is evidence of effusion. That alone will prompt us to tap the joint first. Gram Stain and Direct microscopic examination will reveal if septic, or reactive, or non-articular. It will also releive some of the pain. In case of inflammatory fluid, polarized microscopy would confirm the diagnosis of crystal-related arthritis. Culture would confirm the diagnosis of septic arthritis.

The second time around, the pain and effusion are on the left. Hopefully by then we would have diagnosed it before. Sequential monoarthritis in several joints is characteristic of gonococcal arthritis or rheumatic fever. What is the first step? Same. Tap it and examine/culture it. It is mandatory if infection is suspected. Superimposed cellulitis is a relative contraindication to arthrocentesis. The procedure can be performed safely in patients who are taking warfarin (Coumadin). If joint fluid is inflammatory, then NSAID's. If it is infectious, then antibiotics prior to culture results.

If Gout has been diagnosed and is recurrent, then patient should be put on prophylaxis as well as alkalinization of urine. PRobenecid or Allopurinol? Probenecid inhibits secretion and reabsorption of Uric acid. However it has high likelihood of stone formation, therefore alkalinization of urine is important. It is contraiondicated if renal impairement or in association with aspirin. Allopurinol blocks xanthine oxidase therefore inhibiting formation of uric acid. It is preferred for severe hyperuricemia (as probenecid will make stones in kidneys), poor renal function, and in drug-induced hyperuricemia. The patient should be advised to present to consultation as soon as having an arthritis and treat the arthritis with NSAID's as both probenecid and allopurinol are not indicated for acute attacks.


Follow Ups:



12.Alcohol Withdrawal Syndrome

Sx include anxiety, tremulousness, easy startability, diaphoresis, tachycardia, elevated BP, mydriasis, and hyperreflexia. Occasionally, there are brief, transient visual or auditory hallucinations. The tremor, when mild, is fine and may only be appreciated when the pt's hands are held out with the fingers parted; in severe cases, the tremor is coarse and obvious, at times involving not only the hands but also the tongue and eyelids. Although pts remain oriented, thinking becomes difficult and concentration poor. Insomnia may be severe.

Ddx: An almost identical syndrome may be seen after abrupt discontinuation of benzodiazepines or barbiturates.
Hypoglycemia is suggested by relief with food. Importantly, glucose preparations should not be given to alcoholics until after parenteral administration of thiamine, as a glucose load may precipitate Wernicke's encephalopathy.

Thyroid storm is suggested by proptosis and thyromegaly.

Rx: Moderate or severe sx may be treated with a benzodiazepine (e.g., lorazepam (Ativan)) or with carbamazepine (Tegretol).

Source:Same

13.Alcoholism

Epidem: Lifetime prevalence in USA ~10%; male-female ratio 3:1.

Sx: Onset gradual in late teens or 20s, later in females than males; onset >45 yr is unusual.

Lab: Lab abnormalities reflect complications, noted below. The combination of an elevated SGGT and MCV (reflecting, respectively, hepatic and bone marrow toxicity) is highly suggestive of alcoholism.

Etiol: Twin and adoption studies indicate a strong genetic component

Ddx: Alcohol abuse distinguished by the absence of both tolerance and withdrawal.

Rx: Abstinence is the goal, and this must be clearly stated

Hospitalization is often required, not only to treat complications but also to secure an enforced period of abstinence

Give thiamine 100 mg im × 3 d then po thereafter (do not give glucose or food generally until 3 h after thiamine given, as this may precipitate Wernicke's encephalopathy); multivitamin 1 qd; assess for any complications (esp hypomagnesemia).

Measure CBC, electrolytes, liver enzymes, bilirubin, glucose, magnesium, ammonia, and if abdominal pain present, lipase and amylase.

Counsel pts to avoid all old "playgrounds" (e.g., bars, nightclubs) and "playmates" (e.g., drinking buddies).

AA should be recommended, and attendance at "outside" hospital meetings should begin during the inpatient stay. Pts should be encouraged to attend "90 meetings in 90 days," with the first of the 90 meetings being on the day of discharge.

Three medications may be helpful: disulfiram (Antabuse), naltrexone (ReVia), and acamprosate.
Source: The Little Black Book of Psychiatry
David P. Moore, MD



Follow Ups:


14.SCREENING RECOMMENDATIONS- NOTES
[ Follow Ups ] [ Post Followup ] [ Forum 2 ]

--------------------------------------------------------------------------------

Posted by ACE from IP 65.81.151.254 on August 08, 2003 at 08:20:33:

Prostate Cancer:

RF: AGE, AA, FMHX PCa.
The American Cancer Society recommends annual screening after age 50 years for men with a life expectancy of at least 10 years. The American Urological Association likewise recommends screening begin at age 50 years with DRE and PSA, and at 40 years for men with a family history of prostate cancer and for American blacks.

Cervical Ca.
RF: multiple partners, STDs, HPV ( 16, 18 ) previous abnormal PAP smear, early age first coitus, smoking, low socioecon.
The ACP–ASIM and the US Preventive Services Task Force recommend that sexually active women between 20 and 65 years of age be screened every 3 years. Women at increased risk (including those with previous abnormal smears, multiple sexual partners, or early onset of intercourse; those who have HIV infection; black American women and women of low socioeconomic status; and those who smoke) are appropriate candidates for more frequent screening. The American Cancer Society recommends onset of screening at age 18 years, with consideration to less frequent screening in low-risk women after three consecutive normal annual examinations. Older women who have not had screening in several years should also be specifically targeted in screening efforts.

Breast Ca.
RF: Family Hx, menarche before 12, late menopaise, late first pregnancy, previous lobular ca insitu, previous Ca of UTERUS< OVARY AND SALIVARY GLANDS.
Screening tests for breast cancer include breast self-examination, clinical breast examination, and mammography. Self-examination, though widely recommended, has an uncertain sensitivity and specificity.The US Preventive Services Task Force and a majority opinion expressed in an NIH consensus conference offered firm recommendations for screening every 1 to 2 years in women aged 50 to 69 years, but found insufficient evidence to recommend for or against routine screening in women aged 40 to 49 years.

COLORECTAL CA.
Persons aged 50 years or older are recommended to undergo annual fecal occult blood testing and/or flexible sigmoidoscopy every 5 years, double-contrast barium enema every 5 to 10 years, and colonoscopy every 10 years, as long as the results of the tests are negative If the positive test is fecal occult blood, follow up with double-contrast barium enema plus flexible sigmoidoscopy is adequate. Colonoscopy is required to evaluate any abnormality detected by double-contrast barium enema or flexible sigmoidoscopy. In patients with a more equivocal history (colorectal cancer in one or two first-degree relatives or adenomatous polyps in first-degree relatives before age 60 years), the screening tests performed in normal-risk individuals are used, but surveillance begins at age 40 rather than age 50 years


CAD
The ACP–ASIM and the US Preventive Services Task Force agree that screening should begin in middle age: 35 to 65 years for men; 45 to 65 years for women. Screening in men younger than 35 years or women younger than 45 years is not recommended unless the patient has a family history of premature cardiac disease in a first-degree relative, physical examination suggests a familial lipoprotein disorder, or the patient has major risk factors for coronary disease

THYROID
The ACP–ASIM in 1998 stated that it was reasonable to screen women older than 50 years for unsuspected thyroid disease with the sensitive TSH assay (ACP–ASIM); abnormal results should be followed by a measurement of serum free thyroxine

IMMUNIZATIONS
TETANUS_DIPHERIA
The Advisory Committee on Immunization Practices of the ACP–ASIM now recommends vaccination status assessment for all adults reaching age 50 years

INFLUENZA/PNEUMOCOCCAL
ACIP) has recommended lowering the age for routine influenza vaccination to 50 years. Patients who receive pneumococcal vaccine before age 65 years should receive a second dose after 5 years have elapsed. This recommendation for one-time revaccination also applies to highest-risk adults of all ages. Patients at high risk for pneumococcal disease include those with chronic disorders of the cardiovascular or pulmonary system, metabolic diseases, alcoholism, cirrhosis, immunosuppression, functional or anatomic asplenia (such as sickle cell disease or splenectomy), lymphoma, or multiple myeloma

VARICELLA
The live-attenuated varicella vaccine appears to be safe and effective in preventing disease, which tends to be more severe in adults than children. Women of child-bearing age should not become pregnant for 3 months after receiving the vaccine.


Follow Ups:


15.Of the following, for whom is the influenza vaccination least advised?
a. a dental hygienist
b. an adult on long term aspiring therapy
c. mom with 12yr who has cystic fibrosis
d. pregnant womand with steroid dependant asthma.
e. 24 yr with AIDS.

2. All of the statements are true regarding influenza vaccination EXCEPT:
a. it can be given at the same time as the pneumococcal vaccination
b. its 60-70% effective
c. causes an influenza like illness
d. contraindicated in the presccence of allergy to eggs
e. should be postponed in the setting of febrile illness




1.b ( should be in < 18 yrs old on long term aspirin not adults )
2.c ( contrary to popular belief, influeza does not give you an influenze like illness. the vaccine may give you local skin reaction, fever, myalgia and malaise side effects that the patient mistake for the influenza symptoms but is NOT influenza bc the vaccine is made of inactivated virus. ) source; cleveland clinic


16.healthy 45-year-old woman is planning to travel to rural Mexico in 2 weeks and seeks your advice regarding prophylaxis against viral hepatitis. She denies any prior history of liver disease or use of illicit drugs and has a monogamous heterosexual relationship. She is asymptomatic, and her physical examination is normal. antibody to hepatitis A virus (anti-HAV) (both IgG and IgM) is negative.
Which of the following options is the most appropriate?

1.Measure hepatitis B surface antigen (HBsAg) and antibody to hepatitis B core antigen (anti-HBc).
2.Administer immune serum globulin
3.Administer immune serum globulin (ISG) and hepatitis B immune globulin (HBIG)
4.Administer hepatitis A vaccine
5.Administer hepatitis A and B vaccines



2.
She will travel to an edemic area high for hep A so prophylaxis is recomm. Currently, there are two choices for prophylaxis against hepatitis A: ISG and hepatitis A vaccine. Rapid, passive transfer of immunity to hepatitis A is achieved with intramuscular injection of ISG. Although 0.02 mL/kg is the standard dose, current preparations of ISG may have low titers of antibody to hepatitis A virus (anti-HAV) and larger doses (0.06 mL/kg) may be required to confer immunity. Vaccination actively stimulates antibody production in more than 95% of patients, but development of antibody is delayed and may not be protective against HAV infection within the first month after vaccination. And since she is traveling in 2 weeks you want something that will work FAST !!!!


Follow Ups:


17.55 yr Hispanic female who became menopausal 3 yrs ago presents to your office for routine PE. She is on CEE ( conjugated equine estrogen ) and medroxyprogesterone ( Prempro), and denies any vasomotor symptoms, sleep disturbances or change in libido. she reports some " vaginal spotting" twice over last 3 months. you would recommend which of the following?
a.bleeding calendar to mark her days of bleeding
b.hysterectomy
c.inc progesten portion to Prempro oral QD.
d.endometrial biopsy

36 yr obese smoker presents to you for contraceptive counseling. she is married with 2 children and has no Hx of STDs, PID or deep venous thrombosis. she has normal periods with no heavy bleeding or clots. you recommend which of the following?
a.IUD
b. second generation birth control pills
c. Depo Provera
d. Estratest


D A
Depo would cause weight gain in this already obese patient. bc she is a smoker and > 35 this pt risk for thromoboembolic disease if she is placed on birth control pills. Best choice in this married monogamous F with norisk factors for PID is IUD


18pregnant woman is HIV + on routine screening. which is TRUE?
a. confirmatory western blot test may be falsely + in preg.
b. perinatal transmission app. 90%
c. perinatal antiviral trt will DEC transmission to less than 7%
d. PCP prophylaxis should be started
e. termination of the pregnancy will offer some protection against progression of the disease.

2.pt with kown HIV becomes pregnant. you:
a.insist on amniocentesis
b.stop meds until 14wks when organogenesis is complete
c. encourage breastfeeding
d.defer evaluation of abnormal papsmear.
e.inc surveillance for stds.


c and E


19.pregnancy asthmatic comes to the ER in severe resp. distress. she stopped all meds bc of concern for the fetus. apprpiate therapy might eventually include all EXCEPT:
a. subcu epinephrine
b. inhaled metaproterenol
c. O2 by mask
d. inhaled albuterol
e. IV steroids

32 yr in 8th month of pregnancy present with intense itching but no rash and mild jaundice. the aspartate transaminase is 85 and t. bili is 4. the CBC is normal as is the PT and PTT. which do you suspect?
a. acute viral hepatitis
b. intrahepatic cholestasis of pregn.
c. HELLP syndrome
d. acute fatty liver of pregancy
e. choledocholelithiasis


A andB

20.A 25-year-old primipara presents at 27 weeks of gestation with new onset of mild intermittent pruritus. Physical examination is negative for jaundice or features of underlying chronic liver disease; uterine size is 30 weeks’ gestation.

Results of laboratory studies are as follows: international normalized ratio (INR), 0.9; albumin, 3.3 g/dL; bilirubin, 1.0 mg/dL; alkaline phosphatase, 267 U/L; aspartate aminotransferase (AST), 26 U/L; alanine aminotransferase (ALT), 27 U/L; and gamma-glutamyltransferase (GGT), 47 U/L. Ultrasonography of the liver and biliary tree is normal.

Appropriate initial management of this patient’s pruritus would be:

1.Reassurance with frequent outpatient monitoring of symptoms, liver tests, and fetal activity
2.Cholestyramine
3.Diphenhydramine hydrochloride (Benadryl)
4.Phenobarbital
5.Induction of labor



1
This patient presents in the early third trimester of pregnancy with mild and intermittent pruritus but without any other features of liver disease. The mild nature of her symptoms suggests that only outpatient monitoring is warranted; other specific intervention is not currently indicated. In the absence of liver disease, this condition has been commonly referred to as pruritus gravidarum. It is benign, usually self-limited


Follow Ups:


21.24-year-old woman (G3P2A0) presents at 32 weeks of gestation with nausea, anorexia, mild abdominal discomfort, and jaundice after a trip to Central America. PE reveals jaundice, no stigmata of chronic liver disease or encephalopathy, and a uterine size of 32 wks gestation.

Laboratory studies reveal the following: international normalized ratio (INR), 1.12; blood glucose, 105 mg/dL; creatinine, 1.0 mg/dL; albumin, 3.2 g/dL; bilirubin, 3.6 mg/dL; alkaline phosphatase, 322 U/L; aspartate aminotransferase (AST), 628 U/L; and alanine aminotransferase (ALT), 954 U/L. Which test is likely to be diagnostic?


1.Serologic tests for hepatitis E
2.Antibody to hepatitis B surface antigen (Anti-HBsAg)
3.IgG antibody to hepatitis A virus (IgG anti-HAV)
4.Computed tomography of the abdomen and liver
5.Fetal monitoring





1

22.A 32 yo woman presents with concerns regarding hair growth.Within the past 6mo she has noticed increased hair on her chin and abdomen that’s darker in color.On Ph.E she’s normotensive,has a normal body habitus and has dark,coarse hair on her chin& abdomen.
What’s the most appropriate next step?
A:LH&FSH levels
B:bimanual exam of the pelvis
CHEAS
D:urine free cortisol
E:testosterone



B-bimanual exam of the pelvis,

in this pt. it seems a goood choice to do a pelvic exam first, to note some findings, like possible clitoromegaly or not,presence/absence of vagina, palpate the ovaries to see if enlarged, etc..it is very informative , and easy to do and could be part of the PE,

then can run some tests, to find out the potential cause of the hirsutism... i would order DHEAS and then or at the same time testotserone,..

if DHEAS is increased --> hirsutism is due to adrenal hyperplasia or neoplasm, mo