set 9 (Nasi)

[cyrus1345]

1

A 15-year-old boy with Duchenne muscular dystrophy is brought to the emergency department with increasing respiratory distress and cyanosis. On examination, he is diaphoretic, with gasping respirations, poor air entry, and diminished responsiveness. He is tachycardic at 160 beats/min. His chest x-*** film shows a lingular pneumonia, and he is intubated. He improves over the next 10 days with antibiotics but is not extubated secondary to hypoventilation on weaning because of muscle weakness. Which of the following modalities will most likely help wean him off the ventilator?
A. Nasopharyngeal tube
B. Pressure controlled ventilation
C. Pressure supported ventilation
D. Supplemental oxygen
E. Tracheostomy
Explanation:
The correct answer is E. This patient has irreversible muscle weakness, and his tidal volume is diminished, causing impaired alveolar ventilation. The tracheostomy will reduce the dead space and airway resistance. It may allow deep suctioning, helping effect ultimate weaning off the ventilator.
The nasopharyngeal tube (choice A) would help only if there were an obstruction between the nose and the posterior nasopharynx.
Pressure controlled ventilation is a ventilator mode (choice B) and not an aid to spontaneous ventilation.
Pressure supported ventilation (choice C) can improve spontaneous breathing, but the patient would need to remain intubated.
Supplemental oxygen will improve oxygenation, but not ventilation (choice D).

2

A 4196 g (9 lb 4 oz) infant is delivered via vaginal delivery to a 31-year-old mother with gestational diabetes. The delivery was complicated by shoulder dystocia. He is taken to the newborn nursery where his initial plasma glucose level is 20 mg/dL. The initial spun hematocrit is 65%. Which of the following congenital anomalies is this baby most likely to have?
A. Aniridia
B. Cleft palate
C. Macroglossia
D. Omphalocele
E. Single palmar crease
F. Small left colon
Explanation:
The correct answer is F. This is a classic presentation of an infant of a diabetic mother. Exposure to hyperglycemia in utero causes hyperinsulinism in the fetus, which leads to macrosomia, since insulin is a growth factor. Hyperinsulinism continues after birth, causing mild to severe hypoglycemia. Other common features include polycythemia, hypocalcemia, jaundice, and respiratory distress syndrome. Several congenital anomalies are associated with infants of diabetic mothers, including small left colon, which can cause meconium plugging, CNS and cardiac anomalies, sacral agenesis and renal vein thrombosis.
Aniridia (choice A) actually refers to a hypoplastic iris, although the name suggests an absence of the iris. It occurs either through dominant inheritance or sporadically. Patients with aniridia may develop Wilms tumor, glaucoma, nystagmus and other vision problems. There is also an abnormality of chromosome 11 that causes aniridia, genital anomalies and mental retardation. There is no association with maternal diabetes.
Cleft palate (choice B) is a common facial anomaly that occurs sporadically or in association with a genetic syndrome (i.e. Pierre Robin Syndrome) or due to maternal drug exposure. It is more common in Asians and least common in blacks. Cleft palate results from the failure of the palatal shelves to fuse during fetal development. It is not usually associated with infants of diabetic mothers.
Macroglossia (choice C) is a key feature of Beckwith-Wiedemann Syndrome, an overgrowth syndrome involving a large-sized patient, liver and kidney enlargement, hyperinsulinism, omphalocele and macroglossia. People with Down Syndrome also have a relative macroglossia, due to a small mandible and maxilla.
Omphalocele (choice D) is a herniation or protrusion of abdominal contents into the base of the umbilical cord. The abdominal contents are covered only with peritoneum and no overlying skin. It occurs sporadically in about 1 in 5000 births, or as part of the Beckwith Wiedemann Syndrome. Immediate surgical correction before the abdominal contents dry out is the treatment of choice.
A single palmar crease (choice E) is a common feature of Trisomy 21 (Down Syndrome) but also can be seen as an isolated finding in many healthy people who have a normal karyotype. This is not a feature caused by maternal diabetes.

3

A fetus is delivered at 40 weeks' gestation. During labor, the fetal heart monitor shows late decelerations and loss of short- and long-term variability. The membranes are ruptured to expedite the delivery. The fluid is noted to contain meconium. The infant is delivered 45 minutes later. At delivery, the infant appears to be cyanotic and limp. He has poor tone and deep reflexes. Moro's reflex is absent. Ten hours later, he experiences a seizure. Which of the following best explains this infant's perinatal course?
A. Encephalopathy from asphyxia
B. Inborn error of metabolism
C. Respiratory distress
D. Subarachnoid hemorrhage
E. Werdnig-Hoffman disease
Explanation:
The correct answer is A. Perinatal asphyxia would explain the fetal heart tracings. The poor tone and respiratory effort indicate the same. Seizures would be expected several hours after moderate hypoxia.
Inborn errors of metabolism (choice B) should not complicate the pregnancy.
Respiratory distress (choice C) after a term pregnancy is unlikely given adequate surfactant.
Subarachnoid hemorrhage (choice D) is associated with no symptoms or with irritability that resolves over days.
Infants with Werdnig-Hoffman syndrome (choice E) have hypotonia but no encephalopathy.

4

A 37-year-old woman with HIV, last CD4 count 390/mm3 and last viral RNA copy number 120,000 copies/mL, presents to the medical walk-in clinic with cough, fever and shortness of breath. The patient has been well and has been compliant with her triple drug therapy. She reports that 3 weeks ago, she began to experience increasing shortness of breath and developed a non-productive cough. Over the past few weeks, both of these complaints have gradually worsened. She also reports fevers to 103 degrees F over the past few days. On examination, her blood pressure is 130/70 mm Hg, pulse is 90/min, and oxygen saturation on room air is 71%. Her lungs have diffuse crackles, no egophony and no dullness to percussion. The rest of her examination is unremarkable. A chest radiograph shows diffuse interstitial and alveolar infiltrates with hilar predominance bilaterally. Which of the following is the most appropriate course of therapy for this patient?
A. oral isoniazid, rifampin, pyrazinamide and ethambutol
B. intravenous trimethoprim-sulfamethoxazole
C. intravenous azithromycin
D. intravenous trimethoprim-sulfamethoxazole and prednisone
E. intravenous amphotericin B
Explanation:
The correct answer is D. This is an HIV patient with signs of a pulmonary infection and a chest radiograph suggesting a pulmonary process. The concept underlying this question is two-fold. First, HIV patients suffer from atypical infections and second, one of the more common organisms, Pneumocystis carinii can present with ANY RADIOGRAPHIC finding. Once these concepts are understood, the course of action is immediately clear, begin the appropriate intravenous therapy. Given that this patient has a room air oxygen saturation of less than 75%, steroids are indicated. Steroids are only given if the question of adrenal insufficiency, a common complication of HIV, is suspected.
Oral INH, rifampin, pyrazinamide, ethambutol (choice A) would be appropriate for the treatment of tuberculosis. We have yet to see any data that this patient also has TB. We would need to see sputum positive for AFB staining or a positive AFB PCR on sputum.
Intravenous trimethoprim-sulfamethoxazole (choice B) is not the indicated therapy for PCP pneumonia when oxygen saturation is less than 75% on room air.
Intravenous azithromycin (choice C) is the incorrect antibiotic. In an otherwise healthy 37-year-old, the likely diagnosis would be atypical community-acquired pneumonia, for which azithromycin might be useful. In an HIV patient however, this is incorrect.
Intravenous amphotericin B (choice E) is not appropriate since we have no suspicion of a fungal infection in this patient.



36.match the clinical description with the most likely organism:

a- Strep. Pneumoniae
b- Staph. Aureus
c- Strep. Viridans
d- Providentia stuartii
e- Actinomyces israelii
f- Hemophilus ducreyi
g- Neisseria meningitides
h- Listeria monocytogene

1- 30 y/o female with MVP, MR develops fever, anorexia & weight loss after a dental procedure

2- 80 y/o male hospitalized for hip Fx, has foley cath. in place, develops shaking chills, fever & hypotension.

3- young man develops painless, fluctuant, purplish lesion over mandible, after several weeks cutaneous fistula is noted.

4- sickle cell patient presents with high fever, toxicity signs of pneumonia & stiff neck.



1- c, 2- d, 3- e, 4-a
About the q2, I chose b also, but based on my ref. it's d and here is the explanation;
This patient has developed a nasocomial infection, secondary to urosepsis, providencia species frequently cause UTI in the hospital.


Follow Ups:


37.65 y/o male with Hx of DM & cardiomyopathy, presents with severe knee pain. On P/E, knee is swollen, red & tender. Knee X-*** shows linear clcification.
*** Dx is best made by:
A- Serum uric acid
B- Serum calcium
C- Arthrocentesis & identification of birefringent rhomboid crystals
D- Rheumatoid factor

*** Further workup inthis patient should include evaluation for:
A- Renal dis.
B- Hemochromatosis
C- PUD
D- Lyme dis.

Answers are C & B. Acute monoarticular arthritis in association with linear calcification in the cartilage of knee makes the Dx of pseudogout which is positive for birefringent crystals in joint fluid. Pseudogout maybe associated with hemochromatosis.


Follow Ups:


38.65 y/o woman with a 12 Hx of symmetric polyarthritis, presents with splenomegaly, ulcers on lat. Malleoli, synovitis of wrists, shoulders and knees, and no hepatomegaly.
Lab results : WBC=2500, RF= 1:4096, this patients WBC diff is most likely to show what ?
A- pancytopenia
B- lymphopenia
C- granulocytopenia
D- lymphocytosis
E- basophilia



Answer is C. case of felty’s syn. ( RA+ splenomegaly+ leukopenia ), the mech. Of granulocytopenia is poorly understood.


Follow Ups:


39. patient with low grade fever & weight loss has poor excursion on the Rt. side of chest with decreased fremitus, flatness to percussion and decreased breath sounds. Trachea is deviated to the Lt. What’s the most likely Dx?
A- Pneumothorax
B- Pleural effusion secondary to histoplasmosis
C- Consolidated pneumonia
D- Atelectasis



Answer is B. Physical findings all consistent with pleural effusion, which in large amount can shift trachea to the Lt. in pneumothorax hyperresonance of the affected side is present. Atelectasis on the Rt would shift trachea to the Rt.


Follow Ups:


40.A patient have an unexpected high value for diffusing capacity, this finding is most consistent with which of the ffg?
A- Anemia
B- Cystic fibrosis
C- Emphysema
D- Intrapulmonary hemorrhage



Answer is D. Decreased diffusing capacity is seen in: primary parenchymal disorder, anemia & removal of lung tissue.
Increased value is seen in : polycythemia, CHF & intrapulmonary hemorrhage


41.Delirium and dementia are both characterised by cognitive impairment. Delirium differs from dementia in that there are impairment of attention and awareness. To test Attention we check some backward tasks, like digit span... But how to test Awareness???


as the above stated by SN and Samantha,

the awareness is simply a matter of weather the is oriented.., so ask the 3 things:

1.Person -does the pt. know her name or with whom she lives

2.Place-does she know where she is- ask do you know which hospital you are at, or what floor of the hospital

3.Time- does she know the year, day, or time

if the pt. can not answer the first one , or any one of those ...than there is no sense to aks the rest- you know she is not aware,..

if pt. is orinted and answers all 3 , the pt. is oriented x 3,..


Awareness of environment, also referred to as orientation, you can find it out if they ( patients )answer correctly to some qs like these: Do they know where they are and what they are doing here? Do they know who you are? Can they tell you the day, date and year?
Hope this helps...


42.9 yr. old chid with nocturnal enuresis. no medical cause detected. most appropriate first step would be
a.water restriction at night
b.behaviour modification using awards for dry days
c.non physical punishment like time out
d.normal at this agee. low dose tricyclic antidepressants
2.a patient has a pain sufficient to render him disabled and unabled to return to full employment. which statement is correct
a. disability represents secondary gain and diagnostic of somatoform disorder.
b.disability is a secondary gain seen in factitious disorder
c.disability is a secondary gain reinforcing pain behaviour
d. disability is more likely to be a secondary gain if neurologic tests reveal no clear physiologic basis for pain.
q-3 I read somewhere saying 3%of alcoholics are on "skid row". what in world is a skid row?


Follow Ups:


ans-b,c
43.A 44-year-old man complains of recurrent syncope
associated with upper extremity exercise. What is the
MOST likely cause?
(A) Trigeminal neuralgia
(B) Hypoglycemia
(C) Carotid sinus hypersensitivity
(D) Subclavian steal syndrome
(E) Vasovagal syncope
(B) hypercholesterolemia
(C) estrogen replacement medications
(D) diabetes
(E) cigarette smoking



The answer is D. An association between upper extremity exercise and
syncope suggests the presence of subclavian steal syndrome. If blood pressure is measured
on each arm, a difference of at least 20 mm Hg is often noted. Obstruction of the
brachiocephalic or subclavian artery causes shunting of blood through the vertebrobasilar
system from the normal side past the obstruction, resulting in brain


44. patient has a blood pressure of 210/140 accompanied
by severe headache, nausea, and vomiting.
Which category of hypertension BEST describes this
presentation?
(A) Hypertensive emergency
(B) Hypertensive urgency
(C) Uncomplicated hypertension
(D) Transient hypertension
(E) Chronic hypertension



The answer is A. Category of hypertension is based on clinical presentation
and the level of aggression required for treatment, not on the absolute number of
the blood pressure. A hypertensive emergency is defined as elevated blood pressure with
evidence of end-organ damage or dysfunction. A hypertensive urgency is an elevation of
blood pressure to a level that may be potentially harmful, usually sustained at greater
than 115 mm Hg diastolic without signs, symptoms, or other evidence of end-organ dysfunction.
Mild, uncomplicated hypertension is defined as a blood pressure less than 115
mm Hg diastolic without symptoms of end-organ damage. Transient hypertension can be
seen in many conditions such as pain states, anxiety, pancreatitis, thrombotic stroke,
early dehydration, alcohol-withdrawal syndromes, epistaxis, and some overdoses. Treatment
of the underlying condition rather than administration of antihypertensive medications



45.A patient, 8 months’ pregnant, with no medical history
presents with a BP of 160/100 and seizures. Which
of the following is the BEST drug for lowering BP in
this setting?
(A) Sodium nitroprusside
(B) Hydralazine
(C) Intravenous nitroglycerin
(D) Nifedipine
(E) Furosemide




The answer is B. During pregnancy-induced hypertension (PIH), uterine
blood flow decreases, placing the fetus at risk. Blood pressure reduction is best
accomplished with magnesium sulfate and hydralazine. Hydralazine should be administered
in 10- to 20-mg intravenous boluses every 30 min until the desired effect is
achieved. Sodium nitroprusside can be used, but the infusion should be brief and thiocyanate
levels must be monitored. Labetalol is another second-line agent in this setting.
Diuretics are contraindicated because the patient with PIH is already volume-contracted.
Angiotensin-converting enzyme (ACE) inhibitors should not be used because they cross
the placenta and may depress angiotensin II levels in the fetus. The definitive treatment
of PIH is delivery of the baby.


46. 50-year-old man presents with a painful, swollen
leg that occurred over 2 days. He smokes two packs of
cigarettes per day, and he is moderately overweight. He
recalls striking his calf against a coffee table 3 days
before and suffered an abrasion. His temperature is
100.5°F, and the leg is visibly swollen to the groin with
moderate erythema. Pulses are normal. Which of the
following statements is correct?
(A) Absence of palpable cords and a negative
Homans’ sign make DVT unlikely
(B) The fever and erythema make a diagnosis of
DVT very unlikely
(C) The patient may be started on heparin anticoagulation
immediately
(D) Because there is no evidence of pulmonary
embolism, the patient may be started on
coumadin alone
(E) A venogram must be performed within 24 h


The answer is C. A patient with four or more risk factors has a high
probability for deep venous thrombosis (DVT). It is reasonable to start anticoagulation
with heparin or LMWH pending confirmation with diagnostic studies. Coumadin should
never be started alone because it can cause a transient hypercoagulable state that promotes
thrombus propagation and embolization. Homans’ sign has no clinical predictive
value. A mild fever is consistent with DVT, as is redness. Although venography was
once the gold standard test, duplex ultrasonography is currently favored.


Follow Ups:


47.A 67-year-old man is brought to the ED by ambulance
after a syncopal episode. He was well before the
event, except for mild chronic hypertension. He fell on
pavement, striking his head, so paramedics placed him
in a cervical collar and strapped him to a spine board.
He complains of low back pain, which he attributes to
the spine board. BP is 100/50, and heart rate (HR) is 80
beats per minute. Which of the following is the best
course of action?
(A) Analgesia, ECG, and outpatient referral to
cardiologist
(B) ECG, cardiac enzymes, admit for telemetry
monitoring
(C) Lateral abdominal x-***, with aortogram
if inconclusive
(D) Intravenous fluids, morphine, computed
tomography (CT) of the abdomen
(E) Immediate surgical consultation, multiple
large-bore intravenous lines, type and
cross-match blood



The answer is E. Unheralded syncope in an elderly patient, with new
back or abdominal pain, is suspicious for acute rupture of an abdominal aortic aneurysm.
Because the patient may suddenly become hypotensive, immediate surgical consultation
and preparation for surgery is indicated. Aortography may be falsely negative, and the
associated delay may be fatal. Likewise, delay for CT scanning may also


Follow Ups:


48.A 60-year-old man presents with 1 h of chest and
upper back pain “like I’m being ripped apart!” BP is
170/110 in the right arm and 110/50 in the left arm.
ECG shows sinus rhythm with left ventricular hypertrophy.
Chest x-*** is unremarkable. Which of the following
is the most appropriate intervention?
(A) Nitroglycerin sublingual  3, cardiac enzymes,
admit
(B) Intravenous r-tPA or streptokinase, admit to
cardiac care unit
(C) Intravenous heparin 80 U/kg bolus and 18
U/kg per hour as continuous infusion, ventilation/
perfusion lung scan, admit
(D) Intravenous nitroprusside to keep systolic BP
 110, intravenous propranolol to keep HR
 60, contrast-enhanced CT of the thorax
(E) Intravenous morphine sulfate, emergency gastrointestinal
consultation for endoscopy
symptom




D.Tearing pain, pulse disparity, and hypertension make
aortic dissection the most likely diagnosis. Emergency management includes reducing BP
(with vasodilators such as nitroprusside), reducing shear forces of the aorta with  blockers,
and testing to determine the extent of dissection. CT, aortography, magnetic resonance
imaging (MRI), and transesophageal echocardiography have all been used successfully.
Although testing protocols differ by institution and test availability, the goal is to determine
the need for surgery. Dissections that involve the ascending aorta (Stanford type A) are
usually best treated surgically, whereas dissections that involve only the descending aorta
(type B) are managed medically unless major vessels or organs are seriously compromised.


Follow Ups:


49.A 62-year-old man is brought to the ED by ambulance
with confusion and dyspnea. BP is 80/60. With
inspiration, SBP decreases to 55. The monitor shows a
HR of 121 beats per minute, with vacillating amplitude
of the QRS complex. RR is 26 breaths per minute, and
oximetry saturation is 91 percent. Physical examination
shows jugular venous distention (JVD), distant heart
sounds, cool extremities, and diaphoresis. Chest x-*** is
grossly normal. Which of the following would be the
MOST effective therapeutic intervention?
(A) Large-volume resuscitation with crystalloid,
oxygen, and emergent diagnostic spiral CT
(B) Large-volume resuscitation with crystalloid,
oxygen, and dopamine
(C) Immediate intubation, large-volume
resuscitation, and dopamine
(D) Large-volume resuscitation, oxygen, and
immediate involvement of cardiology consult
for placement of an intraaortic balloon pump
(E) Large-volume resuscitation, oxygen, and
pericardiocentesis


The answer is E. The patient’s presentation is classic for acute percardial
tamponade. He displays Beck’s triad (hypotension, JVD, and muffled heart sounds),
and electrical alternans, created by the heart swinging in the pericardial fluid. Differential
diagnosis includes pulmonary embolism (PE), tension pneumothorax, AMI, myocardial
contusion, and air embolism. Echocardiography is the diagnostic modality of choice
because it can rule out constricting pericardial effusion, show increased right-sided pressures
suggestive of PE, and detect wall-motion abnormalities associated with myocardial
compromise. Treatment of pericardial tamponade includes intravenous fluids, oxygen,
and pericardiocentesis. Dopamine may be helpful as a temporizing measure to elevate
BP. Intubation and other forms of positive pressure ventilation are not recommended
because they decrease venous return.


50.A 25-year-old runner is brought to the ED by ambulance
after experiencing witnessed syncope on the track.
Paramedics arrived within 3 min and found the patient
in ventricular fibrillation. A 200-J shock converted the
rhythm to sinus tachycardia, and the patient has
remained stable. He complains of some chest discomfort
and tells you he has a familial heart problem and
was told he should not run. BP is 100/80, respiratory
rate (RR) is 20 breaths per minute, and pulse oximetry
is 93 percent. The ECG shows sinus tachycardia at 115
beats per minute with septal Q and upright T waves. In
addition to oxygen administration, which of the following
is the MOST important therapeutic intervention?
(A) Aspirin and nitroglycerin
(B) Intravenous fluids and 5 mg
intravenous labetalol
(C) Nitroglycerin and a lidocaine drip
(D) CPAP, nitroglycerin, and furosemide
(E) Aspirin, nitroglycerin, and dopamine
immediate involvement of cardiology consult
for placement of an intraaortic balloon pump



The answer is B. This is the typical presentation of a patient with hypertrophic
cardiomyopathy: a familial disorder with asymmetric hypertrophy of the left ventricle,
in particular the septal wall. The ECG shows Q waves with upright septal T waves,
typical of the “pseudo-infarction” pattern. Chest pain is usually due to an imbalance
between the oxygen demand of the hypertrophied myocardium and the available bloodflow. Tachycardia worsens the symptoms by decreasing diastolic coronary perfusion time,
increasing the end diastolic intraventricular pressure.  Blockers are the intervention of
choice. Nitroglycerin and CPAP would not be indicated because they decrease venous
return and further compromise filling of the noncompliant ventricle. Dopamine would
increase the incidence of dysrhythmias after a ventricular fibrillatory arrest.


Follow Ups:


51.A previously healthy 25-year-old woman with no medical
history presents to the ED complaining of 4 h of substernal
chest pain, shortness of breath, dyspnea on
exertion, and “not feeling well” during the past few days.
She denies illicit drug use or alcoholism. Vital signs are
remarkable for a BP of 92/60, HR of 135, RR of 30, and
temperature of 101.5°F. ECG shows normal sinus rhythm
with nonspecific T-wave changes. Chest x-*** is normal.
In addition to oxygen, which one of the following represents
the BEST initial treatment regimen?
(A) Aspirin, nitroglycerin, check troponin and
myoglobin levels
(B) Aspirin,  blocker, check TSH
(C) Intravenous fluids, analgesia, emergent
echocardiogram
(D) Aspirin, nitroglycerin, emergent ventilation
perfusion scan
(E) Intravenous fluids, lorazepam, antacids



The answer is C. Acute myocarditis presents in previously healthy
patients as a viral prodrome followed by dyspnea and tachycardia out of proportion to
the fever. Other possible diagnoses in the described setting include PE, hyperthyroidism,
toxins, and myocardial ischemia. Anxiety is a diagnosis of exclusion. Although all of the
listed interventions should be considered, nitroglycerin is contraindicated in PE because
it decreases needed preload, and  blockers or lorazepam could precipitate hypotension
in a patient with acute myocarditis. Echocardiography would be the next diagnostic
modality of choice in the work-up of this patient.


52.A 28-year-old intravenous drug user presents with
dyspnea, agitation, diaphoresis, cool extremities, and
cough productive of pink frothy sputum. He has had
fevers and chills for 2 days but suddenly became short of
breath 1 h before. Vital signs are BP of 105/40, HR of
126, RR of 38 with oximetry saturation of 88 percent,
and temperature of 103.5°F. He has quick, upsweeping
pulses and a diastolic murmur. In addition to emergent
intubation and intravenous furosemide administration,
what is the MOST important immediate action?
(A) Administer naloxone and nitrates
(B) Call for a cardiac surgeon
(C) Perform emergent echocardiography
(D) Draw blood cultures and give intravenous
antibiotics
(E) Administer naloxone and intravenous
antibiotics and place an intraaortic
counterpulsation balloon


The answer is B. This patient has pulmonary edema secondary to
acute aortic insufficiency with the characteristic clinical findings of a wide pulse pressure
and short upsweeping pulses. The most likely cause for acute cardiac failure in this
febrile intravenous drug user is infective endocarditis leading to valve rupture. Concurrent
with resuscitation, the most important action is to call a cardiac surgeon to performemergency valve repair. Furosemide and nitrates are helpful temporizing measures to
reduce afterload and improve cardiac output. Blood cultures and empiric antibiotics are
also indicated. Emergent echocardiography would be helpful to confirm the diagnosis
while preparations for surgery are underway. Naloxone has no role, and an intraaortic
counterpulsation balloon is contraindicated.


Follow Ups:


53.You respond to a “code blue” on the labor-and-delivery
ward. The nurse tells you that the patient is a previously
healthy 41-year-old African-American woman, 4
days status post normal spontaneous vaginal delivery.
She complained of chest pain and dyspnea and then fell
to the floor unconscious. No seizure activity was noted.
Although initially pulseless, vital signs returned with
assisted ventilations. You find the patient confused,
grunting, and cyanotic. Vital signs are BP 68/50 mm Hg,
HR 121 beats per minute (sinus tachycardia), and RR 28,
with pulse oximetry of 78 percent on high-flow oxygen.
Physical examination shows distended neck veins, normal
heart sounds with a prominent S2, a thready pulse
with cool, cyanotic extremities, and adequate tidal volume
with no rales or wheezes. Chest x-*** is normal.
Bedside ultrasound of the heart shows a dilated right ventricle
with parodoxical septal wall motion. In addition to
immediate intubation and fluid resuscitation, what is the
MOST appropriate therapeutic intervention?
(A) Emergent diagnostic spiral CT
(B) Heparin bolus of 80 U/kg intravenously followed
by 18 U/kg infusion
(C) LMWH 1 U/kg every 12 h
(D) r-tPA at a dose of 100 mg over 2 h
(E) Emergent transfer to the angiography suite for
pulmonary arteriography and local infusion
of urokinase



The answer is D. Pregnancy is considered a hypercoagulable state and
thus a risk factor for DVT and PE. PE is the most common cause of nonsurgical maternal
death in the peripartum period. Women older than age 40 years and of African
descent are at highest risk. Thrombolytic therapy is indicated for treatment of massive
PE with refractory hypoxemia and circulatory collapse. The use of thrombolytic agents
has largely replaced thrombectomy, except in cases in which thrombolytic therapy is
contraindicated. This patient is at risk for uterine bleeding because she is 4 days postpartum.
Urokinase and streptokinase are less effective than r-tPA in improving symptoms.
Heparin and LMWH are possible treatments for hemodynamically stable PE patients but
would not be indicated in this scenario. Intrapulmonary artery infusion is no more effective
than peripheral intravenous administration, and the risk of bleeding at the pulmonary
catheter placement site is high.
V .


54.A 56-year-old man with a history of hypertension and
tobacco use complains of intermittent substernal chest
pain without radiation or associated shortness of breath,
nausea, or diaphoresis. Chest pain occurs both with
exertion and at rest and lasts 5 to 10 min at a time. He is
currently pain free, but his ECG shows LVH and
inverted T waves in leads V4 to V6. Two sets of cardiac
enzymes are negative. Which of the following diagnostic
tests would be MOST appropriate?
(A) An ECG exercise stress test
(B) A T99 exercise stress test
(C) Echocardiography for evaluation of wall
motion abnormalities
(D) Coronary angiography
(E) A 24-h Holter monitor



The answer is B. Despite two sets of negative cardiac enzymes and a
prolonged pain-free period, this patient needs to be risk-stratified for evidence of coronary
ischemia. In patients with LVH and a possible strain pattern, ECG stress tests can
be nondiagnostic. An echocardiogram can show wall-motion abnormalities in patients
with nonspecific ECG changes but is unlikely to show a wall-motion abnormality in this
patient in the absence of chest pain. A Holter monitor might pick up dysrhythmias but
would not be the best test to evaluate for ischemia. Angiography is invasive and not generally
used as the first line to evaluate for coronary ischemia in a pain-free patient.


55.drug resistance of hiv drugs,side effects of clozapine,aminogly,cephalosporins,floroquinolones.
flow vol loop in cvs!
digoxin half life.
kawasaki-complications seen
genetic testing in obs
cant remember more



56.how to differentiate between septic and anaphylactic shock?? on August 08, 2003 at 22:20:50:

early septic shock has increased Cardiac Output (PCWP, systemic resistance, and o2 saturation are reduced)

late septic shock has increased systemic resistance (like hypovolemic shock) all other values are reduced.

anaphylactic shock has features of hypolemic shock but can have all low values...

look for other clues in the history like exposure to antigens and peripheral edema, laryngoedema, and flushing of the skin, that will clue u in to anaphlyaxis, hope this helps



57.the q exam inhassan 'exam:PERSONALITY DISORDERS
SIDE EFFECTS OF MEDS
LITHIUM INDUCED HYPOTHYROIDISM
ANOREXIA NERVOSA
BULIMIA NERVOSA
DEMENTIA

THAT'S WHAT I GOT

OTHER HAVE SEEN THE OTHER ONES, SINCE I WAS STUDYING THEM PRIOR TO MY EXAM BASED ON OTHER PEOPLE'S FEED BACK.

58.A 30-year-old male presents to the emergency room with shortness
of breath and right-sided pleuritic chest pain. His chest x-*** in the emergency
room is normal. An arterial blood gas is obtained while the patient is
breathing room air. The results show a pH of 7.48, PaCO2 of 35, PaO2 of 68,
and an oxygen saturation of 92%. What is his A-a gradient?
a. 20
b. 30
c. 40
d. 50
e. 60



Answer is c. The patient most likely has a pulmonary
embolism because of shortness of breath, right-sided pleuritic chest
pain, a normal chest x-***, and abnormal blood gases. A useful calculation
is the assessment of Alveolar oxygenation and calculating the gradient
between Alveolar and arterial partial pressures of the oxygen. At room air,the PaO2 (Alveolar) can be calculated by the following formula. PaO2 =
150 - 1.25 × PaCO2. Once PaO2 is determined, the A-a gradient is simply the
difference between PaO2 and arterial PaO2. In a healthy young person breathing
room air, the PaO2 - PaO2 is normally less than 15 mmHg; this value
increases with age and may be as high as 30 mmHg in elderly patients.


Follow Ups:


59.A 76-year-old man comes to your office in January with complaints
of abrupt onset of cough, with small amounts of green sputum, worse in
the morning, without any blood in it. He also has fever as high as 103°F,
very rapid respirations (32/min), and chest pain on his right side, worsened
with coughing. He exhibits some difficulty remembering the details of
his illness. On the basis of these clinical findings, you consider a diagnosis
of pneumonia. Which one choice would you make?
a. Obtain a chest x-*** and schedule him to return tomorrow
b. Treat his symptoms with antipyretics and cough syrup
c. Prescribe an oral antibiotic and also antipyretics and cough syrup and schedule
him to return in 2 days
d. Admit him to the hospital in the intensive care unit for parenteral antibiotic
treatment
e. Administer a tuberculin skin test (PPD), treat his symptoms with antipyretics
and cough syrup, obtain a chest x-***, and schedule him to return in 2 days for
interpretation of the skin test


Answer is d. Elderly patients and patients with
other comorbid illnesses have a higher chance of complications following a
community-acquired pneumonia, and they need to be admitted to the hospital
for parenteral antibiotic treatment and close monitoring. Elderly
patients with tachypnea and acute alteration in mental status are at high
risk of adverse outcomes from pneumonia and need to treated in the hospital.


Follow Ups:


60.A 12-year-old boy is brought to your office by his mother because he
developed a painless rash on his face and legs. The rash began as red
papules and then became vesicular and pustular and finally it coalesced in
honeycomb-like crusts. The boy does not have fever, but he does have several
insect bites and he is unwashed and dressed in dirty clothes. This rash
is likely to be
a. Herpes simplex
b. Shingles
c. Impetigo
d. Scarlet fever
e. Erysipelas


The answer is c. The rash is impetigo, which is
caused by group A streptococci, occasionally by other streptococci, and
also by Staphylococcus aureus. It occurs in children who have poor hygiene,
and the streptococci, which colonize the skin, gain entrance through a
break in the skin, such as a scratch or an insect bite. The rash is painless,
unlike herpes simplex or shingles, which is due to Herpesvirus varicellae.
Herpes simplex occurs on the face and mouth and genitals; shingles follows
the distribution of a nerve, mainly the temporal nerve and the intracostal
nerves. Scarlet fever, also due to streptococci, characteristically
covers the trunk and extremities with a fine papular rash, sparing the
palms and soles. Erysipelas is a streptococcal cellulitis.


61.A 22-year-old college student comes to your office because of a cold
and respiratory symptoms of about 12 days’ duration that do not seem to
be lessening in intensity. He is anorexic and tired. His respiratory rate is
24/min, and he has a cough productive of small amounts of white sputum,
but no hemoptysis or pleuritic chest pain. He chest x-*** shows infiltration
in the right lower lobe. He has a leukocytosis of 18,000 and his cold agglutinin
titer is elevated. The organism that is the likely cause of this illness is
a. Leptospira
b. Influenzavirus
c. Mycoplasma pneumoniae
d. Legionella spp.
e. Coxiella burnetti


The answer is c. Mycoplasma pneumoniae
pneumonia occurs predominantly in adolescents and young adults and also in elderly adults. It begins insidiously with fever, cough, and scant
white sputum, but not hemoptysis. The cold agglutinin antibodies are elevated
in this infection, usually in about one-half of cases and not in the
other infections. The chest x-*** is usually positive and the infiltrate is
interstitial, mainly in the lower lobe on one side; occasionally, it involves
both lungs.


Follow Ups:


62.A 45-year-old woman veterinarian who is a faculty member at the
nearby veterinary school comes to your office with complaints of a flulike
syndrome of 9 days’ duration including persistent fever for all 9 days,
extreme fatigue, and severe headache. She has a dry cough, an increased
white count, and thrombocytopenia. Which one of the following is the
likely cause of her infection?
a. Influenzavirus
b. Mycoplasma pneumoniae
c. Chlamydia psittaci
d. Coxiella burnetii
e. Chlamydia pneumoniae


The answer is d. Infection with Coxiella
burnetii (or Q fever) represents an occupational hazard of veterinarians. Q
fever is characterized by fever, extreme fatigue, and headache, and about
one-fourth of persons with the infection develop thrombocytopenia, unlike
in the other infections. Mycoplasma pneumoniae infection is insidious and
causes pneumonia as does Chlamydia pneumoniae infection; thrombocytopenia
is not a characteristic of these infections. Influenza develops
rapidly, in 2 to 3 days from exposure.


63.A 47-year-old man walks into the emergency room because of feeling
very weak, tired, short of breath, and dizzy. He has numbness and tingling
of his fingers. He appears pale and sallow. On examination, his heart rate is
132. His sclerae and nailbeds are pale. His heart is enlarged and he has
dependent edema of his ankles. Laboratory findings include a negative
Coombs’ test and a hemoglobin of 4 g/dL. The likely diagnosis is
a. Traumatic hemolytic anemia
b. Autoimmune anemia
c. Blood loss
d. Pernicious anemia
e. Iron-deficiency anemia


The answer is d. Pernicious anemia, a megaloblastic anemia, results from a
complex cascade of events that is autoimmune in origin. Antibodies against
gastric parietal cell components and intrinsic factor are common, and
antibody-generating B lymphocytes are found in the gastric mucosa. The
signs of vitamin B12 (cobalamin) deficiency are delayed by the liver storage
of cobalamin, provided that the patient’s intake has previously been normal.
Cobalamin deficiency is almost always due to malabsorption. Normal
diets usually provide adequate intake of cobalamin; however, in vegetarians
the intake is inadequate. Persons suffering from pernicious anemia can
develop very low hemoglobin levels, as low as 4 g/dL, unlike other anemias.
Multiple neurologic findings (due to demyelination at first and then
axonal degeneration) include numbness and paresthesias, weakness,
ataxia, difficulties with mentation, and abnormal deep tendon reflexes and
pathological reflexes, high output failure, sallow color are consistent with
pernicious anemia. In autoimmune hemolysis, the Coombs’ test is positive.


Follow Ups:


64.A 66-year-old white woman with a known history of small cell lung
cancer comes to your office because of engorgement of her neck veins on
the right side and over her chest wall. She also has cyanosis of the extremities,
facial edema, and difficulty with her mentation. Her diagnosis is most
likely
a. Congestive heart failure
b. Lymphatic obstruction of the upper body
c. Superior vena cava syndrome
d. Deep venous thrombosis


Follow Ups:


The answer is c. The definitive diagnosis is
superior vena cava syndrome until proven otherwise with scans. It means
that the superior vena cava is obstructed. Ninety percent of these cases are due to malignant tumors such as carcinoma of the lung, lymphoma, and
various metastatic tumors. The findings described in this patient are not
due to the other diagnoses.


Follow Ups:


65. 52-year-old white woman with breast cancer receiving adjuvant
therapy presents with back pain that intensifies on movement and pain
over the L1 vertebral body when she coughs and that radiates down her left
lower extremity to her leg and foot. The most likely etiology of this disorder
is
a. Paraneoplastic disorder
b. Trauma to the lumbar disk
c. Muscular spasm of the intercostal muscles
d. Possible spinal cord compression



The answer is d. Any back pain in a
patient with a known history of carcinoma should be evaluated for the possibility
of spinal cord compression. It occurs in 5 to 10% of patients with
cancer. Lung cancer is the most common primary malignancy causing
spinal cord compression. Localized back pain and tenderness are the most
common initial complaints.


66A 45-year-old white man with a limited small cell lung cancer presents
to the emergency room of a local hospital and exhibits agitation and confusion,
ataxia, nystagmus, peripheral sensory loss, and generalized weakness.
The most likely etiology of this disorder is
a. Hypercalcemia
b. Paraneoplastic syndrome
c. Cerebral vascular accident
d. Myasthenia gravis


Follow Ups:


The answer is b. The paraneoplastic syndromes
include endocrine syndromes and hematologic syndromes. The
paraneoplastic endocrine syndromes include hypercalcemia of malignancy,
inappropriate vasopressin secretion (SIADH), Cushing’s syndrome,
acromegaly, and gynecomastia. The paraneoplastic hematologic disorders
include erythrocytosis, granulocytosis, thrombocytosis, eosinophilia, and
thrombophlebitis.


67.A 22-year-old man comes to the emergency room of your hospital
because he has a diffuse, erythematous rash involving nearly all of his
body. His total WBC count is greater than 100,000 cells/mm3. He also complains
of bone pain, severe irritability, weakness, fatigue, nausea and vomiting,
constipation, photophobia, and polyuria. His electrocardiogram
(ECG) shows shortening of the QT interval, prolongation of the PR interval,
and nonspecific T wave changes. The most likely cause of his symptoms
is
a. Hypercalcemia
b. Hypocalcemia
c. Hypophosphatemia
d. Hyperkalemia


Follow Ups:


The answer is a. Hypercalcemia of
malignancy is the most common paraneoplastic syndrome. It accounts for
about 40% of all hypercalcemia. The signs and symptoms of hypercalcemia
include bone pain, irritability, weakness, fatigue, constipation, nausea, and
vomiting, as this patient manifests. Symptoms begin at a serum calcium of
about 2.6 mmol/L. Hypercalcemia of malignancy is common in cancers
with squamous cell histology.


68. 30-year-old man has pain in the left scrotum. What is currently valid
concerning types of tumor?
a. Alpha fetoprotein (AFP) is only elevated in seminomas.
b. The half-life of AFP is 24 to 36 h.
c. Lactate dehydrogenase (LDH) is an important marker to follow tumor progression
or regression.
d. Human chorionic gonadotropin-â subunit (â-hCG) is only elevated in seminoma.


Follow Ups:


The answer is c. LDH is an important marker
to follow in any germ cell tumor. AFP elevation is seen only in nonseminoma,
whereas â-hCG is seen in both nonseminoma and seminoma. The
half-life of AFP is 5 to 7 days.


Follow Ups:


69.A 55-year-old man has lung cancer in the right middle lobe. Which
paraneoplastic syndrome is associated with GHRH secretion and lung
cancer?
a. Hypocalcemia
b. Hypocortisolemia
c. Hypophosphatemia
d. Acromegaly
e. Gynecomastia


The answer is d. Ectopic acromegaly is a paraneoplastic
endocrine disorder related to small cell lung cancer and secretion
of growth hormone–releasing hormone (GHRH). Hypercalcemia is a
paraneoplastic endocrine syndrome associated with non-small cell cancers
which is caused by secretion of parathyroid hormone–related peptides
(PTHrP); hypercortisolism caused by ACTH release occurs with
small cell lung cancers, and cellular release of phosphorus causes hyperphosphatemia
associated with lung cancer; gynecomastia caused by
human chorionic gonadotropin secretion (hCG) also occurs with lung
cancers.


Follow Ups:


70.A 48-year-old white woman has what she believes is a suspicious lump
in her breast, but a mammogram does not reveal any suspicious lesions.
Truthful statements concerning potential pitfalls in management and diagnosis
include
a. Assuming that mammography is “diagnostic”
b. Assuming that a radiographic lesion seen on mammography is the same as a
palpable lesion
c. Letting a negative or nonsuspicious mammogram influence the judgment of
whether a palpable mass needs to be biopsied
d. Assuming that a benign aspiration cytology is definitive


The answer is c. Any suspicious palpable mass
should be biopsied despite a negative mammogram. Negative mammograms
can occur in 10 to 15% of instances of a palpable breast mass.


Follow Ups:


71.An infant with multiple fractures, bony deformity, blue scleras,
wormian bones in the skull, and beaded ribs died of respiratory difficulties.
He most likely had
a. Type I osteogenesis imperfecta
b. Type II osteogenesis imperfecta
c. Type III osteogenesis imperfecta
d. Type IV osteogenesis imperfecta


The answer is b. Wormian bones are isolated
islands of mineralization in the skull. Type II osteogenesis imperfecta usually
results in death in infancy.


72.A 13-year-old child with blue scleras, mildly short stature, and no
deformity with a history significant for 10 fractured bones most likely has
a. Type I osteogenesis imperfecta
b. Type II osteogenesis imperfecta
c. Type III osteogenesis imperfecta
d. Type IV osteogenesis imperfecta


The answer is a.Type I osteogenesis imperfecta is
mild. Type II is severe and usually lethal in the perinatal period. Type III is
considered progressive and deforming. Type IV is deforming, but with normal
scleras.


73.A patient who has the autosomal dominant gene for type I osteogenesis
imperfecta has blue scleras and slightly reduced height, whereas his
brother has multiple fractures and deformities. This is an example of
a. Polymorphism
b. Mutation
c. Variable expressivity
d. Fitness


The answer is c. The phenomenon of different
phenotypes in individuals with the same genotype is known as variable
expressivity. Polymorphism is an allele that is present in 1% or more of the
population. Mutation refers to an event such as a nucleotide change, deletion,
or insertion that produces a new allele. Fitness refers to the ability of
an affected individual to reproduce.


74.A patient with recurrent infections with yeast and the incapacity to
control viral infections may indicate a deficiency in
a. Cellular immunity
b. Complement
c. Granulocytes
d. Humoral immunity
e. Eosinophils


The answer is a. Individuals with T cell
deficiencies are susceptible to infections with microbes that reside within host cells (virus, Mycobacterium species, and fungi). Humoral immune deficiency
or complement deficiency usually results in recurrent bacterial,
rather than viral, infections. Granulocyte deficiency may also result in bacterial
and yeast infections. Because the statement indicates that the patient
has problems with viral infections, the best answer is a deficiency in T cell

75.A 6-year-old boy has received a deep puncture wound while playing
in his neighbor’s yard. His records indicate that he has had the standard
DPT immunizations and a booster when he entered school. What is the
most appropriate therapy for this child?
a. Tetanus toxoid
b. Tetanus antitoxin
c. Both toxoid and antitoxin at the same site
d. Toxoid and antitoxin at different sites
e. No treatment



The answer is e. Because the boy
received his booster within the last 2 years, his level of immunity should be
adequate. If an individual has no history of immunization, both antitoxin(passive immunization with tetanus immune globulin) for temporary andfast protection and toxoid (toxin detoxified with formaldehyde) for future
and long-lasting protection should be given at different sites.



76.73 y/o male with Hx of HTN, presents with short episode of Lt. sided weakness & slurred speech. Also he has a Hx of 3 brief episodes of sudden Rt. eye vision impairment in the last month.
1- What’s the best next diagnostic test?
A- Cerebral MRI
B- Holter monitoring
C- Visual evoked responses
D- Carotid artry doppler US
E- Conventional cerebral angiography

2- Episodes of visual loss are related to:
A- Retinal vein thrombosis
B- Central retinal A. ischemia
C- Post. cerebral A. ischemia
D- Middle cerebral A. ischemia
E- Post. ciliary A. ischemia



looks like carotid artery stenosis because of atherosclerosisin a HTN.
so ---do carotid artery duplex scanning
and blindness will be because of the central retinal artery ischemia.
correct me


Answers are D & B. This is a classicd case of extracranial internal carotid A. dis. which include episodes of ipsilat. transient monocular blindness ( amaurosis fugax ) & contralat. TIA consisting of motor weekness. The most appropriate test to confirm the Dx of carotid stenosis is Doppler us. The mech. of transient monocular blindness is embolism to the central retinal A. or one of its branches


77.70 y/o man with Hx of COPD, presents with worsening SOB of the last couple days. He’s coughing yellow-colored sputum and gets no result from his beta 2 agonist & ipratropium aerosolized pumps. On P/E, RR=40, HR=110, BP= 155/85, he’s afebrile and using his accessory muscles for respiration. Also inspiratory & expiratory diffuse wheezing on both sides of his lungs are heard. What’s the most likely Dx?
A- Acute exacerbation of COPD
B- Alfa-1 antitrypsin def.
C- Chronic bronchitis
D- Exacerbation of asthma
E- Pneumonia



Answer is A- Acute exacerbation of COPD, it occurs when patient develops acute onset of marked dyspnea & tachypnea with use of accessory mucles with no response to medication.


78.72 y/o man with Hx of UTI & CHF is admitted for sepsis & pulmonary edema. He’s treated with clindamycin, tobramycin & IV furosemide. After 4 days, sepsis signs are improves but BUN= 60 & Cr.= 5 mg/dl. BP=125/75 , PR=72( no postural changes ).
1-What’s the most likely cause of his renal dysfunction?
A- Prerenal azotemia
B- ATN
C- Interstitial nephritis
D- Hypercalcemic nephropathy

2- What’s the best way to confirm the Dx?
A- Urine Na of 25 mEq/L
B- Renal tubular epithelial cells & muddy brown casts in sediment
C- Negative US
D- Abnormalities of medulla in IVP




Aswers are B & B. There’s no clinical evidence of prerenal azotemia, so the most likely Dx is ATN due to toxicity with aminoglycoside. Urine sediment in ATN is abnormal and shows renal tubular epithelial cells, debris & muddy brown casts. Since patient has been getting diuretics, high urine Na is less specific.



79match this drugs with their associated syndrome:
A- barbiturates
B- Ecstasy
C- Inhalants
D- Marijuana
E- Methamphetamine
F- PCP

1- Severe encephalopathy
2- Lung cancer
3- Rhabdomyolysis during intoxication
4- Wanting to touch/be touched during intoxication
5- Seizures during withdrawal
6- “ Swiss cheese “ appearance on functional brain imaging



A-5, B-4, C-1, D- 2, E-6, F-3


Follow Ups:


80.A 2 y/o has a chronic cough. CXR reveals hyperinflation of the left hemithorax. Bilateral decubitus views showed that the right lung becomes appropriately atelectatic however, the left side shows no change in appearance with decubitus positioning. What’s the most likely diagnosis?


Follow Ups:


Asymmetric hyperinflation suggests the possibility of an aspirated foreign body in this two year old infant. These findings suggest the diagnosis of an aspirated foreign body or a possible obstruction of the left main stem bronchus from a central etiology. Bronchoscopy is both diagnostic and therapeutic.


81.35 y F with signs and symptoms of viral URI and pain over the thyroid gland.with diagnosis of initial stage of subacute thyroiditis,which lab test do u expect to see?
1-elevation in T4,decreased T3
2-Decreased both T3 and T4
3-incease in TSH level
4- decrease radioactive iodine uptake
5-decrease ESR


4
That's right that in initial stages of suacute thyroiditis T4 and T3 are elevated but this is because of thyroid gland destruction and leack and RAIU is LOW,ie it's not because of increased uptake and synthesis of thyroid hormones.
Good luck


82.Within a 2-week period you see an unusually large number of patients of all ages who complain of painless loss of central vision. You refer them appropriately to an ophthalmologist. The feedback you get is that most of these persons have bilateral central scotomas caused by an ophthalmoscopically visible macular defect.

Which one of the following events would most likely explain this problem?



1 A solar eclipse
2 A factory accident exposing persons over a wide area to dangerous levels of carbon monoxide
3A severe dust storm
4 The recent winner-take-all boxing tournament
5The annual community Fourth of July picnic where lots of potato salad was consumed



Direct observation of the sun without an adequate filter, which often occurs during a solar eclipse, results in a specific type of radiation injury termed solar (eclipse) retinopathy. The lens system of the eye focuses the sun's light onto a small spot on the macula, usually in one eye only, producing a thermal burn. The resulting retinal edema may clear spontaneously with minor functional loss, or it may cause significant tissue atrophy, leaving a defect seen with an ophthalmoscope as a macular hole. This macular injury produces a permanent central scotoma. Visual blurring and difficulty with light perception are reversible manifestations of the tissue hypoxia associated with carbon monoxide poisoning. Dust and other particulate matter can produce injury to the cornea and conjunctiva. These lesions are painful, usually prompting medical attention and appropriate treatment. While severe contusions to the globe and periorbital structures can produce retinal detachment, the clinical vignette does not support a boxing-type injury. Although potatoes have eyes, there is no other significant relationship between potato salad and ophthalmologic disease. Ref: Vaughan D, Asbury T, Riordan-Eva P: General Ophthalmology, ed 15. Appleton & Lange, 1999, pp 186, 371.



83.45 yr old woman comes to the clinic with 4mo history of headaches and changes in her vision. she has been previously healthy and on no medications. on exam, she has a small field defect in both eyes. the diagnosis of pituitary microadenoma is considered. which of the following is the most sensitive diagnositic study for this condition:
a. CT
b. insulin-tolerance test
c. MRI
d. serum prolactin measurement
e. visual field examination


84.pt with narcolepsy, what is the diagnostic test and whts TX
Dx- sleep studies--> watch for pt. going into REM sleep rt away, etc..

Tx- stimulants--> methylphenidate, timed naps, avoid alcohol , add antidepressants if cataplexy is present


Follow Ups:


85. 64yo woman presents with finding of a VILLOUS adenoma in the sigmoid colon on screening colonoscopy.Her FH is significant for colon cancer.Next step of Mx?

Aolypectomy
B:repeat colonoscopy in 3yr
C:segmental resection
D:cauterization
E:annual colonoscopic observation
F:both A&B



C-segmental resection,

in this case pt. has VILLOUS adenoma--> which of all the adenomas has the highest malignant potential,... also pt. has aHx of colon CA- a significant risk factor..

Tubular adenoma - smallest malignant potential,
Tubulovilous adenoma - intermediate between Tubular and Vilous adenoma


86.A 64yo woman presents with finding of a TUBULAR adenoma in the sigmoid colon on screening colonoscopy.Her FH is significant for colon cancer.Next step of Mx?

Aolypectomy
B:repeat colonoscopy in 3yr
C:segmental resection
D:cauterization
E:annual colonoscopic observation
F:both A&B



F- both A & B,

do polypectomy as TUBULAR adenoma has the smallest malignant potential ,...but also do colonoscopy in 3 yrs. as pt. has a FH for colon CA,

Tubular- has the smallest potential for malignancy
Tubulovillous adenoma- intermediate
Villous adenoma - greatest potential for malignancy



1.A 27yo woman with a history of IV drug abuse presents with fever,cough and sore throat and complains of eye burning for 3days.Diffuse erythema of her entire body develops with conjunctival injection peeling of the mouth&lips.The skin rash has now progressed to include portions of the arms& legs and is indistinguishable from a severe burn.What’s the most appropriate next step of Mx?
A:ELISA for HIV
B:skin biopsy
C:streroids
D:blood cultures
E:silver sulfadiazine cream



B:skin biopsy
this pt has toxic epidermal necrolysis:it’s characterized by detachment of full-thickness epidermis.More common in females,occurs in older indivisuals and in those who use drugs.Other RFs include HIV,BM transplantation,SLE.The primary cause of TEN is an adverse drug reaction,although it’s occasionally seen with hepatitis or mycoplasma infection.The most common drugs responsible r sulfonamides,Phenobarbital,phenytoin,carbamazepine ,cephalosporins,quinolones,allopurinol.The mean time between drug administration to the onset of symptoms is 14days.
Pts with TEN should receive care in burn units.fluid repletion is important.An early skin biopsy is important because pts with true TEN should not receive steroids,which may benefit pts with erythema multiforme.ELISA should be ordered,but is not the most important test at this time.silver sulfadiazine should be avoided because it’s a sulfonamide.



2A 22yo woman gravida 1 presents for her prenatal visit.She has a history of being treated with a tetracycline antibiotic 4wk earlier for Chlamydia cervicitis.She was unaware of her pregnancy at that time,bcoz her menses have always been irregular.An US is done and shows that she’s at 12wk gestation.She asks u about the effect of this antibiotic on her fetus.What’s ur answer?


Follow Ups:


although tetracycline may stain developing fetal teeth,this effect would not occur until after 12wk of gestation.because the deciduous teeth don’t begin to calcify until 16wk.The staining can’t occur until the teeth begin to calcify.Exposure after 12-16wk ia associated chiefly with staining of the deciduous teeth.
Despite the lack of a true teratogenic effect of tetracycline,these drugs should generally be avoided during pregnancy and it should rarely be necessary to prescribe during a known pregnancy.


3.A 34 yo woman presents with 2 large,painless,moist,flat,pale lesions on either side of her anus.She’s otherwise asymptomatic.What’s the most likely diagnosis?


Follow Ups:


condyloma lata r painless,moist,flat,pale lesions that appear in the perianal region as a manifestation of secondary syphilis and r highly infectious.
condyloma acuminata r pedunculated lesions of the genitalia or perirectal area that result from infection by HPV.


Follow Ups:


4.A patient presents with a bilateral homonymous
quadranopsia involving the right upper visual field.
Which of the following represents the MOST likely
anatomic location of the abnormality?
(A) Prechiasmal, right side
(B) Optic chiasm
(C) Postchiasmal, prethalamic, left side
(D) Occipital lobe, right side
(E) Occipital lobe, left side
(E) Pseudomonas aeruginosa



The answer is E. Homonymous visual field cuts imply a postchiasmal
location of the abnormality because this is the first point where fibers from the same
visual field of both eyes join. Fibers further divide between the thalamus and occipital
lobe into upper and lower quadrant visual fields. The most common location for quadranopsia
defects is the occiptal lobe. Stroke, tumor, and atypical migraine may present with
quadranopsia. Visual fields are named from the perspective of the patient, i.e., the right
visual field corresponds to the left side of the retina. Therefore, a right-sided visual field
cut involves the left-sided neurologic tracks.


5.An 18-year-old male presents to the ED with his
mother complaining of right-sided monocular blindness
after being struck in the face by a younger sibling. Examination
of the head and neck shows no obvious signs of
trauma. Visual acuity is “no light perception” OD and
20/20 OS. Pupillary response is normal, and there is no
afferent pupillary defect. Slit lamp examination and fundoscopy
are normal. Neurologic examination is nonfocal.
The most likely etiology of this patient’s disorder is
(A) cortical blindness
(B) functional blindness
(C) retinal detachment with macular involvement
(D) vitreous hemorrhage
(E) traumatic lens dislocation





The answer is B. Patients with functional blindness fall into two categories:
hysterical conversion reaction and malingering. “No light perception” vision in
the setting of a normal pupillary response and an absent afferent pupillary defect strongly
suggest functional blindness. Cortical visual tracts can be tested by eliciting optokinetic
nystagmus. This is an involuntary reflex in which the affected eye tracks objects moving
in a horizontal direction, e.g., a tape measure moving back and forth or a spinning top
with painted vertical lines. Cortical blindness can occur with bilateral occipital infarction
(unlikely in this patient).


Follow Ups:


6.A 15-year-old male presents with no significant
medical history and complains of right-sided headache,
nausea, and fatigue. Before the onset of the headache,
the patient experienced a large dark “hole” in his right
visual field with adjacent bright flashing lights. All
visual symptoms resolved with the onset of headache.
Physical examination is notable for bilateral photophobia,
normal visual acuity, and normal external eye and
slit lamp examinations. The patient has a supple neck
and nonfocal neurologic examination. The MOST likely
etiology of the patient’s symptoms is
(A) amaurosis fugax
(B) TIA
(C) subarachnoid hemorrhage
(D) retinal detachment
(E) ocular migraine


The answer is E. This patient is describing a classic, prodromal aura
of migraine headaches. Typical aura symptoms precede the headache, last 10–15 min,
and consist of a wide range of photoimagery: scotomas, scintillations, flashing lights, and
even visual hallucinations. Although amaurosis fugax and TIA can present with scotoma,
these are unlikely to occur in this age group or in association with headache. Retinal
detachment would not resolve with time, and subarachnoid hemorrhage, although still a
consideration, should have meningismus and no aura.


Follow Ups:


7.A 22-year-old female complains of 1 day of dull
right eye pain and blurry vision. Review of systems is
positive for occasional double vision, and one episode
of right-hand numbness the previous year which spontaneously
resolved. The patient denies fevers, weight
loss, or rash. Visual acuity is 20/100 OD and 20/20 OS.
There is pain on range of motion in the affected eye.
Conjunctiva, sclera, and slit lamp examinations are
normal. Fundoscopy shows a swollen, hyperemic optic
disc on the right side. What is the MOST likely cause
of this disorder?
(A) Intracranial mass lesion
(B) Multiple sclerosis (MS)
(C) Orbital cellulitis
(D) Acute angle closure glaucoma
(E) Iridocyclitis


Follow Ups:


The answer is B. This patient has optic neuritis, defined as inflammation
or demyelination of any portion of the optic nerve. Classic signs and symptoms
include visual loss of variable severity and dull eye pain that typically is worse with eye
movement. Patients also describe a dimness to their vision and a loss of color intensity.
When the optic disc is involved, it appears swollen and hypervascular. Causes include
MS, Lyme disease, lupus, sarcoid, syphilis, and toxin exposure. Optic neuritis is a classic
first presentation of MS as is diplopia because of lesions of the medial lateral fasciculus.
This patient’s ag