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questions discussed - elbamaritza
#1
Hey friends
Here the questions that we have been aswering during the last month.
I CAN NOT ASSURE YOU, that there is not one or another NMBE, so if you plan to take the NMBE, do not do this to avoid the bias in your result.

There is 62 pages, you can printed for review
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#2
A 45-year-old woman presents to your office after developing a pruritic rash and a fever. She first noticed it on her wrists two weeks ago but states that it has now spread to her feet as well. Her past medical history is significant for a seizure disorder following the removal of a meningioma. She has been treated with Dilantin. Physical examination is significant for icteric sclera. There are polygonal, flat-topped, violaceous papules limited to her wrists and her ankles. A white, reticulated, lacy lesion is also evident on examination of her buccal mucosa. Her liver is enlarged and is nontender to palpation. Laboratory analysis reveals: PT 11 seconds, albumin 3.6 g/dL, alkaline phosphatase 160 U/L, AST 700 U/L, ALT 960 U/L, ANA 1:160. Anti-hepatitis C virus (second generation) is negative; anti-hepatitis-B surface antibody (HBs) is positive; and anti-hepatitis-B core antibody (Hbc)is negative. She has an erythrocyte sedimentation rate of 20 mm/h and a cholesterol of 160 mg/dL. Anti-smooth muscle antibody test is negative, and an ultrasound of the abdomen is normal. What would you do next?

(A) Start prednisone
B) Initiate interferon~-2b therapy
© Administer N-acetylcysteine
(D) Stop Dilantin
(E) Start methotrexate


A 28-year-old female comes to the emergency department with a headache and fever. She has not had any recent infections, nor has she been exposed to any drugs. Her medical history is unremarkable. On examination, the patient appears lethargic. Her temperature is 100.5 F, pulse is 100/minute, blood pressure is 130/85 mm Hg, and respirations are 18/min. Her conjunctivae are yellowish, and scattered petechiae are noted on the lower extremities. The liver and spleen are not enlarged.

Laboratory studies show the following results: WBC 12,000/mm3; hematocrit 27%; platelets 14,000/mm3; bilirubin 4.5 mg/dL; direct bilirubin 0.5 mg/dL; BUN 40 mg/dL; creatinine 3.5 mg/dL. PT, fibrinogen, and PTT are all normal. Her peripheral blood smear shows fragmented red blood cells.

What is the most effective treatment for this patient?

(A) Splenectomy
(B) Glucocorticoids
© Plasmapheresis
(D) Intravenous immunoglobulins
(E) Platelet transfusion


A 58-year-old woman comes to your office. She is currently in atrial fibrillation and is asymptomatic. Her rate is 70/min. She denies hypertension, diabetes, and congestive failure. There is no other past medical history. What is the most appropriate management of this patient?

(A) Warfarin and clopidogrel
(B) Heparin followed by warfarin
© Low-molecular-weight heparin
(D) Aspirin (325 mg) daily
(E) Warfarin to maintain an INR of 2 to 3


A 62-year-old man presents to your clinic complaining of four days of dysuria, frequency, and urgency. He feels slightly feverish and has had dull, lower-back pain for the past few months. He has had several episodes of the dysuria over the last several months. Each time he was given antibiotics for one week, and the symptoms resolved. Currently his temperature is 100.4 F. The genital examination is unremarkable, and the digital rectal examination reveals a nontender prostate, which is normal in size and consistency, with no palpable masses. After gentle massage of the prostate, a small amount of purulent discharge is extruded from the urethral meatus. The urine culture grows 100,000 colonies/mL of E. coli. Urine cultures from his prior symptomatic episodes also grew E. coli but only 10,000 colonies/mL. Which of the following is most appropriate?

(A) Cystoscopy
(B) Ciprofloxacin and azithromycin orally once now
© Trimethoprim/sulfamethoxazole for one week
(D) Renal ultrasound
(E) Ciprofloxacin for 4 to 6 weeks


A 37-year-old, HIV-positive man comes for evaluation of generalized weakness, diffuse muscle pain, and frequent headaches that began eight weeks after the start of new HIV medications. He has never had any symptoms from his HIV infection, and he has a CD4 of 255/μL and an HIV RNA viral load of 25,000 (by PCR). He was recently started on zidovudine, lamivudine, and ritonavir/lopinavir. His past medical history is significant for hypertension and hypercholesterolemia. His medications include simvastatin and metoprolol. His physical examination is significant for diffuse muscle tenderness of the extremities. The range of motion is decreased because of pain with movement. His potassium level is 5.4 mEq/L, serum bicarbonate is 16 mEq/L, BUN is 35 mg/dL, creatinine is 1.6 mg/dL, and his viral load is RNA 40,000. The genotyping test result is pending. What will you do while waiting for this result?

(A) Switch zidovudine and lamivudine to didanosine and stavudine, and continue ritonavir
(B) Switch zidovudine, lamivudine, and ritonavir/lopinavir to didanosine, stavudine, and indinavir, and stop simvastatin
© Continue all medications but stop simvastatin
(D) Continue zidovudine and lamivudine, and switch ritonavir/lopinavir to efavirenz
(E) Switch to didanosine, stavudine, and efavirenz, and stop simvastatin

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* Re:.....5 good mcq's...................
#989613
aiissman - 10/14/07 11:10

(D) Stop Dilantin

Explanation:

The patient has Dilantin-induced hepatitis. Drug-induced hepatitis may resemble autoimmune hepatitis, including the presence of hypergammaglobulinemia and positive antinuclear antibodies (ANAs). This can result in a false-positive anti-HCV ELISA test. The liver biopsy confirms the picture of drug-induced cholestatic hepatitis. Prednisone and/or azathioprine are the initial treatments of choice for autoimmune hepatitis. Although this patient had a positive ANA, additional tests, such as anti-smooth muscle antibody and anti-LKM (liver, kidney, microsomes), are needed to confirm the diagnosis of autoimmune hepatitis.


© Plasmapheresis

Explanation:

This woman has a combination of hemolytic anemia with fragmented RBCs on peripheral smear; thrombocytopenia; fever; neurologic symptoms; and renal dysfunction -- a classic pentad of symptoms that characterizes thrombotic thrombocytopenic purpura (TTP). Approximately 90% of patients will respond to plasmapheresis. Patient should be emergently treated with large-volume plasmapheresis. Sixty to 80 mL/kg of plasma should be removed and replaced with fresh-frozen plasma. Treatment should be continued daily until the patient is in complete remission. Platelet transfusions in patients with TTP are contraindicated and can be associated with acute clinical deterioration. Antiplatelet agents, splenectomy, intravenous immunoglobulin, and immunosuppressive agents have not been of reliable benefit to patients with TTP. Each is less effective than plasmapheresis. Glucocorticoids are useful in patients if plasmapheresis does not work.


(D) Aspirin (325 mg) daily

Explanation:

This is a young patient who has an episode of atrial fibrillation in the absence of other preexisting conditions. The American College of Chest Physicians has established guidelines for anticoagulation in nonrheumatic atrial fibrillation. Patients with risk factors for the formation of thrombi such as a previous stroke, transient ischemic attack, systemic thromboembolism, left ventricular dysfunction, recent congestive heart failure, systemic hypertension, or diabetes should be placed on warfarin to an INR of 2 to 3. Patients with no risk factors who are younger than 65 years are considered to be low risk and should take one aspirin daily. Aspirin is also suitable for patients with a contraindication to warfarin therapy. The efficacy of other antiplatelet agents has not been proven in patients with atrial fibrillation.

(E) Ciprofloxacin for 4 to 6 weeks

Explanation:

This patient has chronic bacterial prostatitis. Chronic prostatitis can present with lower abdominal pain, perineal pain, or low back pain. There is usually no dysuria unless there is accompanying cystitis. On physical examination, the prostate usually feels normal and is nontender. As in this patient, chronic prostatitis may manifest as a recurrent urinary tract infection (UTI). The key to the diagnosis is culture of urine or urethral discharge. Pathogens for chronic prostatitis in older men are the same as for a UTI, with E. coli being the most common organism identified. One may extrude purulent discharge by massaging the prostate, which will grow the offending organism. One can also culture the urine post massage of the prostate, which should grow ten times more colonies than premassage urine. This patient cultured 10,000 colonies of E. coli in prior cultures, and currently he grew 100,000 colonies postprostatic massage. Ciprofloxacin for 7 days would be appropriate treatment if this were just a UTI. Therapy for one week is not long enough to clear chronic bacterial prostatitis. Most antibiotics don't have good penetration into the prostate, and it takes at least four weeks of therapy with ciprofloxacin to clear the infection. Ciprofloxacin and azithromycin for a single dose would be the treatment for urethritis. This patient does have a urethral discharge, which may be confused with urethritis. However, since the discharge is extruded only on palpation of the prostate, this strongly suggests that the prostate is the source of infection. Cystoscopy would be useful in a patient with recurrent UTIs in whom you suspected a structural malformation of the genitourinary tract. This patient's UTIs are originating from his chronically infected prostate. Trimethoprim/sulfamethoxazole for 12 weeks is an acceptable alternative for treating chronic prostatitis.


(E) Switch to didanosine, stavudine, and efavirenz, and stop simvastatin

Explanation:

This patient presents with a drug interaction between the protease inhibitors and the HMG-CoA reductase inhibitor. In this case, it is with ritonavir and simvastatin. This can produce significant toxicity from the statin. Ritonavir can increase the serum concentration of simvastatin, causing severe myalgias, rhabdomyolysis, and potential renal insufficiency. The next necessary step is to stop simvastatin or change the protease inhibitor to a non-nucleoside reverse-transcriptase inhibitor, such as efavirenz. However, in this case, the patient also presents with failure to achieve a reduction in HIV viral load of 1 log after eight weeks of therapy. In the event of inadequate treatment of HIV infection, the best choice would be to start two new nucleoside reverse-transcriptase inhibitors (NRTIs) and use efavirenz instead of ritonavir, in addition to discontinuing the simvastatin. It is not enough to change ritonavir to indinavir because high-level cross-resistance is very likely. Genotyping guides the therapeutic choice of all treatment failures. The best thing to do when treatment is insufficient is to use as least two, and preferably three, new drugs.

62-year-old woman with a 10-week history of rheumatoid arthritis presents with persistent pain and swelling of her hands and knees. She also has generalized fatigue and weakness. She reports a mild improvement of her symptoms after starting rofecoxib, prednisone, and physical therapy but still has more than 1 hour of stiffness upon awakening each morning. She has a history of macular degeneration and peptic ulcer disease. On physical examination, she has tenderness and soft-tissue proliferation of the proximal interphalangeal and metacarpophalangeal joints. This is symmetrical bilaterally, with limited flexion and extension of both wrists. There is fluid in each knee and soft-tissue swelling. Laboratory tests show a hemoglobin concentration of 10.2 g/dL, and the erythrocyte sedimentation rate is 45 mm/h. Kidney and liver function tests are normal. What therapy should be started in this patient?

(A) Naproxen
(B) Methotrexate
© Hydroxychloroquine
(D) Infliximab
(E) Intra-articular glucocorticoids

]
62-year-old woman with a 10-week history of rheumatoid arthritis presents with persistent pain and swelling of her hands and knees. She also has generalized fatigue and weakness. She reports a mild improvement of her symptoms after starting rofecoxib, prednisone, and physical therapy but still has more than 1 hour of stiffness upon awakening each morning. She has a history of macular degeneration and peptic ulcer disease. On physical examination, she has tenderness and soft-tissue proliferation of the proximal interphalangeal and metacarpophalangeal joints. This is symmetrical bilaterally, with limited flexion and extension of both wrists. There is fluid in each knee and soft-tissue swelling. Laboratory tests show a hemoglobin concentration of 10.2 g/dL, and the erythrocyte sedimentation rate is 45 mm/h. Kidney and liver function tests are normal. What therapy should be started in this patient?

(A) Naproxen
(B) Methotrexate
© Hydroxychloroquine
(D) Infliximab
(E) Intra-articular glucocorticoids

anemia.. methotrexate contraindicated
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Contraindications of MTX
Renal Insufficiency (Serum Creatinine > 1.5)
Pleural Effusion
Ascites
Active stomatitis
Diarrhea
Infection


Relative Contraindications (due to hepatotoxicity)
Alcohol Use
Pre-existing liver disease
Diabetes Mellitus
Obesity
Age >70 years



A 78-year-old white woman is brought to the emergency department unconscious and intubated by paramedics. The patient was found lying unresponsive on the bathroom floor with a heart rate of 30/min. She was apneic and hypotensive with a systolic blood pressure of 60 mm Hg. They gave atropine 1 mg intravenously in the field. The family arrives and tells you that she has a history of congestive heart failure, coronary heart disease, and hypertension and takes furosemide, metoprolol, digoxin, and enalapril. On admission to the emergency department, she has a temperature of 100 F, a heart rate of 35/min, and a blood pressure of 60/40 mm Hg. You give another dose of atropine 1 mg intravenously without any change in the heart rate or blood pressure. Her potassium is 3.6 mEq/L, with a bicarbonate of 22 mEq/L, BUN of 50 mg/dL, and a creatinine of 2.3 mg/dL. An EKG shows third-degree AV block at a ventricular rate of 35/min. Her toxicology screen is negative. What would you do next?

(A) Gastric lavage using activated charcoal
(B) Digibind
© Lidocaine
(D) Potassium
(E) Transcutaneous pacing..
A 52-year-old woman presents to the emergency department with fever, weakness, and abdominal pain for the past three days. It has been associated with nausea and three episodes of vomiting. Her husband states that her temperatures have been as high as 103.5 F and that she has not been herself lately, appearing confused and lethargic. She has a history of hypothyroidism and migraine headaches. She appears lethargic, dehydrated, and is oriented only to person. Her blood pressure is 75/50 mm Hg, temperature is 102.9 F, and pulse is 108/min. She has dry oral mucosa and hyperpigmented areas of her skin spread diffusely over the posterior neck, hands, and knuckles. Rales are heard over the right lower lung field, and the chest x-ray shows a right lower lobe infiltrate. The EKG is normal. The patient is placed on intravenous hydration. Laboratory studies show a white cell count of 6,300/mm3, and the differential shows 82% neutrophils, 7% lymphocytes, and 9% eosinophils. The sodium level is 112 mEq/L, with a potassium of 5.9 mEq/L and a chloride of 92 mEq/L. Bicarbonate level is 20 mg/dL, and BUN is 32 mg/dL. The creatinine level is normal. The glucose level is 60 mg/dL, and the urinalysis is normal. What is the best initial test to diagnose this disorder?

(A) Immediate cortisol and assess ACTH level
(B) Metyrapone stimulation test
© Early morning cortisol
(D) A cosyntropin stimulation test
(E) 24-hour urine cortisol
this is an emergency and the pt is in addison's crisis.Needs immedeate steriod replacement

The concerned parents of a 14-year-old girl bring their daughter to the clinic for evaluation of a
possible eating disorder. They state that over the past 1 to 2 months, the girl seemed to drink
nothing but diet soda and water and lost 15 lb. They do admit that she "eats like a horse" and
wonder if she purges her meals. The girl, once her parents are out of the room, denies any
problems with her self-image and wishes she could keep her weight up, as she feels her
weight loss is limiting her ability as an athlete. She reports feeling weak and fatigued over the
past month and asks if she might have a urinary tract infection, as she always seems to be
urinating. She has never been ill and knows of no illnesses that run in the family. Examination
reveals a thin, well appearing teenager. Which of the following is a likely finding upon further
examination and laboratory testing?
A. Antiglutamic acid decarboxylase antibodies
B. Elevated fasting cholesterol and triglyceride levels
C. Parotid gland hypertrophy and loss of tooth enamel
D. Significant proteinuria on a urine dipstick
E. Retinal vessel proliferation


A 31-year-old woman is brought to a local police precinct by a pedestrian because she
appeared confused. She does not know how she arrived in this town. She has had other
discrete episodes of being in cities, not knowing how she arrived. Additionally, she has a
history of finding clothes in her apartment that she does not remember buying and hotel
receipts in her pockets with another woman's signature. Which of the following factors is most
likely present in this patient's history?
A. Cardiac disease
B. Food allergies
C. Lead exposure
D. Neuroleptic malignant syndrome
E. Physical or sexual abuse
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The correct answer is A. This patient is likely a new-onset type 1 diabetic, with a
classic presentation of polyuria, polyphagia, polydipsia, and weight loss. The most
common cause of type 1 diabetes is autoantibody production against pancreatic
antigens, such as glutamic acid decarboxylase. These antibodies are present in over
70% of type 1 diabetics at the time of presentation and can be a useful test to help
confirm the mechanism of disease in unclear cases
Parotid gland hypertrophy and loss of tooth enamel (choice C) are insensitive findings
that suggest bulimia. Dramatic weight loss is not common in bulimic patients, unless
there is also an anorexic component, and most patients directly or indirectly admit to
self-image problems.



The correct answer is E. The patient most likely has dissociative identity disorder.
There is a high correlation between physical and sexual abuse and dissociative
disorders. For patients with dissociative identity disorder, the fragmenting of a distinct
and integrated personality into multiple personalities may have the adaptive purpose of
protecting the more vulnerable and frightened facets of the core personality after abusive
trauma.

34-year-old white woman comes to the Emergency Room complaining of difficulty breathing that started suddenly several hours ago. She has never had such symptoms before. Her past medical history is significant for rheumatoid arthritis. Her current medications include naproxen and an oral contraceptive. She smokes 1½ packs a day, but does not consume alcohol. Her blood pressure is 110/70 mmHg and heart rate is 105/min. Lungs are clear on auscultation. EKG and chest x-ray are normal. Ventilation/perfusion scan was performed, but the results were inconclusive. What is the best next step in the management of this patient?


A. Pulmonary angiography
B. Pulmonary function tests
C. Venous ultrasonography ..
D. Contrast phlebography
E. Transesophageal echocardiography
A 45-year-old Caucasian male comes to the emergency room complaining of shortness of breath that began 3 hours ago. He also has a nonproductive cough, slight fever and right-sided chest pain that worsens with inspiration. He denies coughing up blood, wheezing, palpitations, leg pain or swelling of lower extremities. He recently had a trip to Singapore. Past medical history reveals hypertension for 8 years, and diabetes mellitus for 4 years. His medication includes captopril and glyburide. He is allergic to penicillin. He doesnot smoke. He drinks alcohol occasionally. His vital signs are T: 101 F (38.3C), BP: 115/70 mmHg, PR: 128/min, and RR: 32/min. Physical examination shows slightly obese white man in acute distress. He is alert and cooperative without any cyanosis or jaundice. His physical examination reveals slightly displaced apex beat with loud S 4. Chest-x ray shows mild cardiomegaly. EKG shows sinus tachycardia and left ventricle hypertrophy; no acute ST-T changes seen. His Arterial Blood Gases shows: pH 7.52, pCO2 30, pO2 60, and 86% O2 saturation on room air. He is started on oxygen. What is the next best step in the management of this patient?


A. Ventilation perfusion scan
B. Pulmonary angiogram
C. Doppler of lower legs
D. Spiral CT scan of chest
E. Start heparin
F. Give thrombolytic therapy with t-PA
G. Placement of inferior vena cava filter
H. Embolectomy
I. Cardiac enzymes
J. PTCA
K. Echocardiogram
elbamaritza - 08/31/07 10:36

AAAAAAA
Ventilation perfussion SCAN after X ray, ABG, EKG
Spiral CAT scan we will chose instead of ventila/perf scan if the RX will be abnormal

If v/q is positive ( missmatche patter ) then treat
if it is normal ...then rule out trombo embolism
if it is inconclusive...venous ultrasound
if it is inconclusive but the symptoms and sign are very clear for PTE do Chest Cat angiogram.
Please correct me if wron
nope, start Heparin remember in a typical case of P.E w/supporting evidence of Chest X ray, EKG and ABG (test that have r/o other causes) and high supuspician Rx precedes V/Q Scan b/c Mortality rates in Pe are very high if not Rx promptly

So if it comes down to the point thta V/Q and heparin are given both in the questions and the initial test have r/o other causes of his Sx's and supician is stil high --- Alwasy choose Rx over testing!!!!
so if the qs says what is the best step in diagnostic i will chose V/Q??
if the test says best step in managment I will chose heparine because with the clinical suspicion is enough to proceed??
Yes

A 36-year-old Hispanic female presented to the emergency room with fever, chills and productive cough. The resident, who was on call, suspected community acquired pneumonia and has prescribed azithromycin for 5 days. After 5 days, she returns to your office with no improvement of her symptoms and worsening foul smelling sputum. Further inquiry reveals that she had undergone upper GI endoscopy for a long history of heartburn and suspected acid peptic disease 8 days ago. She also has a history of manic type bipolar disorder. Her vital signs are, Blood Pressure: 130/80 mm of Hg; Pulse Rate: 108/min; Temperature: 38.7C(101.6F); Respiratory Rate: 26/min. Which of the following antibiotics is the most appropriate therapy that should be considered before sending the patient for further investigations?

A. Doxycycline
B. Levofloxacin
C. Trimethoprim-sulphamethoxazole
D. Clindamycin
E. Gentamycin + ampicillin
A 34-year-old white woman comes to the Emergency Room complaining of difficulty breathing that started suddenly several hours ago. She has never had such symptoms before. Her past medical history is significant for rheumatoid arthritis. Her current medications include naproxen and an oral contraceptive. She smokes 1½ packs a day, but does not consume alcohol. Her blood pressure is 110/70 mmHg and heart rate is 105/min. Lungs are clear on auscultation. EKG and chest x-ray are normal. Ventilation/perfusion scan was performed, but the results were inconclusive. What is the best next step in the management of this patient?


A. Pulmonary angiography
B. Pulmonary function tests
C. Venous ultrasonography
D. Contrast phlebography
E. Transesophageal echocardiography
agree CC , / inconclusive V/Q the next non invasive or less invasive test before going on to gold standard pulm angio
A 22-year-old man with a 2-year history of asthma comes to see you because of worsening respiratory function. He states that he has seen a couple of doctors and tried a couple of inhalers, but has not had much success in controlling his asthma exacerbations. He has had two episodes of pneumonia in the last 2 years and often suffers from episodes of coughing and wheezing. These episodes are associated with blood-tinged, greenish sputum, fever, malaise, and expectoration of brownish mucous plugs. Past medical history and review of symptoms are otherwise unremarkable. Vital signs are: temperature 37.0 C (98.6 F), blood pressure 120/72 mm Hg, pulse 68/min, and respirations 28/min. Examination reveals an ill appearing man in moderate distress. Respiratory examination reveals rare inspiratory crackles in the left lung base and coarse breath sounds in both upper lung lobes. The rest of the examination is normal. A chest radiograph reveals a small amount of parenchymal infiltrates in the upper lobes, some plate-like atelectasis at the left lung base, and some branched, tubular radiodensities that the radiologist describes as œgloved finger shadows. A skin test reveals hypersensitivity to Aspergillus. Serum IgE levels are sent and come back as 1,500 ng/mL (normal is less than 1,000 ng/mL). Which of the following is the most appropriate therapy?
A. Amphotericin B
B. Caspofungin
C. Fluconazole
D. Prednisone ..
E. Surgery
A 60-year-old Caucasian man comes to the physician because of a productive cough and dyspnea on exertion. He denies hemoptysis, chest pain, and leg swelling. He has smoked one-and-a-half packs of cigarettes daily for 40 years and drinks 2-ounces of alcohol daily. He has worked in a shipyard for 10 years. His temperature is 37.2 C (99 F), blood pressure is 140/80 mmHg, pulse is 80/min, and respirations are 20/min. His chest x-ray shows prominent bronchovascular markings and mild diaphragmatic flattening. His pulmonary function testing shows decreased FEV1/FVC ratio and normal DLCO. Which of the following is the most likely diagnosis?


A. Emphysema
B. Chronic bronchitis
C. Sarcoidosis
D. Silicosis
E. Asbestosis
F. Pulmonary fibrosis
G. Scleroderma
H. Rheumatoid lung
B. Chronic bronchitis
decreased FEV1/FVC ratio and normal DLCO
prominent bronchovascular markings and mild diaphragmatic flattening

does that sound more like Chronic Bronchitis, I think shipyard is a distractor
A 25-year-old patient with Hodgkin disease who has recently completed chemotherapy is sent to the emergency department from the oncology clinic. The oncology resident wished to have him admitted for neutropenic fever. He has had approximately 3 days of fever with temperatures of approximately 38.0 C (100.4 F), and he has recently developed a dry cough with occasional small amounts of hemoptysis and pleuritic chest pain. At this time, he has a temperature of 38.3 C (101.0 F), blood pressure of 110/71 mm Hg, pulse of 112/min, and respirations of 28/min. His oxygenation saturation is 94% on room air. Pulmonary examination reveals diffuse, coarse inspiratory crackles. In the emergency department, the patient is evaluated for a pulmonary embolus with a CT scan with angiography, which did not show evidence of a clot. CT scan and chest radiograph, however, show upper lobe nodular lesions and diffuse infiltrates. Additionally, the radiologist reports that a œhalo sign is present, an area of infiltrate surrounded by a crescent of air. Laboratory studies at this time reveal an absolute neutrophil count of 108 cells/mm3. The patient is admitted and presumptive treatment is begun for pneumonia. The patient is started on broad-spectrum antibiotics and granulocyte colony stimulating factor. Cultures are sent for bacterial and fungal growth. By day three the patient has not improved. He continues to spike fevers and has a worsening cough. The pulmonary medicine service performs a flexible fiberoptic bronchoscopy with bronchoalveolar lavage and biopsy. Histopathologic examination of the tissue and lavage fluid reveals narrow, septated hyphae with acute angle branching suggestive of aspergillosis. Fungal cultures obtained at admission also grow a similar organism. At this time, which of the following is the most appropriate therapy?
A. Amphotericin B
B. Caspofungin
C. Itraconazole
D. Prednisone
E. SurgeryA 13-year-old boy comes to his physician with fever and breathlessness for the past two days. For the past 4 years he has been having persistent cough associated with occasional expectoration of brownish mucus plugs. Repeated chest X-rays showed transient pulmonary infiltrates in different lung zones. He was started on antibiotics for these symptoms. He also has mild asthma for which he takes inhaled albuterol. His immunizations are up-to-date and has a normal height and weight. Chest examination is normal. Chest X-ray shows pulmonary infiltrates in lower lung zones. Laboratory testing shows hematocrit of 39%, WBC count of 12,000/microL with eosinophils of 32%, platelet count of 170,000/microL, serum IgA of 150mg/dL, IgG of 800mg/dL, IgM of 170mg/dL, and IgE of 1300 IU/mL. Based on these findings, what is the most likely diagnosis in this patient?

A. Job syndrome
B. Wiskott Aldrich syndrome
C. Allergic bronchopulmonary aspergillosis .
D. Chronic eosinophilic pneumonia
E. Churg Strauss syndrome
A 42-year-old white male presents to your office complaining of periodic breathing difficulty and wheezing. He visited an otolaryngologist for persistent nasal blockage recently. His past medical history is significant for unstable angina experienced five months ago. His current treatment includes aspirin, diltiazem, and pravastatin. He does not use tobacco, alcohol, or drugs. His vital signs are within limits. What is the most probable cause of this patient™s respiratory complaints?


A. IgE-mediated reaction
B. Immune complex disease
C. Cytotoxic antibodies
D. Cell-mediated hypersensitivity
E. Pseudo-allergic reaction
A 40-year-old Caucasian man comes to the emergency department because of fever, dry cough, and shortness of breath. Symptoms started 24 hours ago. He denies hemoptysis. He was recently discharged from the hospital after a second cycle of chemotherapy for acute myeloid leukemia. He does not use tobacco, alcohol, or drugs. His temperature is 38.9 C (102.0 F), blood pressure is 120/70 mmHg, pulse is 112/min and respirations are 28/min. The patient's pulse oximetry showed 86% at room air. Examination shows diffuse crackles all over the lung fields. His chest x-ray shows diffuse interstitial infiltrates. Which of the following is the most likely cause of his condition?


A. Coccidioidomycosis
B. Histoplasmosis
C. Tuberculosis
D. HIV infection
E. Pneumocystis carinii
F. Hodgkin™s lymphoma
G. Berylliosis
H. Silicosis
I. Metastatic testicular cancer
J. Bronchogenic carcinoma
K. Sarcoidosis
L. Rheumatoid nodule
M. Wagener™s granulomatosis
N. Aspergillosis
O. Candida pneumonia
A 54-year-old black male from the southeast USA presents to you with complaints of generalized malaise, fever, and a cough. He claims that he has had intermittent hemoptysis for the past six months. He denies smoking and has never had tuberculosis. Examination is unremarkable and his chest x-ray is shown below. On changing position, you notice that the part of the lesion seen on x-ray also moves. The most likely diagnosis is?





A. Lung abscess
B. Pulmonary embolism
C. Aspergilloma
D. Histoplasmosis
E. Bronchiectasis
ABPA...TREATMENT STERIOD

ASPERGILLOMA ..TREATMENT ..SURGERY

INVASIVE ASPERGILLOSIS .....AMPHOTERICIN B
An 80-year-old Caucasian female is brought to the emergency room by her son with a three-day history of fever and a foul-smelling, productive cough. Her past medical history is significant for advanced dementia, diabetes, and hypertension. She takes aspirin, metformin, insulin, and atenolol. She was admitted two times with pneumonia during the past two months. Her temperature is 38.3 C (101 F), blood pressure is 100/70mmHg, pulse is105/min, and respirations are 20/min. The patient is not oriented in time and place. Physical examination reveals dry mucus membranes and decreased skin turgor. Breath sounds are decreased to the right. A chest x-ray revealed right, lower lobe infiltrate. Which of the following is the most important predisposing factor for this condition in this patient?


A. Decreased lung elasticity
B. Gastro-esophageal reflux
C. Impaired epiglottic reflex because of dementia
D. Decreased thyroid function
E. Depressed cell-mediated immunity
F. Depressed humoral immunity
G. Impaired lymphatic drainage
H. Impaired venous drainage


A patient who has been in hemodialysis
for 18 years has persistent tingling
of his left hand. He has been
diagnosed with carpal tunnel syndrome.
He is well dialyzed and takes his
medications as directed. His blood
pressure is 120/80 mm Hg. Examination
reveals tenderness over the left
median nerve at a left upper arm AV
graft. Thyroid stimulating hormone is
within normal limits.Which of the
following is the most likely cause of
his carpal tunnel syndrome?


A. Dialysis-associated amyloid

B. Occult hypothyroidism

C. Pressure on the median nerve
from the AV graft

D. Recurrent trauma at dialysis

E. Repetitive motion injury
Explanation:

The correct answer is A. Carpal
tunnel syndrome in dialysis patients
is usually due to the deposit of
beta-2 microglobulin, which causes
dialysis-associated amyloid. This can
cause osteoarterial amyloid. There is
no evidence to support any of the
other choices here as a cause of the
carpal tunnel syndrome. Occult
hypothyroidism (choice B) could cause
carpal tunnel syndrome but the normal
TSH makes this diagnosis unl
A 71-year-old man presents to his
physician for follow-up of a recent
emergency department visit. The
patient has a 2-year history of mild
congestive heart failure in the
setting of long-standing hypertension.
He reports that yesterday he sought
care at the local emergency department
for palpitations and shortness of
breath. He was told that his heart was
"fibrillating", but later, the
fibrillation had "stopped on its own."
His medications include a thiazide
diuretic and an ACE inhibitor. On
physical examination, he appears well
and in no distress. His blood pressure
is 130/80 mm Hg, and his pulse is
100/min and regular. His lungs have
scant bibasilar rales, and no gallops
are appreciated. He has a grade 2
holosystolic murmur heard best at the
apex. His jugular venous pressure
(JVP) is 10 cm at 30 degrees. An ECG
taken in the office reveals atrial
fibrillation at a rate of 94/min with
normal ST segments. Which of the
following is the most appropriate next
step in management?


A. Discontinue the ACE inhibitor

B. Initiate amiodarone therapy

C. Initiate beta blocker therapy

D. Initiate digoxin therapy

E. Initiate furosemide therapyikely
The correct answer is D. An important
concept to recognize in the treatment
of medical conditions is that certain
medications overlap syndromes and are
efficacious in many areas. This
"co-treatment" option maximizes the
benefits of each drug in a regimen and
often addresses two or more issues
simultaneously. In this case, ACE
inhibitors have been shown to be very
beneficial in prolonging the survival
of patients with congestive heart
failure (CHF). They are also useful
antihypertensive agents. Given this,
discontinuing his ACE inhibitor
(choice A) is clearly incorrect. This
patient requires rate control for his
atrial fibrillation, that, even at
explan..... moderately elevated rates, causes
cardiovascular embarrassment and
pulmonary edema. Short of restoring
this patient's atrial contractions,
rate control is the best method to
ensure adequate management of atrial
fibrillation. Digoxin, with or without
a nodal agent such as a beta blocker,
has been shown to be reasonably
effective at rate control.

You have been following a 12-year-old girl who was diagnosed with autoimmune thrombocytopenic purpura of childhood (childhood ITP) 1 year ago following a viral illness. She has continued to have thrombocytopenia despite medical therapy. She recently received prednisone for 2 weeks followed by 2 days of intravenous immune globulin therapy. Her platelet count recently dropped below 20,000/mm3 requiring platelet transfusion and she repeatedly presents with diffuse petechiae and epistaxis. You and your colleagues decide that a splenectomy is the next step in treatment due to her persistent and dangerously low platelet count. Following the splenectomy and an uncomplicated postoperative course, she returns to your clinic for follow up. The thrombocytopenia has resolved and she has clinically improved. The most appropriate next step in this patient's management includes
A. a 1-month course of penicillin prophylaxis and influenza vaccine
B. a 1-month course of prednisone with concomitant IVIG therapy
C. permanent penicillin prophylaxis, pneumococcus vaccine, and H. influenza vaccine
D. permanent prednisone therapy and influenza vaccine
E. a 2“week course of prednisone therapy
Explanation:

The correct answer is C. Autoimmune thrombocytopenic purpura of childhood (childhood ITP) is a disorder that usually occurs after a viral illness. The pathophysiology involves antibody (IgG or IgM) binding to platelets. These antibody- coated platelets are subsequently destroyed in the spleen. Thrombocytopenia ensues and most often resolves spontaneously within 6 months. Persistent thrombocytopenia is treated with 2 weeks of prednisone 2-4 mg/kg/day or IVIG 1g/kg/day. Cases refractory to medical therapy in which severe thrombocytopenia persists are treated with splenectomy to prevent further destruction of platelets. An extremely important aspect of management of the asplenic patient includes permanent penicillin prophylaxis in addition to pneumococcal and Haemophilus influenza vaccines. These measures decrease the risk of morbidity and mortality associated with overwhelming sepsis by encapsulated organisms in asplenic patients.

One month of penicillin prophylaxis and influenza vaccine (choice A) is an inappropriate choice. Patients should remain on penicillin prophylaxis due to the continued risk of infection. Asplenic patients are susceptible to infection with encapsulated organisms including Pneumococcus and H. influenza, thus vaccination against influenza is unnecessary.

One month of prednisone with concomitant IVIG therapy (choice B) is not indicated at this point. This patient has already failed these therapies and her condition has improved after the splenectomy.

Permanent prednisone therapy and influenza vaccine (choice D) is an inappropriate choice. Permanent prednisone would act to chronically suppress this patient's immune system making her more susceptible to an infection. Once again, influenza vaccination is not warranted in asplenic patients.

Two weeks of prednisone therapy (choice E) is inappropriate at this point. As stated before, prednisone therapy has already failed and the patient has improved post splenectomy.
A 71-year-old woman comes to the emergency department because of severe shortness of breath, retrosternal chest pain, a fever, and a dry cough that has worsened over the past three weeks. She says that she is rarely sick and she prides herself on being the "healthiest and most active grandmother in the northeast." She swims everyday and goes out with friends four nights a week since her husband passed away five years ago. She blushes as she admits that she has many male "suitors". She does not smoke cigarettes. However, she drinks a "moderate" amount of alcohol each day. She recalls having an episode of fever, headaches, joint pain, a loss of appetite, and a mild sore throat a few months ago that she did not seek medical attention for because she assumed it was a "virus". Her temperature is 38.8 C (101.8 F) and respirations are 35/min. She has bibasilar rales and significant cervical, axillary, and inguinal lymphadenopathy. A chest x-ray shows bilateral patchy alveolar infiltrates. Histologic evaluation of a sputum sample obtained by bronchoalveolar lavage shows round structures when stained with methenamine silver. An important question to ask at this time is:
A. "Did you or your late husband ever install insulation or brake lining, do construction work, or work in a shipyard?"
B. "Do you engage in unprotected sexual intercourse at the present time or at any other time in the past?"
C. "Have you ever been involved in a homosexual relationship?"
D. "Have you ever had a morning drink to get started (an "eyeopener")?"
E. "Have you ever had a positive PPD or been exposed to anyone with tuberculosis?"
BB she has pcp and likely to nave aids
A 14-year-old boy is brought to the emergency department after he collapsed on the high school football field during a game. He is awake and alert but is unable to tell you exactly what happened. His teammate says that the patient was running down the field and was about to catch the ball, but he collapsed before he even made contact with the ball. The patient remembers becoming dizzy before he collapsed, but he did not experience any arrest of motion during this time. He has no medical conditions and does not take any medications. He is sexually active with 2 different girls and they "sometimes" use condoms for protection. His temperature is 36.7 C (98.0 F), blood pressure is 110/70 mm Hg, pulse is 100/min, and respirations are 14/min. Physical examination is normal. Blood is drawn and sent for evaluation of electrolytes, BUN, creatinine, magnesium, and calcium. The most appropriate next step is to
A. admit him for cardiac monitoring
B. order echocardiography
C. order electrocardiography
D. order electroencephalography
E. request consultation with a neurologist
F. schedule a tilt-table test
Explanation:

The correct answer is C. This young, healthy, athletic patient had a syncopal episode, which can be cardiogenic or neurogenic in origin. After the history and physical, blood work is usually sent to rule out anemia, infections, hypocalcemia, or hypomagnesemia and an EKG must be performed. An EKG may show evidence of cardiac abnormalities such as Wolf-Parkinson-White syndrome (r wave slurring), idiopathic hypertrophic subaortic stenosis, or congenital prolonged QT syndrome.

It is inappropriate to admit him for cardiac monitoring (choice A) before even performing an EKG. You need to first try to distinguish the etiology of this syncopal episode, therefore an EKG and other studies should be done in the emergency department. Cardiac monitoring may be necessary if an arrhythmia is found.

An echocardiogram (choice B) may be necessary to evaluate cardiac abnormalities, however this should not be done until an EKG is performed.

An electroencephalogram (choice D) may be performed if a seizure is suspected. However this should not be performed at this time in this patient because it does not seem like he had a seizure.

A neurology consultation (choice E) is not necessary at this time because you must first try to determine whether this syncopal episode was cardiogenic or neurogenic in etiology. An electrocardiogram is an easy test to perform in the emergency department to assess for cardiac abnormalities.

A tilt-table test (choice F) is useful in establishing the diagnosis of vasovagal/neurocardiogenic syncope, which is caused by venous pooling, decreased venous return, inappropriate vasodilatation, hypotension, and relative bradycardia. A positive test will show hypotension and bradycardia, and syncope. This test is not part of the initial evaluation of a single syncopal episode in a young, healthy, athletic patient. It is usually used in patients with multiple unexplained syncopal episodes. An electrocardiogram is easier to perform and is more likely to help establish a diagnosis in this patient at this time.
elp establish a diagnosis in this patient at this time.
patient with a long history of
bipolar disorder, mixed type, was
recently started on an anticonvulsant
that he was told would help with his
mood swings. He had been on it for 5
weeks when he developed skin changes
that looked like burns. He was rushed
to the hospital and diagnosed with
Stevens-Johnson syndrome. Which of
the following medications did this
patient most likely take?


A. Carbamazepine

B. Clonazepam

C. Gabapentin

D. Lamotrigine?

E. Valproate
A 54-year-old woman that you have been treating for hypertension comes to the office for a "blood pressure check." She tells you that she recently stopped taking the enalapril that you prescribed because of the "annoying" side effects. A friend of hers, who is also hypertensive, told her about an herbal therapy that has "done wonders" for his blood pressure. The patient says that she was a bit hesitant at first, but that she has been taking it for about 3 months now, and she feels great. You review her chart and note that her blood pressure has been ranging from 120/80 to 130/80 mm Hg over the past year. Today, her blood pressure is 150/90 mm Hg and pulse is 70/min. Physical examination is otherwise unremarkable. You should advise her that:
A. Her blood pressure is still elevated, and that the herbal therapy is not only doing her "no good," but it may actually lead to dangerous complications
B. It is difficult for you to continue treating her if she is just going to discontinue the medications that you prescribe
C. She should consider going to another physician who will incorporate herbal remedies with medications
D. She should have called you when she decided to discontinue the enalapril
E. You can give her a different medication, without the "annoying" side effects of enalapril, that she can take instead of the herbal therapy.
A 78-year-old woman is complaining to
the doctor in her nursing home about
her new problems. She reports that
her old boyfriend from 50 years ago
called her and is now harassing her
by controlling her blood pressure,
movements, and thoughts. She is
convinced that he was initially doing
this through the phone by sending
special signals with a device that
the CIA uses, but now he is able to
control her through his thoughts. She
stated that she couldn't tell the
police because they probably would
not believe her. This patient most
likely has which of the following
thought disorders?


A. Clang associations

B. Ideas of influence

C. Ideas of reference

D. Noesis

E. Obsessions
Explanation:

The correct answer is B. Ideas of
influence constitute a type of
delusion in which a person believes
that he or she is being controlled
by another person or external force.

Clang associations (choice A) are
disorders of thought in which the
associations of words are similar in
sound but not in meaning. Words have
no logical connection, but there may
be rhyming.

Ideas of reference (choice C) are
delusions in which a person has a
false belief that others (including
people on TV or radio) are talking
about him or her. In a broader
sense, the behavior of others refers
to oneself, other persons, or
objects that have special
significance and meaning.

Noesis (choice D) refers to the
feeling of revelation in which a
person experiences illumination
associated with a sense of being
chosen as a leader.

Obsessions (choice E) are
pathologically persistent intrusive
thoughts or impulses that cannot be
eliminated from consciousness by
logical effort and thus cause
anxiety. The person is aware that
they are not imposed from the
outside but are a product of his or
her own mind.
a previously healthy 37 yo woman comes to the physician beccause ofa 3 mth hx of episodes of severe anxiety, SOB, palpitaltions and numbness in her hands and feet. her vital signs are within normal limits, PE shows no abnormalities, thyroid function studies and an ECG show no abn. which of the following is the most appropriate pharmacology/
lithium
methyphenidate
olanzapine
paroxetine..srri.en etapa aguda alprazolam
valproic acid
25-year-old primigravid woman comes
to the physician for her first
prenatal visit. Her last menstrual
period was 7 weeks ago. She has had
some nausea and vomiting but otherwise
has no complaints. Past medical and
surgical history are unremarkable. Her
family history is significant for
cystic fibrosis with an affected aunt.
Her husband has an affected cousin.
Physical examination is unremarkable.
Given her family history, she is
concerned about the risks of having a
child with cystic fibrosis. She
inquires about cystic fibrosis
screening. Which of the following is
the appropriate response?


A. Screening is available.

B. Screening is inappropriate in
her case

C. Screening is mandatory

D. Screening is not available

E. Screening is unnecessary: she
has a 1 in 4 chance of having an
affected child
A 35-year-old HIV-positive man comes
to medical attention with a 6-month
history of progressive memory loss and
incontinence. He is taking zidovudine
and a protease inhibitor. He first
noticed difficulties with handwriting.
Neurologic examination demonstrates
deficits in cognitive and fine motor
control functions. Laboratory
investigations show a CD4 cell count
of 25/mm3. MRI studies reveal moderate
brain atrophy but no focal lesions. A
lumbar puncture shows no CSF
abnormalities. Which of the following
is the most likely diagnosis?


A. CMV encephalitis

B. Cryptococcal
meningoencephalitis

C. HIV encephalitis

D. HIV myelopathy

E. Primary brain lymphoma

F. Progressive multifocal
leukoencephalopathy

G. Toxoplasmosis
Explanation:

The correct answer is C. AIDS may
lead to various complications
affecting the CNS. Among these, HIV
encephalitis, clinically known as
AIDS dementia complex, is the most
common. The pathologic substrate is a
subacute inflammatory infiltration of
the brain caused by direct spread of
HIV to the CNS. Presence of the HIV
genome can be demonstrated by in situ
hybridization in microglia and
histiocytes. The diagnosis of HIV
encephalitis (or AIDS dementia
complex) must be reached by exclusion
of other infective and neoplastic
conditions associated with AIDS. AIDS
dementia complex is characterized by
cognitive impairment, incontinence,
impairment of motor skills, and
confusion. MRI studies and CSF
analysis are useful in excluding
other CNS diseases (see below).

CMV encephalitis (choice A) usually
affects the periventricular regions
of the brain and the retina. CMV
encephalitis is usually associated
with disseminated infection. CMV can
be isolated in the CSF. MRI may also
demonstrate periventricular white
matter abnormalities.

Cryptococcal meningoencephalitis
(choice B) is an acute
life-threatening disease manifesting
with signs and symptoms of increased
intracranial pressure and fever. The
CSF would show numerous cryptococcal
organisms.

HIV myelopathy (choice D) manifests
mainly with spastic paraparesis. It
is a complication similar in
pathologic substrate to vitamin B12
deficiency, i.e., vacuolar
degeneration of the posterior and
lateral columns of the spinal cord.
Its pathogenesis is still unclear,
but a direct viral effect is
suspected.

Primary brain lymphoma (choice E) is
a frequent manifestation of AIDS. The
MRI would show a ring-enhancing mass,
which is not the typical radiologic
presentation of brain lymphomas in
immunocompetent hosts.

Progressive multifocal
leukoencephalopathy (choice F)
consists of multifocal areas of
myelin destruction. These changes
would be visible on MRI. This
complication is due to JC virus, a
papovavirus that causes asymptomatic
infections in immunocompetent
individuals.

Toxoplasmosis (choice G) manifests on
MRI in a manner similar to lymphoma,
i.e., a ring-enhancing mass. This
opportunistic infection is extremely
frequent in AIDS patients.
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An otherwise healthy 5-year-old boy is
brought to the emergency department of
a small hospital because of a simple
3-cm laceration in his forehead. The
patient is crying and frightened. The
practitioner decides to perform
conscious sedation before suturing the
laceration. Support personnel and
equipment are available for monitoring
the patient's vital status and
carrying out resuscitation measures if
needed. Which of the following is the
most appropriate pharmacologic agent
to achieve a safe level of conscious
sedation in this situation?


A. Oral or rectal midazolam or
diazepam

B. Concomitant opioid and
benzodiazepine administration

C. Intravenous propofol

D. Intravenous ketamine

E. Concomitant analgesic-sedative
agents and muscle relaxants
The correct answer is A. Suturing a
laceration is one of the most common
situations in which sedation may be
required in a child. Sedation may be
classified as conscious or deep. By
definition, during conscious sedation
the patient is able to maintain
airway patency, protective airway
reflexes, and responses to physical
stimuli. This level of sedation is
indicated for children (or adult
patients) who have not fasted prior
to the procedure, or patients who do
not require a deep level of sedation.
Nevertheless, conscious sedation
should be performed by appropriately
trained personnel, and only when
equipment for resuscitation measures
is readily available, should the need
arise. For minor surgical procedures
such as suturing uncomplicated linear
lacerations, administration of a
short-acting or long-acting
benzodiazepine (midazolam or
diazepam, respectively) by the oral
or rectal route provides sufficient
sedation. Intravenous access is not
required. Intravenous midazolam or
diazepam can be used for procedures
that produce more intense pain or
discomfort, such as repair of complex
lacerations, bone marrow aspiration,
and reduction of fractures.

Concomitant opioid and benzodiazepine
administration (choice B) is used to
achieve not only sedation, but also
an adequate level of analgesia. The
synergistic action of opioids and
benzodiazepines increases the risk of
respiratory depression.

Intravenous propofol (choice C)
provides rapid onset of sedation that
resolves quickly once infusion is
discontinued. This drug is used for
procedures requiring deeper levels of
sedation in appropriately fasted and
stable children.

Intravenous ketamine (choice D) is an
appropriate alternative to propofol.
Its most common side effect is the
production of visual and auditory
hallucinations (about 10% of cases).

Concomitant analgesic-sedative agents
and muscle relaxants (choice E) is
employed for deep sedation and when
muscle relaxation is necessary for
endotracheal intubation or other
diagnostic/therapeutic procedures
A physician is called to see a
69-year-old woman who underwent
cardiac catheterization via the right
femoral artery earlier in the morning.
She is now complaining of a cool right
foot. Upon examination she has a
pulsatile mass over her right groin
with loss of her distal pulses, and
auscultation reveals a bruit over the
point at which the right femoral
artery was entered. Which of the
following is the most likely
diagnosis?


A. Cholesterol emboli syndrome

B. Femoral aneurysm

C. Femoral hernia

D. Femoral pseudoaneurysm

E. Retroperitoneal hematoma

what drug is used for a pregnant who just has contact with the patient with meningococus meningitis.. Rifampin is not safe in pregnancy.
meningococal vaccine reccom -- high risk cases
if not vaccinated b4 .... ceftriaxone , preffered ,prophylactic

An 18-year-old man is taken to the
emergency room by his family when he
develops very severe headache
accompanied by high fever. On physical
examination, the patient is incoherent
and demonstrates nuchal rigidity. CSF
shows gram-negative diplococci. When
talking to the family, the physician
learns that the patient has had 5
episodes of meningococcal meningitis
in the past, the earliest being at age
6. Immunodeficiency related to
impaired function of which of the
following should be suspected?


A. B cells

B. Complement factors

C. Eosinophils

D. Neutrophils

E. T cells
40-year-old woman is brought to the emergency department by her daughter who states that she found her mother at home several hours ago, confused, lethargic, and unable to get up from her chair or speak. Her mother has a seizure disorder for which takes an antiseizure medication. She also has a history of alcohol abuse in the remote past. For the past several weeks, her mother has been complaining of difficulty sleeping and anxiety. The patient is stuporous and unresponsive to verbal stimuli. Her blood pressure is 100/60 mm Hg, heart rate is 50/min, and respiratory rate is 9/min. The pupils are pinpoint, and there is horizontal nystagmus. Asterixis is present.

Laboratory examinations reveal: white cell count 9,800/mm3, sodium 150 mEq/L, BUN 18 mg/dL, creatinine 0.9 mg/dL, glucose 50 mg/dL, calcium 5 mg/dL, ammonia 100 μg/dL, albumin 3.0 g/dL, AST 100 U/L, ALT 80 U/L. The urinalysis and lumbar puncture are normal. A CT scan of the brain shows cerebral edema. Arterial blood gas shows a pH of 7.20, a pCO2 of 46 mm Hg, and a pO2 of 79 mm Hg. Osmolar gap is zero. The toxicology screen is negative for benzodiazepines and opioids. What is the most likely substance that this patient overdosed on?

(A) Phenytoin
(B) Carbamazepine
© Valproic acid
(D) Ethanol
(E) Valium
This patient most likely is intoxicated with valproic acid. This drug is widely used in the management of seizure and mood disorders. Valproic-acid intoxication produces a unique syndrome consisting of hypernatremia, metabolic acidosis, hypocalcemia, elevated serum ammonia, and mild liver aminotransferase elevation. Hypoglycemia may occur as a result of hepatic metabolic dysfunction. Coma with small pupils may be seen, and this can mimic opioid poisoning. Encephalopathy and cerebral edema can occur.

Phenytoin and carbamazepine are also commonly used antiseizure medications. Phenytoin intoxication can occur with only slightly increased doses. The overdose syndrome is usually mild. The most common manifestations are ataxia, nystagmus, and drowsiness. Hepatic encephalopathy would be unusual. Choreoathetoid movements are occasionally seen. Carbamazepine is a first-line agent for temporal lobe epilepsy, as well as trigeminal neuralgia. Intoxication causes drowsiness, stupor, coma, or seizures. However, dilated pupils and tachycardia are more common.

Signs of ethanol intoxication are similar to the signs of anticonvulsant medication. In addition, it causes a high osmolar gap. Valium is an unlikely cause of intoxication because this patient's blood benzodiazepine levels are negative.
A 25-year-old man comes to your clinic stating that he can no longer take his seizure medication because his gums "look horrible." He is seeing you for the first time. He has been on phenytoin 100 mg, three times a day, for the last 6 years for generalized tonic-clonic seizures. Despite therapeutic levels of phenytoin, he also experiences occasional jerking of his extremities and has spells in which he "blanks out" for a few seconds. His physical examination shows gingival hyperplasia. His neurological exam is within normal limits. An MRI of his head was normal two years ago. Also, an EEG performed one year ago showed generalized spike and wave abnormalities. What is the most appropriate recommendation at this time?

(A) Start gabapentin and taper the phenytoin
(B) Discontinue phenytoin and switch to carbamazepine
© Increase the dose of phenytoin from 300 to 400 mg daily
(D) Serum phenytoin level and liver function tests should be obtained and the dosage adjusted
(E) Add valproic acid and taper the phenytoin..
(F) Continue the phenytoin and tell him not to operate a moving vehicle for at least one year

A 56-year-old man presents to the clinic with complaints of fatigue for the past 2 months. He has a history of iron-deficiency anemia. Currently, he is on iron supplements. He denies nausea, vomiting, and diarrhea and has one to two, formed, brown bowel movements per day. He denies weight loss. He has a history of hypertension, which has been controlled on medications. Physical examination is remarkable for pale sclera. Otherwise, the examination is normal. Stool occult blood test is negative, and an upper endoscopy is normal. The colonoscopy revealed a 4-mm polyp that was noted to be hyperplastic on biopsy. Laboratory studies show a hematocrit of 29%. Iron studies are as follows: serum iron 7 μmol/L (normal 9-31 μmol/L), ferritin 14 (normal 16-300 μg/mL), and total iron-binding capacity 92 μmol/L (normal 45-82 μmol/L). Which of the following is the next best step in management?

(A) Repeat fetal occult blood test, upper endoscopy, and colonoscopy
(B) Increase dose of iron therapy
© Mesenteric angiogram
(D) Serology testing for IgA antiendomysial antibody
(E) Quantitative analysis of fecal fat
Celiad sprueendomisial antibody d is rt.
A 56-year-old man is admitted to the hospital for elective cardiac bypass surgery.

As part of his preoperative evaluation, you note an elevated alkaline phosphatase. The other liver function studies are within normal limits. Serum calcium and phosphate are within normal limits. The patient denies any history of bone pain, and the physical examination is normal. What is the next step in the management of this patient?

(A) Obtain a radiologic bone survey
(B) Order a nuclear bone scan
© Begin risedronate orally
(D) Order a 24-hour urine test for hydroxyproline
(E) Begin intranasal calcitonin
paget; but which one is first xray, or nuclear scan:


..bone scans are useful when therapy is planned to document the extend of disease or to confirm diagnosis when radiologic findings are inconclusive...

so ans AA.
A 21-year-old woman presents with a history of ulcerative colitis and insulin-dependent diabetes mellitus. She is admitted for a diabetic foot ulcer and is started on cefotetan. On the day of admission, her colitis flares up, and she has seven episodes of diarrhea. She stops eating, fearing that food may exacerbate her symptoms. She also develops a headache for which she takes acetaminophen every four hours. Four days after the admission, she starts having a nosebleed, which stops with nasal packing. The following day, while ambulating, the patient trips and falls against a chair, resulting in a bruise that develops into a large hematoma. She denies easy bruising or excessive bleeding during dental procedures in the past.

Laboratory studies show the following results:

WBC 6,200/mm3; hemoglobin 9.6 mg/dL; hematocrit 27.5%, platelets 300,000/mm3. Bleeding time 3 minutes (normal); PT 18 seconds; INR 1.5; PTT 42 seconds; albumin 3.5g/dL; total bilirubin 1.2 mg/dL; alkaline phosphatase 95 U/L; ALT 32 U/L; AST 2 5 U/L; ESR 70 mm/h.

What would be the most appropriate in treating this hemostatic disorder?

(A) Desmopressin acetate
(B) Vitamin K
© Factor VIII
(D) Fresh frozen plasma
(E) Aminocaproic acid
patient This has vitamin K deficiency based on the recent onset of an increase in bleeding combined with a normal platelet count and an increase in PT, PTT, and INR. She is receiving cefotetan, a cephalosporin known to interfere with the vitamin K-dependent production of clotting factors, and she has not eaten for several days. Antibiotics of any kind can kill off colonic bacteria that produce vitamin K. In addition, the flare-up of colitis will interfere with the absorption of fat-soluble vitamins, such as vitamin K. She does not seem to have significant liver disease based on the normal liver function tests.
Desmopressin, a synthetic derivative of vasopressin, promotes the release of von Willebrand's factor and factor VIII from subendothelial stores and is the first treatment for von Willebrand's disease and very mild hemophilia. Although our
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