MINOR : Decision-Making Capacity

MINOR : Decision-Making Capacity

The definition of emancipated minor varies somewhat from state to state. Generally, legislation defines emancipated minors as those who have graduated from high school, members of the armed forces, those who are married, those who are pregnant or parents, or those who live apart and are financially independent from their parents.
The legal notion of mature minor varies even more. Many courts and some legislatures recognize that individual children, beginning at approximately age 14 years, may be assessed sufficiently mature to make decisions, including some medical ones, for themselves.

Prophylaxis for PCP for all infants born to HIV-infected women should be initiated at:

A. immediately after confirming that infants is HIV positive
B. at 4 to 6 weeks of age, regardless of the infant's HIV status
C. at 1 to 3 weeks of age, regardless of the infant's
HIV status
D. depends on CD-4 counts
E. Prophylaxis for PCP is not reccomended at all during first year

B

Initiating PCP Prophylaxis for HIV-Exposed Infants

Prophylaxis for PCP for all infants born to HIV-infected women should be initiated at 4 to 6 weeks of age, regardless of the infant's CD4+ lymphocyte count. Infants who are first identified as being HIV-exposed after 6 weeks of age should begin prophylaxis at the time of identification. These recommendations are based on the following: (1) most cases of PCP among HIV-infected children occur during the first year of life; (2) the risk for PCP begins to increase dramatically at 2 months of age (when HIV infection cannot yet be reasonably excluded ; and (3) the reliability of CD4[+] lymphocyte counts in predicting risk for PCP is relatively low during infancy, particularly among infants 6 months of age or younger, the age at which the peak incidence of PCP occurs.

Prophylaxis for PCP should not be administered to infants younger than 4 weeks of age because they are at low risk for PCP and the use of sulfa drugs among infants at this age is not advised because immature bilirubin metabolism may result in adverse drug effects. Additionally, the concurrent use of sulfa drugs among infants receiving zidovudine during the first 6 weeks of life to prevent perinatal HIV transmission could exacerbate the anemia that some infants receiving zidovudine experience. Therefore, to avoid the potential for adverse drug reactions in infants receiving zidovudine, prophylaxis against PCP should be started at 6 weeks of age, the age at which zidovudine is discontinued.

Ref: AMERICAN ACADEMY OF PEDIATRICS

P. carinii pneumonia occurs most often at three to six months of age, an age when infection has not yet become apparent in many HIV-exposed infants.
Prophylaxis should be initiated at four to six weeks of age in all infants born to HIV-infected women.

Mr. B is a 75-year-old male with Parkinson's disorder and depression. For 4 years, he was put on Paxil, that caused him to be delirious and didn't help much. He has decreased energy, but sleeps well and has a good appetite. The Anti Depressant of choice would be:

1) Prozac

2) Wellbutrin (Bupropion)

3) Increase the dose of Paxil

4) Nardil (MAO inhibitor)

5) Serzone

Serzone (generic name nefazodone hydrochloride) was approved by the FDA for use in the United States for the treatment of depression in 1994. It has been prescribed in Europe for over 15 years with no long term side effects reported thus far.
An anti-depressant in a class of its own in terms of its structure and composition, Serzone shares some characteristics with other serotonin uptake inhibitors like Prozac, Paxil and Zoloft. It is most often used to treat a specific form of depression without some of the side effects so commonly experienced by users of other similar drugs.
Unlike other anti-depressants Serzone does not cause weight gain in the majority of users, although it can increase appetite. While Zoloft and Prozac can often cause insomnia, tiredness, restlessness and loss of libido, Serzone has the opposite effect and does not aggravate existing sleep problems; indeed it often encourages and supports better sleep patterns. Likewise, Serzone is not associated with a decrease in libido or sexual functioning.

Match the following statement with the appropriate response: Small cell carcinoma of the lung

a. TNM staging closely correlates with survival.
b. Most patients present with early stage disease.
c. Immunohistochemistry plays a limited role in the diagnosis.
d. Paraneoplastic syndromes seldom occur in patients with small cell carcinoma of the lung.
e. Represents 20% of all lung cancers.

E

SCLC
-common paraneoplastic syndrome
-small, dark-staining cells with little cytoplasm
-rapid growth, early meta.(chemotherapy first)

Germ cell malignancies in men and women share certain clinical characteristics. Current therapy has significantly improved the prognosis. All of the following statements about germ cell malignancies are true except:

a. Seminomas typically present with localized disease and negative serum markers; they exhibit an excellent response to radiation therapy.
b. Elevation of -fetoprotein (AFP) or human chorionic gonadotropin (HCG) in a patient whose tumor appears to be pure seminoma suggests undetected nonseminomatous tumor and more advanced stage, which impacts on future treatment recommendations.
c. Hydatidiform mole may be differentiated from choriocarcinoma by greater elevation of HCG and absence of a 46 XX androgenic genotype.
d. Malignant trophoblastic disease must be included in the differential diagnosis of any woman of childbearing age who presents with unexplained stroke, intraperitoneal hemorrhage, or pulmonary metastases. Diagnosis is confirmed by elevation of serum HCG in the absence of pregnancy.
e. Systemic chemotherapy in nonseminomatous tumors and malignant trophoblastic disease may result in dramatic reduction of HCG and eventual cure.

The correct answer is c.
c. Malignant trophoblastic disease may follow any type of pregnancy including ectopic gestations, term pregnancies, spontaneous or therapeutic abortions, or hydatidiform mole. More than half of these malignancies are diagnosed when serum HCG titers rise after the evacuation of a classic or complete hydatidiform mole, a benign trophoblastic neoplasm.

Select the most appropriate diagnosis for this clinical presentation: Peripheral anemia with marrow megaloblastic erythroid hyperplasia; 15% progression to acute leukemia.

a. Refractory anemia
b. Chronic myelomonocytic leukemia
c. Refractory anemia with ringed sideroblasts
d. Agnogenic myeloid metaplasia
e. MGUS

B

Myelodysplastic syndrome (MDS) refers to a heterogeneous group of closely related clonal hematopoietic disorders. All are characterized by a cellular marrow with impaired morphology and maturation (dysmyelopoiesis) and peripheral blood cytopenias, resulting from ineffective blood cell production.

Myelodysplastic Syndromes
Refractory Anemia (RA)
Refractory Anemia with Ringed Sideroblasts (RARS)
Refractory Anemia with Excess Blasts (RAEB)
Refractory Anemia with Excess Blasts in Transformation (RAEB-T)
Chronic Myelomonocytic Leukemia (CMML)

The average age at diagnosis is usually >60 years; less than 10% diagnosed before the age of 50 years.
MDS should not be diagnosed if there is evidence of either a B12 or folate deficiency. Remember megaloblastoid changes are often seen in the erythroid and megakaryocytic lines of MDS and are similar to abnormalities of megaloblastic anemia.

Chemotherapy, bone marrow transplantation, and hematopoietic growth factors (GM-CSF;G-CSF) are current options for treatment of MDS.

The theraputic goal is to eliminate the abnormal clonal population of cells and to replace it with normal hematopoietic elements.

The MDS transform to acute myeloid leukemia (AML) in about 30% of patients after various intervals from diagnosis, and at variable rates
RA-16%
RARS-15%
CMML-29%
RAEB-48%
RAEBT-62%
The acute leukemic transformation is much less responsive to chemotherapy than is de novo AML. Prognosis is also related to the type of myelodysplastic syndrome.

Megaloblastic erythroid hyperplasia with macrocytic anemia associated with normal B12 and folate levels is frequently observed. Circulating granulocytes are frequently severely reduced in number, often hypogranular, and display the acquired pseudo Pelger-Huet abnormality.

Which of the following statements about renal cancer is true?

a. It seldom occurs in patients under age 50.
b. It must be considered if an asymptomatic renal mass is demonstrated by an ultrasound.
c. It may metastasize to bone, lung, or brain only after local recurrence manifests.
d. It is exquisitely sensitive to chemotherapy.
e. It rarely exhibits a protracted latency between initial presentation and development of metastases.

B

1. Common in age 50 and 60.
   b. classic triad(hematuria, flank pain,abdominal mass)is only seen <10%
   c. metastasize to bone(49%), lung(50%), brain(3%),skin(11%) and liver(8%)
   d.radical nephrectomy)localized RCC standard Tx.
   chemotherapy-stage IV

Match the following statement with the appropriate response: Mesothelioma

a. Chemotherapy and radiation therapy offer no survival benefit.
b. Subtotal pleurectomy is often curative.
c. Women are affected five times more commonly than men.
d. The interval between asbestos exposure and tumor formation is under five years.
e. Immunohistochemistry plays no role in diagnosis.

A

Neither surgery, chemotherapy, nor radiation alone improves survival. Death usually occurs in 4-12 months due to complications of pneumonia or respiratory failure.
Many have a significant history of asbestos exposure 30-40 years prior to clinical presentation during the fifth through sixth decade of life. Men are three times more likely to have the disease than women. For obvious reasons, more men were involved in the high-risk occupations like mining, manufacturing, and ship construction.

All of the following statements regarding Hodgkin's disease are true except:

a. Sixty percent of patients have clinical Stage I or Stage II disease, potentially curable with radiation alone.
b. Pathologic cell type remains the most significant prognostic factor.
c. Staging laparotomy often represents the most effective method of detecting splenic or upper abdominal disease in clinical Stage I or Stage II patients.
d. If radiation therapy is not a treatment option for any reason, patients should not undergo staging laparotomy but should receive combination chemotherapy.
e. The risk of myocarditis and pericarditis is increased in patients receiving chest irradiation and doxorubicin.

The correct answer is b.
b. Patients with stage I or stage II disease remain potentially curable with radiation alone. The pathological cell type is not as important as the initial stage in overall prognosis.

Chemotherapy may be a curable treatment in all of the following situations except

a. Testicular cancer with metastases to the pelvis and lungs
b. Hodgkin's disease with bone marrow involvement
c. Diffuse large cell lymphoma
d. Metastatic melanoma to regional lymph nodes
e. Ewing's sarcomaChemotherapy may be a curable treatment in all of the following situations except

a. Testicular cancer with metastases to the pelvis and lungs
b. Hodgkin's disease with bone marrow involvement
c. Diffuse large cell lymphoma
d. Metastatic melanoma to regional lymph nodes
e. Ewing's sarcoma

D

1. Metastatic melanoma remains particularly resistant to systemic chemotherapy (as does hepatocellular cancer)..
   -curable by CTx.-
   ALL
   AML
   Ewing's sarcoma
   Hodgkin's lymphoma: burkitt's lymphoma, follicular
   mixed lymphoma,diffuse large cell lymphoma
   rhabdomyosarcoma
   testicular carcinoma
   wilms' tumor
   gestational trophoblastic carcinoma
   -CTx.has minor activity-
   melanoma, brain tumor,.

A 60-year-old asymptomatic white woman has an annual physical examination. Laboratory studies show an elevated leukocyte count on complete blood count. Her physician performs a careful physical examination and proceeds with further studies.
All of the following statements about this patient's diagnosis are true except:

A. Physical examination reveals bilateral nontender soft cervical adenopathy and a palpable spleen tip. Review of the peripheral smear demonstrates significant absolute lymphocytosis, anemia, and mild thrombocytopenia. Other laboratory studies demonstrate hypogammaglobulinemia. Median survival with conservative therapy should be approximately 10 years.
B. Physical examination reveals no adenopathy, but the spleen tip is palpable. Review of the peripheral smear demonstrates myeloid cells, including metamyelocytes, myelocytes, an occasional blast, NRBCs (nucleated red blood cells), mild anemia, and thrombocytosis. Other laboratory studies reveal bcr-abl and isochromosome 17. Median survival with conservative therapy will be less than 5 years.
C. Physical examination reveals massive splenomegaly. Subsequent peripheral blood smears demonstrate granulocytopenia and tartrate-resistent acid phosphatase lymphoid cells. Median survival with immunotherapy may be extended.
D. Physical examination reveals generalized peripheral adenopathy and splenomegaly. Review of the peripheral smear demonstrates lymphocytes with convoluted nuclei, T4 immunophenotype, anemia, and thrombocytopenia. Median survival time is brief despite aggressive therapy.
E. Physical examination reveals a large abdominal mass and massive splenomegaly. Review of the peripheral smear demonstrates some prolymphocytes, anemia, and thrombocytopenia. Biopsy of the abdominal mass demonstrates large cells. Median survival is brief despite aggressive therapy.

The correct answer is a.
a. Patient (a) has rather advanced chronic lymphocytic leukemia, which has a shorter life expectancy than patients who present with earlier-stage disease. Patient (b) has chronic myelogenous leukemia, in a more aggressive phase, with isochromosome 17 frequently the adventure of blast crises. Conservative therapy will not yield a 5-year survival in such a patient. Patient (c) has hairy cell leukemia, which should respond well to treatment with interferon. Patient (d) has a T-cell disease, which may be highly aggressive. Patient (e) has the clinical presentation of Richter's syndrome, which has an aggressive course despite treatment.

PBS; leukocytosis, all kinds of myeloid cells(myelopoiesis), thrombocytosis(60%0 or normal(30%)
left-shifted(neutrophil)
philadelphia chromosome
PEX: severe splenomegaly(90%) rare lymphadenopahy, hepatomegaly(50%)
on the chronic phase(90%), median survival 2years

All of the following are risk factors for thromboembolism except

a. Atrial fibrillation
b. Pancreatic cancer
c. Antiphospholipid antibodies
d. Polycythemia vera
e. Hypercholesterolemia

The correct answer is e.
e. Any condition that predisposes to thrombosis such as pancreatic cancer, antiphospholipid antibodies, and polycythemia vera increases the risk of thromboembolism. Atrial fibrillation often leads to mural thrombi, which may dislodge and circulate as systemic arterial emboli. Hypercholesterolemia per se does not cause thromboembolism.

6 weeks old baby was taken by mom to primary physician with cleft lip physician also saw she has cleft palate & Lower lip pit (depression).Doc shuld say that A
a)This is familial
b)This is sporadic
c)This is autosomal Recessive
d)This is autosomal Dominent
e)Mitrochondrial transmission disease

D

Actually cleft lip and palate are multifactorial Or sporadic but if some one have lip pit it is autosomal dominant penetration(>50%) chance to be in subsequent pregnancy

van der Woude syndrome is an autosomal dominant syndrome typically consisting of a cleft lip or cleft palate and distinctive pits of the lower lips. There are wide variations in the degree to which those carrying the gene may be affected, even within families. These variable manifestations include lip pits alone, absent teeth, or isolated cleft lip and palate of varying degrees of severity.

Special Concerns:
Although any lip pits should at least suggest van der Woude syndrome, not all children with lip pits have the syndrome. In fact, commissural pits not associated with van der Woude syndrome occur in about 2% of neonates and may be associated with preauricular sinuses.
Midline pits are unusual and often sporadic, as are pits of the upper lip.
Reports exist of children with cleft lip and palate, lip pits, and complex congenital heart disease who did not have family histories suggestive of van der Woude syndrome. This may be a variant (30-50% of individuals with van der Woude syndrome do not have a family history of the disorder and most likely represent de novo mutations in the disease gene) or a similar, but different entity.

inheritance of facial clefting is multifactorial. Familial inheritance of both cleft lip and palate occurs with varying frequency, depending on whether a parent or sibling is affected. For cleft lip with or without cleft palate, the risk rate for future offspring is 2% with only one parent affected, 4% with only one sibling affected, 9% with two siblings affected, and 10-17% with one parent and one sibling affected. For cleft palate alone, the risk rate for future offspring is 7% with only one parent affected, 2% with only one sibling affected, 1% with two siblings affected, and 17% with one parent and one sibling affected. Chromosome aberrations such as trisomy D and E have increased incidence of clefts

Which one of the following statements about pregnant women with human immunodeficiency virus (HIV) infection is correct?


A: Pregnant women should not be given zidovudine (Retrovir) because of extensive resistance.
B: Administration of influenza and pneumococcal vaccines should be avoided in pregnant patients.
C: The chance of neonatal infection with HIV is decreased by active management of delivery, including artificial rupture of membranes.
D: Infants whose mothers were treated with zidovudine during labor do not require postpartum treatment.
E: Pregnant patients with positive purified protein derivative (PPD) test results should receive prophylactic therapy during pregnancy.

Answer is E. All pregnant patients with HIV infection should also undergo tuberculin skin testing as part of their routine prenatal care. If patients test positive but do not have active tuberculosis, chemoprophylaxis with isoniazid (INH) and pyridoxine (vitamin B6) is recommended after the first trimester.

CC: 25 year-old-female was admitted to the hospital because of fever, headache and uncontrolled hyperglycemia.


HPI: Patient had been well until nine months earlier, when she started noticing weight gain accompanied by an increased appetite. About 6 months before admission, she began to have polydypsia, polyuria and felt fatigued. She did not seek any medical attention until 2 months ago when she went for her routine physical exam. She had gained approximately fifty pounds, was noted to be hypertensive and had high blood glucose. She was diagnosed with Diabetes Mellitus and started on insulin. Pap smear done at the same time revealed severe cervical dysplasia and she underwent LEEP (Loop Electro Excision Procedure) one week before this hospital admission.

The patient subsequently began to notice severe fatigue along with decreased appetite. Three days before admission, a headache developed which was described as frontal, dull, constant, and moderate in intensity, 6/10, with no aggravating or relieving factors. She also felt feverish but did not take her temperature. On the day of admission, she had nausea and went to see her primary care physician. Her blood glucose was noted to be high at 650 mg/dL and she was admitted. She denied any emesis or abdominal pain. She denied any neck stiffness or visual changes.


PMH: She had asthma during her childhood. She was taking NPH Insulin for Diabetes and was not allergic to any medications.


SH: She was single and was sexually active with one partner for the last six years. She denied any history of sexually transmitted diseases. She had never been pregnant and had had irregular menstrual period for the last six months. She did not smoke and rarely drank alcohol. She denied any other substance abuse.


FH: Her mother and an elder brother have Diabetes Mellitus. Her father and other siblings are well.


ROS: Significant for whitish, thick vaginal discharge with vaginal prurutis. She felt lightheaded with standing.


Physical Examination: Revealed a pulse of 110/min, blood pressure of 154/90 mmHg, temperature of 101.1 F, and respiratory rate of 18/min. She was orthostatic. She weighed 250 pounds with a BMI of 34. Pupils were equal and reactive to light and extra ocular movements were intact. Fundoscopic exam was normal. Her oropharynx was extremely dry without any erythema or lesions. Sinus exam revealed frontal sinus tenderness bilaterally. Neck was supple without any nuchal rigidity. Lungs were clear to auscultation bilaterally. Heart sounds were normal without any murmurs or gallops. Abdomen was obese with striae, nontender with no organomegaly or masses. Pelvic exam revealed cheesy, white discharge with erythema of vaginal wall. There was no cervical motion tenderness but mild right adnexal tenderness. Neurological exam was unremarkable.

LABS: Na 122 meq/L, K 5.3 meq/L, Cl 79 meq/L, HCO3 23.4 meq/L, Glucose 806 mg/dL, BUN 24 mg/dL, and Cr 1.6 mg/dL.

WBC 10,900/mm3, B 0.1, N 8.4, L 2.2

Hgb 17.2 gm/dL, MCV 88, MCH 32, RDW 13, Platelets 350,000/mm3.

U/A: SG 1.031, Glucose 3+, Ketones 2+, RBC <5, WBC <5. Serum Acetone 4+.

Hospital Course: Patient was admitted and started on intravenous fluids, insulin-drip and work-up for the fever was initiated. Headache intensified and next day the temperature increased to 103.5oF. CT of the head did not reveal any abnormalities. Specimens of blood, urine and sputum were obtained for culture. LP done the following day and revealed a normal opening pressure with RBC of 792, WBC 8, N 94%, L 6%, glucose of 177 (serum glucose=250), protein 45. She was started on ceftriaxone. She continued to be febrile with daily temperature ranging from 103-104oF and required large doses of insulin (50 U/hour). CT of the abdomen and pelvis showed enlarged right ovarian cyst but was otherwise negative. On the fourth day, she became hypotensive with blood pressure of 90/50. Antibiotic coverage was broadened and she was transferred to Intensive Care Unit and started on dopamine

You are asked to evaluate a 19-year-old man who presents to the emergency department with a sudden onset of right-sided weakness and dysarthria. He has no significant past medical history. He last saw a physician for a broken arm 4 years ago. He denies using illicit drugs, denies smoking, and is a social drinker. His physical examination and laboratory data are normal, despite the neurologic deficit. His ECG reveals a normal sinus rhythm with a normal QRS, ST, and T wave. A magnetic resonance imaging (MRI) scan is obtained and is positive for an embolic event.
Following your evaluation, you would next suggest:

a. No cardiac workup is necessary because this condition is most likely related to drugs.
b. Obtain a serial ECG and cardiac enzymes to detect a silent MI.
c. Obtain an echocardiogram focusing on the atria and intraatrial septum.
d. Obtain a carotid duplex scan to rule out a carotid stenosis.
e. Obtain a transesophageal echocardiogram focusing on the aorta for intraaortic debris

2. Paradoxical emboli that reach the brain from the peripheral circulation through an intraatrial communication are becoming a well-recognized etiology of cerebral embolism, especially in younger people. It is unlikely that this patient has suffered a myocardial infarction, given the normal echocardiogram. A transesophageal echocardiogram and/or a carotid duplex scan would be warranted if the emboli source were suspected to rise from either the carotids or the aorta, which is of lower likelihood in a younger person. Drugs are always a concern when cerebral vascular events occur and should be identified if suspected. A transthoracic echocardiogram with the injection of agitated saline (contrast echocardiogram) in a peripheral vein will reveal if a functional communication exits across the intraatrial septum with the appearance of bubbles on the left side of the heart. (N Engl J Med 1988;318:1148)

For those asymptomatic patients diagnosed with an accessory pathway on a surface ECG, you would suggest:

a. Perform immediate electrophysiologic studies to determine the location of the pathway and consider ablation.
b. Initiate a prophylactic calcium channel blocker.
c. Obtain a single average ECG to look for late potentials.
d. Administer a a-blocker.
e. None of the above.

e is CORRECT.
e. In those asymptomatic patients (without known supraventricular tachycardia) in which an accessory pathway is identified on the surface ECG, no therapy or other diagnostic modality is warranted. Efforts should be made while taking the patient's history to uncover dizziness, palpitations, syncope, or other symptoms that may be attributed to a tachycardic event. Currently, there is no evidence that the risk of sudden death can be altered in these asymptomatic patients.

Which of the following statements regarding disease-modifying antirheumatic drugs (DMARDs) is true?

a. They reliably induce remission in patients with seropositive rheumatoid arthritis (RA).
b. They are indicated only for patients with seropositive RA.
c. They cannot be coadministered with nonsteroidal antiinflammatory drugs.
d. They may slow the progression of joint erosion.
e. All of the above.

D

DMARDs, also referred to as slow-acting antirheumatic drugs (SAARDs), may retard the progression of erosive and deforming disease in patients with seropositive and seronegative RA. They are frequently coadministered with nonsteroidal antiinflammatory drugs (NSAIDs), although individual agents may be subject to drugdrug interactions. DMARDs, also referred to as slow-acting antirheumatic drugs (SAARDs), may retard the progression of erosive and deforming disease in patients with seropositive and seronegative RA. They are frequently coadministered with nonsteroidal antiinflammatory drugs (NSAIDs), although individual agents may be subject to drugdrug interactions.

Proximal renal tubular acidosis (RTA) is associated with which finding?

a. High anion gap metabolic acidosis
b. Urine pH always >5.4
c. Associated with membranous glomerulonephritis (GN)
d. Reduced bicarbonate reabsorption
e. Decreased H+ and K+ secretion by the distal tubule

d is CORRECT.
d. Patients with proximal RTA have a decrease in the maximum capacity of the proximal tubule to reabsorb bicarbonate. Bicarbonate is lost into the urine until the filtered load of bicarbonate is less than the reabsorptive capacities of the proximal tubule. Because distal acidification is normal, urine pH may be appropriately low.

1)A 54 year-old Hispanic man with Type 2 diabetes came to you for annual visit.
A microalbumin determination on the spot urine sample is 146 mg per gram of creatinine.
Which of the following should you do now?

a Repeat the microalbumin level in one year
b Repeat the microalbumin level in the next 3-6 months to confirm it
c Normalize glycemic control first, then repeat the microalbumin level
d Normalize blood pressure control first, then repeat the microalbumin level
e Start an ACE inhibitor agent


2)A microalbumin level is repeated one month later, the result is 161 mg per gram of creatinine.
Which of the following should you do now?

a Repeat the microalbumin level in one year
b Repeat the microalbumin level in the next 6 months to confirm it
c Normalize glycemic control, then repeat the microalbumin level
d Normalize blood pressure control, then repeat the microalbumin level
e Start an ACE inhibitor agent

1. Answer is B. Repeat the microalbumin level in the next 3-6 months to confirm it. Because there is inherent variability in urinary albumin excretion, at least 2 out of 3 samples collected on different occasions within a 3- to 6-month period must be abnormal to reliably diagnose microalbuminuria . False elevations of urinary albumin may be precipitated by fever, infection, congestive heart failure, severe hypertension, hyperglycemia, or exercise within the preceding 24 hours. Once confirmed, however, aggressive glycemic control, control of coexisting hypertension and use of angiotensin-converting enzyme (ACE) inhibitors will retard the progression of microalbuminuria to renal failure, independent of blood pressure reductions.
   Annual screening for microalbuminuria should be done only for those patients with normal albumin excretion. Microalbuminuria caused exclusively by hyperglycemia or hypertension usually occurs when either is severe; hyperglycemia or hypertension do not need to be completely normalized to rule them out as contributors to microalbuminuria. There are no current data to indicate that ACE inhibitors delay the onset of microalbuminuria, thus, there is no reason to indicate ACE inhibitors before the diagnosis of microalbuminuria. However, some patients may benefit from the preventive cardiovascular benefits of ACE inhibitors.
   
   2. Answer is E. Start an ACE inhibitor agent
   Clinically significant microalbuminuria on 2 separate samples warrants treatment with an ACE inhibitor agent. Annual screening for microalbuminuria is reserved for patients with normal albumin excretion. There is no need to repeat the microalbumin level again before starting therapy. It is unlikely that the patients current level of hyperglycemia or moderate hypertension would cause a falsely-elevated microalbuminuria level on 2 separate occasions.

A patient with history of HTN treated with captopril came to office with angeonuretic edema. what would be the cause?
a)Due to C1 esterase defficience
b)A anaphylactic reaction
c)Activation of C3,5
d)Activation C678
e)Ch allergic vasculitis

C

This is a type of anaphylactoid reaction that due to activation of local mediators and complements.specially C3,5

Angioneurotic edema is an infrequently reported adverse reaction to ACE inhibitors. It has been associated with each of the drugs in this class, but is most commonly reported with captopril.An incidence of 0.1% is estimated for captopril, whereas reports suggest an incidence of 0.02% for enalapril.
The most attractive hypothesis for the pathogenesis of angioneurotic edema precipitated by ACE-inhibitors
involves activation of the kininogen-kinin system. In the susceptible individual, an increase in the level of bradykinin is critical. The breakdown of bradykinin is prevented by ACE inhibitors. The subsequent increase in bradykinin leads to activation of inflammatory modulating peptides such as substance P and neuropeptide Y. A local release of histamine is promoted. Bradykinin is also a potent vasodilator promoting both local and systemic angioedema. Diminished levels of angiotensin II allow vascular dilatation and tissue edema to proceed unchallenged.

A diabetic patient with lipid profile LDL 240mg% HDL 34
Triglyceride 500mg% which one possess highest risk of CAD?
a)LDL level
b)HDL level
c)Triglyceride level

B

Normal Risk
LDL>HDL>Triglyceride
But when HLD<35mg% It becomes No 1 CAD risk

The ADA has made recommendations for the treatment of dyslipidemia in adults with diabetes. Treatment of elevated LDL is considered the first priority for pharmacologic therapy of dyslipidemia, based on existing research demonstrating a reduction in CHD following such treatment. The first choice for therapy is statins, and the second choice is a bile acid binding resin or fenofibrate.

The second goal for treating diabetic dyslipidemia is to increase HDL levels. For this goal, the ADA recommends initially using behavioral interventions, such as weight loss, increased physical activity, and smoking cessation. These should be followed with glycemic control and treatment with fibrates or nicotinic acid (with careful monitoring of glycemic control).

Lowering triglycerides is the third goal defined by the ADA. Glycemic control is the first priority, followed by use of a fibric acid derivative (gemfibrozil or fenofibrate). The ADA notes that statins are moderately effective at lowering triglycerides when used at high doses in hypertriglyceridemic patients who also have high levels of LDL.

All of the followings are coronary risk factors except
a. diabestes
b. Dad with Hx of MI at 57 yo
c. Elevated homocysteine
d. sedentary lefestyle
e. left ventricular hypertrophy

B or E

I think b. If the age of DAD at the time of MI was less than 55 than it is a risk factor

CHF without associated systolic dysfunction least commonly occure in patients with

a. Hypertension
b. Chronic mitral regurgiutation
c. mitral stenosis
d. chronic aortic insufficiency
e. constrictive pericarditis

predominant systolic failure
1.coronary heart disease
2.HTN
3.DCMP-idiopathic ,toxic,infection
TR and MR are common due to the effect of chamber dilatationon the valvular apparatus
predominant diastolic failure
1.HTN
2.HCMP
3.RCMP
4.constrictive pericarditis
5.high output failure-chronic anemia,AV shunt,thyrotoxicosis

A patient has no cardiac risk but has a carotid bruit. His LDL-cholesterol level should be maintained at
a. <190 mg/dl
b. <160 ..
c. <130 ..
d. <100 ..
e. <75 ..

52 yrs Pt h/o smoking and Total cholesterol 148mg% and HDL 34 mg% and FBS 110mg% BP 120/80 mg what do you want to do next?
a) Advice for glucose tolerance test
b)Lipid profile in next 5 yrs
c)Fasting lipid profile
d)Lipid cheek in 1 yr
e)Advice for type I diet & exercise

C

This pt has low HDL (<35mg%) needs fast lipid profile a risk factor for coronary disease.

All of the following statements about radioiodine thyroid ablation are true except:



Answer
A - This is the preferred method of treatment for patients over 21 years of age in the U.S.A.
B - Dose of radioiodine is calculated according to patients ideal body weight
C - It usually takes 6-12 weeks for patients to become euthyroid.
D - The major complication is hypothyroidism.
E - It is necessary to increase the dose of radioiodine if patient has previously been treated with antithyroid drugs

E

A radioactive iodine treatment takes about two to four months to work, after which most patients actually develop a permanent underactive thyroid condition (hypothyroidism).The radioactive iodine treatment is effective about 90 to 95 percent of the time, however an occasional patient may require a second dose.
Radioactive iodine cannot be given to pregnant or nursing women.Antithyroid drugs may be given before and/or after radioiodine therapy to help control the hyperthyroidism until the radiation has a chance to work.

A 36-year-old female patient with Graves disease has been treated with propylthiouracil (PTU). Her maintenance dose is 100 mg twice a day, and her disease is well controlled. She develops sore throat and fever. What is the appropriate management in this situation?



Answer
A - She should be started on empiric antibiotic therapy.
B - She should be advised to take plenty of fluid but no antibiotics since her sore throat is most likely just viral illness.
C - Dose of propylthiouracil should be increased since febrile illness may stimulate increased release of hormones from thyroid.
D - Dose of propylthiouracil should be decreased since febrile illness requires higher basal metabolism than suppressed thyroid can provide.
E - Propylthiouracil should be stopped immediately; white blood cell count and differential should be obtained

E

Sore throat is an early sign of neutropenia

All of the following are features of myxedema coma except:



Answer
A - Gradual onset of lethargy progressing to stupor and coma
B - Hyponatremia
C - Hyperthermia
D - History of previous thyroid disease
E - High serum carotene

C

With which of the following conditions is hypothyroidism most frequently confused?



Answer
A - Depression
B - Addisons disease
C - Panhypopituitarism
D - Nephrotic syndrome
E - Cushings syndrome

A

A 54-year-old male has been diagnosed with hypothyroidism. He has typical clinical signs, but he also has marked dyspnea on exertion, which is occasionally accompanied with chest pain. This pain is mid-sternal, pressing, and radiates to neck and left shoulder. Rest relieves pain and shortness of breath. Which of the following options is the best management for this patient?
Answer
A - Start patient on levothyroxin and proceed with cardiac evaluation simultaneously.
B - Start patient on levothyroxin and proceed with cardiac evaluation in 6 weeks when it can be demonstrated that patient is euthyroid.
C - Patient should be started on levothyroxin and aspirin and observed for next 3 months because it is likely that his dyspnea and chest pain will disappear with successful treatment of hypothyroidism.
D - Patient should have cardiac evaluation; and coronary artery disease, if present, should be corrected (PTCA, CABG) prior to start of the levothyroxine replacement therapy.
E - Patient should be started on levothyroxine and long acting nitrate. Cardiac evaluation should be postponed at least 1 year because his cardiac condition is most likely not caused by coronary artery disease, but more likely by myocardiopathy, which may gradually improve

An infant born of a mother with Hashimotos thyroiditis develops respiratory difficulties with cyanosis, jaundice, umbilical hernia, poor feeding, weakness, and retardation of bone maturation. Which of the following tests is most likely to reveal the reason for his condition?



Answer
A - TSH and T4 determination
B - Peripheral blood smear
C - MRI of the sella turcica
D - MRI of the brain
E - Ultrasound of the liver

A

All of the following are measures that may be employed in the treatment of the syndrome of inappropriate ADH secretion (SIADH) except:

Answer
A - Water restriction
B - Hypertonic or normotonic saline infusion
C - Furosemide or ethacrynic acid administration
D - Demeclocycline administration
E - Aldosterone administration

E

73-year-old patient with advanced bronchogenic carcinoma but still stable body weight is found to have marked hyponatremia. Which of the following is the likely cause of his condition?
Answer
A - Poor oral intake of sodium
B - Syndrome of inappropriate secretion of ADH
C - Congestive heart failure
D - Severe liver disease due to hepatic metastases
E - Nephrogenic diabetes insipidus

B

A 56-year-old female presented with vague symptoms of weakness, polyuria, and confusion. She was found to be markedly hyponatremic (Na-118). Her serum osmolality was 257 mosm/L and urine osmolality was 111 mosm/L. After overnight water restriction her urine osmolality was 450 mosm/L. Which of the following is the most likely cause of her hyponatremia?



Answer
A - Nephrogenic diabetes insipidus
B - Neurogenic diabetes insipidus
C - Syndrome of inappropriate ADH secretion
D - Psychogenic polydipsia
E - Congestive heart disease

D

After a bilateral adrenalectomy for Cushings disease, a patient presents with hyperpigmentation of the skin, headache and visual disturbances, and extra-ocular muscle palsies. Which of the following is the most likely diagnosis?

Answer
A - Nelsons syndrome
B - Recurrent Cushings disease
C - Addisons disease
D - Hypoaldosteronism
E - Hyperreninemia

A

All of the following statements about Cushings disease are true except:
Answer
A - It is caused by hypersecretion of ACTH and characterized by bilateral adrenocortical hyperplasia and hypercortisolism.
B - Circadian periodicity of ACTH and cortisol secretion are absent.
C - Responsiveness of ACTH and cortisol to stress are absent.
D - There is an abnormal negative feedback of ACTH secretion by glucocorticoids.
E - Iatrogenic disease is today the most common form of the disease

E

Which one of the following is the simplest and most specific dynamic test for acromegaly diagnosis?



Answer
A - Basal fasting growth hormone level
B - Growth hormone stimulation with TRH
C - Paradoxical suppression of growth hormone by levodopa
D - Oral glucose suppression test
E - Absence of nocturnal growth hormone surge

D

All of the following may be seen in patients suffering from acromegaly except:



Answer
A - Glucose intolerance
B - Hypothyroidism
C - Hypoinsulinemia
D - Gynecomastia
E - Visual deficit

B

A 52-year-old male patient noticed a gradual increase in the size of his shoes and hat. He also noticed increased sweating, heat intolerance, oiliness of the skin, fatigue, and weight gain. Which of the following is most likely to be responsible for his symptoms?

Answer
A - Autonomously increased thyroid function
B - Pituitary adenoma
C - Pituitary hyperplasia
D - Hypothalamic dysfunction
E - Destruction of the pituitary by adjacent tumor

B

A 33-year-old female is diagnosed with pituitary adenoma (8 mm) secreting prolactin. Her symptoms are classic: galactorrhea and amenorrhea. She is about to start therapy with prolactin. She wishes to know what the chance is that this therapy will be successful. Which one of the following describes her prognosis accurately?



Answer
A - In patients with microadenomas bromocriptine is virtually always successful.
B - Chances for improvement of galactorrhea are about 99% but the normal gonadal function returns in only 30-40% of patients.
C - There is an 80% likelihood of improvement; and if therapy is continued for 1 year or more, the likelihood of permanent remission is about 60%.
D - About 80% of patients achieve normal prolactin levels, and their gonadal function normalizes.
E - Only 50% of patients have successful suppression of the prolactin hypersecretion

C

A 58-year-old female complained of intermittent right upper quadrant pain. Upper abdominal ultrasound revealed calcified gallbladder stones. Her history includes remote perforated duodenal ulcer that required multiple surgeries at the time and occasional residual dyspepsia since that time despite H2-blocker therapy. What is the modality of choice to treat cholelithiasis in this patient?

A - Oral dissolution of the stones
B - Extracorporeal shock wave lithotripsy
C - Laparoscopic cholecystectomy
D - Cholecystectomy via open subcostal incision
E - Contact dissolution therapy

D

d-- If it has to be cholecystectomy.. it is d..not LAp.
The patent has had prev abdo SX .. ie he should have adhesions .. and a laparoscopy would not be easy in this case.

Which one of the following statements about hepatitis B vaccine is true?
A - The preferred injection site is the buttocks.
B - After the initial immunization series, routine booster vaccination is recommended.
C - Despite the availability of effective vaccines, the incidence of hepatitis B appears to be rising in the United States.
D - Patients who receive the vaccine and already are carrying the hepatitis B virus may have severe adverse effects.
E - Individuals who do not respond to initial vaccination are highly likely to respond to repeated vaccination.

D

The Centers for Disease Control and the American Academy of Pediatrics recommend that all newborns, infants and children, especially sexually active teenagers be vaccinated against hepatitis B.

Vaccination is also recommended for individuals at high risk of being infected with the hepatitis B virus (HBV). These include:

Health care workers, including doctors, dentists, nurses, blood and lab technicians;
Emergency workers - including paramedics, fire fighters and police;
Hemodialysis patients;
Military personnel;
Morticians and embalmers;
Patients and staff of institutions for the mentally handicapped, inmates of long-term correctional institutions;
Ethnic groups with a high rate of hepatitis B including Chinese, Koreans, Indochinese, Filipinos, Alaskan Eskimos, Haitians, and American Indians;
People with multiple sexual partners;
Intravenous drug users;
Recipients of certain blood products;
Household contacts and sex partners of hepatitis B carriers;
International travelers
Those who are already infected will not benefit from vaccination. However, infants born of mothers who are carriers of the hepatitis B virus can be protected. A simple blood test can determine whether someone is a hepatitis B carrier.
Immunization requires three doses of vaccine according to the following schedule:

1st dose: For infants born to infected mothers - within 12 hours.
For infants born to mothers who test negative - within one to
two months following delivery.
2nd dose: 1 month later
3rd dose: 6 months after the first dose.
Administration is by intramuscular injection in the thigh or upper arm.

Addition:
HIV + individuals are encouraged to get HB vaccination, as well hemophyliacs.
Booster vaccinations are reccomended according to antibody titers. Such recc varies according to the country and type of work.

Which one of the following findings would be most characteristic in a patient with chronic persistent hepatitis?

A - A serum bilirubin of 4 mg/dl
B - Fatigue and malaise
C - A prolonged prothrombin time
D - Piecemeal necrosis on liver biopsy
E - AST and ALT levels greater than 300 IU/L

B

the fatigus ans weakness are the most common findings rest are with active hepatitis

A 23-year-old Irish man presents to you with diarrhea and weight loss. He has a positive anti-endomysial antibody. His small bowel biopsy is most likely to show:

A - Large, PAS positive macrophages
B - Flattened villi and hyperplastic crypts
C - Microsporidia
D - Giardia lamblia
E - Normal mucosa

B

Celiac disease is a genetic, immunologically mediated small bowel enteropathy that causes malabsorption. The immune inflammatory response to gluten frequently causes damage to many other tissues of the body. Sprue primarily affects the mucosal layer, which is where an inflammatory state, caused by a cascade of immune events, is activated in predisposed individuals by the exposure to gliadins. The condition causes a deepening and hyperplasia of the crypts and a concomitant flattening of the villi (ie, fingerlike projections of the mucosa with the primary function of increasing its absorptive surface). The condition is frequently underdiagnosed because of its protean presentations. New prevalence data indicate that symptomatic and latent celiac disease is present in one of 300 people of European descent. Symptomatic presentations include general ill-health, as well as dermatologic, hematologic, musculoskeletal, mucosal, dental, psychologic and neurologic diseases. Celiac disease has a 95 percent genetic predisposition and, thus, it is frequently associated with autoimmune conditions such as diabetes mellitus type 1 and thyroid disease. Untreated patients have an increased incidence of osteoporosis and intestinal lymphoma. Excellent diagnostic screening tests are now available, including those that detect antigliadin and antiendomysial antibodies. Therapy with a gluten-free diet is effective, resulting in complete resolution of symptoms and secondary complications in almost all patients. Local and national celiac-sprue associations facilitate care of patients with celiac disease and support dietary compliance.

Which one of the following statements about peptic ulcer disease is true?



Answer
A - The mortality rate of upper gastrointestinal bleeding has decreased with the introduction of proton pump inhibitors.
B - Misoprostol but not lansoprazole has been shown to prevent NSAID induced ulcers.
C - The hematocrit is a reliable test after acute hemorrhage.
D - The prevalence of H. Pylori in duodenal ulcer disease in the United States is about 75%.
E - Enteric-coated 81 mg aspirin will not decrease gastric mucosal prostaglandin production.

D

According for the Centers for Disease Control and Prevention, more than 90% of duodenal ulcers are caused by Helicobacter pylori (H. pylori) bacterium.

A 55-year-old female has recently undergone successful medical therapy for endoscopically proven helicobacter pylori serology positive duodenal ulcer. The best method to confirm H. pylori eradication is:

A - Repeat serology
B - Histology
C - C14 urea breath test on omeprazole therapy
D - Culture
E - C13 urea breath test after therapy

E

Confirming H pylori eradication is not mandatory in most situations due to cost. It is reasonable to confirm eradication in patients with complicated ulcer disease, low-grade MALT lymphoma, or following resection of early gastric cancer. The need to confirm H pylori eradication in other situations should be decided on a case-by-case basis. Testing to document eradication should be delayed at least 4 weeks after completion of therapy to avoid false-negative results. Urea breath test is the method of choice to confirm eradication; serology is not useful because antibody levels remain elevated after treatment.

Gastrointestinal endoscopy is superior to contrast radiography in all of the following illnesses except:

A - Peptic ulcer disease
B - Colonic neoplasm
C - Esophagitis in AIDS
D - Intussusception
E - Crohns colitis

D

Which one is not a complication of ch HCV infection
a)Porphyria cutenia terda
b)Cryoglodulinimia -II
c)Ch vasculitis
d)Lichen planus
e)T cell lymphoma

E

extrahepatic manifestation of chronic HCV
responsive to management of the underlying HCV infection.
vasculitic syndromes (essential mixed cryoglobulinemia and cutaneous vasculitis) and membranoproliferative glomerulonephritis.
Less well established associations include porphyria cutanea tarda, Sjogren's syndrome, lichen planus, Mooren corneal ulcerations and perhaps, pulminary fibrosis and rheumatoid arthritis.

Complications of Chronic HCV infection, seen after 20-30 years are usually:

Cirrhosis 10-20%

Hepatocellular Carcinoma (HCC) seen in 1-5% patients after 20-30 years but the incidence in patients with Cirrhosis is higher and is usually 1-4% per year (signifying more active disease)

Mortality is a rare complication.

HCV infection has also been implicated in the pathogenesis of a number of other diseases e.g.:

Arthritis

Kerato-conjuctivitis sicca

Lichen planus

Autoimmune hepatitis

Porphyria cutanea tarda

Cryoglobulinemia

Glomerulonephritis

Non-hodgkins lymphoma

A 23-year-old man presented with a 2-week history of a 'rash' on both wrists. He complained of generalized pruritus that seemed to be worse at night. He has tried a 1/2% hydrocortisone cream topically which has been minimally effective in relieving his symptoms. He did not recall any recent change in his normal routine, with the exception of spending a weekend at friend's cabin in Michigan a month earlier, where he borrowed a friend's sleeping bag. He denied any contact with 'poison ivy' while in Michigan. Examination of the man's wrists show numerous papules and pustules. The lesions can also be observed between the fingers on both hands. Linear burrows are not observed.

WHAT IS MOST LIKELY DIAGNOSIS:

A.Atopic dermatitis
B.Scabies
C.Tinea manuum
D.Warts
E.Contact dermatitis

Answer is B. This patient is suffering from scabies. Scabies is caused by infestation with the Sarcoptes scabiei mite. The intense pruritus is a result of sensitization to a mite protein. Answer is B. This patient is suffering from scabies. Scabies is caused by infestation with the Sarcoptes scabiei mite. The intense pruritus is a result of sensitization to a mite protein.

A 40-year-old white man with known HIV positive serology for 5 years was referred to the Dermatology clinic with complaints of blisters on both of his hands and face of several weeks duration. Some of the blistered areas had healed; however, new blisters formed in the same regions and in new locations. He noticed that the condition worsened wih exposure to sunlight. In addition, he indicates that has a history of Kaposis sarcoma on his feet and genital regions treated with radiation and chemotherapy 1 year ago.

The patient has vesicles and ruptured bullae in various stages of healing on the dorsum of both hands. These affected areas, in addition to the face, show thickening and scarring with post-inflammatory hyperpigmentation. Scleral icterus and extensive facial hair was also noted on physical examination.

WHAT IS MOST LIKELY DIAGNOSIS:

A.Porphyria Cutanea Tarda
B.Bullous Pemphigoid
C.Bullous Impetigo
D.Atopic dermatitis
E.Herpes Simplex

Answer is A. Porphyria cutanea tarda (PCT) is the most common type of porphyria. Porphyrias are caused by hepatic damage and abnormalities in the heme biosynthetic pathway. This results in abnormal porphyrin metabolism and excessive accumulation of various porphyrins. PCT is characterized by subepidermal bullae on the hands and markedly elevated urine uroporphyrins and coporphyrins (ratio of 3 : 1, respectively). These metabolic changes are diagnostic. Liver function tests and serum iron levels are also elevated. Bullae, vesicles, crusts, erosions and scarring occur on sun-exposed skin, especially the dorsum of hands. Facial hair and mottled facial pigmentation also occur. PCT is commonly associated with HCV and HIV positive serologies.

Which of the following statements is false?


a) A relationship has been noted between maternal smoking and Sudden Infant Death Syndrome (SIDS)

b) Overall, even after controlling for maternal smoking and other covariants, paternal smoking remained associated with SIDS

c) The risk of SIDS associated with smoking increased when the comparison was restricted to smoking in the same room as the infant

d) A 5- to 10-fold increase in risk of SIDS is typically found among children of smokers

D

SIDS is the leading cause of death among children under one year of age and is responsible for nearly half of the deaths for children between two and four months of age. When a woman smokes during pregnancy, the risk of SIDS is at least doubled, and possibly tripled. It's estimated that more than 1/3 of all SIDS deaths are due to maternal tobacco use.

Few points about maternal smoking.
Women who smoke are 33% more likely to have a low birth weight baby. The risk of miscarriage in smokers in the first 20 weeks of pregnancy is 33% higher than in nonsmokers.Maternal smoking increases the risk of stillbirth by 33%.Growing evidence suggests that smoking during pregnancy may also be associated with deficits in intellectual ability and behavioural problems in children.

higher risk)
1.males versus females, among infants aged 2-4 months 2.lower socioeconomic status.
3.when infants sleep on their front (prone) than when they sleep on their back (supine)
4.Maternal smoking during pregnancy
There is also evidence of an independent increased risk to infants exposed to tobacco smoke in the household.
5.Overheating

Which of the following is not a contraindication for OC(ORAL CONTRACEPTIVES)use:

a) Active viral hepatitis

b) Benign liver tumor

c) Diabetes

d) Endometriosis

D

OC is used as treatment for endometriosis
absolute CIx. for OC
1.venous thrombosis
2.pulmonary embolism
3.coronary vascular disease
4.CVA
5.breast/endometrial ca.
6.melanoma
7.hepatic tumor
8.abnormal liver function
DM is relative CIx.

Oral contraceptives offer protection against all of the following except:

a. Dysmenorrhea and menorrhagia
b. Ectopic pregnancy
c. Breast cancer
d. Ovarian cysts
e. Pelvic inflammatory disease

C

Because many of the risk factors for breast cancer are related to natural hormones, and because OCs work by manipulating these hormones, there has been some concern about the possible effects of medicines such as OCs on breast cancer risk, especially if women take them for many years. Sufficient time has elapsed since the introduction of OCs to allow investigators to study large numbers of women who took birth control pills for many years beginning at a young age and to follow them as they became older.

However, studies examining the use of OCs as a risk factor for breast cancer have produced inconsistent results. Most studies have not found an overall increased risk for breast cancer associated with OC use. In June 1995, however, investigators at the National Cancer Institute (NCI) reported an increased risk of developing breast cancer among women under age 35 who had used birth control pills for at least 6 months, compared with those who had never used OCs. They also saw a slightly lower, but still elevated, risk among women ages 35 to 44. In addition, their research showed a higher risk among long-term OC users, especially those who had started to take the pill before age 18.

A 1996 analysis of worldwide epidemiologic data, which included information from the 1995 study, found that women who were current or recent users of birth control pills had a slightly elevated risk of developing breast cancer.

according to the blueprint
noncontraceptive health benefit of OC
1.decrease life threatening disease
ovarian ca.
ectopic pregnancy
anemia
PID
endometrial ca
2.alleviate quality of life problem
IDA
dysmenorrhea
functional ovairan cyst
benign breast disease
osteoporosis

30 yrs women forgot to take her OCPs and had sex with her husband for two consequtive days and came on third day to family physician to know what to do. What would be the avvice?
a)Take three pills to night then regular
b)Take 2 pills for 2 consedutive night then regular
c)Order pregnancy test & 2 pills for 2 consequtive days the regular
d)Take 2 pills for 2 consequtive days then regular plus condom up to cycle
e) Stop taking pills use condom for the cycle and pregnancy test.

D

Missed pill
If it has been less than 24 hours since the last pill was taken, the patient takes a pill right away and then returns to normal pill-taking routine.
If it has been 24 hours since the last pill was taken, the patient takes both the missed pill and the next scheduled pill at the same time.
If it has been more than 24 hours since the last pill was taken (i.e., two or more missed pills), the patient takes the last pill that was missed, throws out the other missed pills and takes the next pill on time. Additional contraception is used for the remainder of the cycle
ref-up date on OCP in american family physicians

abortion laws differ from state to state ,I believe. And so I was told that this wont tested on the exam.
I think minor has no rights (correct me if I am wrong)partial emancipation(>/= 16 yrs ) have rights for contraception,std counselling and treament,prenatal care ,substance abuse Rx.
Emancipated minor(13 yrs) living by self/marriedthemthey get adult rights.

No, you don't need parents' consent.you can do any treatment related to pregnancy(prenatal care,abortion)
with just the minors' consent.

see my other message in which I have given a tabular column sort of thing which tells you the requirements for consent at different situations.

30 years female h/o siezure well conrolled with pills recently changed her contraceptives to OCP came in ER with acute attack of seizure. Where she was given phenytoin and seizure was well controlled.Next day on round the medical student saw that her phenytoin level 20(some unit) and eye exam shows horizental nystigmas. He rushed to the resident to do some thing for her.what do you wantto do next?
a)Stop phenytoin
b)Stop phenytoin and cheek blood level
c)Wait and see
D) Cheek LFT
e) Decrease the dose of phenytoin.

C

Horizental nystigmas is a sign of good working level
Vertical nystigmas is a sign of toxicity(>25 blood level)

The patient was stable on some anti-convulsant (ACV).
She started OCP's and the got a seizure..ie the estrogen increased the albumin level and hence more of the ACV was protein-bound. The free level of the drug decreased leading to a seizure. Makes sense??

znow, She is given Phenytoin and stops seizing.. but develops a phenytoin tox the nxt day..Nystagmus is often the first sign of tox.

60 years oid man with history ASD with primum defect cand BHP with temp 99.1 degree came with acute urinary retention, lower abdominal discomfort and distention. what do you want to do next
a)Bladder catheterization
b)DRE + Catheter
c)Amoxicillin prophylaxis + catheter
D) DRE + amoxicillin prophylaxis + Catheter

C

Acute retention no DRE
UTI with catheter needs endo prophylaxis but patient without UTI with catheter no need of prophylaxis
Primum defect needs prophylaxis not in secundum defect

20 years lady came to family physician that recently her boy friend was diagoned with HPV infection.She is worried that it is associated with Cx ca. you did the PAP that shows normal. what do you want to do next
a) Advice for using condom
b)Re evaluate her boy friend
c) Colposcopy
d)Serology for HPV on her
e)PAP after I year

C

If partner has HPV infection do colposcopy whatever the PAP .

58 years old woman came to family physician regarding her vaginal bleeding . Family physician ordered PAP smear that shows atypical endometrial & endocervical cells . What would be the next step-
a)Repeat PAP
b)Do colposcopy
c) Do colposcopy + endocervical curettage
d)Do Colposcopy + ECC + Endometrial biopsy
E)Testosterone +repeat PAP

A

atypical Endocervical cells or endometrial cells needs repeat PAP if same result do colposcopy with ECC and endometrial biopsy. atypical Endocervical cells or endometrial cells needs repeat PAP if same result do colposcopy with ECC and endometrial biopsy.

The finding of atypical glandular cells (AGUS) is completely different and much more significant than ASCUS.Studies indicate that upwards of 30% of cases of AGUS represent serious underlying conditions, notably adenocarcinoma in situ, adenocarcinoma of the cervix, endometrial adenocarcinoma, and squamous lesions of the cervix. Therefore, a patient with AGUS should be referred immediately for a complete evaluation, including colposcopy, endocervical curettage, and possible endometrial biopsy.
If a postmenopausal patient is found to have atypical squamous cells of undetermined significance (ASCUS), repeat the Pap smear in 4 weeks. In the interval, recommendation is that the patient use vaginal estrogen cream (conjugated equine estrogens [Premarin], one full applicator nightly) for the first 2 weeks and then wait 2 weeks before the visit. The estrogen eliminates atrophy as a cause of atypia.

Ref: Cleveland Clinic Journal of Medicine September 2000
Volume 67
Number 9
Pages 610-611

Management of postmenopausal bleeding.

Mild spotting may be observed on initiation of HRT. Otherwise, postmenopausal bleeding always requires complete evaluation for endometrial hyperplasia or carcinoma, with endometrial biopsy or D&C followed by hysteroscopy if bleeding continues. Alternatively, an endovaginal ultrasound showing an endometrial stripe of less than 5 mm excludes endometrial carcinoma with sensitivity close to 100%, specificity 75%. Biopsy is required if stripe is 5mm or greater. The specificity is markedly reduced in women on HRT because of the resulting increase in endometrium. The same contraindications for OCPs should be considered. For bleeding due to atrophic endometrium, start HRT, or if already on HRT increase the estrogen component by 50% to 100% for 3 months. For bleeding due to proliferative endometrium, start HRT, or if already on HRT increase the progestin component by 50% to 100%.

(I)Mom of a 14 year old boy bring her kid to the family physician regarding his 'round back' .Xray of her lumber spine shows 35 degree angulation. the boy complaining no problems .What would be your primary response to mom?
a)This is normal physiological change dont worry
b)This is Idiopathic scoliosis needs orthopedic refeeral
c)This is juvenail kyposis -use brace & do exercise
d)This is spondylolethiasis needs surgical correction
e)Please come after 3 months.

(II)After getting appropriate advice mom was back after # months with her kid due to back pain prolong standing .Lateral Xray shows 55 degree angulation.what would be the intervention
a) Use brace & back strenthening exercise- see after 3 months.
b)Immediate orthopedic referal.
c)Surgical correction of spodylolethiasis
d)Complete skeletal survey for bone metastasis

Correct ans-(I)-a & (II)-a

Juvenile kyposis when thoracic colum angulation>45 degree
45-60 degree needs brace & back strengthening exercise
>70 degree orthopedic emergency

A 78-year-old black man, a retired chemistry professor, comes to you because of lumbosacral vertebral pain. There is no hepatomegaly. Cardiac exam is normal and there is no evidence of arthritis. His Hct, MCV, WBC and differential are normal. Liver enzymes are normal, but total serum protein is mildly elevated. The serum Ca is normal. You find no protein in his urine. A marrow aspirate&biopsy showed 6% plasma cells (normal=0-5%). A roetgenographic survey was negative.
What is the most likely diagnosis based on the history and laboratory findings?

A. Waldenstrom's macroglobulinemia
B. Amyloidosis
C. Myeloma
D. Monoclonal Gammopathy of Unknown Significance
E. Heavy Chain Disease

Answer is D. This is a monoclonal gammopathy of unknown significance (MGUS) in which there is no underlying cause, despite marrow plasmacytosis and an M protein. MGUS is seen in 5% of people >70yrs of age. Approximately 10% of MGUS patients develop myeloma within 5 years and almost 20% will develop a malignant PCD (myeloma,WM, amyloidosis, and ML) within 10 years.
Bone marrow biopsy and aspirate show a mild increase in plasma cells, but no mass lesion as would be seen in myeloma. The lack of significant lymphadenopathy, organomegaly, and renal disease argues against myeloma, Waldenstroms, heavy chain disease, and amyloidosis. Other studies might include immunoelectrophoresis and immunofixation electrophoresis

Table 5. Differential Diagnosis in Plasma-Cell Disorders
Disorder Symptoms Clinical/routine laboratory findings
Monoclonal gammopathy of undetermined significance Asymptomatic or may have peripheral neuropathy None; or may be associated with peripheral neuropathy
Smoldering multiple myeloma Symptoms absent or minimal Lytic bone lesions few or none; anemia mild or absent; hypercalcemia, renal failure, recurrent infections absent
Plasma-cell leukemia Weakness, fatigue Meningeal symptoms sometimes seen (secondary form) >20% plasma cells in peripheral blood; hepatosplenomegaly, lymphadenopathy; fewer lytic bone lesions (primary form)
Osteosclerotic myeloma (POEMS syndrome) Sensorimotor polyneuropathy, amenorrhea (women), impotence (men), fever Sclerotic skeletal lesions; hepatomegaly, lymphadenopathy, splenomegaly; gynecomastia (men), hyperprolactinemia, papilledema, elevated CSF pressure, type 2 diabetes mellitus, hypothyroidism, adrenal insufficiency; skin thickening, hyperpigmentation, hypertrichosis, digital clubbing; peripheral edema, ascites, pleural effusion, thrombocytosis, erythrocytosis
Solitary plasmacytoma of bone Bone pain Palpable mass, bony tenderness
Extramedullary plasmacytoma Symptoms related to site of involvement: e.g., upper-airway obstruction Tumor with no evidence of multiple myeloma
Primary amyloidosis Carpal tunnel syndrome, orthostatic hypotension, peripheral neuropathy, malabsorption, nonthrombocytopenic purpura, articular infiltration ('football shoulder') Macroglossia, cardiomegaly, hepatomegaly; elevated blood urea nitrogen, creatinine. Similar features in myeloma-associated secondary amyloidosis.
Gamma heavy-chain disease (Franklin's disease) Fever, malaise, weakness, recurrent infections Palatal edema in Waldeyer's ring, lymphadenopathy, anemia, hepatosplenomegaly; occasionally thrombocytopenia, eosinophilia
Alpha heavy-chain disease (Seligmann's disease) Chronic diarrhea, malabsorption, weight loss Signs of malnutrition, clubbed fingers; imaging studies reveal abdominal lymphadenopathy
Mu heavy-chain disease Monoclonal lymphocytosis lymphadenopathy, splenomegaly, occasionally hepatomegaly

What is more characteristic of Hodgkin's disease than of non-Hodgkin's lymphoma?

A. leukemic phase
B. nasopharnygeal involvement at onset
C. younger age peak
D. extranodal involvement

Answer is C. Hodgkins lymphoma is most frequent in the 20-30 age range.
Non-Hodgkins lymphomas frequently present as extranodal disease and some may have peripheral blood involvement.

A twenty-five year old man complains of a lump in his right neck. The lump has increased in size in the past seven weeks. He has lost weight - 12 lbs. in the last month and 20 in the last 6 months. His only medication is Tylenol for fever (101 ). He is HIV positive.
You obtain a chest roentgenogram which shows mediastinal widening and hilar lymphadenopathy. Lymph node and bone marrow biopsies are both positive for mixed cellularity Hodgkin's disease.
With the results of this information you make the following comments about HD in HIV+ patients, all of which are true EXCEPT for:

A. there is a higher incidence of HD compared to nonHIV+
individuals
B. HD is likely to present in advanced stages
C. mixed cellularity type is more common
D. extranodal sites of presentation are common
E. the clinical course is aggressive A twenty-five year old man complains of a lump in his right neck. The lump has increased in size in the past seven weeks. He has lost weight - 12 lbs. in the last month and 20 in the last 6 months. His only medication is Tylenol for fever (101 ). He is HIV positive.
You obtain a chest roentgenogram which shows mediastinal widening and hilar lymphadenopathy. Lymph node and bone marrow biopsies are both positive for mixed cellularity Hodgkin's disease.
With the results of this information you make the following comments about HD in HIV+ patients, all of which are true EXCEPT for:

A. there is a higher incidence of HD compared to nonHIV+
individuals
B. HD is likely to present in advanced stages
C. mixed cellularity type is more common
D. extranodal sites of presentation are common
E. the clinical course is aggressive

A

1. HIV-infected people are at a slightly higher risk for developing NHL than non-HIV-infected people.
   NHL can also progress (get worse) faster in HIV-positive people and can be more difficult to treat.
   It is not clear if HIV-positive people are at a higher risk for developing HD.
   
   2. However, HD does occur in HIV-infected people and, because of underlying immune suppression, can progress faster and may be more difficult to treat.
   
   3 Unfortunately, the availability of anti-HIV therapy has not reduced the risk of developing lymphoma.

A 61-year-old man has a platelet count of 360 x10 /L, a WBC count of 36 x 10 /L with 35% lymphocytes and an autoimmune hemolytic anemia most likely has:

A. a clonal rearrangement of the JH region of the lymphocytes
B. an relative lymphocytosis
C. a T-gamma lymphocytosis
D. Sezary syndrome
E. Adult T-cell leukemia/lymphoma

Answer is E. CLL is the most common of the malignant clonal chronic lymphoproliferative disorders, representing about 30% of all leukemia. CLL is a proliferation of lymphocytes, in the marrow, peripheral blood, and various organs. The most characteristic feature of CLL is a peripheral blood absolute lymphocytosis (>5.0 x109/L). Lymphadenopathy and splenomegaly are common especially late in the disease. Anemia and thrombocytosis may indicate marrow replacement or autoimmune destruction

A 55-year-old man complains of dizziness, headaches and pruritis after showering. He notes early satiety and smokes 1 pack of cigarettes/day x 30 years.
On physical examination you find a middle aged man with a ruddy complexion, mild hypertension, and mild spenomegaly.
Clinically you suspect polycythemia and order an erythropoietin level. Based on the above clinical information what is your diagnosis:

A. Polycythemia vera and normal erythropoietin
B. Polycythemia vera and increased erythropoietin
C. Secondary polycythemia and normal erythropoietin
D. Secondary polycythemia and increased erythropoietin

Answer is A. Splenomegaly, pruritis, hypertension, ruddy facial features, dizziness and headaches are common symptoms in polycythemia. The splenomegaly and pruritis are common in polycythemia vera, but are usually absent in secondary polycythemia.
Erythropoietin levels are low or normal in polycythemia vera and high in secondary polycythemia vera.