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Adrenal crisis
Diarrhea: Approach (Harrison)
Principles of Appropriate Antibiotic Use for Acute Respiratory Infections
West Nile Virus
Do you need the mom's consent to test the BABY for HIV
Functional Organization of the Human Body and Control of the 'Internal Environment'
Urinary Incontinence

INJURIES facts(source CDC)


Males are at least four times as likely as women to die from suicide.
Men 65 and older have the highest suicide rate.
More than three-quarters of school homicide and suicide victims were males.
Compared with women, men are twice as likely to sustain a traumatic brain injury and four times as likely to sustain a spinal cord injury.
Among adults ages 65 and older, motor vehicle-related injury rates are twice as high for men than for women.
Male high school students are less likely than female students to wear seat belts.
Men ages 65 and older are 22% more likely than women to die as a result of a fall.
More than 80% of drownings occur among males.
The pedestrian death rate is twice as high for men as for women.
Boys ages 5 to 9 are at highest risk for dog bite–related injuries.


Women are more likely than men to attempt suicide.
In a national survey, 25% of women reported being raped or physically assaulted by an intimate partner at some time in their lives; only 8% of men reported such an experience.
One in three women injured during a physical assault or rape requires medical care.
Women are more likely than men to be murdered by an intimate partner.
Among adults 65 and older, women are hospitalized for hip fractures three times as often as men.

African Americans

More African Americans ages 15 to 19 die from homicide than from any other cause.
African Americans are among those at greatest risk for injuries from residential fires.
The pedestrian fatality rate for African Americans is nearly twice that for whites.
The drowning rate for African Americans overall is about 1.6 times as high as for whites. For African American children ages 5 to 9, it's 2.5 times as high.
African American high school students are less likely than white students to wear seat belts all the time, putting them at increased risk of motor vehicle–related injuries.
The rate of spinal cord injuries is higher among African Americans than among whites.

Hispanic Americans

Motor vehicle crashes are the leading cause of injury-related deaths for Hispanics; poisonings are second.
The pedestrian fatality rate for Hispanics is 1.77 times higher than for whites.
Homicide is the second leading cause of death for Hispanics ages 15 to 34.

Infants and Young Children

For children ages 1 to 4, motor vehicle injuries are the leading cause of death.
Nearly half of children 4 and younger who died in motor vehicle crashes
were riding unrestrained.
Drowning is the second leading cause of injury-related death for children
ages 1 to 4.
In 1999, children under 5 accounted for more than half of all poison exposures.
Children under 5 are among those most at risk for injuries from residential fires.
Head trauma, often the result of violent shaking, is the leading cause of death
and disability among abused infants and children.

Children and Adolescents

For children ages 5 to 14, motor vehicle injuries are the leading cause of death.
Only about 6% of children ages 4 to 8 ride in booster seats, the recommended safety seat for this age group.
Nearly two-thirds of children 15 and younger who died in alcohol-related motor vehicle crashes were riding with the drinking driver.
Drowning is the second leading cause of injury-related death among children 5 to 14.
For children ages 10 to 14, suicide is the third leading cause of death.
Between 1980 and 1997, the suicide rate for children 10 to 14 years old increased 109%.
Nearly one-third of bicyclists killed in traffic crashes are children ages 5 to 14.
An estimated 140,000 children are treated each year in emergency departments for traumatic brain injuries sustained while bicycling.
Children 15 and younger accounted for 11% of pedestrian fatalities and 30% of nonfatal pedestrian injuries in 1998.
Children are at increased risk for dog bites; 2.5% of children are bitten each year compared with 1.6% of adults.
Nearly 30% of rapes occur before age 12.

Teens and Young Adults

Homicide is the second leading cause of death for Americans ages 15 to 19.
In 1997, 85% of young homicide victims were killed with guns.
In a 1999 study, 14% of high school students had been in a physical fight on school property at least once in the preceding year.
For Americans ages 15 to 24, suicide is the third leading cause of death.
The risk of motor vehicle crashes is higher among teen drivers than any other age group.
Only 35% of high school students report that they always wear their seat belt.
In 1998, 21% of drivers ages 15 to 20 who died in motor vehicle crashes had blood alcohol concentrations of at least 0.10%.
The percentage of teens who wear bicycle helmets is close to zero.
More than half the people who sustain spinal cord injuries are between 16 and 30 years old.
Among young males, alcohol is a major factor in 50% of drownings.

Older Americans

Per mile driven, adults 65 and older have a higher crash rate than all but teen drivers.
The pedestrian death rate for people 65 and older is higher than for any other age group.
Falls are the leading cause of injury-related death among this age group.
Hip fractures are among the most serious fall-related injuries. Half of older adults who suffer a hip fracture never regain their previous level of functioning.
Older adults are among those at greatest risk for injuries from residential fires.
Adults 65 and older account for nearly 20% of suicides. This age group has had the highest suicide rate since 1933, when reporting of such data began

A chubby baby was borne after an uneventful pregnancy & delivery. Apgar scores & clinical exam are satisfactory, however, the nurse cannot determine the gender. She thinks it's a girl. But on careful examination, penis is seen between fat genital folds & when pulled out, measures 1 cm. So male gender is assigned. You can tell the nurse that -

a) since the baby is fat, this can be considered normal, no tests are necessary
b) hormone studies are necessary
c) genetic studies are necessary
d) there may be some problems with development

B or C


Diagnostic Tests:

I. Evaluation is usually conducted in consultation
with a neonatologist and a geneticist.
1. Laboratory studies: The most immediate concern
for a neonate with ambiguous genitalia is to
determine whether congenital adrenal hyperplasia
is present.
a. Chromosome analysis: This is the most
appropriate first test. Most laboratories
can provide an expedited result within two to
three days. Buccal smear provides a rapid
answer but are unfortunately highly
i. Normal 46XX karyotype: The neonate
almost always has virilizing congenital
adrenal hyperplasia. For confirmation
• 17-hydroxyprogesterone (17-OHP), 17
hydroxypregnenolone (17OHPe)
dehydroepiandrosterone (DHEA)
• 24 hour urine for 17-ketosteroids
• Daily serum potassium and sodium
• Serum testosterone
ii. Normal 46XY karyotype: The diagnosis of
an incompletely virilized male is
extremely complex.
• Testosterone (T) and
dihydrotestosterone (DHT)
• Luteinizing hormone (LH) and
follicle-stimulating hormone (FSH)
• Human chorionic gonadotropin (HCG)
b. One of the forms of CAH is salt losing.
Neonates may develop severe wasting, weight
loss, hyponatremia, hyperkalemia, metabolic
acidosis and adrenal shock. These signs
rarely occur prior to three to four days of
age but may not present until one month of
2. Pelvic ultrasound should be done to determine
presence or absence of uterus and ovaries.

Which of the following is the most imp risk factor for increased mortality in a 4 month old child with smoking parents?

a)passive smoking
b)no immunizations
c)infant not put in car seat
d)lack of smoke alarm in the house


A 24-month-old African-American female whom you have followed for routine well child care and a few episodes of otitis media is brought to the office by her mother for a regular well child visit. The mother is concerned that the child's language development seems to be slower than she remembers with her older children.

Which one of the following would be a cause for concern at this age?

1)She is making sentences of only two or three words
2)She is unable to name pictures on a standardized test, such as the Denver Developmental Screening Test
3)She is unable to correctly recognize three of four colors
4)She is unable to give her first and last name
5)Her total vocabulary includes about 40 words

By Age One

Recognizes name
Says 2-3 words besides 'mama' and 'dada'
Imitates familiar words
Understands simple instructions
Recognizes words as symbols for objects: Car - points to garage, cat - meows

Between One and Two

Understands 'no'
Uses 10 to 20 words, including names
Combines two words such as 'daddy bye-bye'
Waves good-bye and plays pat-a-cake
Makes the 'sounds' of familiar animals
Gives a toy when asked
Uses words such as 'more' to make wants known
Points to his or her toes, eyes, and nose
Brings object from another room when asked

Between Two and Three

Identifies body parts
Carries on 'conversation' with self and dolls
Asks 'what's that?' And 'where's my?'
Uses 2-word negative phrases such as 'no want'.
Forms some plurals by adding 's'; book, books
Has a 450 word vocabulary
Gives first name, holds up fingers to tell age
Combines nouns and verbs 'mommy go'
Understands simple time concepts: 'last night', 'tomorrow'
Refers to self as 'me' rather than by name
Tries to get adult attention: 'watch me'
Likes to hear same story repeated
May say 'no' when means 'yes'
Talks to other children as well as adults
Solves problems by talking instead of hitting or crying
Answers 'where' questions
Names common pictures and things
Uses short sentences like 'me want more' or 'me want cookie'
Matches 3-4 colors, knows big and little

Which of the following would be most imp risk factor for increased mortality/morbidity in a 5yr old with smoking parents?

a)passive smoking
b)lack of fence around the pool
c)riding a bike without helmet
d)leaving liquor cabinet unlocked
e)lack of smoke alarm in the house

most common cause of death in this group is unfenced pool is more common source of accident than bicycle accidents w/out helmet
so i think the ans is B

Just The Facts: Who Is at Greatest Risk for Fire-Related Deaths?

Children 4 and under
Older adults 65 and older
The poorest Americans
African Americans and Native Americans
Persons living in rural areas
Persons living in manufactured homes or substandard housing


ABCs take priority. Saving only the head will not save the patient.
Hypotension in adults is never caused by an isolated head injury except near death. Look for other injuries including cord injuries.
Physical exam includes complete neurologic exam as well as inspection for evidence of basilar skull fracture (CSF rhinorrhea, Battle's sign, raccoon eyes, hemotympanum), etc.

Low-risk injuries.
Minor trauma, scalp wounds.
No signs of intracranial injury, loss of consciousness.
Treatment. Observation for any sign or symptom of brain injury. Must discharge to a reliable observer who will continue observation at home.

Moderate-risk injuries.
Symptoms consistent with intracranial injury including vomiting, transient loss of consciousness, severe headache, posttraumatic seizures, amnesia, evidence of basilar skull fracture (CSF rhinorrhea, Battle's sign, raccoon eyes, hemotympanum).
Nonfocal neurologic exam.
Treatment. Observation and 'neuro checks'; consider CT; use clinical judgment.
Admit for observation and monitoring.

High-risk injuries.
Criteria. Depressed level of consciousness, focal neurologic signs, penetrating injury of skull or palpable depressed skull fractures.
Approach. Immediate CT, neurosurgical consultation.
Support while awaiting definitive neurosurgical care.
Intubation. Pretreatment with lidocaine 1 mg/kg IV may prevent rise in intracranial pressure (ICP). Hyperventilation to maintain PO2 >90 torrs, PCO2 25 to 30 torrs.
Maintains adequate oxygenation and reduces intracranial pressure.
PEEP relatively contraindicated because reduces cerebral blood flow.
Avoid tight cervical collars. Any pressure on the external jugular veins will increase the ICP.
Maintain normal cardiac output.
If hypotensive from other cause such as multitrauma, hypertonic saline (3% or 7.5%;) may be best IV fluid because stabilizes BP, improves cerebral blood flow, prevents increase in ICP from edema.
If hypertensive, consider labetalol or nitroprusside. Vasodilator such as nitroprusside will increase cerebral blood flow and ICP.
Treating increased ICP.
Hyperventilation as above.
Mannitol 1 g/kg IV over 20 minutes induces osmotic diuresis. (Controversial if patient not herniating. Consult your neurosurgeon.)
Some suggest furosemide (Lasix and others) 20 mg IV.
Elevate head of bed 30 degrees.
Steroids ineffective in controlling ICP in the trauma setting.
Glasgow coma scale.
Useful in a general sense, but 18% of those with a GCS score of 15 have an abnormal CT scan, and 5% of those with a GCS score of 15 require neurosurgical intervention. The GCS score is especially unreliable in children.
Skull radiographs. Head CT with bone windows generally preferable.
Generally not indicated in adults unless one suspects depressed fracture and cannot palpate skull because of hematoma, etc.
Can have intracranial injury without a skull fracture and vice versa.
May be useful in those up to 7 years of age because a skull fracture can lead to nonunion because of rapid head growth. Use clinical judgment as to severity of injury.
Postconcussive syndrome.
May occur with minor trauma.
Characterized by headache, memory difficulty, attention deficit, personality changes, negative CT (may represent disruption of axonal support structures, axonal stretching).
May have findings on formal neuropsychologic testing.
May last for a year or more.
Treat headache with nonnarcotic analgesia and depression.

Coma score is most useful in triage and in following status. Initial score of <7 indicates a poor prognosis if a cause other than trauma cannot be found and corrected quickly. Assessment should be done frequently and recorded accurately on a flow sheet with times documented.


ABCs including cervical spine immobilization if any possibility of trauma.
If hypertension with associated bradycardia, consider increased intracranial pressure.
Intubate to protect airway if no gag reflex.
Check finger-stick glucose and rapidly administer:
Thiamine 100 mg IV prevents Wernicke-Korsakoff encephalopathy.
Do not withold glucose if thiamine not available. A single dose of glucose will not induce Wernicke-Korsakoff encephalopathy.
Glucose 25 to 50 g IV treats hypoglycemia.
Naloxone 2 to 4 ampules of 0.4 mg treats narcotic overdose.
Some will start with 2 mg and then 4 mg if no response.
Make sure to restrain the patient if suspect will precipitate narcotic withdrawal. Recently the routine use of naloxone has been questioned in those patients without evidence of narcotic intoxication. However, it should be considered for use in all patients.
If suspect benzodiazapine overdose (valium, alprazolam, and others).
Flumazenil (Romazicon) 0.2 mg up to 5 mg IV. Do not use flumazenil if suspect concurrent tricyclic overdose or chronic benzodiazapine use. It may precipitate status epilepticus. This should not be routinely administered to the unconscious patient unless there is a clear indication and no contraindication.

Differential Diagnosis of Coma
Coma with no localizing CNS signs can be caused by:
Metabolic insults including hypoglycemia, uremia, nonketotic hyperosmolar coma, Addision's disease, diabetic ketoacidosis, hypothyroidism, hepatic coma.
Children and young adults will often get hypoglycemic and may present with coma after alcohol ingestion including mouthwash!
Respiratory including hypoxia, hypercapnia.
Intoxication including barbiturates, alcohol, opiates, carbon monoxide poisoning, benzodiazepines.
Infections (severe systemic) including sepsis, pneumonia, typhoid fever.
Shock including hypovolemic, cardiogenic, septic, anaphylactic.
Hypertensive encephalopathy.
Hyperthermia (heat stroke), hypothermia.
Coma with meningeal irritation without localizing signs can be caused by meningitis, subarachnoid hemorrhage from ruptured aneurysm, AV malformation.
If focal brainstem or lateralizing signs, can be caused by pontine hemorrhage, CVA, brain abscess, subdural-epidural hemorrhage.
If appear awake but unresponsive:
Abulic state. Frontal lobe function depressed and so may take several minutes to answer question.
Locked-in syndrome. Destruction of pontine motor tracts. Is able to look upward.
Psychogenic state. Unresponsiveness.

Pathophysiology of Coma
Coma can be caused only by:
Bilateral cortical disease.
Reticular activating system compromise.

To Differentiate Between Cortical and Brainstem Lesions
Use calorics - ice water in each ear. Nystagmus refers to the fast return phase. Four possible responses:
Both eyes deviate toward side cold water instilled and have good nystagmus. Patient not comatose.
Both eyes deviate toward cold water; no fast return phase. Brainstem function intact. Coma is caused by cortical problem.
No eye movement despite cold stimuli to both sides, thus no brainstem function (same as absent oculocephalic reflex, or 'doll's eyes').
Not necessarily a permanent lesion; may be caused by severe hypothermia or drug overdose.
Movement of only one eye ipsilateral to stimulus, thus intranuclear lesion, which almost always indicates brainstem damage and demands rapid evaluation to determine if a correctable lesion is present.
Generally resistant to metabolic insult.
Remember that a dilated eye may be secondary to topical or systemic drugs.
A dilated pupil in an alert person is not likely attributable to increased intracranial pressure and herniation.
A dilated pupil in an unconscious patient may herald imminent uncal herniation.
Small reactive pupils. Generally metabolic or diencephalic lesion.
Unilateral, dilated, fixed. Third nerve lesion or uncal lesion.
Bilateral pinpoint pupils. Pontine lesion.
Midposition, fixed. Midbrain lesion.
Bilateral large, fixed. Tectal lesion.
Propoxyphene (Darvon and others) can cause coma without pinpoint pupils.
Eyes will deviate toward side of physiologically inactive lesion (CVA) and away from an active lesion (seizure).
5% of the normal population will have anisocoria (asymmetric pupils).

Laboratory Work-up of Coma
CBC, electrolytes, BUN, creatinine, glucose, calcium, magnesium, arterial blood gas, toxic screen, carboxyhemoglobin, liver enzymes.
CT scan and LP.
If suspect meningitis, do not withhold antibiotics while waiting to do an LP. Antibiotics should be started before the patient goes to the CT scanner. Your culture results will not be affected.

A 65-year-old Greek woman visiting her children in Chicago complains of upper abdominal pain. The patient is brought to the family physician, who notices icteric sclera and a mass in the right upper quadrant. CT reveals a 10-cm multiloculated cyst with mural calcification that is compressing the common bile duct. Which of the following statements is correct concerning this clinical situation?

A)Treatment with the antiamebic agent chloroquine is indicated
B)Treatment with an antiechinococcal agent such as albendazole is sufficient
C)The adult parasite resides in the patient's intestine
D)Infection was probably caused by exposure to infected dogs
E)Surgery is contraindicated because of the risk of anaphylaxis from dissemination of infectious material

The answer is D
This patient hails from an area where echinococcal infection is endemic. It is prevalent in areas where livestock is raised in association with dogs. Dogs, which are the definitive hosts, harbor the adult E. granulosus worm and pass eggs in their feces, which can then be ingested by the intermediate hosts, including sheep, cattle, and humans. After ingestion of the eggs, the hatched embryos enter the portal circulation and frequently travel to the liver or lungs. The larvae develop into fluid-filled hydatid cysts from which secondary cysts develop. A slowly enlarging mass ultimately develops. After 5 to 20 years the mass may enlarge to the point where it may cause symptoms, such as those resulting from compression of the bile duct. Leakage of cyst fluid into the biliary tree also can mimic recurrent cholelithiasis; episodic leakage from the cyst can produce a syndrome of fever, pruritus, and urticaria or possibly even fatal anaphylaxis. The presence of daughter cysts within larger cysts and eggshell calcification in the wall of the cyst is essentially pathognomonic for E. granulosus infection and suggests that carcinoma, bacterial or amebic liver abscess, and hemangioma are less likely. Aspiration of the cyst may be conducted carefully for diagnostic purposes. Serology is not specific. Albendazole is not sufficiently effective to be used as monotherapy. Surgery is indicated for such a space-occupying lesion, although the risks of anaphylaxis and dissemination of infectious scolices may be minimized by instilling ethanol into the cyst cavity.

A 28-year-old Egyptian farmer presents with left flank pain. Ultrasonography reveals enlargement of the left ureter and hydronephrosis of the left kidney. Cystoscopy reveals a mass extending from the left ureter into the bladder. Parasitic ova (150 by 50 mm) are noted in the urine and in a biopsy of the ureteral mass. Which of the following statements is correct?

A-Renal failure is likely in the absence of treatment

B-The lesion is not reversible by chemotherapy

C-In the absence of treatment, the patient has an increased risk for transitional cell carcinoma of the bladder

D-The patient is suffering from schistosomiasis

E-The organism causing this problem is spread by fecal-oral contact

The answer is D.
Schistosomiasis represents the clinical manifestation of infection with a trematode (fluke). The urinary tract disease noted in this patient is characteristic of Schistosoma haematobium infection, which is endemic in parts of Africa and the Middle East. The infective stage of this parasite, termed a cercara, penetrates the unbroken skin of a human who comes in contact with contaminated water. After several days the schistosomules (developing schistosomes) travel to the lungs and then to the portal vein, where they mate and migrate to the ureteral venules (for S. haematobium; S. mansoni and S. japonicum migrate to the venules of the mesentery). Eggs are deposited in the bladder and ureters, with mature ova being released into the water, where they hatch into a meracidium that infects the intermediate host, a snail, eventually releasing thousands of cercaria to renew the cycle. Eggs deposited in the ureters and bladder elicit an intense inflammatory and granulomatous response that may cause functional obstruction. These lesions are reversible with the use of antischistosomal chemotherapy such as praziquantel. As fibrosis ensues, chemotherapy is less effective. The diagnosis is based on the demonstration of the characteristic eggs in the tissues or urine. S. haematobium infection is a predisposing factor for the development of an unusual histologic variant of bladder cancer (squamous cell carcinoma).

Items 1-3

A 45-year-old woman complains of a 9-month history of progressive facial weakness, occasional slurred speech and muscle weakness. She is an administrative assistant at the local university and is now unable to work as a result of her condition. She has a history of hyperthyroidism. Her current medications include an antithyroid preparation. She was hospitalized 2 months ago for respiratory failure although the exact cause of her condition was unable to be determined. Physical examination of the heart, lungs and abdomen are within normal limits. Reflexes and sensation are normal. Electromyography with low frequency repetitive stimulation reveals a decrement in the amplitude of evoked motor responses.

Laboratory studies are shown below:

Creatinine 0.9 mg/dL
Sodium 139 mEq/L
Potassium 4.3 mEq/L
Chloride 102 mEq/L
Bicarbonate 26 mEq/L
Magnesium 1.9 mEq/L
Erythrocyte sedimentation rate (Westergren) 25 mm/h

1. Which of the following entities should be highly considered in the differential diagnosis of this patient?

(A) Bacterial infection
(B) Extracranial mass lesion
(C) Hypothyroidism
(D) Neurasthenia
(E) Overdose of penicillamine

2. This patient undergoes the edrophonium test. Which of the following results are most likely?

(A) Confirmation of the presence of thymoma
(B) Confirmation of the presence of thyroid disease
(C) Rapid progression of dysphagia symptoms
(D) Rapid progression of slurred speech
(E) Rapid and transient improvement in muscle strength

3. The above test is undertaken and the results reported in the patient's chart. Her symptoms are still present. She undergoes a CT scan of the neck which reveals an anterior mediastinal mass. An otolaryngologist and a general surgery perform a neck exploration and the anterior mediastinal mass is removed. The specimen is sent for pathological analysis. The most likely finding by the pathologist is

(A) Rheumatoid arthritis
(B) Thymoma
(C) Thymic hyperplasia
(D) Thyroid carcinoma
(E) Thyroid hyperplasia

Answers 1-D, 2-E, 3-C
1.The correct answer is choice D. This patient has evidence of a neuromuscular disorder on the basis of her EMG findings revealing a decrement in the amplitude of evoked motor responses. She also has appropriate classical symptoms of facial and muscle weakness with slurred speech. Hyperthyroidism, not hypothyroidism is part of the differential diagnosis of this condition. Neurasthenia is weakness or fatigue without an underlying cause and is considered a diagnosis of exclusion in this case.
2.The correct answer is choice E. Edrophonium is a short-acting anticholinesterase, which will produce rapid and transient improvement in muscle strength in this patient who likely has myasthenia gravis. False positive tests can also occur in patients with upper motor neuron disease.
3.The correct answer is choice C. The pathophysiology of myasthenia gravis involves specific anti-acetylcholine receptor antibodies at the neuromuscular junction. The thymus is abnormal in 75% of patients. 65% have thymic hyperplasia while 10% have thymoma. Other autoimmune diseases are found in 10% of patients. The thyroid gland is typically not involved in myasthenia gravis.

You are evaluating a 24-year-old Hispanic female with severe right upper quadrant abdominal pain. Despite a normal gallbladder sonogram, you strongly suspect acute cholecystitis and order a technetium-labeled iminodiacetic acid (TeHIDA) scan.

Which one of the following results is most likely to confirm the diagnosis of acute cholecystitis?

a. Nonvisualization of the gallbladder and bowel
b. Nonvisualization of the gallbladder with normal visualization of the common bile duct and bowel
c. Visualization of the gallbladder delayed more than 2 hours after the ingestion of a fatty meal
d. Visualization of the gallbladder within 60 minutes

Answer is B.
In cholecystitis the radioactive HIDA substance will appear in the bile ducts, but it will not enter the cystic duct or the gallbladder, a finding that indicates obstruction. If the substance enters the bile ducts but does not enter the small intestine, then an obstruction of the bile duct (usually due to stones or cancer) is suspected.

A 68-year-old white male who lives alone is admitted after having been found by his daughter lying on the basement floor. No one knows for sure how long he had been lying there. He seems confused and is noted to have a tri-malleolar fracture of the right ankle. His only prior medication was ibuprofen, 800 mg 3 times a day which he took for a 'sore shoulder.'

After admission, you note that he is oliguric with a 24-hour urine output of 320 cc. His blood urea nitrogen (BUN) is 65 mg/dL and serum creatinine is 2.1 mg/dL. On a physical examination which he had only 2 weeks prior to admission, a chemistry profile had noted the BUN as 14 mg/dL and the creatinine as 1.1 mg/dL. Urinalysis shows 1+ protein, occasional white cells, no red cells, and no cellular casts. Urine osmolality is 618, urine sodium is 3 mEq/L, and urine creatinine is 105 mg/dL.

The most likely cause of his oliguria is

a. bilateral cortical necrosis
b. renal toxicity of ibuprofen
c. acute glomerulonephritis
d. decreased renal perfusion
e. acute tubular necrosis


The clinical picture described in this question is most consistent with prerenal azotemia and oliguria secondary to decreased renal perfusion from volume depletion or hypotension. The disproportionate elevation of blood urea nitrogen (BUN) over creatinine, the high urine osmolality and low urine sodium concentration, and the urine/plasma creatinine ratio favor this diagnosis, rather than acute tubular necrosis or bilateral cortical necrosis. In the latter condition, 24-hour urine output is often less than 100 cc. The absence of red blood cells and red cell casts in the urine makes acute glomerulonephritis an unlikely diagnosis. Renal insufficiency secondary to NSAIDs is more likely to be renal papillary necrosis or acute interstitial nephritis. Urinalysis results are not consistent with those diagnoses.

A painful thrombosed external hemorrhoid diagnosed within the first 24 hours after occurrence is ideally treated by

a. total hemorrhoidectomy
b. thrombectomy under local anesthesia
c. office cryotherapy
d. office banding
e. appropriate antibiotics


A thrombosed external hemorrhoid is described as the sudden development of a painful, tender perirectal lump. Because there is somatic innervation, the pain is intense, and increases with edema. Treatment involves excision of the clots or incision under local anesthesia, mild pain medication, and sitz baths. It is inappropriate to use procedures that would increase the pain, such as banding or cryotherapy. Total hemorrhoidectomy is inappropriate and unnecessary.

A 29-year-old white male who works in a plywood factory is crushed by a press. On examination in the emergency department, you find that six ribs are fractured on the right side of his chest and five on the left. Paradoxical respiratory movement of the right hemithorax is obvious. He is confused, hypoxic, and tachypneic.

Instability of the chest wall in this patient is best managed by

a. use of a volume-controlled ventilator following intubation
b. towel-clip traction of the chest wall
c. strapping the chest
d. placing sandbags against both sides of the chest


Generally, external methods of stabilization have been replaced by intermittent positive-pressure, volume-controlled ventilation. Ventilation is continued to the point of apnea, which produces the same sedative effects as apnea resulting from mild alkalosis. As a result, the patient makes no active inspiratory effort, and the flail segment does not undergo paradoxical motion.
Placing sandbags against both sides of the chest and strapping the chest are methods of stabilization that fix the chest wall in a position of expiration and thereby reduce total compliance. Towel-clip traction of the chest partially stabilizes the chest wall in the inspiration position, but is extremely difficult to maintain.
In the evaluation and management of this type of patient, the physician should not let the chest wall injury (with flail chest) divert his attention from possible underlying pulmonary or myocardial injury.

A 76-year-old white male consults you regarding impotence. He describes not only an inability to achieve an erection but also a marked decline in his libido. A serum testosterone level is reported as low.

Which one of the following laboratory studies should be ordered next?

a.Prolactin level
b.Estradiol level
c.FSH level
d.Cortisol level
e.Renal panel


In patients with impotence, diminished libido, and decreased testosterone, a prolactin level should be ordered, to rule out a pituitary adenoma.

A young male is brought to the emergency department after having been submerged for a prolonged period in a nearby pond. Cardiopulmonary resuscitation was performed at the scene. The patient is being ventilated by mask and bag upon arrival in the emergency department. A brief examination reveals that the patient has no obvious sites of trauma and is conscious but not communicative. His blood pressure is 90/60, pulse is 120, temperature is 36°C (96.8°F), and respiratory rate is 30. Cardiac rhythm reveals sinus tachycardia. Pulse oximetry reveals oxygen saturation of 83 percent. Which of the following is the best method to reverse the patient's apparent hypoxemia?

A: Administration of sodium bicarbonate
B: Administration of acetazolamide
C: Administration of supplemental oxygen
D: Application of continuous positive airway pressure and administration of supplemental oxygen
E: Administration of supplemental oxygen and endotracheal suction to remove aspirated fluid

The answer is D
Ninety percent of drowning patients aspirate fluid; however, the vast majority aspirate less than 22 mL/kg. Although aspiration of fresh water can produce acute hypervolemia with dilutional hyponatremia and possibly even hemolysis, these are rare occurrences. Aspiration of seawater can cause hypovolemia with ensuing hypernatremia. In the absence of documentation of such an electrolyte problem, no specific therapy is required. Aspiration of water of any type leads to considerable venous admixture (i.e., ventilation-perfusion abnormalities), which can produce hypoxemia. The most important therapeutic maneuvers, after resuscitation on the scene, are to provide supplemental oxygen, intravenous access, and transportation to a hospital where the patient can be evaluated for adequacy of ventilation, cardiac function, and blood volume. The best way to reverse drowning-associated hypoxemia consists of the application of continuous positive airway pressure (CPAP). CPAP may be combined with mechanical inflation of the lung as needed; mechanical inflation may be particularly effective in those who have aspirated fresh water, which leads to a change in the surface-tension characteristics of pulmonary surfactant. Correction of severe metabolic acidosis with bicarbonate is controversial. Finally, the universal need for corticosteroid therapy and antibiotics is no longer accepted.

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