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Pediatrics: Stridor and Dyspnea

medicines

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Pediatrics: Stridor and Dyspnea

Epiglottitis.
Definition. Infection of the epiglottis and of the aryepiglottic folds and surrounding soft tissues. Becoming less common since use of H. influenzae vaccine. Is more common in adults in whom it presents as a severe sore throat with drooling, neck tenderness.
Cause. Almost always by H. influenzae type B. Other causes: beta- hemolytic streptococci, Staphylococcus aureus, and Streptococcus pneumoniae.
Clinical presentation. May occur at any age, with a peak incidence at 2 to 7 years. Presents with sudden onset of high fever, respiratory distress, severe dysphagia, drooling, muffled voice, and a toxic appearance. Stridor, if present, may be mild in comparison to croup. Often there is little or no coughing. Child typically prefers being upright in 'sniffing' position.
Lab tests. Invasive procedures and examinations should be avoided until after airway is secured. CBC and blood and epiglottic cultures may then be obtained. Radiographs of lateral area of neck shows characteristic swollen epiglottis (thumb sign). Never send a child suspected of having epiglottitis to be radiographed unaccompanied by someone who can emergently manage airway.
Treatment.
Do not move, upset, or lay child down unless prepared to manage obstructed airway.
Airway. In an emergency, a bag-valve-mask can buy time. Consider a needle cricothyrotomy. Controlled intubation by an experienced operator is preferred. Tracheostomy is acceptable if unable to intubate. Usually safely extubated in 48 to 72 hours after appropriate antibiotics are started. Airway must be secure. Top of size 3 ET tube fits on Luer-lok needle, allowing for easy bagging.
Antibiotics. Initiated once artificial airway secure. Cefotaxime 50 to 200 mg/kg/24 hours divided Q6h or ceftriaxone 75 mg/kg Q24h are the first-line drugs with TMP/SMX as a second-line agent.
Admission to ICU. Use proper sedation and restraints during period of intubation. Antibiotics continue for 7 to 10 days after extubation.

Croup (Laryngotracheobronchitis).
Definition. A syndrome of airway swelling in the glottic and subglottic area of viral origin.
Causes. Parainfluenza virus types 1 and 3 responsible for majority of cases; remainder respiratory syncytial virus, influenza virus, and adenovirus.
Clinical presentation. Age usually 6 months to 6 years. Symptoms of the common cold usually precede onset. Brassy cough (seal bark), hoarseness, and inspiratory stridor are characteristic. If severe may include retractions, decreased air entry, and cyanosis. Usually benign course but can progress to obstruction.
May be resolved by presentation to office or ED from exposure to cool air.
Must differentiate from epiglottitis and bacterial tracheitis, which require emergent management. See Table 12-9.
Classification.
Very mild. Intermittent stridor, present when awake or excited, goes away when sleeping.
Mild. Continuous stridor when awake or asleep not audible without stethoscope.
Moderate. Continuous stridor audible without stethoscope and may be accompanied be sternal retractions.
Severe. Continuous stridor with evidence of respiratory failure, that is, cyanosis, altered mental status.
Lab tests. Usually not indicated and may induce further agitation with respiratory compromise. If in doubt and no need for emergent airway management, AP radiograph of neck may show subglottic narrowing (steeple sign).
Management.
Calm the child on the parents lap and provide cool, humidified air.
Oxygen if saturation <95%.
Reassess status after 15 to 30 minutes.
If mild classification, consider discharge with instructions for cool mist humidifier.
If moderate classification.
The traditional treatment has been nebulized racemic epinephrine, 2.25% solution, 0.5 ml diluted in 3 ml of saline.
Nebulized epinephrine, 5 ml of 1:1000, has been shown to be as safe as, at least as good as, and perhaps superior to racemic epinephrine. May repeat PRN.
There is no 'rebound effect' from epinephrine, but patients may return to their pretreatment state.
Steroids. Generally those who need nebulized epinephrine should also be treated with dexamethasone 0.6 mg/kg/dose IM or PO up to 10 mg. Although not standard of care, nebulized budesonide 1 mg given twice at 30-minute intervals is effective in mild-to-moderate croup and may prevent the need for systemic steroids. However, up to now, it has not been compared to dexamethasone in any trial.
Continuation of cool, humidified air may also be helpful.
Disposition. Patients may be discharged with instructions for cool mist humidifier if, after 3 to 6 hours of observation, they require no further treatment with epinephrine and their croup is mild. If patient remains in the moderate classification, hospitalization with epinephrine or racemic epinephrine PRN and dexamethasone 0.25 to 0.5 mg/kg/dose Q6h for 2-4 doses.
If in severe classification, the decision to intubate should be left to experienced personnel and, when feasible, be performed in the operating room. Management is as above while awaiting trained personnel for sedation and intubation.

Foreign-Body Aspiration.
Clinical presentation. Majority 3 months to 6 years. Have triphasic history:
Initial cough, choking, gagging, stridor, wheeze.
FB then passes into smaller airways and have silent phase.
Then have recurrent pneumonia, wheezing, abscess, bronchiectasis.
A third not witnessed or not remembered by caregiver.
Radiographs. Can show air trapping on exhalation but one fourth have normal radiograph. Radiography is only 50% specific. Do CXR with patient lying on affected side. Dependent lung will not deflate normally if there is foreign body obstruction.
Bronchoscopy. Diagnostic procedure of choice if there is any question.
Treatment.
Without respiratory distress. Refer for removal by bronchoscopy.
Respiratory distress present.
If the patient is breathing, do not interfere; allow the childs efforts to attempt to clear the foreign body.
If not moving air, American Heart Association obstructed airway maneuvers should be employed. For infants, 5 interscapular back blows with the childs head lower than the chest, alternating with 5 chest compressions. In older children, Heimlich maneuver. Advanced cardiac life support protocol should be initiated if necessary.
Bag-valve-mask ventilations can convert a total obstruction to a partial one by pushing foreign body into a main bronchus.
Immediate direct laryngoscopy and removal with Magill forceps should be performed.
If unsuccessful, cricothyrotomy or intubation if needed.
Prevention. Infants and young children should not eat nuts, popcorn, hot dogs, uncooked carrots, whole grapes, or hard candies. Balloons and surgical gloves are especially dangerous for young children. Dice food. Avoid small toys. Educate parents.

Bronchiolitis.
Epidemiology. Illness of young children and infants. Most serious in first 2 years of life. Respiratory syncytial virus (RSV) principal agent. Also associated with parainfluenza, adenovirus, Influenza virus, rhinovirus. The majority occur during winter but can occur any season.
Clinical presentation. Rhinorrhea, sneezing, coughing, low-grade fever. Onset of rapid breathing and wheezing. Signs of respiratory distress in severe cases: nasal flaring, tachypnea, prolonged expiratory phase, retractions.
Lab tests. CBC usually within normal limits. Blood gas, O2 saturation levels, as appropriate. Nasal wash for RSV culture and antigen assay. CXR can be normal but occasionally shows air trapping and peribronchial thickening.
Treatment.
Indications for hospitalization. Use clinical judgment. Some suggested criteria include <6 months old, resting respirations >50 to 60, pO2, <60 mm Hg, pulse oximetry 95%, apnea, unable to tolerate oral feedings.
Supportive measures. Antipyretics, IV fluids, humidified O2, nebulized bronchodilators, such as albuterol 2.5 mg in 3 ml of NS; this can be repeated PRN. Oral albuterol can be used (0.1 mg/kg Q8h up to 12 mg) but is much less effective. Epinephrine, 5 ml of 1:1000 by nebulizer is safe and effective and is an alternative. Steroids are ineffective. However, they continue to be widely used in doses similar to those for asthma.
Ribavirin aerosol. The efficacy of ribavirin has recently been called into question. The use of ribavirin even in severely ill patients is at the discretion of the physician. If croup or bronchiolitis secondary to RSV, consider use of ribavirin in high-risk groups.
Congenital heart disease
Chronic lung disease (such as bronchopulmonary dysplasia)
Infants <6 weeks of age
Neurologic disorders
Immunosuppressed
Severely ill infants.
PaO2 <65 mm Hg or SaO2 <90%
Increasing pCO2
Intubation and mechanical ventilation as indicated.
Respiratory syncytial virus immunoglobulin (RSV-IVIG) 750 mg/kg IV Q30 days can prevent RSV infection and hospitalization in those children with severe underlying illness such as bronchopulmonary dysplasia or prematurity. An alternative is Synagis (Palviziumab), an RSM immunoglobulin that can be given IM (15mg/kg/dose IM Q month). Use with caution in those with thrombocytopenia or coagulation defects because of intramuscular bleeding.



Screening Recommendations

Cholesterol

All men aged 35 and older and all women aged 45 and older should be screened routinely for lipid
disorders.

Younger adultsmen aged 20-35 and women aged 20-45should be screened if they have other risk
factors for heart disease. These risk factors include tobacco use, diabetes, a family history of heart
disease or high cholesterol, or high blood pressure.

Clinicians should measure HDL in addition to measuring total cholesterol or LDL. There is insufficient
evidence to recommend for or against measuring triglycerides.

The optimal frequency of screening has not yet been determined, but every five years seems reasonable. Longer intervals may be appropriate in persons with normal cholesterol and no risk factors for CAD.10


Hypertension

Screening of all adults is recommended at least every two years. Hypertension currently is defined as blood pressure >140/90, though this is more an arbitrary cutoff level than a biological one. In fact, cardiovascular mortality begins to increase at systolic pressures >110 mm Hg, and diastolic pressures > 70 mm Hg.

Hypertension should be diagnosed using an average of more than one reading taken at each of three separate visits. Once confirmed:

Patients should be counseled concerning physical activity, dietary sodium intake, weight loss, and alcohol intake.
Risk factors for CAD such as elevated cholesterol and smoking should be assessed.
Decisions on beginning drug therapy should be based on the level of blood pressure elevation, patient's age, concomitant disease, risk factors, and evidence of target-organ damage.
All patients should be counseled concerning physical activity and weight control as primary prevention of hypertension.


Breast Cancer

Screening women 50 to 75 years of age with mammography significantly decreases the death rate from breast cancer. There is some controversy surrounding the screening of women between the ages of 40 and 49 because early studies showed no improvement in survival rates. However, several studies now show a significant reduction in mortality rates in women in this age group who receive mammograms.11

There is not enough evidence to prove the effectiveness of clinical breast exams (CBE), but most groups recommend annual CBE beginning at age 40.

There is no evidence of benefit in screening women over the age of 75, but each case should be considered on an individual basis.

There is insufficient evidence to recommend for or against teaching breast self-examination.


Colorectal Cancer

Screening for colorectal cancer is recommended for all persons aged 50 and older with fecal occult blood testing (FOBT) and/or flexible sigmoidoscopy.

There is not enough evidence to determine whether FOBT or sigmoidoscopy is the more effective screening tool, or whether there is an advantage in combining the two methods.

FOBT should be done on an annual basis, with the patient following the recommended guidelines for dietary restrictions, collection, and storage.

The optimal frequency of performing flexible sigmoidoscopy is not known, but most experts recommend screening every three to five years.

High risk patients (i.e., familial polyposis, HNPCC, ulcerative colitis, adenomatous polyps, or colon cancer) should have earlier and more frequent screening.

Digital rectal examination (DRE) has poor sensitivity and specificity as a screening test, and although it is recommended by a number of organizations the USPSTF found insufficient evidence to recommend for or against DRE as a screening tool for colorectal cancer.


Cervical Cancer

Regular Pap smear screening is recommended every one to three years in all women with a cervix who are or have been sexually active or who are 18 years of age or older.

There is no evidence that screening annually leads to a better outcome than screening every three years, but screening schedules for individual patients should be determined with consideration of that patient's risk factors for cervical cancer.

Pap smears probably can be discontinued after age 65 if the patient has received regular screening prior to that time and if all of the patient's smears have been normal. Screening after hysterectomy is not necessary unless cancer was the reason for the surgery.


Prostate Cancer

The USPSTF recommends against routine screening for prostate cancer with DRE, prostate specific antigen (PSA), or transrectal ultrasound. The ACS and the American Urological Association recommend annual DRE beginning at age 40, and PSA measurement beginning at age 50 (age 40 for African American men), but there is no evidence that screening for prostate cancer results in reduced morbidity or mortality.

The prevalence of prostate cancer found incidentally at autopsy in men ages 70 to 79 is reported to be as high as 66%, and although millions of men will have prostate cancer when they die, only a small percentage will die from their cancer. There currently is no good screening method to distinguish between aggressive and indolent cancers, and screening can in fact expose patients to potential complications of treatment such as incontinence, impotence, and even death.

If screening is to be performed, the patient should be informed of the potential benefits and risks of screening.

If screening is performed, the best approach is DRE and PSA in men with a life expectancy of >ten years.


Influenza Vaccination

Recommended for all persons 50 years of age and older.9 Also recommended for patients considered to be at high risk for the complications of influenza, including residents in chronic care facilities, and patients with chronic cardiopulmonary disorders, metabolic diseases (including diabetes mellitus), hemoglobinopathies, immunosuppression, or renal dysfunction. The vaccine also is recommended for health care workers who care for high risk patients.

Amantadine or rimantadine prophylaxis is recommended for high-risk persons after exposure or during an epidemic. Medication may be started at the time of immunization and continued for two weeks. If the vaccine is contraindicated, amantadine or rimantadine should be continued daily for the entire season of influenza activity in the community.


Pneumococcal Vaccination

Recommended for all immunocompetent persons 65 years of age and older and those at increased risk for pneumococcal disease. High-risk groups include institutionalized persons >50 years of age, and persons two years of age or older with chronic cardiac or pulmonary disease, diabetes mellitus, or anatomic asplenia.

Though routine revaccination is not recommended at the present time, it should be considered in individuals at highest risk for pneumococcal disease who were vaccinated more than five years previously.

There is not enough evidence to recommend for or against routine vaccination for immunocompromised patients, but many authorities cite a high incidence of pneumococcal disease in this population and a low incidence of severe side effects from the vaccine as reasons to give it. (Immunocompromised conditions associated with a high incidence of pneumococcal disease include alcoholism, cirrhosis, chronic renal failure, nephrotic syndrome, sickle cell disease, multiple myeloma, metastatic or hematological malignancy, acquired or congenital immunodeficiency, and organ transplant.)


Hepatitis B Vaccination

Recommended for all young adults not previously immunized, as well as for those at high risk for acquiring the disease, such as homosexual men, injection drug users and their sexual partners, persons with multiple sexual partners or those who have recently acquired another sexually transmitted disease, patients who receive blood products, and health care workers who are
frequently exposed to blood or blood products.


Td Vaccine Series

Should be completed for all patients who did not receive the primary series. The optimal frequency of booster doses has not been established. Current practice is to give Td boosters every ten years, but giving them every 15 to 30 years is probably adequate in a person who completed a primary series in childhood. The ten year interval is recommended for international travelers.


Hepatitis A Vaccine

Recommended for all high-risk adults (persons living in and traveling to endemic areas, homosexual men, IV drug users, military personnel, and certain hospital and laboratory workers).


Varicella Vaccine

Recommended for healthy adults with no history of previous infection with varicella or previous vaccination. The vaccine is to be given in two doses, four to eight weeks apart. Serologic testing may be offered to patients with no history of infection.


Rubella

All women of childbearing age should be screened for rubella susceptibility by history of vaccination or by serology.

Comparing non-diabetics to type 2 diabetics, how much more likely are the type 2 diabetics to develop coronary heart disease?

A.Two to fourfold
B.Four to sixfold
C.More than sixfold
D.None of the above

A

Type 2 diabetes is associated with a two- to fourfold excess risk of coronary heart disease (CHD). It is not clear, however, how poor glycemic control affects macrovascular disease in those with type 2 diabetes. The finding of increased cardiovascular risk factors before the onset of type 2 diabetes suggests that aggressive screening for diabetes combined with improved glycemic control alone will not be likely to completely eliminate excess risk of CHD in type 2 diabetic patients.

After prolonged artificial feeding, dementia, dermatitis, and hypercholesterolemia may occur as a result of a deficiency of which mineral?

a. Copper
b. Chromium
c. Manganese
d. Zinc
e. Selenium

D

cecil p.1175
deficiency
chromium: hyperglycemia, elevated plasma FFA, neuropathy, encephalopathy
copper: depigmentation of skin and hair, neurologic disturbances, leukopenia, anemia, skeletal abnormalities
manganese: hypocholesterolemia, weight loss, dermatitis, hair and nail changes, impaired synthesis of vitamin k-dependent proteins
selenium: myalgias and cardiomyopathies

A 22-year-old college student with no prior medical problems begins working as a laboratory technician. He subsequently presents because of several recent episodes of shortness of breath, cough, fever, chills, and malaise. Each episode has lasted several days. The patient is seen during the recovery phase of an episode of this type; findings at physical examination are normal. Chest x-ray reveals several ill-defined, diffuse, patchy infiltrates. The laboratory evaluation is positive only for an increased erythrocyte sedimentation rate. Pulmonary function studies display reduced lung volumes.
On further questioning, it is learned that these episodes begin on days when the patient is required to tend to experiments involving laboratory rats at the animal facility. What is the best treatment for this condition?


A Inhaled cromolyn sodium

B Prednisone

C Inhaled beclomethasone

D Discontinuation of visits to the animal facility

E No treatment

D

dyspnea and nonproductive cough, after allergen exposure
x-ray,pft result is fit.
tx.- eliminating or preventing exposure to the offending agent is primary priority
if not possible, then corticosteroid high dose and then tapering

A 64-year-old man presents with progressive shortness of breath. Other than a history of heavy tobacco abuse, the patient has a benign past medical history. Breath sounds are absent two-thirds of the way up on the left side of the chest. Percussion of the left chest reveals less resonance than normal. While you place your hand on the left side of the chest and have the patient say 'ninety-nine,' no tingling is appreciated in the hand. The trachea appears to be deviated toward the left. Which of the following diagnoses is most likely?

A Bacterial pneumonia
B Viral pneumonia
C Bronchial obstruction
D Pleural effusion
E Pneumothorax

The answer is C
In evaluating a patient with shortness of breath, examination of the thorax is crucial. Tracheal deviation to the left indicates either a pleural effusion on the right or loss of volume on the left. Volume loss typically is due to an obstructed bronchus that produces atelectasis in the affected segment or lobe. Loss of aerated lung will be reflected in dullness to percussion, absent breath sounds on auscultation, and a decrease in tactile fremitus. A consolidative process such as bacterial pneumonia may well produce increased fremitus as well as bronchial breath sounds and whispered pectoriloquy, since sounds are well transmitted through a consolidated area. In a pneumothorax, a percussion of the chest would reveal hyperresonance, although breath sounds and fremitus would be absent. A possible cause of obstruction and atelectasis of a large amount of left lung tissue could be obstruction of a major bronchus by carcinoma of the lung, especially in an older patient who is a heavy smoker

tracheal deviation
percussion-dullness
fremitus decreased
absent breath sound over affected area

An 80-year-old woman falls in the kitchen, striking her head against a counter. She does not lose consciousness. Over a period of several days, she becomes progressively lethargic. Her family discovers one morning that she is difficult to arouse and that she has left hemiparesis.
All of the following statements concerning this patient are true except:

a. Differential diagnosis includes ischemic stroke with edema or brain tumor.
b. Treatment with corticosteroids is adequate.
c. The patient's CT scan might show a subdural collection with both acute and chronic blood.
d. This disorder can be treated with surgical drainage.
e. This disorder is not uncommon in ethanol abusers and patients with chronic renal failure.

B

  1. Subdural hematoma (SDH) results from injury to the bridging and emissary veins as they cross the subdural space. Minor trauma can cause sufficient movement of the elderly atrophic brain to tear these vessels. Hemorrhaging can be acute or chronic. The differential diagnosis of this patient is defined by those entities that could produce a fairly rapidly progressive mass effect with the resulting increase in intracranial pressure and decrease in the level of consciousness as well as hemiparesis. This would include a stroke with progressive edema or brain tumor. Subdural hematoma can cause prominent CT scan changes as described above. When symptoms such as decreased level of consciousness, dementia, or hemiparesis occur, surgical drainage either via a burr hole or craniotomy is the treatment of choice. Smaller subdural hematomas without severe symptoms can be followed radiologically. Steroids have not been shown to affect the outcome. Ethanol abusers, people with chronic renal failure with platelet dysfunction, and the elderly are at risk to develop subdural hematoma.

HIV encephalopathy is characterized by all of the following signs and symptoms except

a. Difficulties with concentration and memory
b. Psychomotor retardation
c. Symptoms of motor dysfunction such as hyperreflexia and gait abnormalities
d. Delirium
e. Abnormal CSF examination

The correct answer is e.
e. HIV encephalopathy is a subacute encephalitis that results in a progressive subcortical dementia without focal neurologic signs. Patients usually develop subtle mood and personality changes, memory deficits, impaired concentration, and some psychomotor slowing. Patients can develop delirium, hyperreflexia, spastic or ataxic gait, paraparesis, and increased muscle tone. The neuropathologic picture includes multinucleated giant cells, microglial nodules, diffuse astrocytosis, perivascular lymphocyte cuffing, cortical atrophy, and white matter vacuolation and demyelination. Examination of the CSF may show slight elevations in protein concentrations; about 25% of all HIV-infected patients may show a mononuclear pleocytosis but it is not diagnostic of HIV encephalopathy. The correct answer is e.
e. HIV encephalopathy is a subacute encephalitis that results in a progressive subcortical dementia without focal neurologic signs. Patients usually develop subtle mood and personality changes, memory deficits, impaired concentration, and some psychomotor slowing. Patients can develop delirium, hyperreflexia, spastic or ataxic gait, paraparesis, and increased muscle tone. The neuropathologic picture includes multinucleated giant cells, microglial nodules, diffuse astrocytosis, perivascular lymphocyte cuffing, cortical atrophy, and white matter vacuolation and demyelination. Examination of the CSF may show slight elevations in protein concentrations; about 25% of all HIV-infected patients may show a mononuclear pleocytosis but it is not diagnostic of HIV encephalopathy.

ADC-main features include-
Progressive symptoms may include mental slowing, forgetfulness,poor concentration, apathy, social withdrawal, loss of spontaneity, and reduced libido. Patients display personality changes, including
reduced emotional expression, increased irritability, mania, and disinhibition. Loss of fine motor control (deterioration in handwriting),slowing of gait, unsteadiness, urinary incontinence, and tremor may
be seen. Seizures occur in 10% of patients.
It's a diagnosis by exclusion.



mild form= impaired concentration and attention, slowness in performing complex mental tasks
more severe- cognitive dysfunction worsen, motor dysfunction with gait difficulty
personality change, hyperactivity and agitation
most severe-global dementia, paraplegia, virtual mutism

even asx. HIV infected individuals exhibit mild CSF changes

The single most important factor in the risk for adverse drug reaction is

a. Patient's age
b. Coadministration of multiple medications
c. Renal drug clearance or hepatic drug clearance
d. Bioavailability

B

  1. The coadministration of multiple medications is the single most important factor in the risk of adverse drug effect; thus the fewest number of drugs possible should be used in patients

Which of the following statements regarding advance directives for health care is most appropriate?

a. Advance directives are irrevocable once executed.
b. Advance directives cannot be modified once executed.
c. Advance directives are in effect once executed.
d. Once executed, advance directives remain valid until revoked or suspended.
e. Advance directives are mandatory for admission to a health care facility

D

  1. Advance directives, once executed, remain valid until revoked or suspended but do not become effective until the patient has lost decision-making capacity. Advance directives may be modified, revoked, suspended, and reinstituted. They are not required for admission to a health care facility or for obtaining insurance.

All of the following statements regarding the withholding or withdrawing of life-sustaining treatments are true except:

a. The primary basis for withholding or withdrawing life-sustaining treatments is patient autonomy.
b. There is an ethical difference between withholding and withdrawing life support.
c. Life-sustaining therapy can be limited on the basis of medical futility even without the patient's consent.
d. In the absence of an advance directive, decisions regarding life-sustaining therapy should be guided by the degree to which a patient is benefited or burdened by the treatment.
e. Pain and suffering caused by withholding or withdrawing life-sustaining treatment should be alleviated by appropriate medication even if this hastens the patient's death.

The correct answer is b.
b. There is no ethical difference between the withholding or withdrawing of any medical therapy. An appropriately informed adult patient with decision-making capacity has the right to forgo any form of medical therapy, including life-sustaining therapy. This right is based on the ethical principle of autonomy or self-determination. A patient's physician has the responsibility to carry out the patient's request regarding the withdrawing or withholding of therapy in a humane and compassionate manner. The patient's pain and suffering, which includes dyspnea, should be relieved by the administration of appropriate medications, including sedatives and analgesics. Efficient medication to relieve pain or suffering should be given even if this hastens the patient's death. An example is titrating morphine to higher levels in order to relieve pain from cancer, severe dyspnea from lung cancer, or chronic obstructive pulmonary disease.
In circumstances in which a patient does not have an advance directive or is unable to state his or her desire and there is no surrogate decision, the physician's decision should be to determine what is best for the patient with regard to life-sustaining therapy. The benefits for the patient should be weighed against the burden. Based on the ethical principles of beneficence and nonmaleficence, if the benefits of therapy exceed the burden, therapy should be administered. However, if the burden exceeds the benefits, therapy should not be administered. The purpose of life-sustaining therapy should be to restore or maintain the patient's well-being and not merely to prolong life. Therefore, life-sustaining therapy may be withdrawn from a patient without consent, if the therapy is judged to be futile. Futile therapy prolongs the dying process without any apparent benefit to the patient

a young female with low grade fever and mild tenderness in the lower pelvis b/l came to your office after physical exam you thinks of PID..
do you treat as outpatient or you admit the patient
if you treat as outpatient what ATBs you give and for how long???

in my case, i am gonna treat her as a inpatient

because of the high rate of ambulatory treatment failures and the seriousness of sequelae, patient are now usually hospitalized for treatment of PID.
broad spectrum cephalosporin and doxicycline
cefoxitin 2 g IV q6hours or cefotetan 2g IV every 12hours ( until patient is asymptomatic for 48 hours) with concomitant 10-14days doxycycline 100mg po BID
as outpatient, ceftriaxone 500mg IM everyday or cefoxitin 2g IM plus 1g of probenecid po is used with close follow-up for resolution of symptoms

Therre are some efinite indications for admission including teen patient/pregnant/excesive nausea/failure of PO therapy etc.
Standard regime includes-
Ofloxacin+ Flagyl for 14 days (Outpatient regime)
Cefotetan IV + Doxy IV- switch to PO regime later for inpatient therapy.
These are the CDC regimes

Here are some CCS suggestions from another site to work out-
1) 2 day old with Hyperbilirubinemia( total 12< 5mg/dl raise per daydirect1mg/dL)
2) NidDM out of control.
3) Narcotic overdose
4) Female with fatigue.Colon Ca/hypothyroidism
5) Biochemist with Fatigue..wtih HypercalcemiaRenal Cell Ca
6) #0 yr Female with Major Depressive Episode
7) 7 months infant with Forewign body aspiration.
8)Hyper tensive( cholest/DM/TOB with s/o weakness?
9) Nortriptyline toxicity
10) Ecclampsia in labor
11) heart failure with HTN
12) premature labor
13) Uncontrolled Hyper tension.
14) Unstable angina
15) Diverticulitis 60 yr old LIQ pain
16) perforation DU ulcer
17) Anemia Iron deficiency in all forms
18) Afro-American with G6PD def with sulfa ingestion
19) Post viral dilated cardiomyopathy
20) NIDDM with DKA
21) Pneumococcal Pneumonia
22) Acute Cysititis30 yr lady
23) Irrtiable bowel syndrome
24) Hashimoto thyroditis.
25) Graves Disease( hyperthyroidism)
26) 45 yr Male, cough 3 day febrile tachycardia crackles base lung right
27) simialr lady.but crackles left lung
28) male 75 yrs, cough dry SOB mild confusion, 3 days NIDDM mild renaldiseaseCHFafebrile130 HRBP normalcrackles both lung bases
29)Male 54 yrasthma status.
30) Classical basedow disease. female
31) AMI unrelieved ny NTG
32) young male with Bloody diarhhea
33) 8yr child with feverralespneumococaal pneumonia
34) Maleauto accidentSOB,creps,chest pain,ecchymoses..Hemopericardium
35) Foreign body aspirationchild

POTENTIAL CCS TOPICS- another list

CVS
Aortic aneurysm,
dissecting
heart failure
Hypertension
Crisis
Office management
ischemic heart disease
Angina
unstable
Myocardial infarction


Endocrine
Diabetes mellitus,
resistant to therapy
DKA
Thyroiditis
Hashimotos
Hyperthyroidism

GastroIntestinal
Appendicitis
acute
Cholecystitis, acute
Diverticulitis, acute
Intestinal obstruction
Acute
Pancreatitis
acute
Polyp
Adenocarcinoid colonic polyp in 60 year old
Sigmoid colon
Carcinoma

Health Maintenance
Middle aged man

Hematological
Anemia
Iron deficiency
pediatric
hemophilia a
Hodgkins disease
ITP

Hepatobiliary
Cholecystitis
Acute
Cirrhosis, hepatic
GERD
Hepatitis
A
Jaundice
newborn
PUD
Ulcerative collitis

ID
AIDS
Newly diagnosed HIV pt w/u:
HIV (Oppurtunistic infections)
HIV Pneumocystis Carinii Pneumonia in an AIDS pt
HIV Pneumocystis Carni Pneumonia, Candida vaginitis, thrush
HIV related Pneumonia-ER
HIV with fungal lung infection
HIV with PCP
disseminated fungal infection
neutropenia
chemotherapy induced
Pulmonary TB

UTI
Elderly
Male, ambulatory, middle aged
Ppregnancy and UTI
vaginitis
gonococcal
trichonomas

Immune Complex
Rheumatoid arthritis

Neurology
Alzheimers
Coma
Hyperosmolar
CVA
Subdural hematoma
TIA (resolved)

ObGyn
Adenomyosis
Cervical carcinoma

Dysfunctional uterine bleeding
Eclampsia
Endometrial carcinoma
menopause
menorrhagia
in pubertal girl
Ovarian Cyst
Ovarian malignancy with metastases
uterine bleeding in a 14 y.o.
Vaginal bleeding
vaginal spotting
CIN II young women with post coital spotting after work up HPV -ve
general
post coital

Opthalmology
Glaucoma

Poisoning
Alcohol intoxication
Amitryptiline toxicity
Barbiturate
Nortryptiline toxicity
Salicyclate
Unknown
Valium

Psychiatry
Altered mental status
Dementia
Depression
Elderly
Major

Pulmonary
Asthma
Status asthmaticus in 4 year old
Interstitial pneumonitis
Pneumothorax

UroGenital
Renal failure
Urinary obstruction
BPH and dribbling
Elderly with prostate Ca

Rheumatology
Polymyalgia Rheumatica
SLE

Trauma
ARDS from trauma and multiple fat emboli
Blunt chest injury
GI perforation
Myoglobinuria
Pericardial tamponade s/p MVA (hemopericardium)
Scrotal hematoma
Splenic rupture
Spousal Abuse

How about these fellas?

What is the single most important prognostic factor for survival in patients with vulvar squamous cell carcinomas?

A.tumor size
B.depth of invasion
C.tumor grade
D.Inguinal lymph node status

D

Inguinal lymph node status is the single most important prognostic factor in patients with squamous cell carcinomas. A study of 588 patients treated in two Gynecologic Oncology Group (GOG) trials reported a 5-year survival of 91% in those with negative inguinal lymph nodes. Five-year survival decreased to 75%, 36%, 24%, and 0% in patients with one or two, three or four, five or six, or seven or more positive lymph nodes, respectively. Patients with bilateral lymph node involvement had a survival rate of 25%, compared to 71% for those with unilateral lymph node involvement.
Other major prognostic factors include tumor size, depth of invasion, tumor grade, the presence of lymph-vascular space invasion, and extracapsular growth of lymph node metastases in the groin. These features correlate with one another, and are predictive of lymph node metastasis.

Which of the following risk factors found in pregnant women with chronic hypertension is associated with adverse neonatal outcomes independent of the development of preeclampsia:

A.smoking history
B.proteinuria
C.advanced maternal age
D.black race

B

Proteinuria, detected early in pregnancy, is an independent risk factor for adverse neonatal outcomes, independent of the development of preeclampsia in women with chronic hypertension. Preeclampsia was defined as proteinuria (urinary protein excretion of greater than or equal to 300mg per 24 hours) in women without proteinuria at baseline.

What is the standard treatment for HIV-infected pregnant women?

A.There is no standard treatment for HIV-infected pregnant women
B.combination therapy with zidovudine and lamivudine
C.Zidovudine monotherapy
D.Nevirapine
E.Zalcitabine with Didanosine

A

There is no standard treatment for HIV-infected pregnant women. Many decisions about HIV therapy will be predicated on the stage of HIV disease in the mother. HIV-infected pregnant women should be offered a range of antiretroviral therapy options with discussion of the risks, both known and unknown, of exposing the baby in utero to the medications, particularly in the first trimester, balanced against the benefits of therapy to control HIV infection and improve immunologic status. If possible, pregnant women infected with HIV should be enrolled in clinical trials to ensure that all aspects of therapy and toxicities are carefully documented. Drug exposure should be reported to national pregnancy registries.
Source: Shah SS, McGowan JP.: Preventing HIV Transmission During Pregnancy. Infect Med. 2001;18:94-105.
References
1.US Public Health Service Perinatal HIV Guidelines Working Group. US Public Health Service Task Force recommendations for the use of antiretroviral drugs in pregnant women infected with HIV-1 for maternal health and for reducing perinatal HIV-1 transmission in the United States, 2000. Available at: https://hivatis.org/guidelines/perinatal/PerinatalFeb2500.pdf.

All the following statements regarding the treatment of patients with HIV infection are true EXCEPT

A use of zidovudine (ZDV) therapy during pregnancy reduces the risk of vertical transmission to less than 10 percent
B HIV RNA assays should not be relied upon in making decisions about changing a patient's antiviral regimen
C though a useful agent in antiviral therapy, zidovudine monotherapy is a suboptimal regimen
D primary prophylaxis of Mycobacterium avium complex has clearly demonstrated efficacy in preventing bacteremia and improving survival
E breast feeding is a potential mode of HIV transmission and should be discouraged in women who are HIV-infected

The answer is B
AIDS Clinical Trial Group 076 demonstrated that ZDV (AZT) administration to women reduced the rate of HIV transmission in neonates from 25 percent in the placebo group to 8 percent in ZDV recipients. Postnatal transmission of HIV from mother to infant via breast feeding has been clearly documented. A meta-analysis of several prospective trials indicated a risk of 7 to 22 percent. Certainly, in developed countries, breast feeding by an infected mother should be avoided. There is, however, disagreement regarding this recommendation in developing countries where breast milk is the only source of adequate nutrition for the infant. Plasma HIV RNA assays provide precise and compelling data on the relative magnitude and durability of antiretroviral therapy. Most authorities recommend the use of HIV RNA assays (viral load) and CD4+ counts to guide decisions regarding antiretroviral therapy. While zidovudine has proven benefit in patients with <500 CD4+ lymphocytes, its use as monotherapy is suboptimal and should be reevaluated in any patient receiving it. Rifabutin and macrolides have both demonstrated marked efficacy in the primary prophylaxis against Mycobacterium avium with a concomitant decrease in bacteremia and improvement in survival

Which drug is usually effective for treating lithium-induced tremor?

a. Benztropine
b. Triazolam
c. Propranolol
d. Verapamil
e. Valproic acid

The correct answer is c.
c. Lithium-induced postural tremor is probably the most common of the medication-induced postural tremors. Propranolol in the range of 20 to 160 mg daily, given in two or three divided doses, is generally effective for treating lithium-induced postural tremor. (Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences Clinical Psychiatry)

It's similar to essential tremor-an accentuation. Cogentin is more suitable for DRA-induced tremor(alongwith Clonazepam)

Tremor, as such is a common complication of lithium therapy and it's appearance doesn't mandate discontinuation. It is a sign of toxicity- does not correlate with serum level.
You can continue lithium with Inderal cover.



The most commonly recommended screening interval for cholesterol for adults under age 65 with no history of cardiac disease is

a. Yearly
b. Every 3 years
c. Every 5 years
d. Every 7 years
e. Every 10 years

C

In adults under age 65 with no cardiovascular disease, it is recommended that a serum cholesterol be done every 5 years. If the level is greater than 200 mg/dL, a complete fasting lipid profile should be ordered

In pt with >2 risk factors and total Ch>200, or <2 RF, total Ch>239, you do fsting lipoprotien analysis. If pt has <2 RF and is 200-239, recheck in 1-2 years.
Hope this help.

Starts from 35 in male/45 in female- after 75 discontinue routine screen.
May start earlier in case of premature Family H/O

The number of community elderly people over age 65 who experience a fall is

a. 33%
b. 55%
c. 90%

The correct answer is a.
a. About one-third of community elderly people older than 65 years of age fall each year; this percentage increases to 50% by age 80 years. Most fallers experience multiple episodes. Although the results have been inconsistent, most studies have shown that the frequency of falling is similar in older men and women. Women, however, are about twice as likely to suffer a serious injury during a fall

What is the appropriate indication for influenza vaccine?

a. Adults over age 65 or those with chronic cardiac or pulmonary disease
b. All adults if not previously immunized within the past 10 years
c. Adults with sickle cell disease or splenic dysfunction
d. Staff and patients in dialysis unit

A

. Influenza vaccine is recommended for people over age 65 who have chronic cardiac or pulmonary disease as well as for younger patients with asthma

Which of the following conditions is not associated with smoking?

a. Peripheral vascular disease
b. Parkinson's disease
c. Complications of pregnancy
d. Cancer of the larynx
e. All of the above

The correct answer is b.
b. Peripheral vascular disease, complications of pregnancy, and cancer of the larynx are all associated with smoking. Other diseases related to smoking include coronary artery disease, cerebrovascular disease, lung, esophageal, oral, and bladder cancers, and chronic obstructive pulmonary disease. Parkinson's disease is not associated with smoking but may be inversely related to it

Which condition is predictive of cardiovascular events?

a. Hospitalization
b. Systolic hypertension
c. Diastolic hypertension
d. Antihypertensive medications
e. Normal-pressure hydrocephalus

B

Although the clinical treatment of hypertension has classically focused more on diastolic blood pressure levels, epidemiologic data indicates that for middle age and elderly adults, systolic blood pressure is more predictive of future cardiovascular disease than diastolic blood pressure. Elevation of systolic blood pressure continues to be the single strongest cardiovascular risk factor, but elevation of diastolic blood pressure is diminished substantially in terms of associated risk.

Systolic BP is a sensitive indicator of CVA/Adverse cardiovascular events, more than diastolic(particularly in gero population). However hospitalization is also an independent risk factor.

A 24-year-old, previously healthy woman presents with jaundice, confusion, and fever. Initial physical examination is unremarkable except for scattered petechiae on the lower extremities, scleral icterus, and disorientation on mental status examination. Laboratory examination discloses the following: hematocrit, 27 percent; white cell count, 12,000/L; platelet count, 10,000/L; bilirubin, 85 mol/L (5 mg/dL); direct bilirubin, 10 mol/L (0.6 mg/dL); urea nitrogen, 21 mmol/L (60 mg/dL); creatinine, 400 mol/L (4.5 mg/dL). Red blood cell smear discloses fragmented red blood cells and nucleated red blood cells. Prothrombin, thrombin, and partial thromboplastin times are all normal.
The most effective and appropriate therapeutic maneuver is likely to be


A plasmapheresis
B administration of aspirin
C administration of high-dose glucocorticoids
D administration of high-dose glucocorticoids plus cyclophosphamide
E splenectomy

A

she shows the pentad of TTP(thrombocytopenia, fever ,confusion, MAHA, renal dysfunction)

plasmapheresis is the mainstay of therapy.at least 5days or for 2days after normalization of platelet count, resolution of neurologic signs
we can add methylprednisone 200mg IV qd.
antiplatelet agent (aspirin 325mg qd) in some cases
splenectomy- recurrent , refractory to plasma exchange

Which of the following statements best describes the role of polymerase chain reaction (PCR) in the diagnosis of HIV infection?

A It should be used if the western blot is indeterminate
B It is a useful screening test
C It should be used if two consecutive serologic tests (ELISA) are positive
D It should be used if the initial serologic test is positive, but the second is negative
E It has no real role

The answer is A
The standard serologic test for HIV infection, the enzyme-linked immunosorbent assay (ELISA), has a sensitivity of over 99.5 percent. However, this test is not particularly specific in that low-risk patients are subject to a false-positive rate of over 10 percent. If the ELISA test is indeterminate or positive, the test should be repeated. If the repeat is positive or indeterminate, one should proceed to the next step, which is a western blot test. If the repeat ELISA is negative, then the person can be assumed not to have HIV infection. A western blot test involves the reaction of the serum with a strip impregnated with HIV-1 antigens. Binding of antibodies in the patient's serum to the antigens on the strip is detected with an enzyme-conjugated anti-human antibody. A positive western blot test requires the detection of antibodies to several HIV-1 gene products. If the western blot is indeterminate, perhaps due to infection in evolution or due to cross-reacting antibodies in the patient's serum, one should proceed to a PCR test and repeat the western blot in 1 month. If the PCR is negative and there is no progression on the western blot, the diagnosis of HIV infection is ruled out. The PCR test is extraordinarily sensitive, but the false-positive rate would be too high for use as a cost-efficient screening test. A DNA PCR test for HIV involves the isolation of DNA from blood mononuclear cells and incubation with primers from both the gag and LTR regions, followed by amplification and hybridization to detect HIV proviral DNA. An RNA PCR test can be used to monitor the level of HIV genome present in plasma.

DNA PCR estimates viral load and is an indicator of HAART response-should be zero within 4-6 months of therapy. Ultrasensitive tests are also there but only the PCR is FDA approved for F/U

All of the following statements regarding the epidemiology of HIV infection are correct EXCEPT


A the risk of transmission following skin puncture from a needle contaminated with blood from an HIV-infected patient is less than 0.5 percent

B most cases of AIDS are now among IV drug users

C the risk of transmission from a single donor unit of blood is approximately 1/500,000

D most pediatric cases of AIDS arise because of vertical transmission from an infected mother

E there is no convincing evidence that saliva can transmit HIV

The answer is B
Among U.S. cases of AIDS, male-to-male sexual contact represents the most frequently reported mode of HIV transmission among persons with AIDS. However, over the past few years, the number of newly reported cases of AIDS among other groups, including IV drug users and heterosexuals, from certain large cities have surpassed the number of newly reported cases among men who had sex with men. The proportion of new cases attributed to IV drug use and heterosexual sex has increased dramatically over the past ten years. There is a small but existent occupational risk of HIV transmission. Large, multi-institutional studies have indicated the risk of a penetrating injury, such as a needlestick from an HIV-infected person, to be approximately 0.3 percent. Risk posed by a mucocutaneous exposure is probably closer to 0.1 percent. Current measures used to screen donors now include p24 antigen testing which has resulted in a further decrease in the risk of being infected from a unit of blood to at most 1 in 450,000 to 1 in 660,000. Pediatric AIDS arises mainly from infants born to mothers who are HIV-infected. The remainder are generally exposed via blood transfusions. Although HIV can be rarely isolated from saliva, there is no convincing evidence that saliva can transmit HIV infection, either through kissing or other exposures, such as occupationally to health care workers.

NAT (genomic amplification testing) is also used by big centers, I think it is not yet FDA approved. It shortens the window period by 11 days.
Ref J.B. Henry: Clinical Diagnosis and Management by Laboratory Methods, 20th edition

Which is a risk factor for oral cancer?

a. Radiation to head and neck
b. Alcohol and tobacco abuse
c. Fair skin and sun exposure

B

most important predisposing risk factors for the primary head and neck ca. is the use of alcohol and tobacco,
the use of the two together is more than additive in enhancing carcinogenesis
other associated etiologic agents include viruses.(HPV 6,11,16,18), EBV, HIV genetic susceptibility

Which legal document most correctly defines an advanced directive?

a. Living will
b. Durable power of attorney for health care
c. Both
d. Neither

C

Advance directives are written documents intended to become effective when the patient has lost decision-making capacity. There are three forms of advance directives. The living will specifies medical treatment preference and the medical conditions in which those preferences should or should not be implemented. With the durable power of attorney a person is designated to act as a health care representative with the legal authority to make health care decisions for the patient. However, the decisions are not specified by the document. The third form of advance directive is a combination of the above two forms. A representative is designated with the responsibility to assure that the patient's written instructions concerning medical therapy are respected

A 44-year-old nonsmoking woman presents to your office with a productive cough. She has had asthma since childhood, with several exacerbations requiring hospitalization over the past 10 years. She comes to you for treatment of poorly controlled asthma. She complains of daily productive cough, frequently expectorating brown mucus plugs, and with dyspnea, wheezing, fever, and chills. She currently is on an albuterol inhaler, inhaled beclomethasone, theophylline, and occasional short courses of prednisone for exacerbations. She denies allergies, pets, or travel. She denies postnasal drip, heartburn, and chest pain.
Physical examination reveals a woman in no respiratory distress. Head and neck examination is normal. Lung examination reveals diffuse inspiratory and expiratory wheezing with crackles in the right upper lung field. A chest radiograph reveals a right-upper-lobe infiltrate with subsegmental atelectasis and central bronchiectasis. A room air ABG shows pH 7.45, pCO2 35 mmHg, and pO2 80 mmHg. Hematocrit is 40%, leukocyte count is 15,000 mm3, segmented neutrophils 60%, lymphocytes 20%, and eosinophils 15%. Serum IgE level is 3500. Sputum analysis reveals hyphae consistent with aspergillus. A skin test for aspergillus reveals an immediate wheal and flare response.
The most likely diagnosis of this patient is allergic bronchopulmonary aspergillosis.
Which of the following is the most appropriate therapy for this patient?

a. Itraconazole
b. Amphotericin B
c. Prednisone
d. Surgical resection
e. No specific therapy is required

C

ABPA- allergen avoidance and intermittent use of corticosteroids
Pulmonary aspergilloma-observation and surgical resection for the patients with massive hemoptysis
Invasive aspergilloma- serious invasion:amphotericin B(1mg/kg/day for 2.0-2.5g total)
mild to moderate invasion-Itraconazole(600mg po qd for 4days, then 200-400mg po qd for 1 year)

Which of the following patients should undergo operative excision of an abdominal aortic aneurysm and replacement with a vascular graft?

A: A 58-year-old man with a 8-cm abdominal aneurysm who sustained a myocardial infarction 3 months ago

B: A 65-year-old man with a 7-cm aneurysm who sustained a myocardial infarction 1 year ago

C: A 65- year- old woman with a 4-cm aneurysm and no prior history of heart or lung disease

D: A 58-year-old man with a 7-cm aneurysm and FEV1 of 0.8 L

E: A 67- year- old man with an 8-cm aneurysm and creatinine 3.2 mg/dL



The answer is B
The vast majority of aortic aneurysms are due to atherosclerosis; 75 percent of such aneurysms are located in the distal aorta below the renal arteries. Although these aneurysms are typically asymptomatic, rupture may occur with devastating consequences. The prognosis is related to the size of the aneurysm as well as the presence of coexistent vascular diseases. Patients with aneurysms exceeding 6 cm who are not treated surgically have 50 percent mortality in 1 year, while those with lesions between 4 and 6 cm have 25 percent mortality during the first year. Surgical excision and replacement with a prosthetic graft are indicated for patients with aneurysms greater than 6 cm in diameter as well as in symptomatic patients or those with rapidly enlarging aneurysms regardless of the absolute diameter. Depending on the degree of operative risk, surgery also may be recommended in those with aneurysms with diameters between 5 and 6 cm. Contraindications to elective reconstruction include myocardial infarction within the past 6 months, intractable congestive heart failure, ongoing severe angina pectoris, severe obstructive lung disease, severe chronic renal failure, history of stroke with residual neurologic deficits, and life expectancy less than 2 years. An extensive preoperative evaluation including assessment of coronary disease, renal failure, and pulmonary function studies should be carried out, and if abnormalities are found, they should be ameliorated when possible. For patients in whom the diameter of the aneurysm is less than 6 cm or in whom there is significant operative risk, serial ultrasound may be helpful in defining a group that more urgently requires surgical intervention based on expansion of 0.5 cm or more.

Is a stool ova and parasites (stool O&P) recommended in cases of acute diarrhea?

A. Yes
B. No

B

Because this laboratory evaluation isn't cost-effective in cases of acute diarrhea, it is not recommended. However, the American College of Gastroenterology Practice Parameters Guideline Committee (ACG PPGC) recommends ordering the study if there is a high suspicion of parasitic infection; if the patient hasn't been treated empirically for parasites; or if one of the following conditions exists:
persistent diarrhea in a patient with AIDS or who is a homosexual male;
diarrhea following travel to Russia, Nepal, or mountainous regions;
exposure to infants attending daycare centers;
persistent diarrhea associated with a community outbreak; or
bloody diarrhea with negative fecal leukocyte test results.

A 77-year-old male with COPD has a non-Q wave MI. Should this patient receive a beta-blocker?

A. Yes
B. No

Yes. According to a retrospective review of 201,752 patients with myocardial infarction published in the August 20, 1998 issue of the New England Journal of Medicine, mortality was lower across every subgroup of patients treated with beta-blockade compared with untreated patients, including those with heart failure, chronic pulmonary disease, advanced age, and non-Q wave infarction.

A 25-year-old woman presents with brownish discoloration of the face. She is 6 months pregnant and reports that the areas of hyperpigmentation developed as her pregnancy progressed. What is the most likely diagnosis?

A. Solar Lentigines
B. Pityriasis versicolor
C. Caf au lait Spots
D. Melanoma
E. Melasma

E

Melasma gravidarum (chloasma gravidarum). This form of melasma (chloasma), a fairly trivial cause of skin hyperpigmentation, generally presents in pregnant women as a tan or brownish discoloration on the face. These blotches often proceed as far up as the hairline and extend down to the jawline. The hyperpigmented areas of skin are typically symmetric and localized to the forehead and chin, but may also manifest on the areolae, axilae, and genitals. The condition is more prevalent among dark-skinned individuals and worsens on sun exposure. Levels of progesterone and estrogen -- both of which stimulate melanin formation -- rise during pregnancy, implicating a role for these hormones in the etiology of this pigmented lesion. Although melasma gravidarum usually fades after delivery, it may persist for many years.

A diabetic patient well-known to you has a BP reading of 150/90mmHg at his latest office visit. What is the target BP recommended for patients with diabetes?

A. 130/80 mmHG
B. 120/80 mmHG
C. 120/90 mmHG
D. 130/90 mmHG

A

According to the guidelines for management of hypertension (JNC-VI) which were revised in November of 1997, patients with diabetes should have a BP less than 130/80mmHG.
Other revisions include an emphasis on classification; the previous terms of 'mild,' 'moderate,' and 'severe' hypertension have been replaced with 'Stages 1, 2, and 3.' Because of its small size, Stage 4 hypertension (from JNC V) has been deleted, with Stage 3 now encompassing patients with BP readings greater than 180mmHg systolic and/or greater than 110mmHg diastolic. Prognostic implications of systolic hypertension are more important than those of diastolic hypertension.

Is testing for H pylori recommended in patients with no prior history of ulcer disease and who are not at increased risk of NSAID-induced ulcer complications?

A. Yes
B. No

B

In a patient with no history of ulcer disease and who otherwise is not at increased risk of NSAID-induced ulcer complications, testing for H pylori is not recommended at this time.

Immunocompromised children should be vaccinated against varicella?

A. yes
B. no

B

No. The American Academy of Pediatrics currently recommends that most of these children not receive the vaccine routinely. The results of administering the vaccine under research protocols show that around 40% of those with acute lymphocytic leukemia (ALL) developed a small rash consisting of vesicular lesions that often congregated around the site of injection.[1] Many of these patients needed treatment with acyclovir, and some required admission to the hospital for IV administration.
There is, however, an ongoing study in which children with ALL are receiving the vaccine. The manufacturer makes free vaccine available -- through a research protocol -- to any physician for use in patients who have ALL and who meet certain eligibility criteria.[2] This is also true for renal transplantation patients. The CDC now recommends giving the vaccine to children with HIV who are asymptomatic and have CD4+ age-specific T-lymphocyte percentage of >/= 25%.[3] However, a 2-dose regimen is recommended.

contraIx.of VZV vaccination severe immunocompromised patient , patient receiving gammaimmunoglobulin, during pregnancy, acute febrile illness , hypersensitivity to certain antibiotics(erythromycin..), poor general condition due to renovascular disease, renal disease, and liver disease

high risk group like immunocompromised with chickenpox-
acyclovir 500mg/m2/8hours)

What is the most common pattern of dyslipidemia in patients with type 2 diabetes?

A. elevated triglyceride levels and decreased HDL cholesterol
B. elevated triglyceride levels
C. elevated triglyceride levels and increased high-density lipoprotein (HDL) cholesterol
D. elevated triglyceride levels and increased HDL cholesterol levels
E. elevated triglyceride levels and increased LDL cholesterol levels

A

Dyslipidemia in patients with type 2 diabetes is most commonly manifested by elevated triglyceride levels and decreased high-density lipoprotein (HDL) cholesterol. Although the concentration of low-density lipoprotein (LDL) cholesterol is usually not significantly different from that of nondiabetic individuals, patients with type 2 diabetes typically have a higher prevalence of small denser LDL particles, which have been reported to be more atherogenic.
The American Diabetes Association defines optimal lipoprotein levels for adults with diabetes as LDL cholesterol < 100 mg/dL (2.60 mmol/L) and an HDL cholesterol > 45 mg/dL (1.15 mmol/L). The desirable level of triglycerides is < 200 mg/dL (2.30 mmol/L).

What is the definitive therapy for decompression illness in divers?

A. Hyperbaric oxygen (HBO) treatment
B. Nitrogen treatment
C. 100% oxygen at 30 FSW for 90 minutes bid
D. No definite treatment is available

A

Hyperbaric oxygen (HBO) treatment is gaining popularity as the definitive therapy for a growing number of disorders, including decompression illness, arterial gas embolism, carbon monoxide poisoning, clostridial infections, crush injuries, diabetic leg ulcers, skin graft failures, refractory osteomyelitis, thermal burns, necrotizing soft tissue infections, and osteoradionecrosis.
In the US, hyperbaric oxygen therapy for decompression sickness is guided by the Navy Treatment Tables. The prescribed treatments are very effective, especially when recompression is begun promptly. The purpose of the therapy is two-fold: to promote inert gas elimination and to help cause a decrease in bubble size. The treatment outlined by the tables also provides oxygen to the damaged tissues, treats platelet and clotting damage and allows excretion of harmful metabolites. The oxygen reduces CNS edema and provides a high oxygen gradient (2000 mm Hg) for the ischemic tissues.

Should patients with total hip arthroplasty (THA) receive antibiotic prophylaxis for dental procedures?

A. Yes
B. No

B

Perioperative antibiotics are not necessary in routine dental procedures in nonimmunocompromised patients who have total hip implants. However, they should be used in any post-THA patients undergoing extensive dental procedures involving periodontal work, extractions, and relatively high blood loss.
In a retrospective study of 3000 patients with THA over 14 years from 1982 to 1995, 52 (1.7%) late infections of THA were identified. Of those, 3 patients (6% of those infected) were found to have infections related to a dental procedure both temporally and bacteriologically.

A 55-year-old healthy white postmenopausal female presents to your office with complaints of low back pain. She takes no drugs and does not smoke. Would you recommend that she get a bone density scan?

A. Yes
B. No

Yes. Because of her gender, advancing age (she is postmenopausal and not taking estrogen), and complaints of back pain (which may be due to weakened vertebrae), this patient should be evaluated for osteoporosis. Diagnosis of osteoporosis is based on measurement of bone mineral density, which correlates with fracture risk.
The absence of risk factors, such as family history or the use of certain medications, including anticonvulsants or corticosteroids, which can promote osteoporosis, does not guarantee that this patient does not have the disease; up to 35% of all women with no documented risk factors will develop osteoporosis. And osteopenia may be present in more than half the postmenopausal women seen in a typical primary care setting. Therefore, bone mineral density testing should be considered in any patient with at least one risk factor for osteoporosis, a history of hyperthyroidism/hyperparathyroidism, a chronic disease that can cause bone loss, and in all postmenopausal women who are not taking estrogen replacement therapy. Dual energy x-ray absorptiometry is the most widely used imaging technique for measuring bone mineral density.

A 65-year-old cirrhotic male with a history of hepatitis C virus (HCV) infection presents to clinic. What is the recommended screening strategy for assessing this patient for hepatocellular carcinoma (HCC)?

A. ultrasound every six months
B. alpha-feto protein (AFP) every six months
C. ultrasound and alpha-feto protein (AFP) every three months
D. ultrasound and alpha-fetp protein (AFP) every six months.
E. No screening is recommended

Answer is C.
According to a report from the American College of Gastroenterology Annual Scientific Meeting (held October 15-20, 1999, in Phoenix, Ariz), for patients at 'extremely high risk' of developing HCC, such as those with cirrhosis associated with active ethanol ingestion and HCV infection, ultrasonography and serum alpha-fetoprotein (AFP) measurements should be performed every 3 months.
HCC is the most common primary liver cancer and has a worldwide distribution. This malignancy is associated with many underlying conditions and events, including hepatitis B virus (HBV) and HCV infection (with or without cirrhosis); end-stage liver diseases due to ethanol ingestion, hemochromatosis, and alpha-1-antitrypsin deficiency; exposure to environmental toxins, such as aflatoxin; and administered medications, such as anabolic steroids.
Establishing a proper screening strategy first requires determination of who should be screened. All patients with at-risk disorders should be considered for screening. In most cases, this means screening those with cirrhosis, especially when HBV, HCV, ethanol, or alpha-1-antitrypsin deficiency are causative diseases.





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