high risk wound-
>5 years since immunization - give immune globulin and booster
<5 years - no intervention
low risk wound-
>10 years - give booster
<10 years - no intervention
**A syndrome of choreoretinitis,
retardation, and intracranial calcifications associated with microcephaly, and
hepatosplenomegaly with jaundice and rash or purpura suggests the diagnosis of
a. cryptococcal meningitis
c. subacute sclerosing panencephalitis
d. congenital neurosyphilis
e. congenital toxoplasmosis
Toxoplasma gondii is an intercellular parasite that affects man and animals. It usually infects asymptomatically, but can cause varieties of disease. Congenital toxoplasmosis classically causes specific syndromes of choreoretinitis, retardation, extracranial calcification associated with microcephaly, hepatosplenomegaly with jaundice and rash or purpura. Subacute sclerosive panencephalitis is a syndrome that occurs in childhood, a result of measles infection, rarely rubella. First symptoms are personality change, intellectual deterioration, development of myoclonal seizures, ataxia, and visual impairment. The diagnosis of genital neurosyphilis is difficult to make since the neonate serum STF, FTA, ABS, and even the CSF, STS may be positive because of passively transferred maternal antibodies and the absence of infection. Newborn's IGM, FTA, ABS with a total IGM of the cord can be measured to aid in diagnosis. Lumbar punctures are performed on all neonates at risk for congenital syphilis. In fungal infections of the central nervous system the usual clinical picture is of chronic meningitis, but intraparenchymal infections may occur with symptoms that resemble bacterial brain abscess. Exuberant inflammatory response fungii will lead to obstruction of CSF pathways and hydrocephalus. A vast majority of cases of fungal meningitis that in this country are caused by cryptococcus neoformans and coccidioides immitis. Leptospirosis is caused by leptospiro anterrogans and in man may cause several types of CNS disease-aseptic meningitis, encephalitis, myelitis, and optic neuritis. The CSF protein may be over 100 mg per 100 milliliters.
**An infant begins to
vomit shortly after birth and his abdomen becomes distended. A radiograph of
the abdomen shows a 'double-bubble' gas shadow.
The infant's problem most likely is
a. congenital megacolon
c. duodenal atresia
d. esophageal atresia
e. tracheoesophageal fistula
Vomiting is the most common presentation of congenital duodenal obstruction in the newborn. Abdominal distension ensues, and a flat plate radiograph of the abdomen shows a classic 'double-bubble' gas shadow above, with an absence of gas in the distal bowel. While a tracheoesophageal fistula, esophageal atresia, and malrotation also cause vomiting, they are not associated with the 'double-bubble' radiograph.
**The method of choice
for initial evaluation of bone involvement in patients with multiple myeloma
A - Technetium-99m bone
B - Conventional roentgenograms
C - CT-scanning
D - MRI of the skeleton
E - None of the above
Answer is B.
Conventional roentgenograms reveal punched-out lytic lesions of the bone,
osteoporosis, or fractures in almost 80% of patients with multiple myeloma at
diagnosis. The most commonly affected areas are vertebra, skull, thoracic cage,
pelvis and proximal humeri and femora. Rechnetium-99m bone scanning is inferior
to conventional x-rays for the detection of lytic lesions and should not be used
for this purpose (it is, however, excellent for detection of osteoblastic
CT scanning and MRI may be helpful in patients who have bone pain but no abnormalities on conventional x-rays (MRI also may have prognostic value). These methods should not be used for initial evaluation.
**An elderly male
complains of severe muscle weakness in his thigh muscles and proximal arm
muscles, although this weakness is mild. He states that his weakness is worse
in the morning immediately after getting out of bed and improves during the
On physical examination it is apparent that muscle strength increases with repetition of the grip strength test and later diminishes. Which of the following tests should be included in the workup of this patient?
A - Chest X-ray
B - Tensilon test
C - Abdominal CT
D - Colonoscopy
Answer is A. Symptoms
in this man are consistent with Eaton-Lambert syndrome. This syndrome shares
the same pathologic site with myasthenia gravis (the neuromuscular junction)
and has a similar path physiology (an autoimmune disease). Eaton-Lambert
syndrome is usually associated with malignancy. Up to 70% of these patients
have associated small cell lung cancer, and this disease must be ruled out in
every patient with presenting symptoms of Eaton-Lambert syndrome.
Clinical presentation of the Eaton-Lambert syndrome includes weakness that is typically seen early in the hip girdle, making it difficult for the patient to rise from a chair or to climb the stairs. Less dramatic is shoulder girdle weakness. Involvement of the bulbar muscles or diplopia is rare, but ptosis is frequently seen. Symptoms are also likely to be more prominent in the morning; autonomic dysfunction may cause erectile dysfunction and dry mouth.
Differentiation from myasthenia gravis may be hard since patients with Eaton-Lambert syndrome have a positive AChR-Ab test in 13% of cases.
**A 16-year-old male
in good health presents to you for a school physical. His family history
reveals that his father died of colon cancer at age 37. Your physical exam
reveals a healthy young man with several lipomas on his back and legs and a
nodule on his jaw. You should:
a. Suggest colonoscopy at age 32.
b. Suggest colonoscopy now.
c. Suggest flexible sigmoidoscopy and barium enema at age 32.
d. Suggest flexible sigmoidoscopy and barium enema now.
e. Biopsy his jaw lesion.
Answer is D. Gardners Syndrome is similar to familial adenomatous polyposis except that it is associated with benign extra intestinal growths such as lipomas and ostromas. The colonic polyps start to grow in the second decade of life and uniformly deteriorate into colon cancer by the age of 40. This young man needs a yearly flexible sigmoidoscopy until he shows his first polyps; then he needs a total colectomy.
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