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Tetanus prophylaxis


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Tetanus prophylaxis

tetanus prophylaxis:--
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
b. leptospirosis
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
b. malrotation
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 is.

A - Technetium-99m bone scanning
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 lesions).
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 day.

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
E Cystoscopy

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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