Myocardial Infarction: Secondary Prevention

A 55-year-old man is admitted following an anterior myocardial infarction. Which of the following drugs is least likely to reduce mortality in the long-term?
A. Atorvastatin
B. Atenolol
C. Ramipril
D. Aspirin
E. Isosorbide mononitrate

Answer:

Neural tube Defects - A Case Study

Mrs X 30 years old G3 P 2+0  (no living child) with history of both pregnancies affected by neural tube defects (NTD) presented at 8 weeks and 3 days period of gestation. In the first pregnancy patient had conceived spontaneously after one year of marriage and did not seek any antenatal care. Patient delivered at a hospital and anencephaly was detected at birth. However, no comment was made on presence or absence of other anomalies. In the second pregnancy she booked at fifteen weeks pregnancy and had level 2 ultrasound at 19 weeks of gestation. She was diagnosed as occipitomeningomyelocele and opted to terminate the pregnancy. On neonatal review the diagnosis of occipitomeningomyelocele was confirmed and no other gross congenital anomalies were detected.
The parents did not consent for postmortem autopsy or chromosomal study.

Other relevant questions to ask in history: 
Present Pregnancy
• Gestational age
• History of exposure to drugs particularly which interfere with folic acid metabolism
• Any history of hyperthermia and hyperglycemia
• Intake of folic acid in periconceptional period
• History of consanguinity.

History of Previous Pregnancies
• Any history of folic acid intake in periconceptional period.
• History of hyperthermia or hyperglycemia in periconceptional period.
• History of antifolate drug intake in periconceptional period.
• Mode of diagnosis of NTDs (prenatal ultrasound, postnatal diagnosis)
• Associated malformations and dysmorphisms to delineate genetic disorders
• Fetal autopsy done or not
• Fetal karyotype done or not
• Family history of neural tube defects.

Examination
In the first half of pregnancy, there may not be anything remarkable in the examination. However, with advanced gestational age, polyhydramnios may cause increased fundal height and presence of
fluid thrill. The presentation of the fetus may be breech or face.

A 44-year-old man is brought to the emergency department by paramedics after he was found stumbling and confused at home. ..

A 44-year-old man is brought to the emergency department by paramedics after he was found stumbling and confused at home.
On physical examination, the patient appears slightly sedated and admits to recent heavy drinking but says his last drink was 34 hours ago. He also says he vomited three times earlier that morning. He denies chest and abdominal pain. He has a 15-year history of heavy alcohol abuse and usually drinks six to seven beers a day.
CT scan of the head is negative for mass lesions or bleeding.
Relevant laboratory findings are as follows:
Aspartate aminotransferase: 57 U/L
Alanine aminotransferase: 18 U/L
Lactate dehydrogenase: 398 U/L

What is the most likely diagnosis?
Alcohol withdrawal.

What is the pathophysiology of this condition?
Alcohol is a central nervous system depressant that causes neuronal changes, including stimulation of the γ-aminobutyric acid (GABA)A receptor. Repeated consumption of alcohol desensitizes GABAA receptors, resulting in tolerance and physical dependence. When a person suddenly stops consuming alcohol, the nervous system is hyperaroused and synapses fire uncontrollably; the result is the symptoms seen in alcohol withdrawal. Increased serum norepinephrine and altered serotonin levels have also been implicated in both alcohol craving and tolerance.

What are the symptoms of this condition?

Chronic liver disease and hepatomegaly (A Case For MRCP PACES)

This man complains of weight loss and abdominal discomfort. His GP has referred him to you for a
further opinion. Please examine his abdomen.

Clinical signs
Signs of chronic liver disease
• General: cachexia, icterus (also in acute), excoriation and bruising
• Hands: leuconychia, clubbing, Dupuytren’s contractures and palmar erythema
• Face: xanthelasma, parotid swelling and fetor hepaticus
• Chest and abdomen: spider naevi and caput medusa, reduced body hair,
gynaecomastia and testicular atrophy (in males)

Signs of hepatomegaly
• Palpation and percussion:
⚬⚬ Mass in the right upper quadrant that moves with respiration, that you are not able to get above and is dull to percussion
⚬⚬ Estimate size (finger breadths below the diaphragm)
⚬⚬ Smooth or craggy/nodular (malignancy/cirrhosis)
⚬⚬ Pulsatile (TR in CCF)
• Auscultation
⚬⚬ Bruit over liver (hepatocellular carcinoma)

Evidence of an underlying cause of hepatomegaly
• Tattoos and needle marks  - Infectious hepatitis
• Slate‐grey pigmentation  - Haemochromatosis
• Cachexia - Malignancy
• Mid‐line sternotomy scar -  CCF

Evidence of treatment
• Ascitic drain/tap sites
• Surgical scars

Evidence of decompensation
• Ascites: shifting dullness
• Asterixis: ‘liver flap’
• Altered consciousness: encephalopathy

Discussion

Effect on Kidneys After a Massive Blood loss

A 35-year-old man is admitted with systolic blood pressure (BP) of 60 mm Hg and a heart rate (HR) of 150 bpm following a gunshot wound to the liver (CT scan shown in picture below).

Axial image of Computed tomography (CT) scan of abdomen at level of both kidneys shows dense nephrogram, which is attributed to decrease in renal perfusion

What is the effect on the kidneys?
(A) They tolerate satisfactorily ischemia of 3–4 hours duration.
(B) They undergo further ischemia if hypothermia is present.
(C) They can become damaged, even though urine output exceeds 1500 mL/d.
(D) They are affected and cause an increased creatinine clearance.
(E) They are prevented from further damage by a vasopressor.

Answer:

Bell's palsy...

Two weeks after a viral illness, a 9-year-old boy presents to your clinic with a complaint of several days of weakness of his mouth. In addition to the drooping of the left side of his mouth, you note that he is unable to completely shut his left eye. His smile is asymmetric, but his examination is otherwise normal.
Which of the following is the most likely diagnosis?
a. Guillain-Barré syndrome
b. Botulism
c. Cerebral vascular accident
d. Brainstem tumor
e. Bell palsy

Answer: e. Bell palsy

Discussion:

Bell palsy is an acute, unilateral facial nerve palsy that begins about 2 weeks after a viral infection. Although the exact pathophysiology is unknown, reactivation of herpes simplex or varicella-zoster virus seems to be the most common cause; demyelination through an autoimmune process or allergic inflammation may also play a part in some cases. On the affected side, the upper and lower face are typically paretic, the mouth droops, and the patient cannot close the eye.

Regarding Tetanus Prophylaxis

A 19-year-old man presents with a compound fracture of his leg following a fall from scaffolding. Examination reveals soiling of the wound with mud. He is sure he has had five previous tetanus vaccinations. What is the most appropriate course of action to prevent the development of tetanus?

A. Clean wound + intramuscular human tetanus immunoglobulin
B. Clean wound + tetanus vaccine
C. Clean wound + tetanus vaccine + intramuscular human tetanus immunoglobulin
D. Clean wound + tetanus vaccine + benzylpenicillin
E. Clean wound

Answer:

Heart Diseases in Pregnancy

Regarding heart diseases in pregnancy answer the following questions:

1. Which cardiovascular change is not physiological in pregnancy:
a. Split 1st heart sound
b. Mid diastolic murmur
c. Shift of apex beat to 4th ICS and outwards
d. Decreased peripheral vascular Resistance.

Answer: b. Mid diastolic murmur

2. Indication for cesarean section in pregnancy is:
a. Mitral stenosis
b. Aortic aneurysm
c. PDA
d. Transposition of great vessels

Answer: b. Aortic aneurysm

3. Surgery for mitral stenosis during pregnancy is done at:
a. 8 wks
b. 10 wks
c. 14 wks
d. 22 wks

Answer: c. 14 wks

4. Which of the following disease has worst prognosis during pregnancy:
a. Pulmonary stenosis
b. Mitral stenosis
c. VSD
d. ASD

Answer: b. Mitral stenosis

5. All of the following are predictors of cardiac event during pregnancy except:
a. NYHA class>3
b. Obstructive lesion of the heart (mitral valve and aortic valve <1 cm2
c. Previous H/O heart failure
d. Ejection fraction <40%.

Answer: a. NYHA class>3

Discussion:

Wenckebach, or type I second-degree AV block

A 62-year-old man with coronary artery disease (CAD) presents with presyncope. His physical examination is normal except for bradycardia (pulse 56 beats/min) and an irregular pulse. The electrocardiogram (ECG) shows Wenckebach’s type atrioventricular (AV) block.

Which of the following are you most likely to see on the ECG?
(A) progressive PR shortening
(B) progressive lengthening of the PR interval
(C) tachycardia
(D) dropped beat after PR lengthening
(E) fixed 2:1 block

Answer: (D) dropped beat after PR lengthening

Discussion:

Regarding initial management of epilepsy...

A 24-year-old man who had been alcoholic since his early teens underwent rehabilitation therapy during which he suffered severe withdrawal symptoms, including a seizure. Subsequently, he had seizures on a regular basis, during which he would turn pale, feel nauseous, become rigid, stop breathing, lose consciousness, and fall to the ground. After a minute, his body would jerk in a violent fashion for an additional 3 or 4 minutes; he would then lapse into a period of flaccid coma, which lasted 30 to 60 minutes more. After recovering consciousness, he had a headache, was disoriented and confused, felt nauseated, and had sore muscles but could remember nothing concerning his seizure. Following a detailed diagnostic workup including electroencephalography, he was put on medication.
Which of the following drugs was most likely used in his initial treatment?
(A) Felbamate
(B) Topiramate
(C) Phenytoin
(D) Ethosuximide
(E) Tiagabine

Answer:

Regarding the chances of recurrence after first spontaneous miscarriage...

After an initial pregnancy resulted in a spontaneous loss in the first trimester, your patient is concerned about the possibility of this recurring.
An appropriate answer would be that the chance of recurrence
a. Depends on the genetic makeup of the prior abortus
b. Is no different than it was prior to the miscarriage
c. Is increased to approximately 50%
d. Is increased most likely to greater than 50%
e. Depends on the sex of the prior abortus

Answer:

Regarding Impaired fasting blood glucose...

You are reviewing the blood results of a 45-year-old obese man who had been complaining of tiredness. His full blood count, urea and electrolytes and thyroid function tests were within normal limits.
The fasting plasma glucose result is 6.2 mmol/l

What is the most appropriate interpretation of this result?
A. Consistent with diabetes mellitus - need to confirm with a repeat sample
B. Normal - no further action needed
C. Borderline - repeat sample in 12 months
D. Impaired glucose tolerance - moderate risk of developing type 2 diabetes mellitus
E. Prediabetes - high risk of developing type 2 diabetes mellitus

Answer:

Regarding Hypermagnesemia...

A pregnant woman in her 32nd week of gestation is given magnesium sulfate for pre-eclampsia. The earliest clinical indication of hypermagnesemia is
a. Loss of deep tendon reflexes
b. Flaccid paralysis
c. Respiratory arrest
d. Hypotension
e. Stupor

Answer:

Regarding Pre-existing maternal conditions

From the list given below regarding the pre existing maternal conditions choose an option for each description:
A Diabetes
B Hypertension
C Epilepsy
D Vitiligo
E Factor V Leiden deficiency
F HIV
G Asthma
H Smoking
I Crohn’s disease
J Mitral valve stenosis
K Myasthenia gravis
L Glomerulonephritis

1 Reduces intrauterine growth in a dose-dependent manner.
2 Increases risk of venous thromboembolism (VTE) in the puerperium.
3 Increased frequency of episodes during pregnancy.
4 Risk of fetal macrosomia if condition not well controlled.
5 Maternal muscle fatigue in labour.
6 Requires prophylactic antibiotics for instrumental delivery.

Answers:

A 25-year-old, generally healthy woman comes to the office with burning on urination...

A 25-year-old, generally healthy woman comes to the office with burning on urination. There are 50 white cells on the urinalysis.

What is the next best step in management?
a. Wait for results of urine culture.
b. Obtain urine culture.
c. Treat with TMP/SMX for 3 days.
d. Treat with ciprofloxacin for 7 days.
e. Perform a renal ultrasound.

Answer:

In the consideration of cardiac tamponade, which of the following statements is most true?

In the consideration of cardiac tamponade, which of the following statements is most true?
A- Bradycardia is common
B- Early diastolic descent (y descent) is exacerbated
C- Pulsus paradoxus is pathognomonic
D- Renal failure is a recognized complication
E- The apex beat is always absent

Answer:

Managing a Child With Fever & Sepsis

A 5-year-old boy presents with a 24-hour history of fever, reduced oral intake and progressive lethargy. He is previously well and fully immunized.

Initial assessment shows :

• Temperature 39.6°C, 
• HR 158/min, 
• RR 40/min,
• SaO2 95% (air),
•  BP 70/40, 
• central capillary refill time 4 seconds.

He is lethargic but opens his eyes in response to his mother’s voice. On examination, he has a
purpuric rash on his trunk, and there are no other specific abnormal findings. After two 20 mL/kg
boluses of normal saline, he remains clinically unchanged.

Which ONE of the following statements best describes the next treatment he should be given?
A. He should be given activated protein C
B. He should be given IV hydrocortisone
C. He should be given inotropes if central IV access has been obtained
D. He should be given inotropes through peripheral or central IV access
E. He should continue to be given boluses of normal saline until there is a clinical response

Answer:

Fast Five Quiz: Compare Your Knowledge of Contact Dermatitis

Contact dermatitis is an acute or chronic skin inflammation caused by cutaneous interaction with a chemical, biologic, or physical agent. Contact dermatitis after a single exposure or multiple exposures may be irritant or allergic. Clinically, differentiating between these processes may be difficult.

Irritant contact dermatitis is caused by direct tissue damage following a single exposure or multiple exposures to a known irritant. By contrast, in allergic contact dermatitis, tissue damage by allergic substances is mediated through immunologic mechanisms. A complete history related to exposures at home, the workplace, and in recreational activities is essential to making the diagnosis and identifying the causative agent.

Acutely, eczematous or nonspecific dermatitis is the most common clinical expression of this induced inflammation. The severity of the dermatitis ranges from a mild, short-lived condition to a severe, persistent, job-threatening, and possibly life-threatening disease. Treatment of both irritant contact dermatitis and allergic contact dermatitis begins with removal of the offending substance.

How much do you know about this condition? Test yourself with this short quiz.

Which of the following is accurate regarding the etiology of contact dermatitis?

A. Poison ivy (Toxicodendron radicans) is the leading cause of allergic contact dermatitis around the world
B. Dry air alone is insufficient to provoke irritant contact dermatitis
C. Acrylates and methacrylates have been significantly associated with contact allergy and allergic contact disease
D. Irritation associated with trauma is not considered contact dermatitis

Answer: C. Acrylates and methacrylates have been significantly associated with contact allergy and allergic contact disease

Discussion: Acrylates and methacrylates have been recognized as emerging, important causes of contact allergy and allergic contact disease. A study that spanned 13 years determined that acrylic nail sources and wound dressings represent emerging sources of sensitization. A separate study found that acrylates and methacrylates were significantly associated with allergic contact dermatitis.

Regarding Theophylline Overdose

A 67-yr -old man with known long-standing asthma presents to the ER following an overdose of his regular theophylline. He took 20 tablets of theophylline 1 hour earlier because he is feeling rather depressed.

Which of the following is true concerning theophylline overdoses?
A. Symptoms of toxicity will always occur within 12 hours
B. Nausea and vomiting are uncommon features of toxicity
C. Bradycardia is the commonest cardiac arrhythmia
D. Large doses of IV potassium should be given as soon as possible
E. Multi-dose activated charcoal is useful in management

Answer:

A 19-year-old girl complained of anxiety and excessive sweating...

A 19-year-old girl complained of anxiety and excessive sweating. She was not taking any medication.

Investigations showed:
TSH concentration 0.9 mU/L (0.5-3.4)
free T4 concentration 16 pmol/L (10-18)
total T4 concentration 180 nmol/L (55-145)
free T3 concentration 8.2 pmol/L (3.5-10.5)
total T3 concentration 3.3 nmol/L (0.9-2.5)

These results are compatible with which one of the following diagnoses?
A) Factitious thyrotoxicosis
B) Familial dysalbuminaemic hyperthyroxinaemia
C) Pregnancy
D) Sick euthyroid syndrome
E) Thyrotoxicosis

Answer:

Septic Arthritis Following an Ear Infection....

A 25-year-old man presents in the casualty department with a two-day history of a painful and swollen left knee. He is pyrexial with a temperature of 38.5 °C. Examination of his cardiovascular and respiratory system is normal. An abdominal examination is normal. He also mentions that he developed a painful right ear and saw his doctor five days ago who told him he had an infected ear and prescribed antibiotics. His left knee is swollen, red, tender and slightly flexed. A diagnosis of septic arthritis is made.

What is the most likely causative organism?
A. Streptococcus viridans
B. Staphylococcus epidermidis
C. Staphylococcus aureus
D. Escherichia coli
E. Neisseria meningitides

Answer:

Venous Thromboembolism: Risk factors

Which one of the following statements regarding the etiology of venous thromboembolism (VTE) is correct?
A. Third generation combined oral contraceptive pills are safer than second generation ones
B. VTE develops in around 5% of patients with rheumatoid arthritis
C. Female gender is a risk factor recurrent VTE
D. The second trimester of pregnancy is associated with a greater risk than the puerperium
E. Tamoxifen therapy increases the risk of VTE

Answer:

Confidentiality Issues In Medical practice

You are seeing patients in clinic when two men in dark suits and dark glasses come in and show you badges marking them as members of a federal law enforcement agency. The identification is legitimate. These  'men in black' inform you that they are making a "minor investigation" of one of your patients. They ask to look at the patient's chart for a few minutes, saying, "You wouldn't want to interfere with a federal investigation, would you?"

What should you do?

a. Give them the chart.

b. Give them the chart but watch what they do with it.

c. Ask them to sign a release for the chart so you are  absolved of responsibility.

d. Tell them you cannot show them the chart unless there is a signed release from the patient.

e. Tell them that you can give copies but not the original record.

f. Don't give them the chart but read the relevant information to them.

Answer:

In high-income countries, what category of disease accounts for the greatest percentage of disability-adjusted life years lost?

In high-income countries, what category of disease accounts for the greatest percentage of disability-adjusted life years lost?
A. Alcohol abuse
B. Chronic obstructive pulmonary disease
C. Diabetes mellitus
D. Ischemic heart disease
E. Unipolar depressive disorders

Answer:

A 45-year-old builder with one episode of unexplained syncope has a transthoracic echocardiogram that is suggestive of hypertrophic cardiomyopathy.,,,

Clinical scenario
A 45-year-old builder with one episode of unexplained syncope has a transthoracic echocardiogram that is suggestive of hypertrophic cardiomyopathy.

Question
Which two of the following features are not associated with a high risk of sudden death?

A History of ventricular tachycardia (VT) or resuscitated ventricular fibrillation
B Recurrent syncope
C Strong family history of sudden death
D Breathlessness on exertion
E Extreme left ventricular hypertrophy (septal thickness >3 cm)
F Non-sustained VT on Holter monitoring
G Syncope while running
H Diagnosis in childhood
I Resting outflow tract gradient >25 mmHg
J BP drops on exercise

Answer:

A 44-year-old male presents to the emergency room with an acutely swollen right knee

A 44-year-old male presents to the emergency room with an acutely swollen right knee. He has been in good health, and he has no chronic health conditions and no history of trauma. 

The most important evaluation should be:
A. MRI of the knee
B. Erythrocyte sedimentation rate
C. Diagnostic arthrocentesis of the knee
D. Complete blood count
E. Rheumatoid factor

Answer:

A 19-year-old male presents with a 1-week history of malaise and anorexia followed by fever and sore throat....

A 19-year-old male presents with a 1-week history of malaise and anorexia followed by fever and sore throat.
On physical examination, the throat is inflamed without exudate. There are a few palatal petechiae. Cervical adenopathy is present. The liver is percussed at 12 cm and the spleen is
palpable. Throat culture: negative for group A streptococci
Hct: 38%, Hgb: 12 g/dL, Reticulocytes: 4%
WBC: 14,000/μL, Segmented: 30%, Lymphocytes: 60%, Monocytes: 10%
Bilirubin total: 2.0 mg/dL (normal 0.2 to 1.2)
Lactic dehydrogenase (LDH) serum: 260 IU/L (normal 20 to 220)
Aspartate (AST): 40 U/L (normal 8 to 20 U/L)
Alanine (ALT): 35 U/L (normal 8 to 20 U/L)
Alkaline phosphatase: 40 IU/L (normal 35 to 125)

The most important initial test is
a. Liver biopsy
b. Strep screen
c. Peripheral blood smear
d. Toxoplasmosis IgG
e. Lymph node biopsy

Answer: c. Peripheral blood smear

The most important serum test is
a. Heterophile antibody
b. Hepatitis B IgM
c. Cytomegalovirus IgG
d. ASLO titer
e. Hepatitis C antibody

Answer: a. Heterophile antibody

Corticosteroids would be indicated if
a. Liver function tests worsen
b. Fatigue lasts more than 1 week
c. Severe hemolytic anemia is demonstrated
d. Hepatitis B is confirmed

Answer: c. Severe hemolytic anemia is demonstrated

Discussion:

A 26 Year Old Woman presents To Her General Physician With Persistent Cough

A 26-year-old teacher has consulted her general practitioner (GP) for her persistent cough. She wants to have a second course of antibiotics because an initial course of amoxicillin made no difference. The cough has troubled her for 3 months, since she moved to a new school. The cough is now disturbing her sleep and making her tired during the day. She teaches games, and the cough is troublesome when going out to the playground and when jogging.
In her medical history she had her appendix removed 3 years ago. She had her tonsils removed as a child and was said to have recurrent episodes of bronchitis between the ages of 3 and 6 years.
She has never smoked and takes no medication other than an oral contraceptive. Her parents are alive, and well and she has two brothers, one of whom has hay fever.

On Examination
The respiratory rate is 18/min. Her chest is clear, and there are no abnormalities in the nose or pharynx or the cardiovascular, respiratory or nervous systems.

Investigations:
• Chest X-ray is reported as normal.
• Spirometry is carried out at the clinic, and she is asked to record her peak flow rate at home, the best of three readings every morning and every evening for 2 weeks. Spirometry results are as follows:
FEV1 (L) = 3.9   ( predicted = 3.6–4.2)
FVC (L) = 5.0     ( predicted =  4.5–5.4)
FER (FEV1/FVC) (%) = 78   ( predicted = 75–80)
PEF (L/min)  =  470   ( predicted = 440–540)

Peak flow recording at home showed diurnal variations.

Questions
• What is your interpretation of these findings?
• What do you think is the likely diagnosis, and what would be appropriate treatment?

Answers and Case Discussion:

A 59 Year Old Woman presents With An Episode Of Postmenopausal Bleeding...

Clinical History
A 59-year-old woman awoke with blood on her nightdress, which was bright red but not heavy. There were no clots of blood and there was no associated pain. The bleeding has recurred twice since in similar amounts.
Her last period was at the age of 49 years and she has had no other intervening bleeding episodes. She suffered hot flushes and night sweats around the time of her menopause, which have now stopped. She is sexually active but has noticed vaginal dryness on intercourse recently.
She has always had normal cervical smears, the last one being 7 months ago. She had two children by spontaneous vaginal delivery and had a laparoscopic sterilization at the age of 34 years. She has never used hormone-replacement therapy (HRT). She takes atenolol for hypertension and omeprazole for epigastric pain.

Examination
She is slightly overweight. Abdominal examination is normal. The vulva and vagina appear thin and atrophic and the cervix is normal. The uterus is small and anteverted and with no palpable adnexal masses.
An outpatient endometrial biopsy is taken at the time of examination and sent for histological
examination.Endometrial biopsy report shows atrophic endometrium with no evidence of inflammation, hyperplasia or malignancy.
A transvaginal ultrasound is normal and shows an endometrial thickness of < 5 mm.

Case Discussion:

A patient presenting with signs and symptoms of cerebral malaria...

A 41-yr-old bird-watcher goes on a beach holiday in Gambia. She takes no malaria prophylaxis. On return to the UK she develops high fevers and self-medicates at home with Lemsip® ( a cough & cold medicine that contains paracetamol & phenylephrine).
On presentation to hospital, she had a fever of 40°C and looked markedly unwell, with a pulse of 130 bpm and BP 90/50 mmHg. She was commenced on IV ceftriaxone and quinine in casualty. Despite this, she deteriorated rapidly, and after 2 hours is found to have a GCS of 3.
Her blood film is reported as showing trophozoites and schizonts of Plasmodium falciparum with a parasitaemia of 20%.

Which of the following is most important as the next step in the management of this patient, once her airway, breathing and circulation have been stabilized?
A. Urgent CT brain scan
B. Blood glucose testing
C. U&E laboratory testing
D. Commence a phenytoin infusion
E. Start chloroquine

Answer:

Regarding the prevention and treatment of hepatitis C?

Which one of the following statements best describes the prevention and treatment of hepatitis C?

A. No vaccine is available and treatment is only successful in around 10-15% of patients
B. No vaccine and no treatment is available
C. A vaccine is available and treatment is successful in around 50% of patients
D. A vaccine is available but no treatment has been shown to be effective
E. No vaccine is available but treatment is successful in around 50% of patients

Answer:

A 14 year Old Boy with an Episode Of DKA - Case Study

A 14-year-old boy with an 8-year history of  type I diabetes mellitus has been sick since yesterday when he began vomiting. His diabetes has been reasonably well controlled with a dosage of 20 units of glargine insulin taken daily. He uses a carbohydrate ratio of 1:20 and correction factor of 1:50 for mealtime bolus insulin. He has had several episodes of DKA in the past, but not for approximately 4 years. Yesterday, when he began vomiting, glucose concentration was 400 and his urine acetone was negative, so he took his usual dose of insulin. He has had intense polyuria and polydipsia for the last
24 hours. This morning, approximately 6 hours ago, his mother decided to withhold his insulin because of continued nausea and vomiting.

Physical examination reveals a drowsy young boy who can respond to questioning. His BP is 90/70 mm Hg; pulse, 124 per minute; respirations, 30 per minute; and temperature, 38.3°C (100.9°F). His mucous membranes are dry and the ocular globes are soft and sunken, but the funduscopic findings
are normal. Bowel sounds are absent and he has generalized abdominal tenderness without rebound. The deep tendon reflexes are hypoactive, but there are no localizing neurologic signs. The rest of the examination findings are normal.

Laboratory data consist of the following:

• Hgb, 16.4 g/dL; hematocrit (Hct), 53%; 
• WBC, 16,942/ mm3 (93% polymorphonuclear leukocytes); 
• BUN, 40bmg/dL; creatinine, 1.8 mg/dL; 
• glucose, 847 mg/dL; serum ketones, strongly positive at 1:4 dilution; 
• sodium, 126 mEq/L potassium, 4.3 mEq/L; chloride, 100 mEq/L; and bicarbonate, 6 mEq/L.
• Urinalysis reveals a specific gravity of 1.030; glucose of 4+; acetone, strongly positive; and trace amounts of protein. 
• Arterial blood gas analysis reveals a pH of 7.08, partial pressure of carbon dioxide (PCO2) of 12 mm Hg, and partial pressure of oxygen (PO2) of 80 mm Hg. 
• An ECG shows sinus tachycardia with flat T waves. 
• Chest radiographic study is normal. 
• Abdominal radiographs show gastric distention, but otherwise the findings are normal.

1. What is the diagnosis and pathophysiologic process of this patient's disease?
2. How is the liver involved in the genesis of DKA?
3. What is the status of the patient's fluid and electrolyte levels?
4. What are the major goals of therapy?
5. What precipitated this episode of DKA?

Answers and Discussion

Rheumatic Fever - Long Case Study

Presenting complains:  18 years old female presents with the complains of:
- Migrating polyarthritis involving bigger joints (knee, ankle, elbow) for … days
-  Fever for … days
- Palpitation, chest pain … for days
- Malaise, weakness, fatigue for … days

History of presenting complains: According to the patient’s statement, she was quite fit and well … days back. Then she suffered from sore throat from which she recovered completely within a few days. After … days, she developed severe joint pain. Initially, it involved the right knee joint, but then sequentially the right ankle, left knee, left ankle and elbow joints were involved. The joints are
swollen, red and very painful, even with mild movement. The smaller joints are not involved. There
was no morning stiffness.
The patient also complains of fever, which is high grade, continued and reduces with antipyretic
drugs. It is not associated with chill and rigor, but there is profuse sweating. She also complains of
palpitation, chest pain, malaise, fatigue, weakness during her disease period. There is no history of
abnormal or involuntary movement (chorea) or skin changes. Her bowel and bladder habits are
normal. She denied any history of diarrhea, sexual exposure, skin rash, mouth ulcer, uveitis or any
urinary complaint.

General Physical Examination: 
- Appearance: Ill looking
-  Built: average
- Nutrition: average
-  Anemia: mildly anemic
- No jaundice, cyanosis, clubbing, leukonychia, koilonychia, edema or dehydration.
-  No lymphadenopathy, thyromegaly, etc

Vitals:
- Pulse: 110/min
-  BP: 130/75 mm Hg
-  Temperature: 39°C
-  Respiratory rate: 24/min

Cardiovascular examination ; Normal with no murmurs audible.

Loco-motor examination: (Knee joint involved)
Swollen and red with increased local temperature. Extremely tender on  palpation and restricted movements due to pain.

Other systemic examination ; Normal

Provisional Diagnosis: Acute Rheumatic Fever

Differential Diagnosis: 

Diagnosis for a 60 year-old man who is referred following a Chest X ray that suggests interstitial lung disease.

A 60 year-old man is referred following a Chest X ray that suggests interstitial lung disease. You proceed to bronchoscopy with transbronchial lung biopsy to try and make a definitive histological diagnosis.
Which of the following is the least likely diagnosis to be confirmed in this way?
A. Cryptogenic fibrosing alveolitis (CFA)
B. Sarcoidosis
C. Extrinsic allergic alveolitis
D. Cryptogenic organising pneumonia (COP)
E. Lymphangitis carcinomatosa

Answer;

Regarding Anorexia Nervosa and Bulimia nervosa...

Regarding Anorexia Nervosa and Bulimia nervosa answer the following question:

Answer and Discussion:

Suspecting Acoustic Neuroma On Clinical Signs...

A 45-year-old man presents with dizziness and right-sided hearing loss to his GP. Which one of the following tests would most likely indicate an acoustic neuroma?

A. Jerky nystagmus
B. Left homonymous hemianopia
C. Tongue deviated to the left
D. Fasciculation of the tongue
E. Absent corneal reflex

Answer:

A 16-Year-Old Girl With a Rash and Shortness of Breath - An Interesting Case Study

Clinical History: 
A 16-year-old girl presents to the emergency department with generalized pruritus, eye swelling, a full-body rash, and shortness of breath after playing basketball at school. She reports that she was playing basketball with her friends when she first noticed itchy palms. She stopped playing and washed her hands. The itch worsened and was followed by a rash and shortness of breath. She also felt that her throat was tightening, and she had difficulty swallowing. She was taken to the school nurse, paramedics were called, and she was brought to the local emergency department.

The patient has had several similar episodes within the past year and feels that the episodes are getting worse. The first episode occurred about 1 year ago while playing volleyball in a hot gym. She developed itchy palms and stopped to go drink some water; the itchiness went away without any medical attention. Recently, the episodes have been occurring more frequently and are more severe. Some episodes are associated with even mild physical exertion, especially when the temperature outside is hot. When she stops the physical activity, the symptoms typically go away. She cannot recall eating any specific foods that are related to her episodes. She is not taking any medications, vitamins, or herbal supplements.

The patient is otherwise healthy, with no significant medical history. She denies any malaise, fatigue, weight loss, nausea, vomiting, fever, or joint pain. She is in the 11th grade and does well in school, getting mostly A's and only a few B's. She wants to go to college. She has many friends at school. She enjoys biking, dancing, and texting. Occasionally, dancing causes her to feel itchy, but she just "takes a break," and the itch goes away.

Physical Examination and Workup

Upon physical examination, the patient is a well-nourished, well-developed teen in mild respiratory distress. Her temperature is 98.6o F, respiratory rate is 30 breaths/min, heart rate is 110 beats/min, and blood pressure is 100/60 mm Hg. Periorbital angioedema and facial erythema are noted. Extraocular eye movements are within normal limits. Her nasal cavity shows normal nasal mucosa, septum, and turbinates bilaterally.

Carbon monoxide Poisoning...

Two patients are brought in from the same flat, unconscious with suspected carbon monoxide poisoning.
Which of the following is true concerning the symptoms, signs and management of carbon monoxide poisoning?
A. Pre-existing arteriosclerosis does not increase mortality
B. Carboxyhaemoglobin concentrations are always below 5% in healthy patients
C. Pregnancy is a contraindication to hyperbaric oxygen therapy
D. Cerebellar signs are the most reliable sign of neurological toxicity
E. Sodium bicarbonate is useful in correcting minor metabolic acidosis


Answer:

Features Characteristic of Early Alzheimer's disease?

Which of the following features is characteristic of early Alzheimer's disease?
A) ataxic gait
B) impaired short term memory
C) myoclonic jerks
D) urinary incontinence
E) visual hallucinations

Answer:

A man in surgical ward develops excruciating pain in his right ankle joint, a day after cholecystectomy.

You are asked to see a 50-year-old man in the surgical ward at 6 am who underwent an uncomplicated cholecystectomy for gallstones the day before. He has developed excruciating pain in his left ankle joint. He has a history of angina and hypertension for which he takes bendroflumethiazide (bendrofluazide) and aspirin.
Examination of his cardiovascular and respiratory system is unremarkable, as is his abdomen. His left ankle is red, warm, swollen and tender. Routine blood tests show mildly impaired renal function.

What is the most likely diagnosis?
A. Cellulitis
B. Deep vein thrombosis
C. Septic arthritis
D. Gout
E. Rheumatoid arthritis


Answer:

Factors that may potentiate the effects of wafarin

A 63-year-old female on long-term warfarin for atrial fibrillation attends the anticoagulation clinic. Despite having a stable INR for the past 4 years on the same dose of warfarin her INR is measured at 5.4.
Which one of the following is most likely to be responsible?
A. St John's Wort
B. Smoking
C. Carrot juice
D. Cranberry juice
E. Camomile tea

Answer:

Confidentiality In Medical Ethics

You are working at the desk in your hospital when another employee of the hospital asks for information about a patient who was admitted last night with a pulmonary embolus secondary to cancer. You know the details of the case. The person requesting the information states that he is a close friend and coworker of your patient. He shows you proper identification proving he really is a coworker of your patient who also works in the hospital.

Which of the following is the most appropriate response to this request?

A. Give him the information on the patient.
B. Give him the information only if he is a relative of the patient.
C. Inform him that you are not at liberty to give details regarding the patient without the patient's permission.
D. Have him sign a release or consent form before revealing the information.

Answer:

Standard measure for determining the impact of a health condition on a population?

Which of the following is the standard measure for determining the impact of a health condition on a population?
A. Disability-adjusted life years
B. Infant mortality
C. Life expectancy
D. Standardized mortality ratio
E. Years of life lost

Answer:

A previously fit and well 8-year-old boy, was brought into the emergency department by ambulance following a road traffic collision ....

A previously fit and well 8-year-old boy, was brought into the emergency department by ambulance following a road traffic collision in which he was a pedestrian hit by a car driving at 40 mph. There was dried blood over his hair. He was intubated and ventilated and made no spontaneous respiratory effort. Oxygen saturations were 97% in FiO2 100%. His heart rate was 70, capillary refill time 2 seconds and blood pressure 185/90. His Glasgow Coma Score was 3.
On examination of his eyes, the right eye was deviated down and outwards with a fixed and dilated pupil; the left eye was in the midline position with a pupil that constricted to light.

Which ONE of the following cranial nerve(s) is involved in the localizing sign identified in the
clinical examination?
A. Cranial nerve I
B. Cranial nerve I and III
C. Cranial nerve III
D. Cranial nerve IV
E. Cranial nerve IV and VI

Answer:

A 32-year-old athlete presents with severe interscapular pain after training....

Clinical scenario
A 32-year-old athlete presents with severe interscapular pain after training. He is of slim build and tall (210 cm). He has a sinus tachycardia and his BP is 180/100 mmHg with no deficit between his right and left arm. There are no murmurs and all his peripheral pulses are palpable.
The rest of his physical examination is normal.
A CXR shows widened mediastinum and a CT confirms an aortic dissection distal to the left subclavian artery that does not involve the aortic arch.

Question
Which of the following is the most appropriate intervention?
A Intravenous calcium antagonist
B Intravenous labetalol
C Urgent cardiothoracic surgical referral
D Transoesophageal echocardiography
E Oral angiotensin-converting enzyme inhibitor

Answer:

A 38 year old woman presents with dysuria and fever...

A 38-year-old female presents complaining of urgency, frequency, and dysuria. She is found to have a temperature of 38°C (102 F), no flank pain, and a urinalysis positive for nitrites and leukocyte esterase. 

Which of the following is the most appropriate treatment regimen?

A. Trimethoprim-sulfamethoxazole DS bid for 3 days
B. Norfloxacin 400 mg PO bid for 7 to 14 days
C. Ciprofloxacin 250 mg PO bid for 5 days
D. Trimethoprim 300 mg PO every day for 3 to 5 days
E. Amoxicillin 500 mg PO bid for 10 days

Answer :

A 20-year-old female college student presents with a 5-day history of cough and low-grade fever ...

A 20-year-old female college student presents with a 5-day history of cough, low-grade fever (temperature 100°F), sore throat, and coryza.
On examination, there is mild conjunctivitis and pharyngitis. Tympanic membranes are inflamed, and one bullous lesion is seen. Chest exam shows few basilar rales.
Laboratory findings are as follows:
Hct: 38
WBC: 12,000/μL
Lymphocytes: 50%
Mean corpuscular volume (MCV): 83 nL
Reticulocytes: 3% of red cells
CXR: bilateral patchy lower lobe infiltrates


The sputum Gram stain is likely to show
a. Gram-positive diplococci
b. Tiny gram-negative coccobacilli
c. White blood cells without organisms
d. Acid-fast bacilli

Answer:

A 19-year-old boy has a history of repeated chest infections.- Case Study

History
A 19-year-old boy has a history of repeated chest infections. He had problems with a cough and sputum production in the first 2 years of life and was labelled as bronchitic. Over the next 14 years he was often ‘chesty’ and had spent 4–5 weeks a year away from school. Over the past 2 years he has developed more problems and was admitted to hospital on three occasions with cough and purulent sputum. On the first two occasions, Haemophilus influenzae was grown on culture of the sputum, and on the last occasion 2 months previously, Pseudomonas aeruginosa was isolated from the sputum at the time of admission to hospital. He is still coughing up sputum. Although he has largely recovered from the infection, his mother is worried and asked for a further sputum sample to be sent off. The report has come back from the microbiology laboratory showing that there is a scanty growth of Pseudomonas on culture of the sputum.
There is no family history of any chest disease. Routine questioning shows that his appetite is reasonable, micturition is normal and his bowels tend to be irregular.

Examination
On examination he is thin, weighing 48 kg, and is 1.6 m (5 ft 6 in) tall.
• The only finding in the chest is of a few inspiratory crackles over the upper zones of both lungs. Cardiovascular and abdominal examination is normal.

The chest X-ray is shown below:

Questions
• What does the X-ray show?
• What is the most likely diagnosis?
• What investigations should be performed?

Answers And Discussion:

A 24-year-old woman presents with the absence of periods for 9 months.... Case Study

A 24-year-old woman presents with the absence of periods for 9 months. She started her periods at the age of 13 years and had a regular 28-day cycle until 18 months ago. The periods then became irregular, occurring every 2–3 months until they stopped completely.
She has also had headaches for the last few months and is not sure if this is related. She has a regular sexual partner and uses condoms for contraception. She has never been pregnant. There is no previous medical history of note.
She works as a primary school teacher and drinks approximately 4 units of alcohol per week. She does not smoke or use recreational drugs. She jogs and swims in her spare time.
Examination
The woman is of average build. The blood pressure and general observations are normal.
The abdomen is soft and non-tender and speculum and bimanual examination are unremarkable.

Investigations: 
Follicle-stimulating hormone  = 7 IU/L (normal on day 2-5 = 1–11 IU/L)
Luteinizing hormone  = 4 IU/L (normal on day 2-5 = 0.5–14.5 IU/L)
Prolactin   = 1800 mu/L (normal range = 90–520 mu/L)
Testosterone  = 1.8 nmol/L (normal range = 0.8–3.1 nmol/L)

A MRI scan of the head was done which revealed asymmetrical enlargement of pituitary gland,
representative of a small pituitary adenoma most likely a prolactinoma.

Case Discussion:

HIV Post Exposure Prophylaxis

While inserting a central line, a medical senior house officer injures herself with a suture needle that had been used to stitch a patient with HIV infection. The injury is sufficient to draw blood. The Patient is 45 yrs old and has been infected with HIV for 11 yrs. He has been compliant with therapy for several years and has recently changed his tablets because of alterations in his appearance. His last CD4 count was 350 cells/mm3. The house officer is offered post exposure prophylaxis.
Which regimen should she take?
A. AZT and lamivudine
B. Tenofovir and emtricitabine
C. AZT, lamivudine, abacavir
D. AZT, lamivudine, DDI
E. AZT, lamivudine, stavudine

Answer: