The Official StepI "Pimp each other" thread...

[Mike59]

Hey all,

To keep our brains well tuned for stepI in the upcoming months, who else is up for some quizzing while we're on SDN?

I'll start: (answers to follow)

1. Arthritis is characteristic of what stage of Lyme Disease?

2. Which autosomal trisomy is characterized by polydactyly, microphthalmia, umbilical hernia and cleft lip?

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[doc05]

those are not the type of questions you'll see on step 1.

 

[Mike59]

those are not the type of questions you'll see on step 1.

I'm not trying to rewrite qbank here, just trying to stimulating some recall....

 

[mjl1717]

1)Stage 3
2)Patua syndrome- Trisomy 13

 

[Mike59]

1)Stage 3
2)Patua syndrome- Trisomy 13

Bam! Nice job

Here's some more, anyone else wanna play?

- describe 2 enzyme abnormailities that contribute to hyperuricemia...
- A suspicious skin lesion is biopsied and sent to pathology. Histology shows "keratin pearls", what's the diagnosis?

 

[mjl1717]

1)HGPRT def., aldolase b def.
2)Squamous cell ca skin

 

[carrigallen]

I made this question up myself, in the style of step 1...took about 15 minutes:

Question: A 35 year old male presents complaining of a neck swelling. The patient has previously worked as an Xray technician. He has no history of iodine deficiency. Upon examination, a solitary enlarged thyroid nodule is discovered. A scintiscan reveals an area of focally decreased uptake of radioactive iodine. A biopsy reveals proliferative fibropapillar stalks of orderly cuboidal epithelial cells with unusual empty-appearing nuclei and concentric calcified bodies.
Based on the lesion and history, which additional diagnostic finding is most likely?

A. Elevated serum calcitonin levels
B. Metastatic invasion to the lung
C. Mononuclear inflammatory infiltrate
D. Histological stain revealing neuroendocrine origin
E. Enlarged cervical lymph node
F. Anti-TSH receptor antibodies

 

[Chandler]

I made this question up myself, in the style of step 1...took about 15 minutes:

Question: A 35 year old male presents complaining of a neck swelling. The patient has previously worked as an Xray technician. He has no history of iodine deficiency. Upon examination, a solitary enlarged thyroid nodule is discovered. A scintiscan reveals an area of focally decreased uptake of radioactive iodine. A biopsy reveals proliferative fibropapillar stalks of orderly cuboidal epithelial cells with unusual empty-appearing nuclei and concentric calcified bodies.
Based on the lesion and history, which additional diagnostic finding is most likely?

A. Elevated serum calcitonin levels
B. Metastatic invasion to the lung
C. Mononuclear inflammatory infiltrate
D. Histological stain revealing neuroendocrine origin
E. Enlarged cervical lymph node
F. Anti-TSH receptor antibodies

E. Great question! When I first read this question I thought about the Super Bowl commercial with the NFL players singing "Tomorrow".

 

[carrigallen]

Correct. I even wrote an explanation for it: (like qbank does)

Answer: This is a papillary thyroid carcinoma. It frequently spreads to local lymphatic nodes (E). The prognosis is excellent following resection. Papillary carcinomas contain branching papillae with uniform cells. The nuclei have an optically clear look, called a “ground glass” or “Orphan Annie eye” nuclei. They are contain calcified spheres called psammoma bodies. Papillary lesions are cold masses on scintiscan; in contrast to benign and follicular thyroid lesions in which iodide uptake is augmented. Thyroid neoplasms are associated with previous radiation exposure, younger, and more often male patients.
Answers A and D apply to medullary thyroid carcinoma, a calcitonin-secreting neoplasm derived from the C cells of the thyroid. C cells have neural crest origin. Answer F applies to Graves disease, a sporadic autoimmune hyperthyroidism common in middle-aged women. Answer B applies to anaplastic thyroid carcinoma, a uniformly fatal neoplasm that frequently presents with invasion and compression symptoms such as hoarseness and dysphagia. A mononuclear inflammatory infiltrate (C), is characteristic of a thyroiditis, particularly Hashimoto thyroiditis.

 

[p53]

Correct. I even wrote an explanation for it: (like qbank does)

Answer: This is a papillary thyroid carcinoma. It frequently spreads to local lymphatic nodes (E). The prognosis is excellent following resection. Papillary carcinomas contain branching papillae with uniform cells. The nuclei have an optically clear look, called a “ground glass” or “Orphan Annie eye” nuclei. They are contain calcified spheres called psammoma bodies. Papillary lesions are cold masses on scintiscan; in contrast to benign and follicular thyroid lesions in which iodide uptake is augmented. Thyroid neoplasms are associated with previous radiation exposure, younger, and more often male patients.
Answers A and D apply to medullary thyroid carcinoma, a calcitonin-secreting neoplasm derived from the C cells of the thyroid. C cells have neural crest origin. Answer F applies to Graves disease, a sporadic autoimmune hyperthyroidism common in middle-aged women. Answer B applies to anaplastic thyroid carcinoma, a uniformly fatal neoplasm that frequently presents with invasion and compression symptoms such as hoarseness and dysphagia. A mononuclear inflammatory infiltrate (C), is characteristic of a thyroiditis, particularly Hashimoto thyroiditis.

How about another one Carrie!

 

[sapience8x]

associations:

1) "slapped cheeks"
2) tabes dorsalis
3)signet ring cells
4) wermer's syndrome
5) HLA B27

 

[mjl1717]

1)?
2)neuro syphillis
3)Kruckenburg tumor
4)MENtypeI
5)Ankylosing Spondylitis

 

[DrMom]

associations:

1) "slapped cheeks"

Fifth's disease

 

[carrigallen]

1. Parvovirus B19
2. T. Pallidum
3. adenocarcinomas (often GI)
4. ?
5. ankylosing spondylitis

 

[carrigallen]

A 50 y/o man presents with complaints of bothersome itching and scleral icterus. He also suffers from ankle swelling which prevents him from wearing his shoes. Based upon the clinical presentation of the man shown here, from what complication is he most at risk of incurring mortality?

A. Thoracic herniation of the intestinal mucosa
B. Cholangiocarcinoma
C. Hepatic asterixis
D. Rapid hypovolemia from hemorroidal bleeding
E. Coma from metabolic encephalopathy
F. Hypertensive stroke

 

[dynx]

Im going w/ D, but only because Im not sure if you can beat yourself to death w/ Asterixis.

 

[carrigallen]

I'll write the answer explanation out like before. These are fun to make up but they are taking too much time, so this is my last.

Answer: E. The patient has symptoms indicative of portal hypertension secondary to liver cirrhosis. Encephalopathic comas and esophageal varices are the most common causes of death in this population. Encephalopathy arises from a buildup of toxic metabolites, particularly ammonia compounds.

Answer choice A is a complication of congenital diaphragmatic fistulas. Choice B is a rare and serious complication of parasitic infections of the biliary tree, particularly Clonorchis sinsensis and Ascaris lumbricoides. Choice C, the coarse hand tremor associated with portal hypertension, may be present in this patient but would be an unlikely cause of mortality. Hemorroids are an important anastomotic complication of portal hypertension, however, they are unlikely to incur severe blood loss (D). The portal system does not supply the vasculature of the brain, so hepatic cirrhosis would be unlikely to cause a malignant hypertensive crisis (F).

 

[Chandler]

1. Parvovirus B19
2. T. Pallidum
3. adenocarcinomas (often GI)
4. ?
5. ankylosing spondylitis

Key Associations that I like

5. Don't forget about Reiter's Sydrome of HLA B27. "Can't See, Can't Pee, and Can't flex Knee" . Ankylosing Spondylitis - 20-30 year old sexually active male, Neisseria Gonorhea or Chylamydia Trochamotis.

2. Tabes Dorsalis assocaited with TERTIARY SYPHILLIS (also associated with ascending aortic dissections). Neuro Tie - Affects dorsal columns. Romberg Sign, Parestheisa, Pain, ataxia, loss of kinesthesia.

3. Adenocarcinoma associations include Antral Region, Acantosis Nigricans, Serrohagic Kerratosis, 40-60 Year old Asian Woman, Cervical lymph node, Periumbilical lymph nodes, Hemorragic Spread to Ovaries, Helicobacter Pylori - Postive Urease Test, 42 degrees.

1. Parvovirus B19 - African American teenager with sickle cell. Aplastic Anemia. Chlorophenicol also gives aplastic anemia by inhibiting 50S subunit. Decrease in ferritin, serum iron, and increase in EPO levels.

 

[sapience8x]

associations:

1) "slapped cheeks"- 5th disase; parvovirus 19
2) tabes dorsalis- tertiary syphillis
3)signet ring cells- adenocarcinoma- usually GI; seen in mets from GI
4) wermer's syndrome- MEN I
5) HLA B27- Reiters(arthritis, urethritis, iridocyclitis), ankylosing spondylitis, acute anterior uveitis, reactive arthritis (yersinia)

carrie- good questions!

 

[carrigallen]

bump - someone post a question!

 

[Mike59]

bump - someone post a question!

Yay!, Some more players...here goes:

A 43y/o male with a history of gout (on allopurinol) is recently diagnosed with lymphoma. When considering 6-MP treatment, what must we do with the allopurinol and why?

 

[smgilles]

Yay!, Some more players...here goes:

A 43y/o male with a history of gout (on allopurinol) is recently diagnosed with lymphoma. When considering 6-MP treatment, what must we do with the allopurinol and why?

6-MP is converted to an inactive metabolite by an oxidation catalyzed by xanthine oxidase. Simultaneous therapy w/allopurinol and 6-MP results in excessive mercaptopurine toxicity unless the dose of 6-MP is reduced to 25-30% of the usual level.

 

[mjl1717]

Decrease allopurinol. Because allopurinol inhibts degradation of 6 MP and increases its toxicty. {6MP is used in acute leukemia}
Allopurinol inhibits xanthine oxidase
6MP works at several steps of purine synthesis fo inhibit purine formation

 

[mjl1717]

What happens to glomeruar cappilary pressure, peritubular cappillary pressure,
nephron flow and filitration pressure when you constrict the efferent arteriole?

 

[bonovox]

What happens to glomeruar cappilary pressure, peritubular cappillary pressure,
nephron flow and filitration pressure when you constrict the efferent arteriole?

Constriction of the efferent arteriole leads to increased GFR, increased glomerular capillary pressure, decreased peritubular caillaryp pressure, and decreased nephron [blood] flow.

Same question, but regards to constriction of the afferent arteriole?

--Vinoy

 

[carrigallen]

Not sure how good this question is, I'm still learning this material.

A 32 y/o woman presents complaining of hematuria. Her history reveals frequent epistaxis and gingival hemmorage. Fecal blood is positive. Bleeding time is prolonged but PT and PTT are normal. The patient takes no medications and has a healthy diet. Careful physical exam of the abdomen reveals confluent petechae and bruising but no other abnormalities. No hemarthrosis or family history. Based upon the history and exam, what is the most likely cause of her condition?

A. Decreased production of platelets
B. Decreased platelet survival
C. Mechanical injury of platelets
D. Splenic sequestration of platelets
E. Clotting factor deficiency
F. A collagen type III deficiency

 

[Janders]

Not sure how good this question is, I'm still learning this material.

A 32 y/o woman presents complaining of hematuria. Her history reveals frequent epistaxis and gingival hemmorage. Fecal blood is positive. Bleeding time is prolonged but PT and PTT are normal. The patient takes no medications and has a healthy diet. Careful physical exam of the abdomen reveals confluent petechae and bruising but no other abnormalities. No hemarthrosis or family history. Based upon the history and exam, what is the most likely cause of her condition?

A. Decreased production of platelets
B. Decreased platelet survival
C. Mechanical injury of platelets
D. Splenic sequestration of platelets
E. Clotting factor deficiency
F. A collagen type III deficiency

Just playing process of elimination:
A-D would present very similarly(identically, with the info given), so its not one of them.
E would result in a change in PTT or PT, eh?

F however... gum bleeding is textbook, as is bruising and petechiae. I choose F!

 

[carrigallen]

Here is the explanation I wrote:

The correct answer is B. The patient is presenting with Immune Thrombocytopenic Purpura (ITP). This is an autoimmune disorder in which platelet destruction results from formation of antiplatelet autoantibodies. The clinical signs and symptoms associated with ITP are not specific for this condition but rather reflective of general thrombocytopenia. Therefore, the diagnosis is made by ruling out other causes of thrombocytopenia (ie drugs, megaloblastic anemia, HIV, neoplasia). The disease commonly presents in females under 40 years of age. See page 650 Robbins.
Decreased platelet production (A) would indicate an aplastic anemia or vitamin B12/folate deficiency. Mechanical injury (C) is common in artificial valve prosthesis and conditions secondary to sepsis, such as microangiopathic hemolytic anemia. Splenic sequestration (D) is a common cause of thrombocytopenia, however careful physical exam did not detect splenomegaly. A clotting factor deficiency (E) may often manifest with hemarthrosis (especially hemophilia) or family history, and in this case PT or PTT may be abnormal. Ehler-Danlos syndrome (F) is a rare heritable connective tissue disorder that presents with bleeding and bruising, but the patient has no family history to suggest this syndrome.

 

[DRoshal@UHS]

40 yr old male with a significant sexual history, presents to the internist with the complaint that he has recently been having trouble walking. A careful history reveals that the patient is a fisherman with a very ravenous appetite for seafood. The internist performs the physical exam and notices that the patient has bilateral loss of proprioception, 2-point-tactile discrimination, and vibratory sensation. Further examination reveals that the patient has bilateral spastic paralysis with hyperreflexia, hypertonia, and a positive Babinski sign. A positive Romberg test was also noted. With respect to the general appearance of the patient, the physician noted that the patient was in slight distress and appeared pale. There were no other remarkable physical findings. The physician ordered lab work which included: CBC, blood cultures, and urinalysis. The CBC revealed an RBC=2.5billion, WBC=11,000, MCV=110, HCT=45%. The urinalysis revealed presence of excess amounts of methylmalonic acid. The blood cultures were negative. Imagine that you are this patient’s physician, based on the above, what is a reasonable working diagnosis for this case?

A. Tabes Dorsalis
B. Thrombosis of Anterior Spinal Artery
C. Subacute Sclerosing Panencephalitis
D. Friedrich’s Ataxia
E. Subacute Combined Degeneration
F. Schwanoma

 

[smgilles]

40 yr old male with a significant sexual history, presents to the internist with the complaint that he has recently been having trouble walking. A careful history reveals that the patient is a fisherman with a very ravenous appetite for seafood. The internist performs the physical exam and notices that the patient has bilateral loss of proprioception, 2-point-tactile discrimination, and vibratory sensation. Further examination reveals that the patient has bilateral spastic paralysis with hyperreflexia, hypertonia, and a positive Babinski sign. A positive Romberg test was also noted. With respect to the general appearance of the patient, the physician noted that the patient was in slight distress and appeared pale. There were no other remarkable physical findings. The physician ordered lab work which included: CBC, blood cultures, and urinalysis. The CBC revealed an RBC=2.5billion, WBC=11,000, MCV=110, HCT=45%. The urinalysis revealed presence of excess amounts of methylmalonic acid. The blood cultures were negative. Imagine that you are this patient’s physician, based on the above, what is a reasonable working diagnosis for this case?

A. Tabes Dorsalis
B. Thrombosis of Anterior Spinal Artery
C. Subacute Sclerosing Panencephalitis
D. Friedrich’s Ataxia
E. Subacute Combined Degeneration
F. Schwanoma

E. The excess amounts of methylmalonic acid=deficient in B12=demyelination. I believe this is also known as Putnam-Dana syndrome.

 

[north2southOMFS]

40 yr old male with a significant sexual history, presents to the internist with the complaint that he has recently been having trouble walking. A careful history reveals that the patient is a fisherman with a very ravenous appetite for seafood. The internist performs the physical exam and notices that the patient has bilateral loss of proprioception, 2-point-tactile discrimination, and vibratory sensation. Further examination reveals that the patient has bilateral spastic paralysis with hyperreflexia, hypertonia, and a positive Babinski sign. A positive Romberg test was also noted. With respect to the general appearance of the patient, the physician noted that the patient was in slight distress and appeared pale. There were no other remarkable physical findings. The physician ordered lab work which included: CBC, blood cultures, and urinalysis. The CBC revealed an RBC=2.5billion, WBC=11,000, MCV=110, HCT=45%. The urinalysis revealed presence of excess amounts of methylmalonic acid. The blood cultures were negative. Imagine that you are this patient’s physician, based on the above, what is a reasonable working diagnosis for this case?

A. Tabes Dorsalis
B. Thrombosis of Anterior Spinal Artery
C. Subacute Sclerosing Panencephalitis
D. Friedrich’s Ataxia
E. Subacute Combined Degeneration
F. Schwanoma

Are you serious? it would take like 5 minutes to read the damn vignette! I hope you are never on the board making real questions!

 

[north2southOMFS]

I don't like this thread.


It scares me.

 

[DRoshal@UHS]

6 yr old male presents to his pediatrician with weakness in the arms and legs of 3 day duration. The boy's mother states that he recently recovered from an upper respiratory tract infection 1 week ago. History of present illness reveals that the weakness started in the lower extremities and then spread to the upper extremities. The physician orders a spinal tap and the CSF profile returns with the following finding: “Albuminocytologic dissociation”. What is the diagnosis?

A. Poliomyelitis
B. Multiple Sclerosis
C. Duchene-Muscular Dystrophy
D. Guillain-Barre Syndrome
E. Polymyositis
F.

 

[smgilles]

6 yr old male presents to his pediatrician with weakness in the arms and legs of 3 day duration. The boy's mother states that he recently recovered from an upper respiratory tract infection 1 week ago. History of present illness reveals that the weakness started in the lower extremities and then spread to the upper extremities. The physician orders a spinal tap and the CSF profile returns with the following finding: “Albuminocytologic dissociation”. What is the diagnosis?

A. Poliomyelitis
B. Multiple Sclerosis
C. Duchene-Muscular Dystrophy
D. Guillain-Barre Syndrome
E. Polymyositis
F.

D. "albuminocytologic dissociation" is pathognomonic for Guillain-Barre' Syndrome.

 

[DRoshal@UHS]

Patient presents with portwine stain, varicose veins, and bony and soft tissue hypertrophy of the left lower extremety. What is this syndrome called?

 

[Chandler]

40 yr old male with a significant sexual history, presents to the internist with the complaint that he has recently been having trouble walking. A careful history reveals that the patient is a fisherman with a very ravenous appetite for seafood. The internist performs the physical exam and notices that the patient has bilateral loss of proprioception, 2-point-tactile discrimination, and vibratory sensation. Further examination reveals that the patient has bilateral spastic paralysis with hyperreflexia, hypertonia, and a positive Babinski sign. A positive Romberg test was also noted. With respect to the general appearance of the patient, the physician noted that the patient was in slight distress and appeared pale. There were no other remarkable physical findings. The physician ordered lab work which included: CBC, blood cultures, and urinalysis. The CBC revealed an RBC=2.5billion, WBC=11,000, MCV=110, HCT=45%. The urinalysis revealed presence of excess amounts of methylmalonic acid. The blood cultures were negative. Imagine that you are this patient’s physician, based on the above, what is a reasonable working diagnosis for this case?

A. Tabes Dorsalis
B. Thrombosis of Anterior Spinal Artery
C. Subacute Sclerosing Panencephalitis
D. Friedrich’s Ataxia
E. Subacute Combined Degeneration
F. Schwanoma

GREAT QUESTION!!! Very Representative.

I go with E, secondary to Diphyloabtum Latum (fish tapeworm). I'm not sure that is how you spell it. The tapeworm absorbs the B12, thus little B12 is absorbed in the terminal ileum. The elevation in methylmalonic acid is due to a block in the breakdown of odd chain fatty acids so succinyl CoA is not produced to funnel into the TCA cycle. The presentation is classic for megaloblastic amemia.

Don't forget about the "patriotic" hook worm that can cause a microcytic anemia.

 

[smgilles]

I like this question so I will use this question stem to illustrate a point.

On the USMLE they don't ask for the diagnosis but rather an association of the disease. This is known as a 2nd order question since you have to know the diagnosis. Here is an example using your thread.

----------------------------------------------------------------------
6 yr old male presents to his pediatrician with weakness in the arms and legs of 3 day duration. The boy's mother states that he recently recovered from diarrhea. History of present illness reveals that the weakness started in the lower extremities and then spread to the upper extremities. The physician orders a spinal tap and the CSF profile returns with the following finding: “Albuminocytologic dissociation”. Which of the following is associated with this disease?

A. Gram positive, Catalase Positive cocci
B. Gram + Anaerobic Rod
C. Gram + Aerobic Rod
D. Gram - Diplococci
E. Gram - Rod


P.S. This is what Goljan Calls a 2 for 1. You have to apply your pathology to get the diagnosis, and then once you have the diagnosis you have to have the microbiology knowledge to identify the bug, and know the characteristic of the bug. This is an example of integration of topics.

You go with Campylobacter jejuni, which is a comma-shaped, gram (-) bacilli

 

[Chandler]

You go with Campylobacter jejuni, which is a comma-shaped, gram (-) bacilli

Right, good call.

http://content.nejm.org/cgi/content/short/334/12/802

Don't forget Camplybacter grows well at 42 degrees celsius. On my NBME micro shelf exam, it gave a presentation of someone with diarrhea, and the 5 choices were mannitol, catalase +, grows at 42 degrees celsius, urease positive, and something else. It is assumed that you knew it was camplybacter, and you had to choose the distinguishing feature of the bacteria. They love these 2nd order questions that assume that you know diagnosis, or the bacteria's name and can remember a key feature of the disease or bacteria.

 

[DRoshal@UHS]

A 5 yr old boy is rushed to the emergency room with a fever of 105F and a diffuse petechial rash over his body. The ER physician orders lab work which shows the following. Glc=30mg/dl, ketones=elevated, ACTH=elevated, Na=120mEq, K=5.7mEq, urinary 17-ketosteroids=low, PT=elevated, PTT=elevated, platelets=50,000. The blood pressure is 90/60 and dropping. The patient does not survive and a pathology report is requested by the ER physician. Which of the following findings would be noted on the pathology report?

A. Necrotic cells in the pituitary
B. Hamartoma in the hypothalamus
C. Red blood cells in the zona glomerulosa
D. Lymphocytes in the CSF
E. Warthin-Finkeldy cells in sample skin tissue

 

[carrigallen]

A 5 yr old boy is rushed to the emergency room with a fever of 105F and a diffuse petechial rash over his body. The ER physician orders lab work which shows the following. Glc=30mg/dl, ketones=elevated, ACTH=elevated, Na=120mEq, K=5.7mEq, urinary 17-ketosteroids=low, PT=elevated, PTT=elevated, platelets=50,000. The blood pressure is 90/60 and dropping. The patient does not survive and a pathology report is requested by the ER physician. Which of the following findings would be noted on the pathology report?

A. Necrotic cells in the pituitary
B. Hamartoma in the hypothalamus
C. Red blood cells in the zona glomerulosa
D. Lymphocytes in the CSF
E. Warthin-Finkeldy cells in sample skin tissue

I would guess C. There is evidence for septicemia and DIC, so C seems the most likely answer. This could fit the profile of a hemolytic uremic syndrome, or perhaps more likely a meningococcemia with adrenal morbidity.
The viral meningitides, like D, would be less likely in this scenario.

 

[Kaposi]

C. was my guess too: DIC secondary to hemorraghic adrenal infarct a.k.a. Waterhouse Freiderichsen. Although no signs immediate signs of acidosis or da stiff neck.

I would guess C. There is evidence for septicemia and DIC, so C seems the most likely answer. This could fit the profile of a hemolytic uremic syndrome, or perhaps more likely a meningococcemia with adrenal morbidity.
The viral meningitides, like D, would be less likely in this scenario.

 

[DRoshal@UHS]

A 6 mo. old male presents to the clinic with recurrent pulmonary infections. The mother states that the boy had had an uncomplicated delivery, but had difficulty passing stool for weeks after birth. When the child was able to move his bowels the mother noted that the stool was greasy in appearance. The mother also states that the child has recently started coughing up large amounts of sputum. On physical exam the physician notes dullness to percussion in both lung fields and several petechiae on the lower limbs. Which of the following medications are used to treat the organism that most commonly affects patients with this presentation?

A. Ceftriaxone
B. Penicillin G
C. Cefotaxime
D. Azithromycin
E. Cefazolin
F. Ceftazidime

 

[Thaitanium]

A 6 mo. old male presents to the clinic with recurrent pulmonary infections. The mother states that the boy had had an uncomplicated delivery, but had difficulty passing stool for weeks after birth. When the child was able to move his bowels the mother noted that the stool was greasy in appearance. The mother also states that the child has recently started coughing up large amounts of sputum. On physical exam the physician notes dullness to percussion in both lung fields and several petechiae on the lower limbs. Which of the following medications are used to treat the organism that most commonly affects patients with this presentation?

A. Ceftriaxone
B. Penicillin G
C. Cefotaxime
D. Azithromycin
E. Cefazolin
F. Ceftazidime

Ceftaz...3rd generation cephalosporin

 

[Chandler]

Ceftaz...3rd generation cephalosporin

Agreed, a cystic fibrosis kid with bronchiectasis secondary to pseudomonas aerigenosa infection. Dullness to percussion signifies, consolidated lobar with productive cough implies alveolar (typical) pnemonia. A positive egophony (A, E sound with stethoscope) would rule out pulmonary effusion. Steatorrhea is secondary to pancreatic exocrine gland atrophy (backpressure of blocked pancreatic duct due to viscuos mucous plug). Decrease in pancreatic exocrine GI lipase decreases absorption of fat soluble vitamins A,D, E, and K(oagulation). No vitamin K, there is little gamma carboxylation of factors 2, 7, 9, 10. Thus, little crosslinking, hence petechiae.

On the USMLE look for bitot spots, erthema in the ear canal, and nasal polyps during the HEENT exam! Don't forget the MCC of otitis externa is pseudomonas aerigenosa.

Take home message, don't give flowers to kids with cystic fibrosis, or allow them to go into hot tubs.

 

[carrigallen]

No vitamin K, there is little gamma carboxylation of factors 2, 7, 9, 10. Thus, little crosslinking, hence petechiae.

Also probably because there is no prekallikrein release from the atrophied pancreas. Good question. In general, you could also treat the pseudo with:

Piperacillin (a penicillin)
Cefepime (2nd gen cef)

If B-lactam resistance:
Imipenem/cilastatin
Meropenem
Cipro

 

[Chandler]

Also probably because there is no prekallikrein release from the atrophied pancreas.

Where did you get this information? Is it in any of the questions in the Robbins Question book, Big Robbins, BRS, Bates, or Goljan Rapid Review? Has there been a proven link between prekallikerin deficiency and cystic fibrosis? I always thought prekallikerin was made in the liver, but I am not sure. Your theory makes sense. Regardless, fat soluble vitamin deficiency is a proven fact for cystic fibrosis patients as shown in this link (check under pancreas section).

http://www.emedicine.com/PED/topic535.htm

Oh yeah, on my pathology shelf exam I had a microscopic picture of a pancreatic gland atrophy in a cystic fibrosis child (the picture was a exact duplicate from Big Robbins page 493, Fig 10-24).

 

[carrigallen]

My mistake...I meant that trypsin could not be released from the pancreas to activate prekallikrein.

As has been discussed, pancreatic enzymes are present in acinar cells in the proenzyme form and have to be activated to fulfill their enzymatic potential. A major role is attributed to trypsin, which itself is synthesized as the proenzyme trypsinogen.....Trypsin also converts prekallikrein to its activated form, thus bringing into play the kinin system and, by activation of Hageman factor, the clotting and complement systems as well ( Chapter 2 and Chapter 4 ). In this way, inflammation and small-vessel thromboses (which may lead to congestion and rupture of already weakened vessels) are amplified. Robbins p943

 

[MGoBlueDO]

A 23 year old baseball player came to your office after he was hit in the head by a baseball 6 months ago. He states that a few days ago whenever he eats, he feels warm and very sweaty when he eats and drinks. Px: Pt. well nourished and Alert and Oriented. HEENT: PERRLA and EOMI. Neuro: DTR 2/4 and Muscle Testing 5/5. CN Exam: I, II, III, IV, , VII, VIII, IX, X, XI, XII WNL. CN V-decreases sensation in V2 region.

A.) Horner's Syndrome
B.) Bogorad's Syndrome
C.) Familial Mediterranean Fever
D.) Frey's Syndrome

I figured I'd try and write a question here...

 

[MGoBlueDO]

61 year old elderly gentleman presented to the ER with Bilateral Periorbital Hematoma. Patient was conscious and he was jumped in an alley.
Px: Normal Vital Signs, however the medical student noticed a few things on the CN exam: Pt had an absent gag reflex and loss of taste on the Posterior 1/3 of the tongue, had a hoarse voice and was drooling, the uvula was deviated to the left. and the patient also had weakness looking towards left and shrugging his shoulders. All other CN were WNL or is it GIB cause we were told that WNL means we never looked?

A.) Villaret Syndrome on the Left
B.) Vernet Syndrome on the Left
C.) Villaret Syndrome on the Right
D.) Vernet Syndrome on the Left

 

[carrigallen]

Try to avoid eponyms, btw. I've never heard of Villaret, Vernet, or Bogorad's. It is rarely helpful to memorize these names, as they are rarely tested. Please go by the objective name of the disease or condition.

For example (instead of Frey's) : Acute injury to the parotid gland.

I do remember 'Frey's = food' - is this the answer to Q1? It seems like the facial nerve would be more likely to be damaged though, since it runs inside the gland.

No idea about Q2 - some vagal motor and accessory motor nerve dysfunction. Also CN 9's special sensory. Probably some compressive phenemena at a certain point, maybe in the medulla or a place the nerves or fasciculi run with eachother.