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TELEGRAM RECALLS 3

1-pts hear a poping sound in hear, before that mild vertigo, the nystigms, and then fall down, now have rt ear total sNHL, rt horner syd, and nystigmas what is the cause.

1)Basilar infract

2)Meningioma.

3)Acoustic neuroma

4)Acute labryinthitis.

Acute occlusion of the basilar artery

may cause brainstem or thalamic ischaemia or infarction. brainstem infarction results in rapid deterioration in level of consciousness and ultimately death.

the exact characteristics of which will depend on the site of occlusion:

sudden death/loss of consciousness

top of the basilar syndrome(This results in bilateral thalamic ischaemia due to occlusion of perforator vessels)

visual and oculomotor(3ed) deficits

behavioural abnormalities

somnolence, hallucinations and dreamlike behaviour

motor dysfunction is often absent

proximal and mid portions of the basilar artery (pons) can result in patients being 'locked in'

complete loss of movement (quadriparesis and lower cranial dysfunction)

preserved consciousness

preserved ocular movements (often only vertical gaze)

basilar artery thrombosis(Medscape):

• motor deficits(hemiparesisor tetraparesis or facial paresis)40-67%

• dysarthria and speech imparement 30-63%

• vertigo, nausea , vomiting 54-73%

• headache 40-42 %

• visual disturbances 21-33%

• altered consciousness17-33 %

Acoustic neuroma(Vestibular schwannoma)

Vestibular schwannomas (acoustic neuromas) account for 80 to 90 percent of cerebellopontine angle tumors (CPAs) in adults.

symptoms

Cochlear nerve ( Symptomatic cochlear nerve involvement occurred in 95 percent of patients [ 15 ]. The two major symptoms were hearing loss and tinnitus.

Vestibular nerve ( Involvement of the vestibular nerve occurred in 61 percent of patients [ 15 ]. Affected patients frequently acknowledged having unsteadiness while walking, which was typically mild to moderate in nature and frequently fluctuated in severity. True spinning vertigo was uncommon because these slow growing tumors cause gradual rather than acute asymmetries in vestibular function. In this setting, the central vestibular system can often compensate for the gradual loss of input from one side.

Trigeminal nerve ( Trigeminal nerve disturbances occurred in 17 percent of patients [ 15 ]. The most common symptoms were facial numbness (paresthesia), hypesthesia, and pain. The average duration of symptoms was 1.3 years; the symptoms usually occurred after hearing loss had been present for more than two years and vestibular symptoms for more than one year. (See "Trigeminal neuralgia" .)

Facial nerve (The facial nerve was involved in 6 percent of patients [ 15 ]. The primary symptoms were facial paresis and, less often, taste disturbances

Diagnosis(JM) is best clinched by high-resolution MRI. Audiometry and auditory evoked responses are also relevant investigations.

اين سئوال يه مشكلى داره :

- در انفاركت بازيلار ما hearing loss نداريم .

- گزينه ديگرى كه به علائم ميخوره آكوستيك نوروما هست كه در اون ما سندرم هورنر نداريم !

اتفاقا شايع ترين علامت هاى اكوستيك نوروما تينيتوس و كاهش شنوايى هستن و بر اساس مد اسكيپ ورتايگو شيوع كمترى داره و بيشتر در تومورهاى كوچيك ديده ميشه

من با اكوستيك نوروما موافقم ولى! تنها دليلى هم كه دارم مداسكيپه كه گفته تومورهاى برين استم كه پره گانگليونيك نورون رو درگير ميكنن ميتونن هورنر بدن

Causes of vertigo :

1- with hearing loss

������������Meniere disease ➡️ old

������������Acoustic neuroma (Schwanoma)

������������Acute labyrintitis ➡️ young/inf

2- without hearing loss

������������Vestibular neuritis ➡️ young/inf

������������BPPV ➡️ old

������������PICA ➡️ old

Dr.Mohamad: Medullary syndromes:Loss of facial pain and temperature sensation (ipsilateral).Horner's syndrome.Ataxia (ipsilateral).Tongue, soft palate, vocal cord, sternocleidomastoid paralysis (ipsilateral).Contralateral loss of pain and temperature sensation elsewhere.

Symptoms reported with vertebrobasilar strokes include:

Vertigo - common - and this may be the only symptom.Nausea and vomiting.Disturbance of consciousness.Headache.Visual disturbance (oculomotor signs such as nystagmus, diplopia and pupillary changes).Visual field defects.Speech disturbance (for example, dysarthria and dysphonia).Sensory changes in the face and scalp.Ataxia.Contralateral motor weakness (may cause a 'drop attack').Sensory disturbance affecting pain and temperature.Incontinence.

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2-A woman brings her husband to your clinic who is a farmer. For the past two years there has been a drought and they have been having a lot of financial difficulties. The woman says her husband hasn’t been acting like himself. He has been having multiple affairs with women in the village and has invested a lot of money in unreliable businesses hoping to get a big profit. He doesn’t sleep very much. Which of the following would you use to treat this patient?

A. Haloperidol

B. Olanzapine

C. Risperidone

D. Sodium valproate

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Management of acute mania This is a medical emergency requiring hospitalisation for protection of both family and patient. First line:

olanzapine 5 mg (o) nocte initially

or

risperidone 0.5–1 mg (o) nocte initially

Second line:

haloperidol or other first-generation

antipsychotic

Prophylaxis for recurrent bipolar disorder

(Over 90% will have a recurrence at some time: consider medication if two or more episodes of either mania or depression in the previous 4 years). Recommended prophylactic agents 5

lithium 125–500 mg (o) bd then adjusted

or

second-generation antipsychotic(quetiapine) agent( or (if depression prominent)

lamotrigine or carbamazine or sodium valproate

Management of bipolar depression

This is a difficult component to treat and antidepressants should not be used alone. Many mood-stabilising agents appear to have a bimodal (antidepressant and antimania) effect and can be

useful in the absence of classical antidepressants.

A recommended regimen is:

lithium, valproate, carbamazepine, quetiapine, lamotrigine or olanzapine

plus

an antidepressant (e.g. SSRI, SNRI or MAOI)

Antidepressants are usually withdrawn within 1–2 months because of a propensity to precipitate mania.

ECT is an effective treatment for bipolar depression while psychological therapies such as CBT and psychoeducation have proven efficacy. Bipolar I patients usually recover but proceed to have further episodes of depression or mania.

Treatment of bipolar disorders in pregnancy: First line medications — For pregnant patients with manic, hypomanic, or mixed episodes, we suggest first generation antipsychotics, which have been widely used during pregnancy. We prefer haloperidol , based upon its demonstrated efficacy in randomized trials. pregnant patients with manic, hypomanic, and mixed episodes often do not respond to or tolerate haloperidol .For these resistant patients, we suggest in order of preference risperidone , quetiapine , or olanzapine.

3-55 yr anemic wt loss angular stomatitis , howell jolly bodies no hx of diarrhea or GI symptoms ix

a-endoscop

b-electrophoresis

c-small bowel bx

Howell jolly =red cell with nucleus ,causes :

asplenia ,high grade hyposplenism (eg, celiac & sickle cell anemia) , rare mielodisplasia ,

hemolysis

4-- A lady is set to sit the AMC on the 12th of May but turns up to your office 2 days after asking for certification of her retrospective illness to explain to the AMC why she could not sit. She is currently asymptomatic and becomes agitated when you refuse to comply with her request. She starts threatening to report you to the board. You in the meanwhile tune her out in your mind and play the radio. Her behavior is a result of:

A. Malingering

B. Narcissistic Personality Disorder

C. Borderline Personality

D. Somatatisation of the Rectum

Me : B

گرينه هاي مطرح يك دو و سه هست:

چون سوْال شواهدي از اصل ماجرا( بيماري خانوم) ذكر نكرده بر اساس رفتار الان بيمار بايد تصميم بگيريم،

معمولا افرادي كه مل اينگرينگ ميكنن وقتي با جواب منفي پزشك مواجه ميشن به عز و التماس ميافتن

افرادي كه بوردرلاين باشن وقتي نه ميشنون تهديد ميكنن كه خودكشي ميكنن يا خودزني ميكنن

تنها افراد نارسيستيك هستن كه به خودشون اجازه ميدن پزشك رو تهديد كنن بعد از شنيدن جواب منفي

5-pt do exercise bmi 19, checks in mirror several times, etc

Anorexia nervosa

Bdd

Hypomania

Ocd

(in my opivion and bases on murtagh its anorexia nervosa)

Refusal to maintain normal body weight at or above a minimum normal weight for age and height (loss to 140 mmHg and DBP >90 mmHg, occurring for first time after 20th week of pregnancy and regressing

postpartum

or

— Rise in SBP >25 mmHg or DBP >15 mmHg from readings before pregnancy or in first trimester

• Mild pre-eclampsia. BP up to 170/110 mmHg in absence of associated features (see following)

• Severe pre-eclampsia. BP >170/110 mmHg and/or associated features, such as kidney impairment(BUN,Cr),

Thrombocytopenia(platelet count), abnormal liver transaminase levels(LFT), persistent headache, epigastric

tenderness or fetal compromise

risk factors

nulliparity/primigravida, family history, chronic essential hypertension, diabetes complicating pregnancy, obesity,

donor sperm or oocyte pregnancy, multiple pregnancy, hydatidiform mole, hydrops fetalis, hydramnios, kidney disease, autoimmune disease (e.g. SLE)

investigations

Test for pre-eclampsia: spot urinary albumin–creatinine ratio, or 24-hour urinary protein excretion.

Signs

Clinical features of superimposed pre-eclampsia include hypertension, excessive weight gain, generalised oedema and proteinuria (urinary protein >0.3 g/24 hours). Late symptoms include headache (related to severe hypertension), epigastric pain and visual disturbances.

Management

The optimal treatment is delivery. The BP level should be kept below 160/100 mmHg. Contraindicated drugs are ACE inhibitors and diuretics. There is no place for the use of diuretics alone unless cardiac failure is present.

•beta blockers (e.g. labetalol, oxprenolol and atenolol) (used under close supervision and after 20 weeks gestation)

•methyldopa: good for sustained BP control

•nifedipine

Treatment of severe pre-eclampsia:

• Control BP: use IV hydralazine or diazoxide—don’t suppress to 38 ° C

• Clinical features of severe pneumonia

• Involvement of more than one lobe

• Inability to tolerate oral therapy

Benzylpenicillin 1.2 g IV 4–6 hourly for 7 days or Procaine penicillin 1.5 g IM daily (drugs of choice

for S. pneumoniae )or Ceftriaxone 1 g IV daily for 7 days (in penicillin-allergic patient)

• If atypical pneumonia use doxycycline, erythromycin or roxithromycin

severe pneumonia

azithromycin 500 mg IV daily (covers Mycoplasma, Chlamydia and Legionella) plus cefotaxime 1 g IV 8 hourly

or ceftriaxone 1 g IV daily.

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Pneumonia in children

Clinical features

• Tachypnoea, expiratory grunt

• Possible focal chest signs

• Diagnosis often only made by chest X-ray

Pathogens

• Viruses are the most common cause in infants.

• Mycoplasma are common in children over 5 years.

• S. pneumoniae is a cause in all age groups.

Treatment

Almost all those under 48 months should be admitted to hospital.

Mild (general guidelines only): amoxycillin (o) or roxithromycin (o)

Moderate: benzylpenicillin IV + roxithromycin (o)

Severe: flucloxacillin IV + gentamicin IV ± azithromycin (o)

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11-female with vaginal bleeding, husband away on 6 mnth trip and she doesn’t want to conceive anymore, asking about contraception?

ocp

minera

pop

(I have no idea!!! she needs evaluation for bleeding for sure)

Overview of causes of genital tract bleeding in women

The source of abnormal bleeding may be from a problem anywhere in the lower genital tract (vulva, vagina, cervix), upper genital tract (uterine corpus, fallopian tubes, ovaries), or from nearby organs (urethra, bladder, bowel).

Bleeding is a common symptom of a variety of disorders related to pregnancy; therefore, all reproductive age women with uterine bleeding should have a pregnancy test as part of their initial evaluation.

UTERINE BLEEDING

Pregnancy

Menstruation:

• Duration between two and seven days

• Flow less than 80 mL

• Occurring in cycles of 24 to 35 days

Menorrhagia: Excessive menstrual blood flow

Anovulation: anovulation is a common cause of abnormal uterine bleeding (AUB).

Adolescents: Anovulatory cycles are the most common cause of AUB in adolescent girls due to a

slowly maturing hypothalamic-pituitary axis during the first two to three postmenarchal years

Menopausal transition

Polycystic ovary syndrome

Endocrine disorders: Both hypo- and hyper- thyroid activity, Cushing's syndrome, Endocrine changes leading to

anovulation may also be caused by strenuous exercise/activity (eg, running, ballet dancing), sudden weight

change, or significant stress.

Anatomic abnormalities: Polyp, Fibroids, Adenomyosis, Hysterotomy scar

Malignancy

Endometritis and pelvic inflammatory disease

Bleeding diatheses: Vw disease, ITP, …

Drugs:

• Combination hormonal contraceptives — Intermenstrual (breakthrough) bleeding is the most common side

effect of combination hormonal contraceptives. Its occurrence does not indicate a decrease in efficacy

(unless the patient has been noncompliant), but reflects tissue breakdown as the endometrium adjusts to a

new thin state in which it is fragile and atrophic. Unscheduled (breakthrough) bleeding is related to a

relatively high progesterone-to-estrogen ratio and was less of a problem when high doses of estrogen were

used because estrogen stabilizes the endometrium. The frequency of bleeding is independent of the type of

progestin, and is increased in women who smoke cigarettes, probably due to the accelerated

metabolism of estrogen caused by smoking [ 18 ]. Women should be cautioned that missing pills results in an

increase in unscheduled bleeding, as well as a decrease in contraceptive efficacy. (See "Risks and side effects

associated with estrogen-progestin contraceptives" .)

• Progestin-only contraceptives — Prolonged bleeding and spotting are common complications of progestin-

only contraceptives, such as depot medroxyprogesterone acetate (Depo-Provera), the levonorgestrel-

releasing intrauterine contraceptive, implantable progestin rods (eg, Implanon), and progestin-only pills.

Bleeding tends to be an early complication of these methods; many women develop amenorrhea with

continued use. The mechanism of progesterone-breakthrough bleeding is endometrial atrophy and

ulceration due to insufficient estrogen.

•Copper IUCs cause a foreign body reaction in the uterus that creates an inflammatory response. The

endometrium may hypertrophy at the site of inflammation with normal cyclic estrogen stimulation, resulting

in intermenstrual bleeding.

12-patient developed middle cerebral artery infraction history of basal renal impairment on 2th day of admission cr raised with decressed e –GFR causes;

renal emboli(bilateral renal emboly is rare)

-aspirin

-glomuronephritis

Maybe due to contriction of afferent artery

13- middle cerebral artery infarction with mild renal imairement at admission.after48 hrs creatinine raised with decressed GFR .what is the cause of increase creatinine?(no other comorbidity mentioned)?

a. Dehydration (more probable)

b.renal embolism

c.aspirin

d.glomuronephriti

14-transient episode of vertigo, slurred speech, diplopia n paresthesia in a man aged 55 suggests:

Basilar artery insufficiency

Anterior communicating artery aneurysm

Hypertensive encephalopathy

Pseudobulbar palsy

Occlusion of the middle cerebral artery

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15- A 65 y/o man presents with left hemiparesia secondry to infarct in right middle cerebral artery. Bp 140/80, cholesterol 4 mmol/l. EKG shows sinus rhythm. Witch of the following is most likely to benefit in preventing further ischaemic stroke?

Aspirin

Warfarin

Heparin

Ramipril

Simvastatin

Answer : ramipril

-Aspirin : 13% decrease ⬇️ in risk

-Statins : 12% ⬇️decrease in risk (20% ⬇️decrease in ischemic stroke offset byincreaese in risk of haemorrhagic stroke)

و خوب يعنى جواب همون استاتين هست .

در مورد آسپرين و استاتين كه اعداد و ارقام رو گفتم .

اون چيزى كه داخل پرانتز اضافه كرده و احتمالاً خيلى مفهوم نبوده اينه :

بطور كلى استاتين ريسك stroke بعدى رو ١٢٪ كم ميكنه . حالا اين رو با جزئيات گفته : استاتين ريسك استروك رو در بيمارى كه استروك ايسكميك داشته قبلاً ٢٠٪ كم ميكنه ، ولى در بيمارى كه استروك هموراژيك داشته قبلاً نه تنها كم نميكنه بلكه بيشتر هم ميكنه . اين كاهش ٢٠٪ و اون افزايش رو كه ميانگين گرفتن شده ١٢٪ .

حالا اينجا ما نوع استروكمون كه ايسكميك باشه مشخصه پس بايد ملاكمون رو همون عدد ٢٠٪ قرار بديم نه ١٢٪ كه ميانگين هست .

15.1- A 73 year old man presents with right hemiparesis and experssive dysphasia due to infarct in the light middle cerebral artery. BP is 153/82, serum cholestrol 4.4, ECG sinus rhythm. Which of the following is the least likely to be benefit in preventing further ischemic stroke?

a. Ramipril

b. Aspirin

c. Warfarin

d. Simvastatin

e. Heparin

Amedex: I am with E too coz in Jm it is written that heparin is only indicated in cases of cavernous venous thrombosis...not routinely given in stroke management...other things will help in reducing further risk of stroke..

15.2-A 65 yr old man presents with left hemiparesis and expressive dysphasia secondary to infarct in right middle cerebral artery.bp 140/80,cholesterol 4mmol/l.ecg shows sinus rythm.which of the following is most likely to benfit in preventing further ischemic stroke

-aspirin

-warfarin

-heparin

-ramipril

-simvastatin

Amedex: ?

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Drop the questions grap the answer!

Secondary preventive therapy:

Blood pressure lowering is the most important action due to decrease future risk of stroke whether firt or subsequent episode. Best done by ACEi (alone or in combination with aduretic) but all other anti hypertensive drugs(except BB)are found to be effective.

All stroke and TIA patients, whether normotensive or hypertensive, should receive blood pressure lowering therapy, unless contraindicated by symptomatic hypotension.

New blood pressure lowering should be commenced before discharge for those with stroke or TIA, or soon after TIA if the patient is not admitted.

Antiplatelet therapy: significantly reduce the risk of subsequent vascular events including stroke, MI or vascular death. It has a little adverse effect due to increasing risk of hemorrhage, but the benefits outweigh the risks.

Aspirin reduce the risk of vascular events by 13%, lowest effective dose is 30 mg daily. Combination of aspirin(75-162mg) and clopidogrel(75 mg) or extended release dipyridamole has no net benefit compared with clopidogrel or aspirin alone. Combined therapy should be used in coexisting acute coronery disease or recent coronary stent.

Anticoagulation therapy for secondry prevention for people with ischemic stroke or TIA from presumed arterial origin should nao be routinely used. It is usually used for patients with ischemic stroke who have AF and in TIA patients who have no signs of intracranial hemorrhage on CT or MRI.

Cholesterol lowering: therapy with statin should be used for all patients with ischaemic stroke or TIA but shouldn’t be used routinely for hemorrhagic stroke.

16-pt with confusing lethargic taking indapamide, ace, k normal, na 120, cause of condition?

SIADH

indapamide

تيازيدها باعث هايپوكالمى و هايپوناترمى ميشن . لذا اگه هايپوناترمى اين مريض بخواد ناشى از اينداپامايد باشه انتظار هايپوكالمى همزمان هم بايد داشته باشيم .

البته مريض داره پتاسيم هم ميخوره لذا ممكنه تا حدى اين رو جبران كرده باشه ولى فكر ميكنم وقتى اين مريض در اين حد ديورتيك مصرف كرده كه سديمش به ١٢٠ رسيده ، اون هايپوكالميش هم بايد شديد باشه و با پتاسيمى كه ميخوره جبران نشه.

خلاصه فكر كنم كه همون SIADH گزينه بهترى باشه كه هايپوناترمى ميده و خيلى با پتاسيم مريض كار نداره (اگرم هايپوكالمى بده كمتر از تيازيدها هست)

17-case of a pt persent with foul smelling cough,high fever with rigor.there was no xray but they give the finding ,it was opacity in middle zone with air fluid level,after giving flucloxacilin what next

1.transpleural drainage

2.waterseal drainage

3.aspiration (suspicious plural eff otherwise surgical procedure for non-responding lung abscess is either lobectomy or pneumonectomy)

(epyema does not have air-fluid level)

17.1- a man c/o fever,x ray shows fluid level,dull on percussion rt middle jone of lung,foul smell cough .wat to do after antibiotics?

a.transpleural drainage (as I said due to probable empyema, dull percussion, chest tube first and VATS is required)

b.ippv

c.lobectomy

d.needle aspirate

Lung abscess

Lung abscess: necrotizing pneumonia: fever, cough, and sputum production putrid or sour-tasting sputum.A lung abscess is typically diagnosed when a chest radiograph reveals a pulmonary infiltrate with a cavity, indicating tissue necrosis.The only methods available for obtaining uncontaminated specimens are transtracheal aspirates (TTA), transthoracic needle aspirates (TTNA), pleural fluid, and blood cultures. clindamycin (600 mg IV every eight hours, followed by 150 to 300 mg orally four times daily)Other drugs: ampicillin-sulbactam 3 g IV every six hours), penicillin plus metronidazole , or a carbapenem.We suggest continuing antibiotic treatment until the chest x-ray shows a small, stable residual lesion or is clear. This generally requires several months of treatment.

Surgical intervention — Surgery is rarely required for patients with uncomplicated lung abscess. The usual indications are failure to respond to medical management (which is often merely a subjective impression), suspected neoplasm, or hemorrhage. However, several predictors of a slow response or no response are: abscesses associated with an obstructed bronchus, an extremely large abscess (>6 cm in diameter), and abscesses involving relatively resistant organisms, such as P. aeruginosa. The usual procedure in such cases is a lobectomy or pneumonectomy.

Alternative approaches for patients who are considered to be poor operative risks include percutaneous and endoscopic drainage . Percutaneous procedures require special care to prevent contamination of the pleural space. Bronchoscopy may be done as a diagnostic procedure, especially to detect an underlying lesion, but this procedure is of relatively little use to facilitate drainage and can result in spillage of abscess contents into the airways. Endoscopic drainage, which requires an experienced operator, is performed by placing a pigtail catheter into the abscess cavity under bronchoscopic visualization, leaving the catheter in place until the cavity has drained

Major considerations in patients with a delayed response include:

An associated condition that precludes response, such as obstruction with a foreign body or neoplasm

Erroneous microbial diagnosis with infection due to bacteria, mycobacteria, or fungi that have not have been suspected and are not being treated

Large cavity size (usually >6 cm in diameter) that may require unusually prolonged therapy or empyema, which necessitates drainage. Empyema can have an air-fluid level that is mistaken for a parenchymal abscess; the two can be distinguished by CT scan.

An alternative, non-bacterial cause of cavitary lung disease, such as cavitating neoplasm, vasculitis, or pulmonary sequestration

Other causes of persistent fever, such as drug fever or Clostridium difficile-associated colitis

empyema

•In patients with a thoracic empyema documented by the presence of pleural pus (eg, category 4) ( table 1 ), we recommend prompt drainage of any remaining pleural fluid rather than observation ( Grade 1B ). Acceptable initial methods for pleural drainage include tube thoracostomy and video-assisted thoracoscopic surgery (VATS) with debridement. The latter may be preferred in patients with multiple loculations and a thick pleural peel.

•When tube thoracostomy is used for initial drainage of an empyema, a chest CT scan should be obtained within 24 hours after chest tube placement to document appropriate placement of the tube and assess drainage. For patients who do not have good drainage of empyema fluid from a well-placed chest tube, we suggest intrapleural administration of a combination of tissue plasminogen activator (TPA) 10 mg and deoxyribonuclease (DNase) 5 mg, twice daily for three days rather than no intrapleural therapy or either agent alone.

•Continued failure of adequate pleural drainage should prompt thoracoscopy or thoracotomy to lyse adhesions, fully drain the pleural space, and optimize chest tube placement. The choice between thoracoscopic debridement and decortication depends on several factors; those favoring decortication include more adhesions, greater visceral pleural thickness, and larger empyema cavity size.

18- man works on a farm of another area brought by police for breaking a window with brick. he said he remember nothing except loss of his job from his farm.dx

1.depersonalization

2.automatism

3.dissociative fuge

4.derealization

5.conversion

The essential feature of dissociative amnesia is an inability to recall important personal information that is more extensive than can be explained by normal forgetfulness. Remembering such information is usually traumatic or produces stress. The main symptom of this disorder is memory loss that's more severe than normal forgetfulness and that can't be explained by a medical condition. You can't recall information about yourself or events and people in your life, especially from a traumatic time. The main symptom of this disorder is memory loss that's more severe than normal forgetfulness and that can't be explained by a medical condition. You can't recall information about yourself or events and people in your life, especially from a traumatic time.

19- girl complaining of wt loss 3 mon after her father death. she denied any symp of depression. on examination she is in good mood. She occasionally vomits after meals. What is Dx

A- Normal grief

B- Depression

C- Bulimia

D- Anorexia

from h/o...in bulimia wt always doesn’t decrease, its fluctuating n need more info to go for bulimia..

Normal bereavement characterized by shock, denial, guilt, and somatic symptoms. Duration varies widely up to 6 month.

Pathologic grief lasts > 6 months, satisfies major depressive criteria (e.g., weight loss, anhedonia,passive death wish), and/or includes psychotic symptoms (e.g., delusions). ref: First AId USMLE..

probably the original question was as following:

19.1- A young woman came to your practice after 6months of the death of her father .Her bmi is 23.She was on strict diet and has lost 10kg.and is concerned about weight. gaining. ON taking to her u find out she is not suicidal or depressed. She also later reveals having taken laxative but reasons that it because she doesn't want any constipation .She now dreads the idea of gaining weight and cannot trust herself around food and wants u to prescribe some weight losing drugs. Dx?

Depression

Bulimia nervosa

Abnormal grief

Anorexia nervosa

20-patient presented with weight loss for last 3 months and fever on urine white cell rbc but no organism Dx

1- renal TB (sterile pyuria)

2- RCC

3-AIN

4-Bladder tumour

Tuberculosis can lead to two major forms of renal disease: direct infection of the kidney and lower urinary tract; and secondary amyloidosis. Other causes include nephrotoxicity induced by antimicrobial agents and hyponatremia due to the syndrome of inappropriate ADH secretion induced by pulmonary involvement or miliary disease.

Clinical manifestations — The clinical manifestations are variable. The onset of clinically evident genitourinary tuberculosis is usually insidious, with dysuria and gross hematuria being the most common symptoms. Renal colic is an uncommon manifestation, as is active extrarenal disease (fever, weight loss, cough, hemoptysis), since rupture of the glomerular granulomas is a random event that is independent of disease elsewhere

Signs of extrarenal disease include ureteral strictures (single or multiple) , a contracted bladder, and, in males, calcifications in the vas deferens, seminal vesicles, or prostate.Some patients are asymptomatic, and are incidentally found to have pyuria and/or microscopic hematuria. These urinary changes are present in more than 90 percent of cases. Heavy proteinuria and cellular casts are not seen, and the plasma creatinine concentration is usually normal or near normal. Ureteral strictures may cause obstructive uropathy, and in severe cases, renal loss .

Refractory hypertension is a less common complication of renal tuberculosis. The elevation in blood pressure in this setting is angiotensin II-mediated, and may result from intimal proliferation of vessels in or near areas of inflammation, leading to segmental ischemia and renin release

Diagnosis — The diagnosis of genitourinary tuberculosis may be suspected from the symptoms, urinary findings, a possible past history of tuberculosis, and a positive tuberculin skin test . The urine is classically sterile by routine culture, but some patients have concurrent bacteriuria. Thus, a positive culture does not exclude the presence of urinary tuberculosis in the appropriate clinical setting.

Radiologic studies, particularly an intravenous pyelogram (IVP), are often helpful. Although the IVP may be normal in early disease, moderate to marked urinary tract abnormalities are usually present by the time the patient becomes symptomatic. The earliest changes on IVP include erosion of the tips of the calyces, blunting of the calyces or overt papillary necrosis, and parenchymal scarring and calcification. These findings may be unilateral or bilateral, and resemble those seen in chronic pyelonephritis or papillary necrosis due to other causes such as analgesic abuse.

Confirmation of the diagnosis requires the demonstration of tubercle bacilli in the urine, although the constellation of dysuria, sterile pyuria, hematuria, and the characteristic IVP findings are highly suggestive of urinary tract tuberculosis . The finding of acid-fast organisms in the urine sediment with a Ziehl-Neelsen stain or fluorescent dye techniques is not pathognomonic for this disorder, since nonpathogenic mycobacteria may occasionally be present; furthermore, false negative results commonly occur.

Thus, urine culture is the gold standard for establishing the diagnosis. Three to six first morning midstream specimens should be sent to maximize the likelihood of a positive result; false negative results may occur if the patient is receiving antituberculous therapy or broad spectrum antibiotics which may inhibit mycobacterial growth because of the high urinary concentrations obtained . Bacilli are shed into the urine intermittently; as a result, only 30 to 40 percent of single specimens are positive in patients with active disease

, some investigators recommend that an IVP or renal ultrasonogram be obtained every 6 months for the first two years in patients with ureteral strictures to detect possible urinary tract obstruction.

21-Baby with 2 wk harsh cough , fever , runny nose with dyspnea

how to dx ?

A) nasopharyngeal aspiration

B) Serology

C) CXR

D) pulmonary function test

Investigations: ( for pertussis)

Laboratory confirmation is not necessary for diagnosis, but may be helpful for infection control.

A nasopharyngeal aspirate/swab for PCR is the investigation of choice. The test is usually negative after 21 days, or 5-7 days after effective antibiotic therapy has been commenced.

Pertussis serology (IgA) may be detectable 2 weeks after the onset of the illness but rarely affects clinical management.

Although the gold standard dx for pertussis is culture but the first measure in pt with 2 wks cough is CXR

22-Pt. with DM on Insulin , HT on perindopril need to start Rx with rifampcin , what to do ?

A) cont. same Rx

B) Inc. perindopril

C) Inc. Insulin

D) dec. perindopril

[pic]

مریض از قبل رو انسولین و پریندوپریل بوده ، حالا ما می آیم ریفامپین و به داروها اضافه می کنیم بعد ریفامپین می اد اثر پریندوپریل و کم می کنه ، وقتی اثر پریندوپریل کم شد خوب نیاز بیمار به انسولین باید بیشتر بشه دیگه ...چون پریندوپریل اثر انسولین و کلا زیاد می کنه.

23-obese pregnant lady in third trimester presents with severe headache, feverish, BP 150/100, tachycardia, RUQ pain, no vag bleeding, intact fetus, normal heart tone, no palpable liver?

Acute cholecyctitis

Pancreatitis

HELLP

24- 9m child with fever 38, cough, dyspnea, tracheal tug, chest was clear?

RSV bronchiolitis

Strep pneumonia

25-young guy recently came back from thiland having sex with prostitute now feverish, tiredness, cervical LMP, arthralgia, throat exudate, monospot test is neg. FBE:high neutrophils n lymphocytes, slight anemia. No abd pain , no jaundice.

HIV

EBV

CMV

Malaria

Answer : EBV

Similar symptoms but: no exudate pharyngitis in CMV, rare cervical LMP in CMV. Althgho monospot test could be still neg in the first week.

[pic]

26-vegan woman in early pregnancy came to you taking folic acid pills regularely. Whats ur advice?

ZN+ Fe

Vit k + Fe

Vit C + Fe

Answer : iron and vit C (vit is needed for optimal absorption of iron)

27-after TURP with large blood loss and bloody urethral wash, pt developed hypotension and tachycardia. What nest?

Check hemoglobin and cross match

Send to operating room

Transfusion of 1 L whole blood over 1 h

1 L NS over 1 h

Answer : d (although I’d like to treat as preshock scenario(first 1L of fluid in 20 mins…)

28- 9 yr old boy is brought by ambulance as he fell down from gymnastic equipment at school. had one vomiting, no LOC, remebers the fall. on exam a slight swelling over forehead. GCS 15/15.

what will u do??

D/c with head trauma assessment sheet

CT

observefpr 4 hrs

observe for 24 hrs

[pic]

[pic]

Answer is A

28-Chest pain and exertional dyspnea, irregular vaginal bleeding, pelvic pain and enlarged uterine in a woman who had normal vaginal delivery 3mo ago.

Which investigation will be most helpful in establishing the dx?

A. Ventilation perfusion scan

B. Echo

C. Quantitative beta HCG

D. Pulmonary function test

E. Chest CT scan

Coriocarcinoma, metastasis to the lung

29-Boy presented with rash on cheeks for 1day and diagnosed with slapped cheek synd. many mothers of his classmates at school are pregnant .what to do

1.nothing

2.withdraw him from school and notify school authoritie

3.withdraw from school

rm health service

5.serology for all possitive mothers

Slapped cheek syndrome (also called fifth disease or parvovirus B19) is a viral infection that's most common in children, although it can affect people of any age. It usually causes a bright red rash to develop on the cheeks.

Parvovirus B19

• This virus causes ‘slapped cheek syndrome’ ( erythema infectiosum , fifth disease ) and can be mistaken for rubella.

• The non-immune are at risk.

• A risk of transplacental infection exists throughout pregnancy.

• Screen for immunity with parvovirus B19 IgG antibodies (reassure if positive).

• Screen for infection with acute and convalescent sera for IgM antibodies.

• Miscarriage rate is 4% if+ go for specific IgG avidity>low=recent inf.

>high=past inf.

[pic]

[pic]

51- at 12 week pregnancy urine culture positive for GBS..treated with ABx for 7 days…future plan

A: swab at 34-37 wks

B pencillin during labour

c fetal prophylactic treatment at birth other 2 I forgot……first I selected b but at final minute I changed to A

اين a ميشه .

اين مدل سئوال رو قبلنا داشتيم :

اون سواب كه از مريض ميگيريم در هفته ٣٤-٣٧ از سريكس هست . و در صورت مثبت بودن در اون زمان نياز به پنيسيلين پروفيلاكسى موقع زايمان داره ، و نيازى نيست در صورت مثبت بود سواب همون موقع درمانش كنيم .

فقط اين وسط يه چيزى هست كه اگه مريض در UC كشت مثبت از نظر GBS داشت چون شديداً كلونيزه هست درمانش ميكنيم (چون معمولاً الودگى سرويكس از ناحيه آنال يا ادرارى هست) و اون پروسه گرفتن سواب در هفته ٣٤-٣٧ به قوت خودش باقيه .

52-corpus luteal cyst complication scenario?

Physiologic/functional cysts

In the process of normal ovulation, a follicle develops to maturity and then ruptures to release an ovum; this is followed by formation and subsequent involution of the corpus luteum. Follicular cysts arise when rupture does not occur and the follicle continues to grow; corpus luteum cysts occur when the corpus luteum fails to involute and continues to enlarge after ovulation (the corpus luteum enlarges for the first six weeks of pregnancy and doubles its prepregnancy size). These cysts are therefore called physiologic or functional. Either type may become hemorrhagic.

The most common complication is rupture:

• Rupture of an ovarian cyst is characterized by the sudden onset of unilateral, lower abdominal pain. The onset of pain is often during strenuous physical activities, such as exercise or sexual intercourse. Light vaginal bleeding may also occur due to a drop in ovarian hormone levels.

• The major goals in the evaluation of women with suspected rupture of an ovarian cyst are to exclude ruptured ectopic pregnancy.

• Differential diagnosis includes mittelschmerz, ectopic pregnancy, ovarian torsion, degenerating leiomyoma, pelvic inflammatory disease, acute endometritis, and nongynecological disorders.

• Cyst rupture is uncomplicated in the absence of hypotension, tachycardia, fever, signs of an acute abdomen, leukocytosis, or sonographic evidence of an enlarging hemoperitoneum or malignancy.

For women with uncomplicated cyst rupture, we suggest expectant management rather than surgical intervention . Later surgical intervention may be indicated for diagnosis and treatment of ovarian cysts that are large(>10cm) or persistent, and those with findings suspicious for malignancy.

• Emergency surgery is performed to control ongoing significant hemorrhage. After controlling hemorrhage, a frozen section diagnosis of the ovarian neoplasm is obtained. In a premenopausal woman with a benign ovarian cyst, we suggest preservation of ovarian tissue via cystectomy rather than complete oophorectomy.

• We also suggest emergency surgical intervention for treatment of a ruptured dermoid cyst . Spillage of sebaceous material can be accompanied by severe hemorrhage and chemical peritonitis.

53-questions on depression with insomnia for almost 6 months treatment…only mirtazapine was given other all antipsychotics and one temazepam

MIRTAZAPINE — Mirtazapine is used to treat major depression, generalized anxiety disorder, and tension type headaches.

. Blockade of the adrenergic receptors increases release of norepinephrine and serotonin. Blockade of the serotonergic receptors increases neurotransmission mediated by serotonin 5-HT1 receptors. In addition, mirtazapine has a high affinity for histamine H1 receptors (which probably accounts for the drug’s sedative properties). Mirtazapine has low affinity for cholinergic, alpha-1 adrenergic, and dopaminergic receptors.

Dry mouth – 25 percent of patients who received mirtazapine

Drowsiness – 23 percent

Sedation – 19 percent

Appetite increased – 11 percent

Weight increased – 10 percent

Mirtazapine may possibly cause agranulocytosis and neutropenia in rare instances [ 36,39 ]. However, we do not routinely monitor white blood cell counts.

54-middle aged man with solid testicular mass. what is next step?

US

FNA

Excision

Answer : a = US

55- a 28 week pregnant with loss of small amount of blood, nearest level2 hospital is 50 km away, and nearest tertiary is 150 km away, after speculum exam you don’t see sign of cord prolapse and everything is normal. After giving antibiotic, and betamethasone, what would be your next best action?

a. Send her home and ask her to come back if anything happens

b. Send her to the tertiary hospital 150 km away***

c. Send her to the level 2 hospital 50 km away

Beacause of NICU

Bleeding after 20 weeks of gestation — The term antepartum hemorrhage typically refers to uterine bleeding after 20 weeks of gestation that is unrelated to labor and delivery. Antepartum hemorrhage complicates 4 to 5 percent of pregnancies. The major causes are:

Placenta previa (20 percent)

Abruptio placenta (30 percent)

Uterine rupture (rare)

Vasa previa (rare)

In the remaining cases, the exact etiology of the antepartum bleeding cannot be determined and is frequently attributed to marginal separation of the placenta.

Evaluation — In contrast to bleeding in the first half of pregnancy, digital examination of the cervix SHOULD BE AVOIDED in women presenting with bleeding in the second half of pregnancy until placenta previa has been excluded. Digital examination of a placenta previa can cause immediate, severe hemorrhage.

سطح يك درمانى ميشه gp. سطح ٢ بيمارستان هاى جنرال و پزشكان متخصص. سطح ٣ بيمارستانهاى تخصصى و پزشكان فوق تخصص

56- SVC picture with facial puffiness, arm and upper chest swelling: investigation:

A: XRAY

b: echo

C: ECG

D:RAST(I don’t know what it means)Radioallergosorbent test

First : CXR

Best : CT with contrast

Ehsan > best : venogram

57- Man working in boiler for many years. Presents with cough, exposed to asbestos. Xray shows plaque. Definitive Dx:

A-Percutaneous pleural biopsy

B-Bronchoscopy

C-CT chest

Asbestosis

ASBESTOS EXPOSURE may lead to a spectrum of pulmonary disorders:

• Asbestosis

• Pleural disease (focal and diffuse benign pleural plaques)

• Malignancies (non-small cell and small cell carcinoma of the lung as well as malignant mesothelioma)

Introduction:

• Asbestosis specifically refers to the pneumoconiosis caused by inhalation of asbestos fibers. The disease is characterized by slowly progressive, diffuse pulmonary fibrosis.

• Exposure to asbestos occurs during the mining and milling of the fibers, in industrial applications of asbestos (eg, work with cement, friction materials, insulation, shipbuilding), and in nonoccupational settings with airborne asbestos (eg, regular exposure to soiled work clothes brought home by an asbestos worker, renovation or demolition of asbestos-containing buildings).

Clinical findings

• Most patients who develop asbestosis are asymptomatic for at least 20 to 30 years after the initial exposure.

• The earliest symptom of asbestosis is usually the insidious onset of breathlessness with exertion, which progresses inexorably even in the absence of further asbestos exposure. Cough, sputum production, and wheezing are unusual. patients may develop bibasilar, fine end-inspiratory crackles (32 to 64 percent) and clubbing (32 to 42 percent)

• Pleural disease: Pleural involvement is a hallmark of asbestos exposure, whereas it is unusual in

other interstitial lung disorders. Approximately 50 percent of persons exposed to asbestos develop pleural

plaques.

Imaging

• Typical high resolution computed tomography (HRCT) scan findings of asbestosis include: subpleural linear densities of varying length parallel to the pleura, basilar and dorsal lung parenchymal fibrosis, with peribronchiolar, intralobular, and interlobular septal fibrosis, coarse parenchymal bands (2 to 5 cm in length), often contiguous with the pleura, coarse honeycombing in advanced disease, and pleural plaques.

Diagnosis

• The diagnosis of asbestosis is based on a reliable history of exposure to asbestos with a proper latency period, and/or presence of markers of exposure (eg, pleural plaques or recovery of sufficient quantities of asbestos fibers/bodies in bronchoalveolar lavage or lung tissue); definite evidence of interstitial fibrosis (eg, end-inspiratory crackles, reduced lung volumes and/or diffusing capacity, typical radiographic findings, or histologic evidence of interstitial fibrosis); and absence of other causes of diffuse parenchymal lung disease.

• No specific treatment has been identified for asbestosis. Management includes supportive care with an emphasis on smoking cessation, avoidance of further asbestos exposure, pneumococcal and influenza vaccination, and supplemental oxygen as needed to maintain adequate oxygenation.

58- old recall: patient after 24 hours of surgery become confused and dyspnea….invest:;

ABG to check for hypoxisa (first inv)

59-PIC of anthology: colonic cancer xray…patient on warfarin for 8 months after heart valve surgery..next

A: stop warfarin and start clopidogrill surgery 1 week

B: vit K and do surgery

C” FFP and proceed surgery(m not confident for this)

D: stop warfarin and do surgery when effects resolved

60-old recal: 7 year old with h/o fall 2 days ago from bicycle and was wearing helmet( helmet not broken) now his mother who is nurse bring her for assessment..neurological exam is normal..only mild tenderness at trauma site..she is aksing to do for CT scan as she is worried..

A: DO CT

B: REF TO NEUROLOGY

C: REASSURE THAT NO NEED FOR CT

اسکرین به اصرار بیمار انجام میشه ولی تشخیص و درمان تصمیم با پزشکه

61-A man had been admitted in the hospital. One day he had fallen from the bed. It was noted that he didn’t allow his head to hit the ground. Then for this he underwent hip surgery following which he developed confused conversation. MMSE was 26/30/ According to him the nurses were responsible for his today’s condition. Mx?

a. Immediate CT

b. Nothing

c. ABG

d. making complaints a/c to his words

62- old recall 23 year old male who has surgery for crypto in past came to u for cancer screening…exam ;left testes slight lower and enlarged..no palpable mass

A: tumor markers

B USG

C no tests

63-epididmyal cyst..usg was done and it was cyst…next

reexamine in 3 months

other options are missing no treatment is required unless pain/cosmetic

Epididymal cysts & spermatocele

— Epididymal cysts are usually palpated in the head (caput) of the epididymis and are generally asymptomatic. They occur with increased frequency in male offspring of mothers who used diethylstilbestrol during pregnancy. In addition, epididymal cystadenomas are seen in more than one-half of patients with Von Hippel-Lindau disease and are often bilateral.

These are usually not mistaken for other scrotal pathology, and they can be diagnosed by scrotal ultrasonography if the clinical examination is equivocal.

Treatment: No treatment is required.Epididymal cysts may be asymptomatic or they may cause discomfort and cosmetic embarrassment and if so can be excised. Aspiration and injection of sclerosant agents can

also be used for epididymal cysts.

The distinction between a spermatocele and an epididymal cyst is mainly one of size; epididymal cystic masses that are larger than 2 cm are called spermatoceles. Spermatoceles are always located superior to the testis and are palpated as distinct from the testis, which differentiates them from hydroceles. Spermatoceles generally range in size from 2 to 5 cm and rarely cause symptoms. Occasional patients require surgical excision for chronic pain related to a spermatocele.

64-ca colon post surgery..histopathology showing node positives,,treatment asked…..

A: CHEMO

B RADIO

C CHEMORADIO

Davidson:About 30–40% of patients have lymph node involvement at presentation (see Fig. 22.63) and are, therefore, at risk of recurrence. Most recurrences are within 3 years of diagnosis and affect the liver, lung, distant lymph nodes and peritoneum. Adjuvant chemotherapy with 5-fluorouracil/folinic acid or capecitabine, preferably in combination with oxaliplatin, can reduce the risk of recurrence in patients with Dukes stage C cancers and some high-risk Dukes B cancers. Post-operative radiotherapy reduces the risk of local recurrence in rectal cancer if operative resection margins are involved.

65-A man travelled to south east Asia 3 months ago. Presented with fever with rigors and pain right upper quadrant. Similar pain he experienced while there but no fever at that time. No jaundice on examination. Whats most likely cause ?

a. Hydatid cyst

b. Amoebic liver abscess

c. Acute cholecystitis

*due to its spontaneous remission nature its most likely to be cholecystitis

66- Cancer with worst 5-year survival rate. Choicec included

small cell lung

adenocarcinoma pancrease

67-Which one of the following is least survival (40 mmHg, endoscopic sphincterotomy is beneficial in some patients.

• Avoidance of unnecessary ERCP is the best way to reduce the number of complications.

• ERCP should be avoided if there is a low likelihood of biliary stone or stricture, especially in women with recurrent pain, a normal bilirubin, and no other objective sign of biliary disease.

• Endoscopists performing ERCP should have appropriate training and expertise before performing advanced procedures.

• With newer diagnostic imaging technologies emerging, ERCP is evolving into a predominantly therapeutic procedure.

70-old recal: hepatitis A with deranged LFTS diagnosis was asked

Hepatitis A

JM P: 652

it does not cause chronic liver disease.

Investigations

LFTs and viral markers confirm the diagnosis. The antibodies to HAV are IgM, which indicates active infection, and IgG antibodies, which means past infection and lifelong immunity and which is common

in the general population. Ultrasound is useful to exclude bile duct obstruction, especially in an older

patient.

Prevention: Immune serum globulin (0.03–0.06 mL/kg IM) confers satisfactory passive immunity for close

contacts (within 2 weeks of contact) and for travellers to endemic areas for up to 3 months. An active vaccine

consisting of a two-dose primary course is the best means of prevention.

[pic]

72- DVT scenario and invest asked: Doppler

73- patient on velefaxine..founf wondering in evening confused and asking about breakfast….investigations…..LFTS(hyponatremia is the cause)

74-Man coming back after short trip from endemic area for only 5 days with severe Jaundice ..fever ..on examination you find tender liver and enlarged 5 cm under costal margin ..you do investigations

Found Very high ALT , AST , GGT,ALP

Diagnosis-

a) Active viral hepatitis A(short incubation period 15-45 days)

b) Active viral hepatitis B

c) Malaria

d) INFECTIOUS mononucleosis

75- soldier for screening 1+ protiens

اين كه بايد تكرار بشه و اگه بازم مثبت بود يا ادرار ٢٤ ساعته يا pr/cr ratio ادرار

76-Pt took naloxone for pin point pupil, took many medication, pcm, indomethacin abg o2 6L

PO2 120,PCO2 65,HCO3 NOT SURE.NEXT?

1ANOTHER NALOXONE DOSE

2. repeatabg

3.reduce o2

4. pcm(paracetamol) assay

Still respiratory depressed(high Pco2)

76.1- Pt took all drugs to decrease his pain and became drowsy, on the way back to hospital staff gave naloxone and later 3 doses were given to

stabilise him,now not depressed,but pain present want to go home- what to do-

involuntary admit/

palliative care/

send him home

اين فرد يه جورايي استيبل شده كه حق انتخاب داره ولي اگه بره باز اوردوز كنه خطرناكه

ارجاع به

palliative care

77-70 y/o woman with COPD was admitted with acute shortness of breath,

was given high flow oxygen, now she is unresponsive with decreased

respiration. What would be the next step?

a) Reduce oxygen to 2L****

b) Endotracheal intubation and ventilation

c) Salbutamol nebulisation

javanmard: respiratory center in COPD patients is more sensitive to oxygen in comparison to normal people

78-Which is the best study to find out the state of Vitamin D deficiency in Australia?

a..cohort

b..case control

c..case study

d..Cross-­‐sectional study

STUDY DESIGNS

اسم ديگر مطالعه ي كراس سكشنال مطالعه ي شيوع است كه شيوع يه مورد را در يك مقطع زماني اندازه ميگيريم.

هر موقع بخوايم ارتباط علت و معلول رو بينيم بايد از كوهورت استفاده كنيم مثلا يه عده بيمار با هايپرتنشن رو بگيريم ببينيم چند درصدشون دچار سكته قلبي ميشن(علت: هايپرتنشن و معلول: سكته ي قلبي).

از مطالعه ي كيس كنترل ميشه در بررسي ارتباط بين دو فاكتور(بدون داشتن رابطه ي علت و معلولي ) استفاده كرد.مثلا اسوسييشن بين اسپونديليت انكلوزان و اچ ال اي- بي بيست و هفت.

رندومايزد كنترل ترايال هم گلد استاندارد براي بررسي موثر بودن يه درمان يا واكسن يا ... جديد است.

Handbook of MCQ 3.386 ( case control vs cohort vs randomized controlled trials

Uptodate:

Cohort study  — A cohort study starts with an exposure and moves forward to the outcome of interest, even if the data are collected retrospectively. As an example, a group of patients who have variable exposure to a risk factor of interest can be followed over time for an outcome(seeking for effect of a that specific risk factor compared to control group).

The Nurses' Health Study is an example of a cohort study. A large number of nurses are followed over time for an outcome such as colon cancer, providing an estimate of the risk of colon cancer in this population. In addition, dietary intake of various components can be assessed, and the risk of colon cancer in those with high and low intake of fiber can be evaluated to determine if fiber is a risk factor (or a protective factor) for colon cancer. The relative risk of colon cancer in those with high or low fiber intakes can be calculated from such a cohort study.

Case-control study  — A case-control study starts with the outcome of interest and works backward to the exposure. For instance, patients with a disease are identified and compared with controls for exposure to a risk factor. This design does not permit measurement of the proportion of the population who were exposed to the risk factor and then developed or did not develop the disease; thus, the relative risk or the incidence of disease cannot be calculated. However, in case-control studies, the odds ratio provides a reasonable estimate of the relative risk

If one were to perform a case-control study to assess the role of dietary fiber in colon cancer as noted above for the cohort study, a group of patients with colon cancer could be compared with matched controls without colon cancer; the fiber intake in the two groups would then be compared. The case-control study is most useful for uncommon diseases in which a very large cohort would be required to accumulate enough cases for analysis.

Randomized controlled trial  — A randomized controlled trial (RCT) is an experimental design in which patients are assigned to two or more interventions. One group of patients is often assigned to a placebo (placebo control) but a randomized trial can involve two active therapies (active control).

As an example, patients with a prior colonic polyp could be randomly assigned to take a fiber supplement or a placebo supplement to determine with fiber supplementation decreases the risk of developing colon cancer.

RCTs are generally the only type of study that can adequately control for unmeasured confounders, and are generally the best evidence for proving causality(effectiveness).

79-a 8 year old boy with h/o nocturnal enurosis come with URTI, on urine exam there is hematuria 1 plus no proteinuria,after 2 weeks URTI was resolved but golerular red cell presents but no cast,cause

1.Nephrotic

2.IgA

3.UTI (but not mentioned simple)

4.GN

80- urine cytology atypical cells investigation….

A: USG RENAL

B urine culture

c: intravenous urogrphy

d: CT SCAN NO CYSTOSCOPY IN OPTION

rule out probable malignancy

81- 2 questions on acute cholecystitis typical scenario,,,

One investigation was asked and other diagnosis was asked,,,

acute cholecystitis

JM P: 350

Acute cholecystitis

Cholecystitis is associated with gallstones in over 90% of cases and there is usually a past history of biliary pain. It occurs when a calculus becomes impacted in the cystic duct and inflammation develops. It is

very common in the elderly. The acute attack is often precipitated by a large or fatty meal. The causative

organisms are usually aerobic bowel flora (e.g. E. coli, Klebsiella species and Enterococcus faecalis).

[pic]

Clinical features

• Steady severe pain and tenderness

• Localised to right hypochondrium or epigastrium

• Nausea and vomiting (bile) in about 75%

• Aggravated by deep inspiration

Signs

• Patient tends to lie still

• Localised tenderness over gall bladder (positive Murphy sign)

• Muscle guarding

• Rebound tenderness

• Palpable gall bladder (approximately 15%)

• Jaundice (approximately 15%)

• ± Fever

Diagnosis

• Ultrasound: gallstones & dilatation of bile ducts but not specific for cholecystitis

• HIDA scan: demonstrates obstructed cystic

duct—the usual cause

• WCC and CRP: can be elevated

Treatment

• Bed rest

• IV fluids

• Nil orally

• Analgesics

• Antibiotics

• Cholecystectomy

If evidence of sepsis, use amoxy/ampicillin 1 g IV, 6 hourly plus gentamicin 4–6 mg/kg IV daily. Change to amoxycillin + clavulanate 875 + 125 mg (o) 12 hourly when afebrile.

82-pic ct gastric outlet obstruction…diagnosis asked

[pic]

82.1- picture of gastric outlet obstruction, asking the amount of k need to infuse during 24 hrs:

5

25

50

more than 50

no need to give k

82.2- gastric outlet obstruction asking about timming of vomiting

a)immediately after meal

b)1 hr after meal

c) after 2 hours after meal

83-pregnant lady started folic acid and she is vegetarian,,other supplement….

VITAMIN C AND

D,,,,,NO OPTION FOR B12…

ALL OTHERS WERE WITH IRON I THINK

Probably the answer due to Mrs Javanmard would be Iron supplement with vit-c(for better absorption of iron)

Dr.Farzin : she is vegetarian she is vegetarian for her aunt the dose of folic acid is the same as those who are not vegetarian .

84-LADY WANTS TO BE PREGNANT USING ALCOHOL 2/DAY UR ADVICE( STOP ALCOHOL

85-child with CBC low HB MCV AND MCHC but ferritin normal, investigation to reache diagnosis(hb electro

87- truck driver with loose stools..colonoscopy normal..what to do…stool for ova and parasites

88- one question for 8 weeks pregnant lady with vaginal bleed and lower abdominal pain….exam: uterus of 7 week size, cervix dilated, tissue seen in uterus,,,investigations was asked I choose USG and cannot recall the others.

“Miscarriage becomes inevitable if uterine bleeding is associated with strong uterine contractions that cause dilatation of the cervix. The woman complains of severe colicky uterine pains, and a vaginal examination shows a dilated cervical os with part of the conception sac bulging through. Inevitable miscarriage may follow signs of threatened miscarriage or, more commonly, starts without warning.

Soon after the onset of symptoms of inevitable miscarriage, the miscarriage occurs either completely, when all the products of conception are expelled, or incompletely when either the pregnancy sac or the placenta remains, distending the cervical canal. In most cases the miscarriage is incomplete. Unless the doctor has been able to inspect all the material expelled from the uterus, or has had an ultrasound examination that shows an empty uterus (or one containing less than 10 mm of tissues or blood clots), the miscarriage should be considered incomplete. This is treated by curettage; an alternative is to give misoprostol 400 μg 4-hourly for three doses or 800 μg as a single dose which will achieve a 60–80% complete evacuation of the uterus.

abortion

Uptodate:

Threatened abortion  — Bleeding through a closed cervical os in the first half of pregnancy is quite common and is termed threatened abortion. The bleeding is often painless, but may be accompanied by minimal/mild suprapubic pain. On examination, the uterine size is appropriate for gestational age and the cervix is long and closed. Fetal cardiac activity is detectable by ultrasound or Doppler examination if the gestation is sufficiently advanced. The exact etiology of bleeding often cannot be determined and is frequently attributed to marginal separation of the placenta.

The term "threatened" abortion is used to describe these cases because pregnancy loss does not always follow vaginal bleeding in early pregnancy, even after repeated episodes or large amounts of bleeding.

The prognosis is worse when the bleeding is heavy or extends into the second trimester

No change in pregnancy management is indicated because of the low predictive value for adverse outcome and the lack of effective interventions.

Inevitable abortion  — When abortion is imminent, bleeding increases, painful uterine cramps/contractions reach peak intensity, and the cervix is dilated. The gestational tissue can often be felt or visualized through the internal cervical os.

Complete and incomplete abortion  — When an abortion occurs before 12 weeks of gestation, it is common for the entire contents of the uterus to be expelled, thereby resulting in a complete abortion. Over one third of all cases are complete, rather than incomplete, abortions. If a complete abortion has occurred, the uterus is small and well contracted with a closed cervix, scant vaginal bleeding, and only mild cramping.

After 12 weeks, the membranes often rupture and the fetus is passed, but significant amounts of placental tissue may be retained, leading to an incomplete abortion, also called an abortion with retained products of conception. On examination the cervical os is open, gestational tissue may be observed in the vagina/cervix, and the uterine size is smaller than expected for gestational age, but not well contracted. The amount of bleeding varies, but can be severe enough to cause hypovolemic shock. Painful cramps/contractions are often present.

Ultrasonographic diagnosis of an incomplete miscarriage or retained products of conception is problematic. Measurement of endometrial thickness and the appearance of the midline echo have been used to make these diagnoses, but there is no agreement on the appropriate cut-off for endometrial thickness (15 mm is commonly used) and no threshold has been proven to be reliable.

When heterogeneous material is present in the endometrial cavity, Doppler ultrasound can be helpful in distinguishing between retained products of conception and blood clot. If blood flow to retained placental tissue is visualized, then it is possible to make the diagnosis of retained products of conception. However, if blood flow is absent, then either devascularized retained products of conception or blood clot could be present.

Missed abortion  — A missed abortion refers to in-utero death of the embryo or fetus prior to the 20th week of gestation, with retention of the pregnancy for a prolonged period of time. Women may notice that symptoms associated with early pregnancy (eg, nausea, breast tenderness) have abated and they don't "feel pregnant" anymore; vaginal bleeding may occur. The cervix is usually closed.

Septic abortion  — Common clinical features of septic abortion include fever, chills, malaise, abdominal pain, vaginal bleeding, and discharge, which is often sanguinopurulent. Physical examination may reveal tachycardia, tachypnea, lower abdominal tenderness, and a boggy, tender uterus with dilated cervix.

Infection is usually due to Staphylococcus aureus, Gram negative bacilli, or some Gram positive cocci. Mixed infections, anaerobic organisms, and fungi, can also be encountered. The infection may spread, leading to salpingitis, generalized peritonitis, and septicemia.

Most spontaneous abortions are not septic. Septic abortion is, however, a common complication of illegally performed induced abortion. Infrequently, septic abortion is related to foreign bodies (eg, intrauterine contraceptive device, laminaria), invasive procedures (eg, amniocentesis, chorionic villus sampling), maternal bacteremia, or incomplete spontaneous or legally induced abortion. Septic deaths related to Clostridium sordellii have been reported after medical termination of early pregnancy.

[pic]

D is correct

MarjanKh:[pic]

89-picture of epididmoorchitis in 25 year old male…most common organisim

در سن جوانی--> STI

در بچه و مسن--> Ecoli

90- 58 year old lady worried for postmenopausal fracture due to osteoporosis,,,she was treated for ca breast 4 years back,,,,u did scan and T value -2.8 treatment….options were

CAL/VIT D

ALENDRONATE

HRT

RELOXIFEN??

اين هم فكر كنم منظورش از مطرح كردن همزمان استئوپروز و كنسر برست ، انتخاب رالوكسيفن بوده .

رالوکسیفن ریسک شکستگی ورتبرا رو ۴۰ درصد کم می کنه و روی شکستگی غیر ورتبرا بی تاثیره

Breast cancer — For patients with breast cancer and bone metastases, bisphosphonate therapy can prevent and/or delay skeletal complications, and palliate bone pain. A survival benefit has not been shown. In women with metastatic breast cancer without clinically evident bone metastases, bisphosphonates do not reduce the incidence of skeletal events. Consequently, therapy with high dose bisphosphonates is recommended to begin after the identification of osseous metastases, unless as part of a clinical trial. Bisphosphonates can also prevent treatment-related bone loss in women receiving chemotherapy or aromatase inhibitors for breast cancer.

Selective estrogen receptor modulators — Raloxifene (60 mg/day) is the only SERM currently approved in the United States for the prevention of postmenopausal osteoporosis. It has been shown to increase BMD and reduce the risk of vertebral fractures but not nonvertebral fractures . Important nonskeletal considerations with raloxifene include reduction in breast cancer risk, increased risk of thromboembolic events, and hot flashes. There is no apparent effect on heart disease or the endometrium.

osteoprosis

JM P: 984

Investigations

• Plain radiography is of limited value. Osteoporosis is not detectable until 40–50% of bone is lost.

• 25-hydroxy vitamin D (most useful test): normal range 75–250 nmol/L.

• Plasma calcium, phosphate and alkaline phosphatase (usually normal).

• TSH.

• Consider tests for multiple myeloma in an osteoporotic area.

• Densitometry can predict an increased risk of osteoporosis and fracture, the best current modality being dual energy X-ray absorptiometry (DEXA scan) in a facility with high-standard quality control. The spine and femoral neck are targeted: the femoral neck is the most useful index.

[pic]

Treatment: Prevention and treatment of osteoporosis consists of non-drug and drug or hormonal therapy.

Nonpharmacologic therapy(recommended for all with osteopenia or normal post menopausal woman who doesn’t receive enough calcium through routine nutrition)

calcium citrate 2.38 g ( =  500 mg elemental calcium) daily

or

calcium carbonate 1.5 g ( =  600 mg elemental calcium) daily with food

Measure serum 25-hydroxy vitamin D and maintain it at 75 nmol/L. If supplementation is required use

colecalciferol 25–50 mcg (1000–2000 IU) (o) daily

Pharmacologic therapy

• HRT (long-term use is not recommended but weigh potential benefits versus harms with the

patient)

or

• bisphosphonates: decrease bone absorption (take care with potential adverse effects of oesophagitis and

osteonecrosis of jaw):

— alendronate 10 mg (o) daily or 70 mg (o) once weekly (take care with potential side effect of

oesophagitis)

— etidronate 400 mg (o) for 14 days then calcium carbonate 1250 mg (o) for 76 days

— risedronate 5 mg (o) daily or 150 mg (o) once monthly or 35 mg (o) once weekly or in combination therapy

with calcium carbonate ± vitamin D

— zoledronic acid, single annual IV injection

• raloxifene (a selective oestrogen-receptor modulator) (SERM) 60 mg (o) daily

• strontium ranelate (uncouples bone resorption and formation):

— 2 g (o), as a powder in water, daily (nocte). Reported adverse effects include vascular complications—to be

used with caution in patients with vascular disease and renal impairment

• teriparatide (a synthetic form of human parathyroid hormone) increases bone formation. Give 20 mcg SC once

daily

• denosumab (a monoclonal antibody) 60 mg SC, once every 6 months, once calcium intake and vitamin D levels are optimal. It is a potential risk factor for osteonecrosis of the jaw especially in patients with bone cancer.

The choice depends on the clinical status, such as the age of the patient and the extent of disease, the patient’s tolerance of drugs and further clinical trials of these drugs. The one preferable solution is to give prophylaxis for individuals identified as high risk and the only widely accepted proven therapy is oestrogen therapy but it has limitations.

Uptodate:

•For the treatment of osteoporosis in postmenopausal women, we suggest bisphosphonates as first-line therapy.

For most postmenopausal women with osteoporosis, we suggest alendronate or risedronate over oral ibandronate.

•We suggest zoledronic acid(the only intravenous bisphosphonate) for patients who cannot tolerate oral bisphosphonates or who have difficulty with dosing requirements, including an inability to sit upright for 30 to 60 minutes.

We suggest raloxifene for postmenopausal women with osteoporosis who cannot tolerate or are not candidates for any bisphosphonates(a reduction in breast cancer risk)

•We suggest PTH therapy for postmenopausal women with severe osteoporosis

91-ecg bradycardia not block pt taking amlodipine , foresmide, amiodarone & digoxin . having lightheadness dizziness n syncope. Cause?

1)fures-amiodarone

2)digoxine-amiodarone

3)fures-dig

Mehri : amiodarone and Lasix (furosemide) hypokalemia

Talk to your doctor before using amiodarone together with furosemide. Combining these medications can increase the risk of an irregular heart rhythm that may be serious. If your doctor prescribes these medications together, you may need regular monitoring of your electrolyte (magnesium, potassium) levels as well as other tests to safely use both medications. You should seek immediate medical attention if you develop sudden dizziness, lightheadedness, fainting, or fast or pounding heartbeats during treatment with amiodarone. In addition, you should let your doctor know if you experience signs of electrolyte disturbance such as weakness, tiredness, drowsiness, confusion, muscle pain, cramps, dizziness, nausea, or vomiting. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor.

92-54y/o since one year on HRT u did scan anf T value -1.7 what to add….

Cal/vit D

RELOXIFEN

ALENDRONATE

Osteopenia: better to take supplement on basis her nutrition doesn’t meet her need for Ca&D

93- scenario of Hand foot mouth disease and cause asked…coxsacie virus

This is a mild vesicular eruption caused by a Coxsackie A virus (usually A16). HFM disease affects both children and adults but typically children under the age of 10. Known as ‘crèche disease’ it often occurs among groups of children in child care centres.

Clinical features

• Incubation period 3–5 days

• Initial fever, headache and malaise

• Sore mouth and throat

The rash appears after 1 or 2 days

• Starts as a red macule, then progresses to vesicles

• Vesicles lead to shallow ulcers on buccal mucosa, gums and tongue

• Greyish vesicle with surrounding erythema

• On hands, palms and soles (usually lateral borders)

• May appear on limbs especially buttocks and genitals

• Lesions resolve in 3–5 days

• Healing without scarring

• Spread by direct contact or aerosol droplets

• Virus excreted in faeces and saliva for several weeks

• Children are infectious until the blisters have disappeared

• Diagnosis is clinical, investigations usually unnecessary

Management

• Reassurance and explanation

• Symptomatic treatment

• Careful hygiene

• Exclusion not usually recommended

[pic]

94 abdominal cellulitis pic ,,started on pencilin and fluclox,,12 hours after redness increased and patient hypotensive…iv fluids given what to do next

1: stop previous ABx and start ticarcilin

2: add gentamicin

3 stop BAx and start gentamicin

اون سئوال هندبوك فقط گفته بود بعد شروع درمان قرمزى بيشتر شده حالا چه كنيم ؟ كه جواب داده بود گسترش قرمزى بعد شروع درمان نشاندهنده شكست درمان نيست و جزئى از سير طبيعيه بيماريه .

[pic]

ولي اينجا همون طور كه دكتر مهدي گفت هايپوتانسيون داده و شايد حساسيت به پني سيلين مورد نظر بوده. حالا اگه حساسيت به پني سيلين هم مد نظر بوده جواب ميشه كليندامايسين احتمالا جواب در گزينه هاي مفقوده هست

cellulitis

Cellulitis in adults most often affects the lower legs. Spontaneous, rapidly spreading cellulitis is most commonly due to S. pyogenes or other streptococci (eg group B, C or G).

Staphylococcus aureus causes cellulitis less frequently; it is often associated with penetrating trauma or

ulceration.

Mild early cellulitis and erysipelas

To treat suspected Staphylococcus aureus or Streptococcus pyogenes infection, use:

di/flucloxacillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 to 10 days.

If S. pyogenes is isolated from cultures, or suspected based on clinical presentation (see above) or local

epidemiology (eg in Indigenous communities in central and northern Australia), use:

1 phenoxymethylpenicillin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 to 10 days

OR

1 procaine penicillin 1.5 g (child: 50 mg/kg up to 1.5 g) IM, daily for at least 3 days.

Cephalexin is used for patients hypersensitive to penicillins (excluding immediate hypersensitivity), and is often preferred in children due to greater tolerability and better palatability of the liquid formulation. Use:

cephalexin 500 mg (child: 12.5 mg/kg up to 500 mg) orally, 6-hourly for 5 to 10 days.

For patients with immediate hypersensitivity to penicillins, use:

clindamycin 450 mg (child: 10 mg/kg up to 450 mg) orally, 8-hourly for 5 to 10 days

Severe cellulitis

If the patient has significant systemic features or is not improving after 48 hours of oral therapy, start IV therapy.

To treat suspected S. aureus or S. pyogenes infection, use:

flucloxacillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly.

For patients hypersensitive to penicillins (excluding immediate hypersensitivity), use initially:

cephazolin 2 g (child: 50 mg/kg up to 2 g) IV, 8-hourly.

For patients with immediate hypersensitivity to penicillins use initially:

1 vancomycin IV 30 mg/kg IV every 24 hours in 2 equally divided doses; not to exceed 2 g/24 hours

OR

2 clindamycin 600 mg (child: 15 mg/kg up to 600 mg) IV, 8-hourly.

Ceftriaxone has a broad spectrum of activity that is not required for routine cellulitis where streptococci and

staphylococci are the likely pathogens.

Even with effective therapy, local symptoms (eg erythematous rash) can worsen for 48 hours after initiation of

therapy while systemic features improve.

Outpatient parenteral antimicrobial therapy may be appropriate in carefully selected adult patients; use:

1 cephazolin 2 g IV, 12-hourly

OR THE COMBINATION OF

1 cephazolin 2 g IV, daily PLUS probenecid 1 g orally, daily.

Switch to oral therapy when systemic features have improved. A total treatment duration of up to 2 weeks (IV + oral) is recommended.

95-old recal..young lady at term in labour and she doesnot want interventions. At presentation cervix 5 cm dilated and head just above IS. After 3 hours cervix is 9 cm dilated and head palpable at Is in LOT position... This was the scenario.…so I picked reexamine in 2-3 hours

Amedex: Probably it seems a normal progressive vaginal delivery …awaiting and re-examination

96- 45 year patient with dementia symptoms..what importnant in history…

father has dementia at young age

[pic]

97-MOST COMMON SITE FOR endometriosis,,believe mean it was stem….

A round ligament

B uterosacral ligmanet

C broad ligmanet

D ovary

E??? may be rectum

The most common sites of endometriosis, in decreasing order of frequency, are the ovaries, anterior and posterior cul-de-sac, posterior broad ligaments, uterosacral ligaments, uterus, fallopian tubes, sigmoid colon and appendix, and round ligaments. Other sites less commonly involved include the vagina, cervix, rectovaginal septum, cecum, ileum, inguinal canals, abdominal or perineal scars, urinary bladder, ureters, and umbilicus. Rarely, endometriosis has been reported in the breast, pancreas, liver, gallbladder, kidney, urethra, extremities, vertebrae, bone, peripheral nerves, lung, spleen, diaphragm, and central nervous system.

98-old lady with recurrent c/o valvular itching last 6 months, treated with clotrimazole recovered but reoccur again. What to do?

Valvular culture

Rectal swab

HIV serology

Urine culture

اين رو من احتمال ميدم سناريو كاملش ليكن اسكلروزيس باشه كه بايد بيوپسى انجام داد . يا گزينه يك رو اشتبه جاى بيوپسى نوشته كشت يا گزينه مفقوده بايد بيوپسى باشه .

Lichen sclerosus

JM P: 1164

Also known as lichen sclerosus et atrophicus this uncommon chronic inflammatory dermatosis of unknown aetiology (perhaps an autoimmune disorder) presents as well-defined white, finely wrinkled plaques that almost exclusively affect the anogenital skin, although they can occur anywhere on the body. Lichen sclerosus spares the vagina. It can run a chronic and complicated course with development of squamous cell carcinoma (SCC) in about 4% a concern. The differential diagnosis is atrophic vaginitis.

[pic]

Clinical features

• Bimodal peak: prepubertal girls, perimenopause

• Mean age of onset in adult women is 50 years

• Pruritus is main symptom

• Soreness, burning, dyspareunia Examination

• Variable distribution

• White wrinkled plaques

• Purpuric and ulcerated areas

• May show figure of 8 pale perianal and perivaginal area

Complications if untreated

• Vulval atrophy and labial (even clitoral hood) fusion, introital stenosis

• Lifetime risk of SCC 2–6%

Management

• Best in consultation with a dermatologist.

• Confirm diagnosis by biopsy (tend to avoid in children).

• Based on potent topical corticosteroids (e.g. betamethasone dipropionate 0.05% ointment or cream applied bd

for 4 weeks, then daily for 8 weeks).

• Reduce to a potent topical steroid once daily for next 3 months, then reduce to hydrocortisone 1% ointment or

cream applied daily for long term.

• Lifelong surveillance with 6-monthly check-up.

• A similar topical program is used in children.

Although Dr.Maryam tends to choose LS but I’d rather not to cos the effectiveness of an azole agent can not be vindicated. Say chronic candidia infection is more justifiable to me: cultur

Chronic vulvovaginal candidiasis

JM P: 1165

This is different from acute candidiasis and remains difficult to treat because there may be a localised

hypersensitivity to Candida.

Clinical features

• Chronic vulval itch–scratch cycle

• Burning, swelling—premenstrual exacerbation

• Dyspareunia

• Discharge not usually present

• Aggravated by courses of systemic antibiotics

Management

• Cease hormone contraceptives e.g. OCP

• Swab—low vaginal—with each suspected episode, especially if discharge

• Aim for symptom remission with continuous antifungal treatment:

— topical vaginal antifungals (imidazoles or nystatin),

or

— daily oral antifungals (monitor liver function tests) until symptoms clear—ketoconazole 200 mg/day (beware

of hepatotoxicity) or fluconazole 50 mg/day, or itraconazole 100 mg day (then weekly for 6 months)

• Relieve itching with hydrocortisone 1% (do not use stronger preparations)

• Use nystatin pessaries in pregnancy.

99- young male with h/o asthma presented with c/o dysphygia on and off and he mentioned that with particular foods its worsened,,..endoscopy fondings given…diagnosis asked eosinophilic esophagitis

Eosinophilic esophagitis should be considered in adults with a history of food impaction, with persistent dysphagia, or with gastroesophageal reflux disease (GERD) that fails to respond to medical therapy. In children, symptoms that may be associated with eosinophilic esophagitis vary by age and include feeding disorders, vomiting, abdominal pain, dysphagia, and food impaction.

In particular, the diagnosis should be considered in young men or boys, and in those with a history of food or environmental allergies, asthma, or atopy. A history of esophageal perforation or severe pain after dilation of a stricture should also raise suspicion of this disorder.

Making a diagnosis of eosinophilic esophagitis requires the presence of both symptoms and histologic findings. In addition, other disorders that can cause esophageal eosinophilia, such as GERD, should be ruled out. In patients suspected of having eosinophilic esophagitis, the first diagnostic test is typically an upper endoscopy with esophageal biopsies, though radiographic and laboratory findings may support the diagnosis. We suggest that, at a minimum, two to four biopsies be obtained from the distal esophagus, as well as another two to four from the mid or proximal esophagus.

Clinical manifestations in adults

Dysphagia

Food impaction

Chest pain that is often centrally located and does not respond to antacids

Gastroesophageal reflux disease-like symptoms/refractory heartburn

Upper abdominal pain

Dysphagia to solid foods is the most common symptom

Stacked circular rings (“feline” esophagus), Strictures (particularly proximal strictures), Attenuation of the subepithelial vascular pattern, Linear furrows, Whitish papules (representing eosinophil microabscesses)

, Small caliber esophagus

[pic]

Endoscopic image of esophagus in a case of eosinophilic esophagitis. Concentric rings are termed trachealization of the esophagus.

100- tibial fracture, ask for treatment,

Reduction and casting

101-old lady being beaten by her 25 y/o son whar to do?

Call police

Send lady to refugee

تا اونجا که من فهميدم اونجا دکترا به پليس زنگ نميزنن برخلاف اينجا که پليس حلال مشکل ما دکتراس������

اول مطمين ميشن از قضيه بعد موضوع ميره سر ساپورت کردن اون بينوا و اطلاع دادن به فارنسيک حتی تلفنی اطلاع ميدن و راهنمايی هم ميشن... اينو راجع به بچه ها تو آر سی اچ خوندم

Maybe b is correct

Amedex: shouldn’t call the police cause its not a child abuse.

102-old patint with IHD now elevated TSH. Tx?

Start levothyroxine by 100 µg

Start levothyroxine by 50 µg

Start medication with levothyroxin 50- 100 microgram, if old ( age > 60) or cardiac disease, start with 25-50

103-52 y/o lady last mentural period was one year ago, having no sexual activity for 1 years noe presented with postcoital bleeding for 24 hours, during intercourse had no pain, pap was normal 2 years ago…

Endometrial ca

Atrophic vaginitis

Cervical ca

Menstrual bleeding

A few words:

Post coital bleeding

• Bleeding during or after coitus is common.

• The most serious cause of postcoital bleeding is cervical cancer, but the risk in women with postcoital bleeding is low.

• Cervical ectropion, polyps, and cervicitis (especially chlamydia) are other possible causes of postcoital bleeding.

• Diagnostic evaluation includes history, physical examination, and testing for infection in patients with vaginal or

cervical discharge. Cervical cancer screening(pap) should be performed if not up to date.

• Colposcopy is indicated in women with abnormal(pap) cervical cancer screening tests or persistent postcoital bleeding. We also offer colposcopy for women who request it after counseling.

Atrophic vaginitis

In the absence of oestrogen stimulation the vaginal and vulval tissues begin to shrink and become thin and dry. This renders the vagina more susceptible to bacterial attack because of the loss of vaginal acidity. Rarely, a severe attack can occur with a very haemorrhagic vagina and heavy discharge:

• yellowish, non-offensive discharge

• tenderness and dyspareunia

• spotting or bleeding with coitus

• the vagina may be reddened with superficial haemorrhagic areas

Treatment

local oestrogen cream or tablet (e.g. Vagifem). The tablet is preferred as it is less messy

or

zinc and castor oil soothing cream

Conclusion:

1-Atrophic vag will b having dyspareunia

2-menstral bleed due to return of follicular activity from a remaining follicle that has responded to raised fsh n

then produce estrogen is possible. Re activation is possible in early 2 to 3 years of menopause due to remaining

one follicle. Especially if the bleeding is prolonged like this case(for 24h)

3-Ca cervix, endometrium ca n atrophic vaginitis uncommon in first two to three years of menopause

4-bleeding pattern of cervical ca or polip usually wont be as long as one day

so I’d like D

104-pregnant lady with genital herpes, what to diagnose latency?

PCR

IgM now

Biopsy from ulcer

First IgG, if was not in options, PCR

If a new HSV infection is clinically suspected during pregnancy, laboratory confirmation is required. Ideally active lesions are still present at the time of presentation and a swab for viral PCR can be collected as well as type-specific serology. PCR positivity for a HSV type for which IgG is negative suggests a primary genital HSV infection. Regardless of whether there is PCR confirmation, serial serology should be obtained to confirm seroconversion. C/S in indicated if active lesion present or rupture of membrane less than 4 hours.

[pic]

105-difference between malignancy and primary hyperparathyroidism?

PTH

Ca

Phosphate

Keyvan: 3 types of hypercalcemia due to malignancy:

1-increase in PTHrp(hypercalcemia& hypophosphatemia (80%)(like primary hayper para)

2-due to lytic bone lesions(hypercalcemia&hyperphosphatemia

3-vit-D secretor tumoral cells(hypercalemia&hyperphosphatemia

Answer : a = PTH(its suppressed)

Hypercalceia of malignancy can be due to secretion of PTH -like substances or bone destruction by metastases.in either case,plasma level of PTH detected by IRMA would be low.in fact,the PTH -like peptides produced by some tumors are not identified by IRMA. Alkaline phosphatase would be high in the presence of osteolysis.

106-pt with Huntington disease , now caught by police for speeding taken to hospital but he does not want to stay…

Inform the mental health

Contact with huntingtons disease

Other health centers

Answer : a?? I have no idea but its B in amedex

107- 4 months somalian male irritable…labs given….HB 90 (range 95-110) ALKP 1135 (normal less then 300) vitamin D 18 ( normal 50-75) bili 23 (normal 20) cause for irritability

A: low Hb

b HIGH ALKP

C LOW VIT

D bili I don’t know why I selected this

E low ca

کلا نمیدونم چجوریه که همه بچه ها تو سومالی کمبود کلسیم دارن هر چی دیدین تو بچه سومالیایی (تشنج و بی قراری و قتل و جنگ و ... ) بزنید هیپوکلسمی

108- 7 year old child is presented after bleeding from frenulum after hitting the coffee table. What is the initial investigation?

-BT

-APTT

-Fac IX

[pic]

در itp خونريزى تابلوى شايعى هست؟ بيشتر به vwd ميخوره. البته تايپهايى از vwd هم اختلال فانكشنال پلاكت ميتونن داشته باشن و هم ترومبوسيتوپنى

Von Willebrand disease

Uptodate:

INTRODUCTION — Von Willebrand disease (VWD) is the most common inherited bleeding disorder

IMPORTANCE OF VON WILLEBRAND FACTOR — Von Willebrand factor (VWF) plays an important role in primary hemostasis by binding to both platelets and endothelial components, forming an adhesive bridge between platelets and vascular subendothelial structures at sites of endothelial injury and between adjacent platelets in areas with high shear . It also contributes to fibrin clot formation by acting as a carrier protein for factor VIII, which has a greatly shortened half-life and abnormally low concentration unless it is bound to VWF

These abnormalities mostly affect platelet plug formation during the primary hemostatic response. As a result, many of the usual clinical manifestations of VWD are similar to those seen in platelet disorders. These include:

Easy bruising

Skin bleeding

Prolonged bleeding from mucosal surfaces (eg, oropharyngeal, gastrointestinal, uterine).

An exception to this general pattern of bleeding occurs in type 2N VWD in which there is a qualitative defect in VWF that affects its binding site for factor VIII . In these patients, the bleeding is due to low factor VIII levels and mimics the findings seen in classical hemophilia, including soft tissue, joint, and urinary bleeding, and bleeding after invasive procedures [ . In patients with type 3 VWD, both types of bleeding (ie, mucocutaneous and soft tissue bleeding as well as joint bleeding) may occur

Bleeding time — The bleeding time (BT) is a measure of the interaction of platelets with the blood vessel wall. It is prolonged in patients with some intrinsic platelet disorders and in moderately severe and severe VWD, but is often normal in those with mild or moderate VWD.

When to suspect von Willebrand disease — Patients with von Willebrand disease (VWD) can become symptomatic at any age. The patient's personal and family history of bleeding episodes is important, and one needs to specifically seek a history of challenges such as invasive dental procedures, tonsillectomy, other surgical procedures (particularly involving mucous membrane surfaces), and menstrual and peripartum bleeding.

A typical history in a patient with mild to moderate disease includes epistaxis lasting longer than 10 minutes in childhood, lifelong easy bruising, and bleeding with or following dental extractions, other invasive dental procedures, or other forms of surgery.

In patients with type 2N VWD, the bleeding is due to low factor VIII levels and mimics the findings seen in classical hemophilia, including soft tissue, joint, and urinary bleeding, and bleeding after invasive procedures. In patients with type 3 VWD, both types of bleeding (ie, mucocutaneous and soft tissue bleeding as well as joint bleeding) may occur .

Initial testing — Three tests are recommended as initial screening tests for VWD:

Plasma VWF antigen (VWF:Ag)

Plasma VWF activity (ristocetin cofactor activity, VWF:RCo and VWF collagen binding VWF:CB)

Factor VIII activity (FVIII)

Desmopressin — Desmopressin (dDAVP), increase VWF and factor VIII levels . It promotes the release of VWF from endothelial cell storage sites;

Short-term replacement — Patients with type 3 VWD and those with more severe type 2A, 2B, and 2M disease often require replacement therapy with VWF. Replacement therapy is also indicated in some patients with type 1 VWD who have a more severe decrease of VWF, particularly in more serious bleeding situations when other measures have failed, or in those who may need more prolonged treatment (eg, post-surgery). VWF replacement therapy is most often used for short term prophylaxis for a planned procedure or following trauma.

Antifibrinolytic therapy — Epsilon aminocaproic acid (EACA) and tranexamic acid have been used to prevent dissolution of the hemostatic plug that is formed,

Topical agents — Topical agents are most often used for nasal or oral bleeding. With this approach, supports such as Gelfoam or Surgicel are soaked in topical thrombin and applied to local areas of bleeding

IVIG — High-dose IVIG (1 g/kg per day for two days) has been used in patients with acquired VWD associated with autoimmune disease or a monoclonal gammopathy.

Recombinant Factor VIIa — Several authors have reported on the successful use of recombinant factor VIIa in the treatment of patients with type 3 VWD

JM P:429 von Willebrand disease

This is the most common disorder of haemostasis (incidence 1% of population) and is usually a mild

problem with an excellent prognosis There are about 22 types .

Clinical features

• Autosomal dominant inheritance (common types)

• Prolonged bleeding time (like plt disorders)

• Bleeding tendency exacerbated by aspirin

• Platelets normal

• Defective platelet adhesion at site of trauma combined with factor VIII deficiency

• APTT prolonged

• Positive vW factor antigen

• Menorrhagia and epistaxis common

• Haemarthroses rare

DxT menorrhagia+bruising+increased bleeding 1. incisions 2. dental 3. Mucosal = vWD

Treatment

• No specific treatment

• Avoid aspirin (including Alka-Seltzer), NSAIDs, IM injections

• Be cautious of surgical and dental procedures

• Preparations that help include desmopressin acetate (DDAVP), factor VIII concentrates and tranexamic acid

109-mother present with her boy complaining persistant bleeding after tripping with a coffee table..what is the treatmnet of this condition?

a)steroid ( thinking of ITP??)

b)IVIG ( again ITP??)

C) platelate ( platelet disorders??)

D)desmopresin

e) factor viii

first desmopresin(increasing vw factor) then tranexamic/EACA(anti fibrinolutic) then last/strongest resort factor viii concentrates

110-fight in pub Swelling over left parietal. Vitals unstable. Left pupil dilated. Left c.n. lesion mentioned.(no ct was there)

a. burrhole rt parietal

b.burrhole left parietal

دكتر درست گفتن، قدم اول در اورژانس در كنار atls انجام ct هست اما يكجا هست كه حتى اگه ct سالم باشه بازم ونتريكولوستومى ميكنيم

با اين توضيحاتى كه تو سوال داده اگر سى تى باشه، من ميزنم سى تى. البته اگر اولين اقدام رو خواست بايد حواستون به ATLS باشه.

اونجا atls رو انجام ميديم: راه هوايى، اكسيژن، حفظ bp بالاى ٩٠ mmhg. اگه علايم به نفع هرنى مغزى داره، مانيتول رو شروع ميكنيم، و stable شد انتقال به مركز داراى سرويس نوروسرجرى.

[pic]

Sites of burr hole.

ICP MONITORING

Indications for ICP monitoring in TBI (traumatic brain injury) are a GCS score ≤8 and an abnormal CT scan showing evidence of mass effect from lesions such as hematomas, contusions, or swelling . ICP monitoring in severe TBI patients with a normal CT scan may be indicated if two of the following features are present: age >40 years; motor posturing; systolic BP ................
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