Wednesday 31 October 2012

Bacterial meningitis case

CASE A 20-year-old college student is your next patient in the emergency room. When you walk into the room, he is lying on the examination table, on his side, with his arm covering his eyes. The light in the room is off. You look at his chart and see that the nurse recorded his temperature as 102.3°F, heart rate 110 bpm, and blood pressure 120/80 mm Hg. When you gently ask how he has been feeling, he says that for the past 3 days he has had fever, body aches, and a progressively worsening headache. The light hurts his eyes and he is nauseated, but he has not vomited. He has had some rhinorrhea, but no diarrhea, cough, or nasal congestion. He has no known ill contacts. On examination, he has no skin rash, but his pupils are difficult to assess because of photophobia. Ears and oropharynx are normal. Heart, lung, and abdomen examinations are normal. Neurologic examination reveals no focal neurologic deficits, but passive flexion of his neck worsens his headache, and he is unable to touch his chin to his chest.

#What condition are you concerned about?

#What diagnostic test would confirm the diagnosis?

Summary: A 20-year-old college student presents with a 3-day history of fever, headache, myalgias, and nausea. He has no respiratory or gastrointestinal symptoms, but now has developed photophobia. He is febrile to 102.3°F, tachycardic, and normotensive. His physical examination is generally unremarkable with a nonfocal neurologic examination but some neck stiffness, suggesting meningeal irritation. He has no skin lesions as might be seen in meningococcemia.

#Most likely condition: Meningitis.

#Diagnostic test to confirm diagnosis: Lumbar puncture (LP) for evaluation of the cerebrospinal fluid (CSF), possibly preceded by a computed tomographic (CT) scan of the head.

ANALYSIS

Considerations This 20-year-old college student has headache, nausea, photophobia, fever, and neck pain and stiffness—all suggestive of meningitis, which could be bacterial or viral. Prompt LP and analysis of CSF are essential to establish the diagnosis. In a patient without focal neurologic signs and a normal level of consciousness, CT scan may be unnecessary prior to performing an LP. If he had a purpuric skin rash, one would be suspicious of Neisseriameningitis, and appropriate antibiotics should be administered immediately. Dosing of antibiotics in suspected meningococcal infection should not await the performance of any diagnostic test because progression of the disease is rapid, and mortality and morbidity are extremely high even when antibiotics are given in a timely manner.

DEFINITIONS

MENINGITIS:A serious inflammation of the meninges, the thin, membranous covering of the brain and the spinal cord, which can be caused by bacteria, viruses, fungi, or protozoa.

PAPILLEDEMA: Swelling of the optic nerve, caused by an increased intracranial pressure. On fundoscopic examination, the optic disc margin appears hazy.

CLINICAL APPROACH

Bacterial meningitis is the most common pus-forming intracranial infection, with an incidence of 2.5 per 10,000 persons. The microbiology of the disease has changed somewhat since the introduction of the Haemophilus influenzae type B vaccine in the 1980s. Now Streptococcus pneumoniaeis the most common bacterial isolate, with Neisseria meningitidisa close second.Group B streptococcusorStreptococcus agalactiaeoccurs in approximately 10% of cases, more frequently in neonates or in patients older than 50 years or with chronic illnesses such as diabetes or liver disease. Listeria monocytogenesaccounts for approximately 10% of cases and must be considered in pregnant women, the elderly, or patients with impaired cell-mediated immunity such as AIDS (acquired immunodeficiency syndrome) patients. Haemophilus influenzaeis responsible for less than 10% of meningitis cases. Resistance to penicillin and some cephalosporins is now of great concern in the treatment of S pneumoniae.

Bacteria usually seed the meninges hematogenously after colonizing and invading the nasal or oropharyngeal mucosa. Occasionally, bacteria directly invade the intracranial space from a site of abscess formation in the middle ear or sinuses. The gravity and rapidity of progression of disease depend upon both host defense and organism virulence characteristics. For example, patients with defects in the complement cascade are more susceptible to invasive meningococcal disease. Patients with CSF rhinorrhea caused by trauma or postsurgical changes may also be more susceptible to bacterial invasion. Staphylococcus aureusandStaphylococcus epidermidisare common causes of meningitis in patients following neurologic proceduressuch as placement ofventriculoperitoneal shunts. The brisk host inflammatory response in the subarachnoid space may cause edema, vasculitis, and coagulation of vessels, leading to severe neurologic complications including seizures, increased intracranial pressure, and stroke. Acute bacterial meningitis can progress over hours to days. Typical symptoms include fever, neck stiffness, and headache.Patients may also complain of photophobia, nausea and vomiting, and more nonspecific constitutional symptoms. Approximately 75% of patients will experience some confusion or altered level of consciousness. Forty percent may experience seizures during the course of their illness.

Some physical examination findings may be useful in the evaluation of a patient with suspected meningitis. Nuchal rigidityis demonstrated when passive or active flexion of the neck results in an inability to touch the chin to the chest. Classic tests include Kernig and Brudzinski signs. Kernig signcan be elicited with the patient on his or her back. The hip and knees are flexed. The knee is then passively extended, and the test is positive if this maneuver elicits pain. Brudzinski signis positive if the supine patient flexes the knees and hips when the neck is passively flexed. Neither sign is very sensitive for the presence of meningeal irritation, but, if present, both are highly specific. Papilledema, if present, would indicate increased intracranial pressure, and focal neurologic signs or altered level of consciousness or seizures may reflect ischemia of the cerebral vasculature or focal suppuration.

Differential Diagnosis

The differential diagnosis of bacterial meningitis is fairly limited and can be narrowed depending upon the patient’s age, as discussed earlier, exposure history, and course of illness. Various viral infections may also cause meningitis. These include enteroviruses, which tend to be more common in the summer and fall, when patients may present with severe headache, accompanied by symptoms of gastroenteritis. The CSF white blood cell (WBC) count will be elevated, with a predominance of lymphocytes, and usually glucose and protein levels are normal (Table 29–1). Either herpes simplex virus (HSV)-1 or HSV-2 can cause herpes simplex meningitis. The CSF of these patients will also have a normal glucose level, whereas protein and WBC counts will be elevated with a predominance of lymphocytes. Typically, these patients have a high CSF red blood cell count, which is not seen in bacterial meningitis in the absence of a traumatic spinal tap. In a patient with human immunodeficiency virus (HIV) infection, fungal meningitis, specifically caused by Cryptococcus, should be considered. Tuberculous meningitis presents subacutely and is more common in older, debilitated patients, or in patients with HIV. Rickettsial disease, specifically Rocky Mountain spotted fever, may also present with meningitis. Intracranial empyema, or brain or epidural abscess, should be considered, especially if the patient has focal neurologic findings. The one nonsuppurative diagnosis in the differential is subarachnoid hemorrhage. These patients present with sudden onset of the “worst headache of their lives” in the absence of other symptoms of infection. They may have photophobia, and the CSF will be grossly bloody; the supernatant will be xanthochromic, reflecting the breakdown of blood into bilirubin.

The necessity of imaging of the head and brain prior to performing an LP is controversial. Studies show that in the patient with suspected meningitis who does not have papilledema, focal neurologic signs, or altered level of consciousness, an LP may be safely performed without preceding imaging. However, in instances in which performance of the LP may be delayed, antibiotics should be administered after blood cultures while awaiting the radiologic studies. Ideally, the CSF should be examined within 30 minutes of antibiotics, but it has been shown that if the LP is performed within 2 hours of antibiotic administration, it will not significantly alter the CSF protein, glucose, or WBC count, or Gram stain. If CSF is obtained, a culture and Gram stain should be sent. If enough fluid is available, it should also be sent for cell count and glucose and protein levels. Latex agglutination tests for S pneumoniae andH influenzaecan be useful in patients pretreated with antibiotics, and, although not very sensitive, if positive they can rule in disease (high specificity). Polymerase chain reaction (PCR) testing is available for some bacteria; however, it may be more useful in the diagnosis of herpes simplex, enteroviral, or tuberculous meningitis. In all, no more than 3.5 to 4 mL of CSF is necessary. The most critical issue in a patient with suspected bacterial meningitis, however, is the initiation of antibiotics. The CSF examination and imaging studies can be deferred in this medical emergency.

During the course of treatment, most patients will undergo some cerebral imaging study. Computed tomographic (CT) scans are most useful in the initial presentation to exclude intracranial mass or bleeding, or to evaluate for other signs of increased intracranial pressure. However, magnetic resonance imaging (MRI) is most helpful for demonstrating any focal ischemia or infarction caused by the disease. When HSV meningitisis suspected, MRI should demonstrateenhancement of the temporal lobes. In tuberculous meningitis, enhancement of the basal region may be seen. An electroencephalogram (EEG) may be helpful in patients suspected of HSV meningitis. Within 2 to 15 days of the start of the illness, periodic sharp and slow wave complexes originating within the temporal lobes can be demonstrated at 2- to 3-second intervals. When the purpuric skin lesions are present, skin biopsy may demonstrateN meningitidisand can be helpful in the diagnosis. Age may give a clue regarding etiology of meningitis.

Therapy

Treatment of meningitis often is empiric until specific culture data are available. Because of the growing incidence of resistant pneumococci as well as meningococci, the recommended empiric therapy in most areas is a high-dose third-generation cephalosporin given concurrently with vancomycin. In other areas, if the disease presentation is typical for meningococcus (with the typical rash) or the organism is identified quickly on Gram stain of the CSF, therapy with high-dose penicillin can be started if the meningococcus in that area is known to be sensitive. Ampicillin is added when there is a suspicion of listeriosis. Acyclovir should be started for suspicion of HSVor four-drug antituberculosis (TB) therapy started if the presentation is suspicious for tuberculous meningitis. The administration of glucocorticoidsto reduce CNS (central nervous system) inflammation is controversial. One study in adults demonstrated decreased mortality in patients with S pneumoniaemeningitis who were given glucocorticoids. There is stronger data for steroids for H influenzae andS pneumoniaemeningitis in children. There is also some evidence for benefit of steroids in severe tuberculous meningitis.

Prevention of meningitis can be achieved through the administration of vaccines and chemoprophylaxisof close contacts. Specific vaccinations are available forH influenzaetype B and some strains ofS pneumoniaeand are now routinely administered to children.Meningococcal vaccinationis recommended for those living in dormitory situations, such as college students and military recruits, but not for the general population. Rifampin given twice daily for 2 daysor a single dose of ciprofloxacin is recommended for household and close contactsof an index case of meningococcemia or meningococcal meningitis.

Sickle cell crisis case study

Case A 25-year-old African American man is admitted to your service with the diagnosis of a sickle cell pain episode. He was admitted to the hospital six times last year with the same diagnosis, and he was last discharged 2 months ago. Again he presented to the emergency room complaining of abdominal and bilateral lower extremity pain, his usual sites of pain. When you examine him, you note he is febrile to 101°F, respiratory rate 25 breaths per minute, normal blood pressure, and slight tachycardia of 100 bpm. Lung examination reveals bronchial breath sounds and egophony in the right lung base. His oxygen saturation on 2 L/min nasal cannula is 92%. Besides the usual abdominal and leg pain, he is now complaining of chest pain, which is worse on inspiration. Although he is tender on palpation of his extremities, the remainder of his examination is normal. His laboratory examinations reveal elevated white blood cell and reticulocyte counts, and a hemoglobin and hematocrit that are slightly lower than baseline. Sickle and target cells are seen on the peripheral smear

What is the most likely diagnosis?

What is your next step?

What are the potential complications of this condition

ANSWERS

Summary: A 25-year-old African American man with a history of numerous pain crises is admitted for abdominal and bilateral lower extremity pain. He is febrile to 101°F, respiratory rate 25 breaths per minute, and slight tachycardia of 100 bpm. Lung examination reveals bronchial breath sounds and egophony in the right lung base. His oxygen saturation on 2 L/min nasal cannula is 92%. He is now complaining of chest pain, which is worse on inspiration. He has a leukocytosis, an elevated reticulocyte count, and a hemoglobin and hematocrit that are slightly lower than baseline. Sickle and target cells are seen on the peripheral smear.

Most likely diagnosis:Acute chest syndrome.

Next step:Chest radiograph and empiric antibiotic therapy.

Potential complications:Respiratory failure, possible death

ANALYSIS

DEFINITIONS

SICKLE CELL ANEMIA:A congenital defect in hemoglobin formation such that both genes code for hemoglobin S, leading to hemolysis and an abnormal shape of the red blood cell. Affected individuals have numerous complications including pain crises.

ACUTE CHEST SYNDROME:A condition found in individuals with sickle cell disease characterized by fever, tachycardia, chest pain, leukocytosis, and pulmonary infiltrates

CLINICAL APPROACH

Pathophysiology

The molecular structure of a normal hemoglobin molecule consists of two alpha-globin chains and two beta-globin chains. Sickle cell anemia is an autosomal recessive disorder resulting from a substitution of valine for glutamine in the sixth amino acid position of the beta-globin chain. This substitution results in an alteration of the quaternary structure of the hemoglobin molecule. Individuals in whom only half of their beta chains are affected are heterozygous, a state referred to as sickle cell trait.When both beta chains are affected, the patient is homozygous and has sickle cell anemia. In patients with sickle cell disease, the altered quaternary structure of the hemoglobin molecule causes polymerization of the molecules under conditions of deoxygenation. These rigid polymers distort the red blood cell into a sickle shape, which is characteristic of the disease. Sicklingis promoted by hypoxia, acidosis, dehydration, or variations in body temperature.

Complications of Sickle Cell Disease

Acute painful episodes, also known as pain crisis,are a consequence of microvascular occlusion of bones by sickled cells. The most common sites are the long bones of the arms, legs, vertebral column, and sternum. Acute painful episodes are precipitated by infection, cold exposure, dehydration, venous stasis, or acidosis. They usually last 2 to 7 days.

Infectionsare another complication. Patients with sickle cell disease are at greater risk for infections, especially with encapsulated bacterial organisms. Autoinfarction of the spleenoccurs during early childhood secondary to microvascular obstruction by sickled red blood cells. The spleen gradually regresses in size and by age 4 years is no longer palpable. As a consequence of infarction and fibrosis, the immunologic capacity of the spleen is diminished. Patients with sickle cell disease are at greater risk for pneumonia, sepsis, and meningitis by encapsulated organisms such as Streptococcus pneumoniaand Haemophilus influenza.For the same reason, patients with sickle cell disease are at greater risk for osteomyelitis with Salmonellaspp. Acute chest syndromeis a vasoocclusive crisis within the lungs and is associated with infection or pulmonary infarction. Patients with acute chest syndrome present with hypoxia, dyspnea, fever, chest pain, and progressive pulmonary infiltrateson radiography. These episodes may be precipitated by pneumonia causing sickling in the infected lung segments, or, in the absence of infection, intrapulmonary sickling can occur as a primary event. It is virtually impossible to clinically distinguish whether or not infection is present; thus, empiric antibiotic therapy is used.

Aplastic crisisoccurs secondary to viral suppression of red blood cell precursors, most often by parvovirus B19. It occurs because of the very short half-life of sickled red blood cells and consequent need for brisk erythropoiesis. If red blood cell production is inhibited, even for a short time, profound anemia may result. The process is acute and usually reversible, with spontaneous recovery

Other complications of sickle cell disease include hemorrhagic or ischemic stroke as a result of thrombosis, pigmented gallstones, papillary necrosis of the kidney, priapism, and congestive heart failure.

Treatment

The mainstay of treatment of pain crisis is hydration and pain control with nonsteroidal anti-inflammatory agents and narcotics. It is important to also provide adequate oxygenation to reduce sickling. One must search diligently for any underlying infection, and antibiotics are often used empirically when infection is suspected. Acute chest syndromeis treated with oxygen, analgesia, and antibiotics. Sometimes exchange transfusions are necessary. In general, blood transfusions may be required for aplastic crisis, for severe hypoxia in acute chest syndrome, or to decrease viscosity and cerebral thrombosis in patients with stroke. Transfusion does not shorten the duration of pain crisis. To protect against encapsulated organisms, all patients with sickle cell disease should receive penicillin prophylaxisand a vaccination against pneumococcus. Hydroxyureais often used to reduce the occurrence of painful crisis by stimulating hemoglobin F production and thus decreasing hemoglobin S concentration, and should be considered in patients who have repeated episodes of acute chest syndrome, or frequent severe pain crises. The antineoplastic agent 5-deoxyazacytidine (decitabine) may also elevate levels of hemoglobin F without excessive side effects.

QUESTIONS Q 1. Which of the following therapies would most likely decrease the number of sickle cell crises?

A.Hydroxyurea

B.Folate supplementation

C.Prophylactic penicillin

D.Pneumococcal vaccination

ANSWER. A

Q. the syndrome to which it is commonly associated in persons with sickle cell anemia

Salmonella species = osteomylitis

Parvovirus B19 = Aplastic crisis

Cardio vascular system multiple choice questions

Q 1. You are evaluating a patient with a wide-complex tachycardia. The patient has a history of Wolff-Parkinson-White (WPW) syndrome. Which medication is the most effective for treating this patient’s tachycardia?

A.Adenosine

B. Digoxin

C.Diltiazem

D.Procainamide

E. Verapamil

ANSWER. D

Q 2. All of the following are electrocardiographic clues supporting the diagnosis of ventricular tachycardia except

A.capture beats

B. concordance of QRS complex in all precordial leads

C.fusion beats

D.QRS duration during tachycardia shorter than during sinus rhythm

E. RSR' pattern in V1

ANSWER. E

Q 3. A 68-year-old man with a history of myocardial infarction and congestive heart failure is comfortable at rest. However, when walking to his car, he develops dyspnea, fatigue, and sometimes palpitations. He must rest for several minutes before these symptoms resolve. His New York Heart Association classification is which of the following?

A.Class I

B. Class II

C.Class III

D.Class IV

ANSWER. C

Q 4. The husband of a 68-year-old woman with congestive heart failure is concerned because his wife appears to stop breathing for periods of time when she sleeps. He has noticed that she stops breathing for ~10 s and then follows this with a similar period of hyperventilation. This does not wake her from sleep. She does not snore. She feels well rested in the morning but is very dyspneic with even mild activity. What is your next step in management?

A.Electroencephalography

B. Maximize heart failure management

C.Nasal continuous positive airway pressure (CPAP) during sleep

D.Obtain a sleep study

E. Prescribe bronchodilators

ANSWER. B

Q 5. You are caring for a patient with heart rate-related angina. With minor elevations in heart rate, the patient has anginal symptoms that impact his quality of life. On review of a 24-h Holter monitor, it appears that the patient has sinus tachycardia at the time of his symptoms. What is the mechanism for this patient’s arrhythmia?

A.Delayed afterdepolarizations

B. Early afterdepolarizations

C.Increased automaticity

D.Reentry pathway

ANSWER. C

Q 6. Where are the most common drivers of atrial fibrillation anatomically located?

A.Left atrial appendage

B. Mitral annulus

C.Pulmonary vein orifice

D.Sinus venosus

E. Sinus node

ANSWER. C

Q 7. Symptoms of atrial fibrillation vary dramatically from patient to patient. A patient with which of the following clinical conditions will likely be the most symptomatic (e.g., short of breath) if they develop atrial fibrillation?

A.Acute alcohol intoxication

B. Hypertrophic cardiomyopathy

C.Hyperthyroidism

D.Hypothermia

E. Postoperative after thoracotomy

ANSWER. B

Q 8. When deciding whether to initiate anticoagulation for a patient with atrial fibrillation, which of the following factors is least important?

A.Age

B. History of diabetes

C.Mitral stenosis

D.Use of antiarrhythmic medications

E. Hypertension

ANSWER. D

Q 9. Which of the following electrocardiographic findings suggests a focal atrial tachycardia as opposed to an automatic atrial tachycardia (e.g., sinus tachycardia)?

A. Initiation of tachycardia with programmed stimulation

B. One P-wave morphology

C.Slow-onset and termination phase

D.Slowing of the rate with adenosine infusion

ANSWER. A

Q 10. You are seeing a return patient in clinic. The patient is a 76-year-old man with a history of hypertension, remote cerebrovascular accident, diet-controlled diabetes, and congestive heart failure with left ventricular systolic dysfunction (ejection fraction = 30%). The patient reports no new complaints and feels well. On physical examination, you palpate an irregular pulse, and an electrocardiogram verifies atrial fibrillation. The patient does not have a history of atrial fibrillation. You and the patient are interested in a trial of direct current cardioversion (DCCV). What is the appropriate management of anticoagulation for this patient?

A.Initiate warfarin (with goal INR 2.0–3.0) following DCCV only if cardioversion is unsuccessful.

B. Give full-dose aspirin (325 mg daily) 3 weeks prior to DCCV, perform transesophageal echocardiogram (TEE) and DCCV (if not contraindicated), then discontinue aspirin if DCCV is successful.

C.Initiate IV heparin and warfarin, perform transesophageal echocardiogram (TEE) and DCCV (if not contraindicated), then discontinue warfarin if DCCV is successful.

D.Initiate IV heparin, perform TEE and DCCV (if not contraindicated), then continue warfarin for at least 1 month.

ANSWER. D

Tuesday 30 October 2012

Various double signs

Double bleb sign : Appearance of amnion and yolk sac at 5-6 weeks. Embryo lies between amnion and yolk sac

Double bubble sign : Sign of duodenal atresia and other forms of duodenal obstruction.

Double decidua sign : Sign of early normal intrauterine gestation.

Double density sign (cardiac) : Sign of left atrial enlargement when right side of the left atrium pushes into the adjacent lung.

Double density sign (Nucs) : Pattern of uptake that may be seen on bone scans in patients with osteoid osteomas.

Double duct sign : Simultaneous dilatation of the common bile and pancreatic ducts that is generally caused by a tumor in the pancreatic head.

Double PCL sign : MRI sign of a bucket-handle meniscal tear.

Double track sign : :Appearance of hypertrophic pyloric stenosis that may be seen on upper GI series.

Cardiovascular system multiple choice questions 1

Q 1. Which of the following conditions is not associated with sinus bradycardia?

A.Brucellosis

B. Leptospirosis

C.Hypothyroidism

D.Advanced liver disease

E. Typhoid fever

ANSWER. B

Q 2. All of the following are common consequences of congenital heart disease in the adult except

A.Eisenmenger syndrome

B. erythrocytosis

C.infective endocarditis

D.pulmonary hypertension

E. stroke

ANSWER. E

Q 3. Acute hyperkalemia is associated with which of the following electrocardiographic changes?

A.QRS widening

B. Prolongation of the ST segment

C.A decrease in the PR interval

D.Prominent U waves

E. T-wave flattening

ANSWER. A

Q 4. All of the following clinical findings are consistent with severe mitral stenosis except

A.atrial fibrillation

B. opening snap late after S2

C.pulmonary vascular congestion

D.pulsatile liver

E. right-ventricular heave

ANSWER. B

Q 5. A 37-year-old male with Wolff-Parkinson-White syndrome develops a broad-complex irregular tachycardia at a rate of 200 beats per minute. He appears comfortable and has little hemodynamic impairment. Useful treatment at this point might include

A.Digoxin

B. Amiodarone

C.Propranolol

D.Verapamil

E. Direct-current cardioversion

ANSWER. E

Q 6. In African Americans with New York Heart Association class II heart failure, which of the following drug combinations should be added to an angiotensinconverting enzyme inhibitor and beta blocker?

A.Hydralazine/angiotensin receptor blockers

B. Hydrazaline/digoxin

C.Isosorbide dinitrate/angiotensin receptor blockers

D.Isosorbide dinitrate/digoxin

E. Isosorbide dinitrate/hydralazine

ANSWER. E

Q 7. All of the following medications have been shown to worsen heart failure in patients with left ventricular systolic dysfunction except

A.angiotensin receptor blockers

B. calcium channel antagonists

C.nonsteroidal anti-inflammatory drugs (NSAIDs)

D.sotalol

E. thiazolidinediones

ANSWER. A

Q 8. Which of the following is true regarding dose escalation of angiotensin-converting enzyme (ACE) inhibitors and beta blockers in patients newly diagnosed with congestive heart failure?

A.ACE inhibitors should be escalated on a daily basis to maximal tolerated doses, while beta blockers should be gently increased in dose over weeks, as tolerated.

B. Beta blockers should be escalated on a daily basis to maximal tolerated doses, while ACE inhibitors should be gently increased in dose over weeks, as tolerated.

C.Both should be escalated rapidly to maximally tolerated doses.

D.Both should be escalated slowly to maximally tolerated doses.

E. Both should be initiated at full doses

ANSWER. A

Q 9. All of the following findings on echocardiographic assessment of patients with congestive heart failure with preserved ejection fraction are relevant except

A.atrial fibrillation

B. left atrial dilatation

C.left ventricular wall thickness

D.left ventricular diastolic filling as measured by tissue Doppler

E. systolic anterior motion of the mitral valve

ANSWER. E

Q 10. A 28-year-old man with long-standing cardiomyopathy presents with worsening dyspnea. Physical examination reveals a blood pressure of 85/50 mmHg, heat rate of 112 beats/min, elevated jugular venous pressure, positive hepatojugular reflex, quiet S1/S2, apical S3, no pulmonary rales, and 3+ lower extremity edema. Chest radiograph shows no pulmonary edema and a small left-sided pleural effusion. What information does the patient’s pulmonary examination give you in regards to his likely pulmonary capillary wedge pressure?

A.It is likely to be elevated.

B. It is likely to be normal.

C.It is likely to be decreased.

D.No information

ANSWER. D

Monday 29 October 2012

Pathology multiple choice questions 1

Q 1. Spontaneous maturation of tumour cells and a more benign clinical course potential is occasionally observed in which of the following neoplasms of childhood?

a) Medullo blastoma

b) Osteogenic sarcoma

c) Nephroblastoma

d) Neuroblastoma

e) Retinoblastoma

ANSWER. D

Q 2. The most common site of carcinoma of the colon is

a) Cecum

b) Ascending colon

c) Transverse colon

d) Splenic flexure

e) recto sigmoid

ANSWER. E

Q 3. The most characterisitc feature of granulation tissue is the

a) Resemblance to a granuloma

b) Growth of fibroblasts and new capillaries

c) Character of the exudate

d) Granular scar that results

e) Presence of monocytes and fibroblasts

ANSWER. B

Q 4. Silicosis is most often complicated by

a) Asthma

b) Carcinoma of lung

c) Mesothelioma

d) Tuberculosis

e) bronchi alveolar carcinoma

ANSWER C

Q 5. Chronic salpingitis is considered to be a significant condition predisposing to

a) Ectopic pregnancy

b) Carcinoma of the cervix

c) Leiomyomata

d) Cystic hyperplasia of the endometrium

e) Choriocarcinoma

ÀNSWER. C

Q 6. Petechiae on pleural and pericardial surfaces and squames in alveoli of an autopsied neonatal infant suggest

a) A transplacentally acquired viral infection

b) Intrauterine anoxia

c) A met plastic epithelial response to oxygen therapy

d) A marked decrease in pulmonary surfactant

e) An inherent clotting defect

ANSWER. B

Q 7. Which of the following statements about alcoholic liver disease is correct?

a) It is rarely associated with fatty change

b) It invariably develops in individuals who consume large amounts of alcohol for more than three months

c) It produces extensive hepatic fibrosis rather than true cirrhosis

d) Mallory bodies and Europhilic infiltrates are morphologic features of the early stages of the disease

e) It is not directly related to toxic effects of alcohol but rather to nutritional disturbances

ANSWER. D

Q 8. All of the following are characterized by geanulomatious inflammation except

a) Sarcoidosis

b) Tuberculosis

c) Histoplasmosis

d) Diphtheria

e) Leprosy

ANSWER. D

Q 9. The principle chemical mediator of enhanced vessel permeability from Europhiles is

a) A cationic protein

b) An acid phosphatase

c) Beta glucuronidase

d) Cholesteryl oleate

e) A mucopolysaccharide

ANSWER. A

Pharmacology multiple choice questions

Q 1. Which of the following is a veterinary anesthetic with hallucinogenic effects?

a) Cannabis

b) Cocaine

c) Phencyclidine

d) Mescaline

e) MPTP (methylphenyltetrahydropyridine)

ANSWER D

Q 2. Each of the following is an effective antidepressant drug except

a) Lithium

b) Imip ramine

c) Phenelzine

d) Desipramine

e) Chlorpromazine

ANSWER E

Q 3. Methadone is useful in the treatment of heroin dependence because it

a) contains 6-monoacetylmorphine

b) is also semi-synthetic

c) doesn't cross the blood-brain barrier

d) acts on the opioid receptor

e) acts on the glutamate receptor

ANSWER. D

Q 4. Which of the following causes muscle paralysis by sustained depolarisation of the post junctional membrane?

a) Pancuronium

b) Atrac curium

c) Both

d) Neither

ANSWER. D

Q 5. Which of the following drugs has a short elimination half life?

a) Diazepam

b) Oxazepam

c) Both

d) Neither

ANSWER. B

Q 6. Side effects of which of the following may include salivation and sweating?

a) Physostigmine

b) Pyridostigmine

c) Both

d) Neither

ANSWER C

Q 7. The principle route for diazepam glucuronidation is a

a) Mitochondrial enzyme

b) Microsomal enzyme

c) Plasma enzyme

d) Cytosolic enzyme

e) None of the above

ANSWER. B

Q 8. Which of the following is the most serious and dose limiting adverse effect of morphine?

a) Extreme sedation

b) Increased intracranial pressure

c) Decreased respiration

d) Decreased myocardial conductivity

e) Decreased blood pressure

ANSWER. C

Q 9. The amount that a receptor agonist affects the activity of its target receptor is called it

a) functionality

b) interactivity

c) cellularity

d) activity

e) efficacy

ANSWER. E

Nutrition multiple choice questions 2

Q 1. An 86-year-old woman with chronic obstructive pulmonary disease (COPD), congestive heart failure, and insulin-requiring type 2 diabetes mellitus is admitted to the intensive care unit with an exacerbation of her COPD. She is intubated and treated with glucocorticoids and nebulized albuterol. She is also continued on her glargine insulin, aspirin, pravastatin, furosemide, enalapril, and metoprolol. On hospital day 8, parenteral nutrition is begun via catheter in the subclavian vein. Her insulin requirements increase on hospital day 9 due to episodes of hyperglycemia. On hospital day 10, she develops rales and an increasing oxygen requirement. A chest radiograph shows bilateral pulmonary edema. Laboratory data show hypokalemia, hypomagnesemia, and hypophosphatemia and a normal creatinine. Her weight has increased by 3 kg since admission. Urine sodium is <10 meq/dL. All of the following changes in her nutritional regimen will improve her volume status except

A.combination of glucose and fat in the parenteral nutrition mixture

B. decreasing the sodium content of the mixture to <40 meq per day

C.increasing the protein content of the parenteral nutrition mixture

D.reducing the overall glucose content

ANSWER . C

Q 2. A new study has been published showing a benefit of 25 mg/day of vitamin X. The recommended estimated average requirement of vitamin X is 10 mg/day, 2 standard deviations below the amount published in the study. The tolerable upper limit of vitamin X is unknown. Your patient wants to know if it is safe to consume 25 mg/day of vitamin X. Which is the most appropriate answer?

A.Two standard deviations above the estimated average requirement defines the tolerable upper limit.

B. 25 mg/day is probably too much vitamin X in 1 day.

C.25 mg/day is statistically in a safe range of the estimated average requirement.

D.The study was not designed to assess safety and therefore should not influence practice

ANSWER . C

Q 3. An elevation in which of the following hormones is consistent with the effects of anorexia nervosa?

A.Cortisol

B. Gonadotropin-releasing hormone (GnRH)

C.Leptin

D.Thyroxine (T4)

E. Thyroid-stimulating hormone (TSH)

ANSWER. A

Q 4. Which of the following statements regarding anorexia nervosa (AN) and bulimia nervosa (BN) is true?

A.Patients with the purging subtype of BN tend to be heavier than those with the nonpurging subtype.

B. Patients with the restricting subtype of AN are more emotionally labile than those with the purging subtype.

C.Patients with the restricting subtype of AN are more likely to abuse illicit drugs than those with the purging subtype.

D.The mortality of BN is lower than that of AN

ANSWER . D

Q 5. You are seeing a pediatric patient from Djibouti in consultation who was admitted with a constellation of symptoms including diarrhea, alopecia, muscle wasting, depression, and a rash involving the face, extremities, and perineum. The child has hypogonadism and dwarfism. You astutely make the diagnosis of zinc deficiency, and laboratory test confirm this (zinc level <70 µL/dL). What other clinical findings is this patient likely to manifest?

A.Dissecting aortic aneurysm

B. Hypochromic anemia

C.Hypoglycemia

D.Hypopigmented hair

E. Macrocytosis

ANSWER. D

Q 6. You are rotating on a medical trip to impoverished areas of China. You are examining an 8-year-old child whose mother complains of him being clumsy and sickly. He has had many episodes of diarrheal illnesses and pneumonia. His “clumsiness” is most pronounced in the evening when he has to go outside and do his chores. On examination, you notice conjunctival dryness with white patches of keratinized epithelium on the sclera. What is the cause of this child’s symptoms?

A.Autoimmune neutropenia

B. Congenital rubella

C.Spinocerebellar ataxia (SCA) type 1

D.Vitamin A deficiency

E. Vitamin B1 deficiency

ANSWER. D

Q 7. After being stranded alone in the mountains for 8 days, a 26-year-old hiker is brought to the hospital for evaluation of a right femoral neck fracture. He has not had anything to eat or drink for the past 6 days. Vital signs are within normal limits. Weight is 79.5 kg, which is 1.8 kg less than he weighed 6 months ago. Laboratory data show a creatinine of 2.5 mg/dL, blood urea nitrogen of 52 mg/dL, glucose 96 mg/dL, albumin 4.1 mg/dL, chloride 105 meq/L, and ferritin on 173 ng/mL. Which of the following statements is true regarding his risk of malnourishment?

A.He has protein-calorie malnutrition due to the rate of weight loss.

B. He has protein-calorie malnutrition due to his elevated ferritin.

C.He is at risk, but a normal individual can tolerate 7 days of starvation.

D.He is not malnourished because he is not hypoglycemic after 6 days of no food or water

ANSWER. C

Q 8. You are doing rounds in the intensive care unit on an intubated patient who is recovering from a stroke and has diabetic gastroparesis. When suctioning the patient in the morning, she coughs profusely, with thick green secretions. You are concerned about the possibility of aspiration pneumonia. All of the following measures are useful in preventing aspiration pneumonia in an intubated patientexcept

A.combined enteral and parenteral nutrition

B. elevating the head of the bed to 30°

C.physician-directed methods for formula advancement

D.post-ligament of Treitz feeding

ANSWER. C

Q 9. Which of these features represents a critical distinction between anorexia nervosa and bulimia nervosa?

A.Binge eating

B. Electrolyte abnormalities

C.Self-induced vomiting

D.Underweight

ANSWER. D

Q 10. You are counseling a patient who is recovering from long-standing anorexia nervosa (AN). She is a 22-yearold woman who suffered the effects of AN for 8 years with a nadir body mass index of 17 kg/m2 and many laboratory abnormalities during that time. Which of the following characteristics of AN is least likely to improve despite successful lasting treatment of the disorder?

A.Amenorrhea

B. Delayed gastric emptying

C.Lanugo

D.Low bone mass

E. Salivary gland enlargement

ANSWER. D

Anatomy multiple choice questions 1

Q 1 Mesoderm gives rise to all of the following structures except :
a) Seminal vesicle
b) Trigone of urinary bladder
c) Upper vagina
d) Penile urethra

ans is D

Q 2 Lung surfactant is mainly secreted by :
a) Type I pneumocytes
b) Type II pneumocytes
c) Kulchitsky cells
d) Clara cells

ans is B

Q 3 Vaginal sphincter is formed by all, except :
A. External urethral sphincter
B. Internal urethral sphincter
C. Pubovaginalis
D. Bulbospongiosus

ans is B

Q 4 All the following maintain the stability of ankle joint, except :
A. Collateral ligament
B. Tendons of muscle cross the joint
C. Cruciate ligament
D. Shape of bones

ans is C

Q 5 The type of joint between the sacrum and the coccyx is :
A Symphysis
B Synostosis
C Synchondrosis
D Syndesmosis

Ans is A

Q 6 Which kidney epithelium has the most mitochondria per cell?
A. Collecting duct
B. Urothelium cap cell
C. Distal convoluted tubule
D. Proximal convoluted tubule

ans is D

Q 7 Optic radiation arises from :
A) Lateral geniculate body
B) Superior colliculus
C) Inferior colliculus
D) Medial geniculate body

ans is A

Q 8 Ulnar injury in the arm leads to all except:

a) Sensory loss of the medial 1/3rd of the hand
b) Weakness of the hypothenar muscles
c) Claw hand
d) Adducted thumb

ans is D

Q 9 Which of the following is not true about thymus :
1. Lies in the anterior and superior mediastinum
2. Has maximum size by 5 years of age and then it regresses
3. It is a primary lymphoid organ
4. It also produces hormones

ans is 2

Q 10 All of the following statements about the vagus nerve are true except that it ?
a. supplies heart and lung
b. carries postganglionic parasympathetic fibers
c. innervates right two third of transverse colon
d. stimulates peristalsis and relaxes sphincters

ans is B

Scleroderma / systemic sclerosis

Q 1 . All the following are features of scleroderma expect
A. Dysphagia
B. Raynaud's phenomenon
C. Skin contracture
D. Calcification in all long bones

Ans is D

Q 2. A 35 years old lady complains dysphagia, Raynaud's phenomenon , sclerodactyly, investigation show antinuclear antibody, diagnosis is
A. SLE
B. Systemic sclerosis
C. Mixed connective tissue disorder
D. Rheumatoid arthritis

Ans is . B

Q 3. All of the following features about generalised systemic sclerosis. Are true , expect

A. Raynaud's phenomenon seen years before skin changes
B. Trunk involvement
C. Anti centromere antibody are characteristic
D. All are true

Ans is . C

Q 4 . Features of systemic sclerosis include all of the following , expect
A. Calvinists
B. Sclerodactyly
C. Hyperpigmentation
D. More common in female
E. More common in young patients

Ans is . E

Q 5 . A 14 year old girl on exposure to cold has pallor of extremities followed by pain and cynosis. In later stages of life she is most prone to develop
A. SLE
B. Scleroderma
C. Rheumatoid arthritis
D. Dermatomycosis

Ans is B

Nutrition mcqs

Q1 A 19-year-old woman with anorexia nervosa undergoes surgery for acute appendicitis. The postoperative course is complicated by acute respiratory distress syndrome, and she remains intubated for 10 days. She develops wound dehiscence on postoperative day 10. Laboratory data show a white blood cell count of 4000/ µL, hematocrit 35%, albumin 2.1 g/dL, total protein 5.8 g/dL, transferrin 54 mg/dL, and iron-binding capacity 88 mg/dL. You are considering initiating nutritional therapy on hospital day 11. Which of the following is true regarding the etiology and treatment of malnutrition in this patient? A.She has marasmus, and nutritional support should be started slowly. B. She has kwashiorkor, and nutritional support should be aggressive. C.She has marasmic kwashiorkor, kwashiorkor predominant, and nutritional support should be aggressive. D.She has marasmic kwashiorkor, marasmus predominant, and nutritional support should be slow

Ans is c

Q2 You are seeing a patient in follow-up 2 weeks after hospitalization. The patient is recovering from nosocomial pneumonia due to a resistant Pseudomonas spp. His hospital course was complicated by a deep venous thrombosis. The patient is currently on IV piperacillin/ tazobactam and tobramycin via a tunneled catheter, warfarin, lisinopril, hydrochlorothiazide, and metoprolol. Laboratory data this morning show an INR of 8.2. At hospital discharge his INR was stable at 2.5. He has no history of liver disease. What is the most likely cause of the elevated INR?

A.The patient has inadvertently overdosed.

B. The patient has developed a recurrent deep venous thrombosis, which has affected the laboratory data.

C.The patient is deficient in vitamin K and needs supplementation.

D.The warfarin prescription was written incorrectly at the time of discharge.

Ans is c

Q 3 A 51-year-old alcoholic man is admitted to the hospital for upper gastrointestinal bleeding. From further history and physical examination, it becomes apparent that his bleeding is from gingival membranes. He is intoxicated and complains of fatigue. Reviewing his chart you f ind that he had a hemarthrosis evacuated 6 months ago and has been lost to follow-up since then. He takes no medications. Laboratory data show platelets of 250,000, INR of 0.9. He has a diffuse hemorrhagic eruption on his legs . What is the recommended treatment for this patient’s underlying disorder?

A.Folate

B. Niacin

C.Thiamine

D.Vitamin C

E. Vitamin K

Ans is D

Q 4 While working in the intensive care unit, you admit a 57-year-old woman with acute pancreatitis and oliguric renal failure. Respiratory rate is 26 breaths/min, heart rate is 125 beats/min, and temperature is 37.2°C. Physical examination shows marked abdominal tenderness with normoactive bowel sounds. A CT scan shows an inflamed pancreas without hemorrhage. You calculate her APACHE-I score to be 28. When deciding on when to initiate nutritional replacement in this patient, which of the following statements is true?

A.Bowel rest is the cornerstone of treatment for acute pancreatitis.

B. Administering parenteral nutrition within 24 h will decrease the risk of infection and mortality.

C.Enteral feeding supports gut function by secretion of gastrointestinal hormones that stimulate gut trophic activity.

D.In severe systemic response to inflammation, feeding can be withheld initially because the patient is likely to have adequate, spontaneous oral intake in the first 7 days

Ans is C

Q 5 The resting energy expenditure is a rough estimate of total caloric needs in a state of energy balance. Of these two patients with stable weights, which person has the highest resting energy expenditure (REE): Patient A, a 40-year-old man who weighs 90 kg and is sedentary, or Patient B, a 40year-old man who weighs 70 kg and is very active?

A.40-year-old man who weighs 90 kg and is sedentary

B. 40-year-old man who weighs 70 kg and is very active

C.REE is the same

D.Not enough information given to calculate the REE

Ans is B

Q 6 All of the following clinical features are common in patients with anorexia nervosa except

A.Avoid food-related occupations

B. Distorted body image

C.Engage in binge eating

D.Exercise extensively

E. Rarely complain of hunger

F. Socially withdrawn

Ans is A

Q 7 You diagnose anorexia nervosa in one of your new clinic patients. When coordinating a treatment program with the psychiatrist, what characteristics should prompt consideration for inpatient treatment instead of scheduling an outpatient assessment?

A.Amenorrhea

B. Exaggeration of food intake

C.Irrational fear of gaining weight

D.Purging behavior

E. Weight <75% of expected body weight

Ans is E

Q 8 It is hospital day 16 for a 49-year-old homeless patient who is recovering from alcohol withdrawal and delirium tremens. She spent the first 9 days of this hospitalization in the intensive care unit but is now awake, alert, and conversant. She has a healing decubitus ulcer, and her body mass index is 19 kg/m2. Laboratory data show an albumin of 2.9 g/dL and a prothrombin time of 18 s (normal range). Is this patient malnourished?

A.Cannot be determined, need more information.

B. No. Given her heavy alcohol intake, her prothrombin time is expected to be delayed.

C.No. She has a low resting energy expenditure and her intact mental state argues against malnutrition.

D.Yes, this degree of hypoalbuminemia is uncommon in cirrhosis and is likely due to malnutrition

Ans is A

Q 9 A 42-year-old male patient wants your opinion about vitamin E supplements. He has read that taking high doses of vitamin E can improve his sexual performance and slow the aging process. He is not vitamin E deficient. You explain to him that these claims are not based on good evidence. What other potential side effect should he be concerned about?

A.Deep venous thrombosis

B. Hemorrhage

C. Night blindness

D.Peripheral neuropathy

E. Retinopathy

Ans is B

Q 10 Doing rounds in the oncology center, you are see a patient with carcinoid syndrome. Due to the increased conversion of tryptophan to serotonin, this patient has developed niacin deficiency. All of the following are components of the pellagra syndrome except

A.dermatitis

B. dementia

C.diarrhea

D.dyslipidemia

E. glossitis

Ans is D

Cystic fibrosis manifestations