COMBANK - GI/Pulmonary

Nonmaleficence

'do no harm'; as physicians, the overall task is to perform more good than harm. In other words, the benefits outweigh the risks.

Light's criteria

1) Effusion protein / serum protein > 0.5 g/dL 2) Effusion lactate dehydrogenase (LDH) / serum LDH > 0.6 3) Effusion LDH > 2/3 the upper limit of normal serum LDH If one or more of these statements are true based on the analysis of the pleural fluid, then the effusion can be considered an exudate. If none of these statements is true regarding the analysis, then the effusion is considered a transudate.

Classic triad of acute thrombosis

1) RUQ abdominal pain 2) hepatomegaly 3) ascites

Researchers at a major medical center in the Midwest notice that there appears to be a higher rate of colon cancer in patients reporting a high fat diet than in other patients. Therefore, a case-control study is conducted to determine whether a high fat diet is a risk factor for colon cancer. Using hospital records from the previous 10 years, they identify 112 patients with colon cancer and 250 patients without colon cancer who had reported dietary information as part of their medical history. Study results show an odds ratio of 1.70 with a 95% confidence interval of 1.25-2.15 and a P value of 0.02 (critical P value is 0.05). What can be concluded from these results?

A case-control study examines 2 groups, 1 with disease and 1 without, and looks back in time in order to identify exposures to risk factors. The odds ratio tells us how likely it is that the people with a disease were exposed to the risk factor in the past compared with people without the disease. In this study, the risk factor is consuming a high fat diet and the disease is colon cancer. This study reported an odds ratio of 1.7, which was significant based upon the P value of 0.02. - Therefore, colon cancer patients are 1.7 times more likely to have consumed a high fat diet compared with people without colon cancer.

A 42-year-old female comes into the emergency department with a chief complaint of upper abdominal pain. She has symptoms of nausea, vomiting, and anorexia. The patient has a past medical history of gallstones. She does not smoke or drink alcohol. Vital signs are temperature of 38.0°C, pulse of 107 beats/minute, blood pressure of 85/62 mm Hg, and body mass index (BMI) of 39 kg/m2. On physical examination, she has an ecchymotic discoloration over the flanks. Alkaline phosphatase and serum amylase are both elevated. What other complications are associated with this patient's disease?

ARDS - This patient is suffering from acute pancreatitis secondary to gallstone disease (Remember the 4 F's = fat, female, forty, fertile). Gallstone induced obstruction is also suggested by the elevated levels of alkaline phosphatase. Her elevated amylase level is consistent with pancreatitis. Other complications of acute pancreatitis include pseudocyst formation, abscess formation, hypocalcemia, and acute renal failure

A 40-year-old female presents to her primary physician with complaint of progressive dysphagia to solids and liquids. History reveals chronic heartburn, frequent hiccups, and difficulty belching. Barium swallow shows a dilated esophagus with distal tapering.

Achalasia is caused by a loss of ganglion cells in the myenteric plexus, which results in less nitric oxide and inability of LES relaxation.

A 65-year-old male presents to the emergency department with lethargy, disorientation, and a change in personality. History reveals cirrhosis of the liver and long time alcohol abuse. The mechanism of action for the most appropriate pharmacologic treatment is...

Acidification of the gut lumen - The liver is damaged to the point that it can no longer run the urea cycle to get rid of excess ammonia. To treat this disease you need to get rid of some of the excess ammonia. This is done with lactulose which is nonabsorbable and broken down by gut bacteria to lactic acid. This leads to the conversion of ammonia to ammonium ions and increases movement of ammonia from tissues into the gut lumen

A 55-year-old male presents to the physician's office complaining of swelling in both of his legs of one-week duration. Past medical history is significant for alcohol abuse. Vital signs reveal blood pressure of 90/82 mm Hg and heart rate of 100/minute. Physical examination of the abdomen reveals a shifting dullness to percussion, mild distension, and dilation of the periumbilical vessels. Osteopathic findings include paravertebral hypertonicity from T6-9, a tender nodule in the 5th intercostal space on the right, and a restricted pelvic diaphragm bilaterally. The most likely mechanism that explains his symptoms is...

Albumin is the main protein in plasma and is decreased in conditions such as cirrhosis. Hypoalbuminemia leads to decreased plasma colloid oncotic pressure and shifting of fluid from the capillaries and into the surrounding interstitial space, causing his lower extremity edema and ascites.

A 45-year-old male complains of dyspnea and wheezing. History reveals that he is a hay farmer and was prescribed a short-acting bronchodilator three weeks ago. Physical examination reveals diffuse fine crackles. Radiography reveals diffuse air-space consolidation with linear radiodensities. The most likely diagnosis is...

Farmer's lung is a hypersensitivity pneumonitis associated with exposure to thermophilic actinomycetes in moldy hay.

A 3-year-old female presents with irritability and difficulties breathing. Physical exam reveals inhalation somatic dysfunction on ribs 8-10 on the right and intercostal muscle spasms. Auscultation reveals localized wheezing over the right lung base.

Foreign body - usually aspirated by children; can present with localized wheezing, decreased breath sounds, cough, and hemoptysis. Physical examination may reveal somatic dysfunction or viscerosomatic reflexes relating to the affected lung lobe.

A 42-year-old male presents to the primary care clinic complaining of unintentional weight loss and constipation of six months' duration. He has never had a colonoscopy and does not have any relatives who have had colorectal cancer. What is the best initial colon cancer screening test?

Fecal occult blood testing - the initial, inexpensive test used to screen for (but NOT diagnose) colorectal cancer; - Recommended screening includes colonoscopy every 10 years, CT colonography every 5 years, flexible sigmoidoscopy every 5 years, fecal occult blood test annually on 2-3 samples.

A 55-year-old female with a previous diagnosis of irritable bowel syndrome presents to her primary care physician with progressive, recurrent episodes of wheezing and difficulty breathing. She is afebrile with a blood pressure of 135/80 mmHg, heart rate of 75/min, respiratory rate of 18/minute, and an oxygen saturation of 96% on room air. Upon further questioning, she admits to occasional periods of diarrhea, flushing of the neck, and dizziness. Pulmonary function tests were completed and show normal lung volumes and a FEV1/FVC ratio of 80%, with minimal change noted with the use of an albuterol inhaler. The patient has no history of asthma or seasonal allergies. A detailed physical examination will most likely reveal

Carcinoid syndrome b/c metastatic neuroendocrine tumor secretes too much serotonin - systolic murmur heard over the left lower sternal border would be heard on auscultation, most commonly at the tricuspid valve; characterized by asthmatic wheezing, diarrhea, flushing, and right-sided heart valve dysfunction.

Burkholderia mallei

Causative agent of glanders, a disease very similar to melioidosis; shares with melioidosis the tendency for an initial cutaneous or pulmonary infection to progress rapidly to sepsis, a prolonged course of therapy and a high associated mortality. Bacteriologically, the key distinction is in motility (B. mallei is nonmotile, while B. pseudomallei is motile). Glanders is also primarily a zoonotic disease, with the most common hosts being horses, mules and donkeys. Glanders also does not cause visceral microabscesses, and while it can develop into a chronic form, it does not exhibit the reactivation activity that melioidosis does.

A 58-year-old male presents with the chief complaints of heartburn and an occasional regurgitation of acidic material, both of which are becoming increasingly common over the past few weeks. His physician believes that his symptoms may be exacerbated by one of the medications that he is currently prescribed. Assuming the patient is taking the medication, which medication is likely causing his symptoms?

Amlodipine - Several medications are capable of decreasing the constrictive tone of the lower esophageal sphincter, and consequently increasing the risk for GERD. These medications include anticholinergics α-adrenergic receptor blockers, β-adrenergic agonists, and calcium channel blockers.

A 65-year-old male presents to the emergency department with progressive shortness of breath of 2 weeks' duration. He has not seen a physician in more than 15 years. Physical examination reveals decreased breath sounds at the right base of the lung and pitting pretibial edema. A chest radiograph reveals a right-sided pleural effusion. A thoracentesis is performed, what should be next step?

An echocardiogram is the next best test to confirm the patient has heart failure, quantify the ejection fraction, and rule out any valvular or anatomical abnormalities that could be contributing to the heart failure.

A 34-year-old male presents to his primary care physician with increasing shortness of breath over the past three months. The patient is not currently taking any medications and has no prior medical conditions. The patient has been having lower back stiffness and ankle pain, which he attributes to his job as a construction worker, though is present even on weekends. The pain is mildly alleviated by over the counter NSAIDs. Pulmonary function tests demonstrate a low total lung capacity and low residual volume. Which of the following is the most likely etiology of this patient's pulmonary pathology?

Ankylosing spondylitis - A young man with lower back pain and stiffness should be considered to have ankylosing spondylitis. Look for extra articular manifestations such as uveitis, restrictive lung disease (seen in this patient), and spinal fractures.

A 50-year-old male comes to the physicians office complaining of a loss of appetite and chest tightness for the past 4 months. He noted that his clothes have been a loose-fitting and his wife has noticed that he appears much thinner. He is a non-smoker and drinks beer socially on the weekends. Recreationally he would go kayaking on the weekends but has been unable to these past 4 weeks. His temperature is 37.4 C, respirations are 14/min, pulse is 88/min and regular, blood pressure is 129/88 mm HG. An EKG is shows non-specific ST-wave changes. Cardiac and abdominal examination is unremarkable. Lung examination has fine crackles bilaterally on auscultation. His fingertips and toes appear wider and rounder than normal. Chest x-ray shows irregular opacities with a fine reticular pattern.

Asbestosis - chronic inhalation of asbestos that is characterized by ferruginous bodies; upon microscopy ferruginous bodies are asbestos fibers that develop a ferritin protein coat and have a long-beaded appearance, resembling a dumbbell.

Ranson criteria for pancreatitis

At admission - Age greater than 55 years - WBC count greater than 16,000/mm3 - Blood glucose greater than 200 mg/dL - Serum LDH greater than 350 IU/L - Serum AST greater than 250 IU/L At 48 hours - Decrease in hematocrit greater than 10% - Increase in BUN of greater than 8 mg/dL - Serum calcium less than 8 mg/dL - PaO2 less than 60 mm Hg - Base deficit greater than 4 mEq/L - Estimated fluid sequestration greater than 600 mL

A 55-year-old man presents with a high fever, dry cough, and flu-like symptoms. History reveals dyspnea of four days' duration and that he drinks two beers and smokes a pack of cigarettes per day. He says that he plans to quit smoking after the summer season of his professional fishing job settles down. A sputum sample reveals growth on charcoal yeast extract agar with cysteine and a positive urine antigen test. What is the most appropriate treatment?

Azithromycin - Legionella is an atypical infection that usually presents with nonproductive cough, fever, and gastrointestinal (GI) symptoms and requires either macrolide or fluoroquinolone for treatment.

A 55-year-old male is consented for an elective surgery for an abdominal hernia repair. During the surgery, the surgeon also removes the patient's appendix due to a suspicious cyst-like lesion. After the surgery, the man contacts a lawyer wishing to know if that were the right thing for the surgeon to do. The lawyer correctly tells the man that he believes the surgeon is guilty of...

Battery - intentional and unauthorized touching of a patient. The patient did not consent to have his appendix removed. If the appendix had been a risk to the patient's life, then it may have been removed under implied consent since it may have been a threat to his life.

A 45-year-old African-American male presents to the Emergency Department with severe mid-gastric pain and associated nausea and vomiting. Although the patient is not currently intoxicated, his girlfriend, who accompanies him, explains that he has been drinking alcohol all weekend with his friends. Physical exam reveals the patient to be uncomfortable due to epigastric pain, tenderness to palpation of the epigastrium, and active vomiting. Labs are drawn, which reveal a lipase of 606 IU/L. The patient is treated with NPO diet with intravenous fluids and morphine for analgesia. If present at admission, what predicts a more complicated course in the underlying disease process?

Blood glucose greater than 200 mg/dl - the most common causes of acute pancreatitis are gallstones and alcohol, which is the most likely cause of this patient's pancreatitis based on his recent history of binge drinking. Other less common causes include autoimmune conditions, hypertriglyceridemia, elevated calcium, and scorpion stings.

C-MYC

Burkitt lymphoma; adolescents or young adults with extranodal masses. Associated with Epstein-Barr virus. t(8;14) involving c-MYC and Ig loci. LN biopsy: "starry sky" pattern.

A 52-year-old Hispanic male complains of upper abdominal pain radiating to his back for the past few months. Review of systems reveals an unintentional weight loss. Physical examination is remarkable for scleral icterus and left supraclavicular lymphadenopathy. Which of the following is the best next step in his diagnosis?

CA 19-9 is the laboratory tumor-marker used in the confirmation and monitoring treatment of pancreatic adenocarcinoma. A contrast-enhanced helical computed tomography (CT) scan with 3D reconstruction is the study of choice to view the pancreas since 2/3 of the pancreas is retroperitoneal (head and body).

Meningocele

Failure of neural tube closure describes a meningocele. Meningocele does not involve nerve herniation into the sac, whereas meningomyelocele will contain nerves as well as meninges. This is commonly associated with spina bifida.

A 34-year-old obese female presents with episodic cramping abdominal pain. She states she has had two episodes per week for the last month, and all have resolved spontaneously. Physical examination reveals a non-tender abdomen without guarding or inspiratory arrest on deep palpation of her right upper quadrant. Osteopathic examination confirms the presence of mild, dull tissue texture changes throughout the mid-thoracic, at the level of T6-T9. The most likely pathology of this patient's chief complaint is due to...

Cholelithiasis - presence of gallstones within the gallbladder that migrate into the opening of the cystic duct and block the outflow of bile during gallbladder contraction. This results in episodes of cramping abdominal pain due to an increase in the gallbladder wall tension from contraction - The pain is localized to the right upper quadrant and may radiate to the right scapula. The pain begins postprandially, usually following a fatty meal. - Physical examination will reveal a benign abdominal exam without rebound tenderness, guarding, or fever since the gallbladder is not inflamed

A 60-year old male is brought into the Emergency Department with constant mid-epigastric pain, vomiting, and diarrhea that has been worsening over the last few weeks. The patient has not had any peculiar foods or travelled in this past month. Past medical history includes chronic renal failure, alcohol abuse and smoking. On physical exam, the abdomen is tender to palpation without rebound. Serum amylase and lipase are within normal limits.

Chronic pancreatitis - Fibrosis, calcification and acinar cell loss; CT shows calcifications within the pancreas. Risk factors: smoking, heavy alcohol consumption, diabetes, and chronic renal failure. Patients typically present with abdominal pain with radiation to the back, weight loss, and diarrhea. Symptoms mild but progressive. Serum amylase normal or low b/c of the pancreas inability to produce pancreatic enzymes.

A 23-year-old-female with a history of lymphoma presents to the Emergency Department with complaints of dyspnea and dysphagia. Review of systems is positive for occasional fevers and drenching night sweats over the last two months. Plain film chest radiographs demonstrate blunting of the left costophrenic angle. CT scan shows moderate left-sided pleural effusion and mediastinal lymphadenopathy. Thoracentesis is performed and milky fluid is withdrawn. Fluid analysis is most likely to reveal...

Chylothorax is caused by a leakage of lymphatic fluid from the thoracic duct and contains increased triglycerides on fluid analysis. This is most commonly due to lymphoma and trauma caused by thoracic surgery.

A 47-year-old woman presents to the office with a fever, a slight cough, and general fatigue. She does not smoke, drinks two beers every day, and has been with her husband for 25 years. They just celebrated their 25th wedding anniversary with a trip to the Grand Canyon. She has a past medical history that includes rheumatoid arthritis. She wants some antibiotics to get rid of her current symptoms and is very persistent about receiving them. Which of the following statements best describes the most likely etiologic agent?

Coccidioides immitis - travel to the desert southwest United States; this dimorphic fungus is only found in this area; see on histology: large spherule with multiple, round endospores; immunocompromised more likely to present with acute coccidiomycosis, which manifests as fever, chest pain, difficulty breathing, and hemoptysis

A 23-year-old male presents to the office after an episode of diarrhea accompanied by bright red blood and diffuse lower abdominal pain. He has a two-year history of chronic diarrhea and low-grade fevers. His family history is positive for an uncle with colon cancer, diagnosed at a young age. On flexible sigmoidoscopy, erythema and active bleeding is noted at the rectum. A rectosigmoid biopsy is taken to confirm the diagnosis. The histologic feature to confirm the most likely diagnosis is...

Collections of neutrophils within crypts of Leiberkuhn

A 34-year-old Caucasian male presents to your office complaining of abdominal pain and blood in the stool with a duration of three days. History reveals that his father was diagnosed with colorectal cancer when he was 40 years old. Physical examination reveals numerous, painless bony growths on his mandible and multiple impacted teeth, paravertebral hypertonicity and tenderness from T1-4 and T8-L2, and a tender nodule over the greater tubercle of the right humerus. Given the patient's condition, what additional finding is most likely present?

Congenital hypertrophy of the retinal pigment epithelium - Gardner syndrome is an autosomal dominant condition characterized by familial adenomatous polyps, osteomas, desmoid tumors, dental abnormalities, and hypertrophy of the retinal pigment epithelium.

A 52-year-old Hispanic male complains of upper abdominal pain radiating to his back for the past few months. Review of systems reveals an unintentional weight loss. Physical examination is remarkable for scleral icterus and left supraclavicular lymphadenopathy. The most likely additional finding upon physical examination is a positive...

Courvoisier's Sign - Adenocarcinoma of the head of the pancreas is associated with Courvoisier's sign, which is an enlarged and palpable, but painless, gallbladder.

A 51-year-old male presents to the emergency department with crushing retrosternal chest pain and upper abdominal pain. History reveals he recently consumed a large quantity of food and alcohol and later vomited repeatedly. He denies hematemesis and described the vomitus to consist mostly of food and alcohol. He has muscle spasms from T2-T8 bilaterally, epigastric and parasternal tenderness, and a restricted thoracoabdominal diaphragm. Vitals reveal a blood pressure of 100/60 mmHg, a heart rate of 110/min, a respiratory rate of 20/min, and a temperature of 38ºC (100.4ºF). The most likely additional finding upon auscultation of the mediastinum is...

Crackles with each heartbeat - esophageal rupture or Boerhaave syndrome; middle-aged men following consumption of alcohol or binge eating; Boerhaave syndrome classically presents with the Mackler triad of a history of vomiting, thoracic pain, and subcutaneous emphysema; On physical exam, this presents with a Hamman crunch, which is a crackling sound heard with each heartbeat. Treatment is immediate surgery.

Carcinoid tumor histology

Cytologically bland cells that have regular round to oval nuclei with finely dispersed chromatin and inconspicuous small nucleoli. The cells are usually polygonal in shape.

Omphalocele

Failure of the linea alba to close in utero describes an omphalocele, which is an outpouching of the abdominal organs through the abdominal wall

BCL2

Follicular lymphoma seen in older adults with generalized lymphadenopathy. t(14;18) forms a BCL2-IgH fusion gene. Lymph node biopsy includes two cells: 1) centrocytes (small cells with irregular nuclear contours and scant cytoplasm) and 2) centroblasts (larger cells with open nuclear chromatin, several nucleoli, and modest amounts of cytoplasm).

A 7-year-old male presents for his annual school physical. The boy reports no problems other than a recent cough. On physical examination, the boy is noted to have a yellow tint to his skin and conjunctivae. Serum studies reveal a hemoglobin of 12.0 g/dL (normal level for 7 year old child is 11-14 g/dl) and a hematocrit of 38% (normal range 35-44%), total bilirubin levels are 5.3 mg/dL and direct bilirubin levels are 0.3 mg/dL His parents state that he had a slight "yellow" complexion when under stress. His birth history and medical history thus far are uneventful. Which of the following is most likely related to the most likely diagnosis?

Decrease of bilirubin to normal levels after administration of phenobarbital - Gilbert syndrome is a hereditary hyperbilirubinemia due to a mild/transient decrease in UDP-glucuronyltransferase; it has no major clinical consequences.

A 53-year-old male presents to his primary care physician with the complaint of dyspnea upon exertion of three months' duration. He admits to a 75-pack-year history of smoking. Physical examination reveals an increased anterior-posterior diameter of the chest, pursed lips, and moderate tachycardia. It is noted that his lower rib cage moves inward during inspiration, with decreased breath sounds on auscultation. The most likely cause of these findings is...

Destruction of alveolar walls

BCL6

Diffuse large B-cell lymphoma most common in adults. Rapidly growing mass. Over-expression of BCL6, which is due to t(3;Var)(q27;Var). The lymph node biopsy would show large cell size.

A 73-year-old male presents to your office after noticing bright red blood in his stool. He denies abdominal pain, pain with defecation, night sweats and recent weight loss. Vitals reveal a temperature of 37.1°C (98.8°F), a blood pressure of 124/60 mmHg, a heart rate of 70/min, and a respiratory rate of 21/min. Anoscopy is performed and is unremarkable. The most likely cause of his symptoms is...

Diverticulosis is the most common cause of painless rectal bleeding in the older population with no visible findings on physical exam coupled with an unremarkable anoscopy.

A 65-year-old man walks into outpatient clinic with a chief complaint of bright red bleeding from his rectum that started two days ago. He notes mild bloating but denies nausea, vomiting, abdominal pain, fever, chills, and chest pain. His temperature is 36ºC, heart rate is 100/min, blood pressure is 95/69 mmHg, and respiratory rate is 19/min. Physical exam shows an abdomen that is soft, nondistended, and nontender without rebound or guarding. CT scan of the abdomen and pelvis shows small outpouchings of the colon but no increased soft tissue density in the pericolic fat or bowel wall thickening. Hemoglobin is 7.5 g/dL. What is the most likely etiology of this patient's problem?

Diverticulum herniation against the vasa recta causes eccentric intimal thickening and thinning of the media, predisposing to rupture of the lumen. Clinically, this presents as painless rectal bleeding.

A 53-year-old male presents to his primary care physician's office with abdominal discomfort. The patient says that his pain is located in the epigastrium and is exacerbated by eating. The patient has a past medical history significant for hypertension, hyperlipidemia, and asthma. A test for fecal occult blood is positive. An upper endoscopy and colonoscopy are performed and the patient is diagnosed with peptic ulcer disease. Which of the following ulcer locations is least commonly associated with malignancy?

Duodenum - Duodenal carcinoma typically arises sporadically, without an ulcerative precursor lesion.

A 63-year-old female presents to the Emergency Department with severe dyspnea and chest pain that is exacerbated by breathing. Her symptoms began three hours ago. History reveals that she had hip replacement surgery three weeks ago and prefers to stay in bed because of the pain. Physical examination reveals mild erythema and swelling of the left lower extremity, inhalation somatic dysfunction of the pelvic diaphragm on the left, and viscerosomatic changes from T2-6 and T12-L2. An electrocardiogram shows sinus tachycardia. Computed tomography of the chest is obtained as shown in the exhibit. Of the following, the most likely additional finding is...

Elevated fibrin degradation products -This woman has a saddle pulmonary embolism. The presentation is classic with dyspnea, chest pain, and tachycardia one week after surgery. Immobilization and vascular injury during surgery has put this patient at high risk for a deep vein thrombosis (DVT), which can dislodge into a pulmonary embolism (PE). The CT scan confirms the diagnosis. Elevated fibrin degradation products suggest a hypercoagulable state consistent with a PE

A 10-year-old male presents with watery, blood-tinged diarrhea and fever for the past 3 days. History reveals that he recently returned from a camping trip in Mexico. Vitals reveal a blood pressure of 115/73 mmHg, a heart rate of 106/min, a respiratory rate of 18/min, and a temperature of 38.5ºC (101.3ºF). Stool studies reveal the presence of red blood cells and white blood cells. Cultures show that the organism ferments sorbitol. Ten days later, his symptoms resolve without antibiotics and without any complications. What is the most likely etiologic agent?

Enteroinvasive Escherichia coli (EIEC) - bloody diarrhea with white blood cells and fever is consistent with EIEC - The bloody diarrhea is a result of direct invasion of the bacteria into the gastric mucosa (hence the name Enteroinvasive), which can lead to an immune-mediated inflammatory reaction causing fever. In addition, white blood cells, specifically neutrophils, migrate to the intestinal wall to clear the infection, so stool studies often show white blood cells. EIEC is grown on MacConkey agar and will ferment sorbitol.

A 60-year-old male presents to his primary care physician with ascites, hematemesis, and caput medusae. His social history reveals that he generally drinks at least four alcoholic drinks per day for over thirty years. His eyes are slightly icteric. He has evidence of portal hypertension. Upper endoscopy is performed and reveals evidence of esophageal varices. Esophageal varices are most likely caused by blood being diverted through which of the following vessels?

Esophageal varices have two main inflows: the left gastric vein and the splenic hilum through the short gastric veins. The most important portosystemic anastomoses involved are the gastroesophageal collaterals which drain into the azygos vein.

A 55-year-old white male presents to his primary care physician complaining of frequent black "tarry" stools over the past week. Social history reveals he currently smokes with a 20 pack-year history and is a heavy drinker. The most appropriate test to assess his condition would be...

Esophagogastroduodenoscopy - Upper gastrointestinal bleeding is defined as bleeding from a source proximal to the ligament of Treitz. Melena generally indicates a UGIB and should be investigated for localization and possibly treatment immediately with an EGD.

A 34-year-old Caucasian male comes into your office complaining of dull epigastric pain of several weeks' duration, which is worse after meals. His past medical history is significant for recurrent kidney stones and progressively worsening vision. Family history reveals that his grandfather had the same set of symptoms at a similar age. Physical exam reveals paravertebral ropiness from T6-9 and a tender nodule in the left 5th intercostal space near the sternum. The most likely cause of this patient's epigastric pain is...

Gastrin overstimulation leading to acid release - The patient is demonstrating signs and symptoms consistent with Multiple Endocrine Neoplasia Type 1. - MEN Type 1 consists of the three Ps: Pituitary, Parathyroid, and Pancreatic involvement. Patients present with watery diarrhea, recurrent peptic ulcer disease refractory to medication, and vision problems or headaches. Gastrinomas stimulate acid release from the stomach, leading to ulcers.

A 5-month-old female is brought to the pediatrician for evaluation of poor feeding and chronic diarrhea. The mother is also concerned about a small bulge at the infant's umbilicus that becomes more prominent with crying. Physical examination reveals macrocephaly with bulging frontal bones, coarse facies, and hepatosplenomegaly. Ophthalmic examination reveals complete corneal opacification. Which of the following explains the pathophysiology of this disease?

Glycosaminoglycan accumulation in lysosomes - This patient suffers from mucopolysaccharidosis Type I, also known as Hurler's syndrome; autosomal recessive, inherited nonsense mutation that results in decreased/absence of a-L-iduronidase. This prevents lysosomal breakdown of GAGs, specifically dermatan sulfate and heparan sulfate. - Ophthalmic examination is very important in these patients because it allows you to differentiate between Hurler's disease and the less severe mucopolysaccharidosis, Hunter's disease (type II). Unlike Hunter's disease, progressive corneal clouding is common in Hurler's disease and can begin during the first year of life. Clouding of the cornea has a ground-glass appearance and may lead to blindness.

A 19-year-old male is using heroin with his friends when he becomes somnolent and then unresponsive, with a respiratory rate of four breaths per minute. A friend calls emergency medical service (EMS). The patient is stabilized and transferred to the emergency department. Under which law can bystanders call EMS for assistance with a suspected drug overdose without fear of negative legal consequences?

Good Samaritan Law - expanded to apply to situations of drug and/or alcohol overdose and also include the administration of naloxone. Many Good Samaritan laws now also cover individuals who help others who have overdosed by calling EMS as well as healthcare workers who administer naloxone out of the hospital to someone suffering from overdose.

An 18-year-old male presents to the emergency department with severe shortness of breath. He says this started yesterday and has gotten worse over the last 24 hours. He states he just returned from an "epic road trip" to the Grand Canyon. His best friend accompanied him on the trip since they both just graduated from high school. Physical examination shows interstitial infiltrates and auscultation reveals rales and wheezing. The patient's symptoms rapidly worsen and he is put on a respiratory ventilator. Which of the following is the most likely cause of this patient's symptoms?

Hantavirus - causes a severe, rapidly progressing pneumonia and is typically acquired in the southwestern US; Transmission typically via inhalation of contaminated rodent feces in the dry air. Patients typically present with moderate to severe respiratory symptoms that quickly worsen into ARDS, with possible hemorrhage and renal failure. Severe disease characterized fluid accumulation in the lungs putting pressure on the heart that can lead to CHF.

An elderly female with stage 4 colon cancer presents with intractable pain. A full body CT shows metastatic lesions in the liver and brain. She has been unresponsive to previous treatment with chemotherapy and radiation. The patient's family inquires about the possibility of home hospice care. To be eligible for home hospice under Medicare guidelines, the patient must...

Have a life expectancy equal to or less than six months - Patients are eligible for Medicare hospice benefits when the meet the following criteria: Their doctor and the hospice medical director certify that they are terminally ill and have 6 months or less to live if their illness runs its normal course. - Patients sign a statement choosing hospice care instead of other Medicare-covered benefits to treat the terminal illness. (Medicare will still pay for covered benefits for any health problems that are not related to the terminal illness.) They get care from a Medicare-approved hospice program. - This patient, given her metastatic cancer that has been unresponsive to treatment would likely meet criteria for hospice, as life expectancy is 6 months or less

A 53-year-old alcoholic male presents to his primary care physician with progressive yellowing of his skin. He also notes that his urine has been darker than usual over the past few days. He was diagnosed with diabetes 5-years ago and for the past 2-years has been noticing frequent large foul-smelling bowel movements. Physical examination reveals scleral icterus and a yellow hue to his skin, paravertebral fullness from T5-9, and a tender nodule near the transverse process of T7 and T8. A firm and non-tender palpable mass can be felt in his right upper quadrant. The most likely cause of these findings is cancer of the

Head of the pancreas - presents with painful obstructive jaundice, dark urine, clay colored stools, steatorrhea, and a palpable non-tender gallbladder.

Adenocarcinoma histology

Histologic diagnosis requires evidence of either neoplastic gland formation or intracytoplasmic mucin.

A 6-year-old male presents to the ED in severe respiratory distress. His mother states that exercise and cold weather have exacerbated similar symptoms in the past, but this time his rescue inhaler is not working. Vitals reveal a heart rate of 110/min, respirations of 28/min, and pulse oximetry of 84% on room air. Physical examination reveals coarse wheezing and blue lips. Osteopathic examination includes hypertonic scalene muscles bilaterally, paravertebral hypertonicity from T2-T6 bilaterally, and bilateral thoracoabdominal diaphragm restrictions with the right worse than left. The most appropriate adjunctive therapy at this time is...

IV methylprednisolone - This boy is having an acute asthma attack that should be treated with supplemental oxygen, short acting β-2 agonists such as albuterol, and intravenous (IV) steroids such as methylprednisolone.

A 5-year-old male is brought to the emergency department (ED) by his grandmother. He has been experiencing sudden shortness of breath and mouth swelling after eating a piece of cake at a party. The grandmother says he is relatively healthy except for seasonal allergies and an allergy to peanuts. She states that she does not know what happens when he eats peanuts but knows that his parents gave her a "pen" to use if he were to experience any symptoms if in contact with peanuts. She could not find the "pen" so she brought him to the ED promptly. What is the mechanism behind the patient's current condition?

IgE cross-linking with antigen - Patients with type I hypersensitivity reactions develop anaphylactic and atopic reactions from free antigen cross-linking to IgE, which will lead to presensitized mast cells and basophils production and release of inflammatory and vasoactive substances. This will cause an immediate release of histamines that will act on postcapillary venules. - Type I hypersensitivity reactions are typically immediate secondary to an IgE cross-linking to an antigen leading to the release of histamine and other inflammatory markers by mast cells and basophils. This has likely occurred from a preformed antibody (IgE) to antigen complex.

A previously healthy 61-year-old man is seen in the office. He states that over the past few months he has noticed that his face is extremely warm and red whenever he drinks alcohol. He has also noticed a change in his bowel habits. Currently he has between five and ten loose bowel movements daily. He has some mild abdominal pain which he attributes to his diarrhea. He has no past medical history and his only medication is a multivitamin. He drinks four to six beers per night on Friday and Saturday nights only. Vital signs are within normal limits. On physical examination he has a 2/6 holosystolic murmur best heard at the left lower sternal border. Physical examination is otherwise normal. Twenty-four hour urine collection shows: 5-HIAA 1586 mg/day (N=2-8 mg/day) Which of the following is the most likely site of the primary tumor in this patient?

Ileum - Carcinoid syndrome secondary to a carcinoid tumor. The patient describes the classic symptoms of facial flushing and diarrhea. On physical examination, a tricuspid regurgitation murmur is heard. The symptoms of carcinoid syndrome are due to release of serotonin and other compounds, such as histamine and bradykinin. The most useful diagnostic test is a 24-hour urine 5-HIAA. Patients with carcinoid tumors will have levels that are quite elevated.

Emergency Medical Treatment and Labor Act (EMTALA)

In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Medicare-participating hospitals that offer emergency services must provide a medical screening examination when a request is made for examination or treatment for an emergency medical condition, including active labor, regardless of an individual's ability to pay. Hospitals are required to provide stabilizing treatment for patients with emergency medical conditions. If a hospital is unable to stabilize a patient within its capability, or at the patient's request, an appropriate transfer should be implemented.

Multiple adults arrive to the Emergency Department three days following a World Series baseball game with fever, shortness of breath, nausea, and vomiting. Many of them are altered with pallor and evidence of cyanosis. Chest radiographs reveal multiple patients with mediastinal widening or pleural effusion. Which of the following is the most appropriate chain of communication?

In the event of a suspected bioterrorism event with inhalation anthrax, local or state health department officials should be immediately notified. Those officials are then responsible to report to the CDC.

V/Q scan indicates that perfusion is reduced at the apex of the right lung when the patient is standing. Which V/Q value is consistent with reduced perfusion at the apex of the right lung in a standing patient with pulmonary embolism?

In the present clinical case, the perfusion to the apex of the right lung is impaired by a PE; therefore, the V/Q ratio must exceed 3.0, the normal value in the apex. - The V/Q ratio is lower at the base of the lungs (≈ 0.6) and higher in the lung apices (≈ 3.0). This variation reflects the fact that basilar pulmonary vessels are perfused with a greater volume of blood compared with apical pulmonary vessels because of gravitational forces.

A 50-year-old female presents to the emergency department for evaluation of nausea, malaise, and melena of three days' duration. Her vitals reveal a blood pressure of 92/65 mmHg, a heart rate of 112/minute, and a respiratory rate of 19/min. Physical examination reveals epigastric tenderness, and dark internal and external hemorrhoids, along with paravertebral hypertonicity, and tenderness from T5-T8. Social history reveals she regularly drinks two to four beers per night, and has done so for fifteen years. Which lab studies are most indicative of her hypotension?

In the setting of an upper gastrointestinal bleed, there can be an elevation of the blood urea nitrogen:creatinine ratio. - The influx of blood into her GI tract will lead to an increase in the patients blood urea nitrogen (BUN) to creatinine ratio. Additionally the volume depletion she is experiencing could quickly exacerbate the problem by decreasing blood flow to her kidneys, resulting in decreased kidney perfusion and further elevating her BUN by decreasing filtration.

A 4-year-old male presents for a routine pediatric examination. During the physical exam, it is found that the processus vaginalis, typically obliterated by the age of 2 years, is persistent and he is found to have an indirect hernia. Which of the following is the best description of the pathway taken by this hernia as it traversed the abdominal wall?

Indirect hernias pass through the deep inguinal ring, lateral to the inferior epigastric arteries, through the inguinal canal, and finally through the superficial inguinal ring into the scrotum.

A 58-year-old Caucasian female is admitted to a health and rehabilitation center after open reduction internal fixation of her right femur. She develops diarrhea, pain, and abd distention two days following her procedure. You note paravertebral hypertonicity from T11-L2 and a tender nodule on the left thigh anterior to tensor fascia lata muscle. A stool sample is obtained and tests positive for C. difficile toxin. She is afebrile with a blood pressure of 110/85 mmHg, heart rate 104/min and a respiratory rate of 15/min. She is started on oral vancomycin and oral metronidazole. Colonoscopy biopsies will most likely reveal...

Inflammatory exudate composed of mucinous debris, fibrin, necrotic epithelial cells and polymorphonuclear cells - The pathology of Clostridium difficile colitis is a pseudomembranous colitis with the formation of an inflammatory fibromucinous exudate that covers the colonic wall.

A 21-year-old Midwestern Asian male is seen by his gastroenterologist for an acute flare-up episode of his Crohn disease. He has been managed on sulfasalazine but it has not been efficacious. The physician recommends a medication that is used for long-term treatment of refractory Crohn disease. Two weeks later he visits his primary care physician with a cough, malaise, and chest pain. Sputum culture reveals fungi-filled macrophages. The most likely pharmacological agent responsible for these symptoms was...

Infliximab - binds TNF and blocks its interaction with cell surface receptors. Infections such as histoplasmosis, among many others, are a box warning for infliximab and other biological modifying agents. This particular patient acquired histoplasmosis, which is a prevalent fungal infection in the Midwest.

A 60-year-old male presents to his primary care physician with dyspnea and a dry cough. His history includes working in a shipyard for 25 years, directly involved in the fabrication of ships. A chest radiograph is obtained as shown in the exhibit. Concerning this man, the most likely statement is...

Inhaled asbestos fibers commonly get coated with protein and iron and are called ferruginous bodies. They stain positive with Prussian blue due to the iron present.

A 50-year-old female presents with acute-onset abdominal pain and distension. She states that the pain began suddenly, is sharp and cramping in quality, and is currently rated 6/10 in severity, with spasms of pain every few minutes increasing to 10/10. She has a past medical history of endometriosis and hypothyroidism, and a surgical history significant for an open appendectomy, an exploratory laparoscopy and multiple cesarean sections. She is a nonsmoker, and reports a history of social alcohol use. Physical examination reveals tachycardia, as well as an abdomen that is moderately distended and tympanitic to percussion. Bowel tones are hyperactive, and there is diffuse moderate to severe tenderness to palpation in all four quadrants. Next step in management?

Insert an NG tube and place on low intermittent suction - one should always suspect a small bowel obstruction in a patient who is presenting with abdominal distention and has a history of multiple abdominal surgical procedures. - Bowel obstruction present with colicky abdominal pain and distension. Abdominal radiography will reveal dilated loops of bowel with air-fluid levels. The most appropriate initial treatment is the placement of a nasogastric tube, set to low intermittent suction.

A 50-year-old man with a history of hypertension and rheumatoid arthritis presents with dyspnea. His dyspnea began 12 months ago and has gradually worsened. Auscultation of the lungs reveals fine inspiratory crackles at both bases.

Interstitial lung disease (ILD) due to rheumatoid arthritis - The fundamental pathophysiological abnormality in ILD is a reduction in compliance - When compliance is decreased, the lung has greater inward elastic recoil, and FRC decreases. - When lung compliance is reduced in ILD, the inspiratory muscles can't inflate the lungs to as great a volume, and TLC is reduced. - Since TLC is significantly reduced, and RV is usually minimally affected, the vital capacity is reduced.

A 47-year-old female comes into the emergency department with a chief complaint of epigastric distress. The pain is most severe after eating dinner and persists over night. Past surgical history includes gastric bypass surgery. She does not take any medications. Physical exam shows a palpable nontender mass in the right upper quadrant. Ultrasound in the right upper quadrant is significant for a structure with a biconvex curvilinear echogenic appearance with acoustic shadowing

Intramural calcification of the gallbladder (porcelain gallbladder) - result of chronic cholecystitis (It is possible to have chronic cholecystitis without prior symptomatic attacks, as in this patient) On ultrasound, a porcelain gallbladder may present in three different ways. Type I - Hyperechoic semilunar appearance with posterior acoustic shadowing Type II - Biconvex curvilinear echogenic appearance with acoustic shadowing (this patient) Type III- Irregular clumps of echoes with posterior acoustic shadowing Pathology could present in two separate ways. There can be calcification broadly within the muscularis, which can appear as a large plaque area on radiologic scans, or multiple punctate calcifications can be present in the glandular spaces of the mucosa, seen as granular calcification on radiographs.

JL decides to participate in a cohort study that compares the effects of an anti-inflammatory agent among patients with his disease and idiopathic pulmonary fibrosis (IPF). As part of the collection of data, a complete pulmonary function test (PFT) is given to all participants before and at different times after treatment with the drug. Which comparison best characterizes an expected difference before treatment with the drug between JL and a patient with IPF?

JL appears to have COPD, and compliance with COPD is greater than in IPF. Compliance refers to the amount of change in volume that occurs with a known change in pressure—or how much pressure is required to cause a change in volume. C = V/P

Large cell carcinoma histology

LCC is characterized by sheets of round to polygonal cells with prominent nucleoli and abundant pale staining cytoplasm without differentiating features. LCC does not have the propensity to secrete PTrH.

A 60-year-old male presents to his primary care physician with complaints of weakness, worsening over 6 months. He says his legs are weak when he tries to get up from a chair, but they improve with use. He also has a persistent cough and shortness of breath. He has a 50 pack-year history of cigarette smoking and currently smokes 2 packs per day. He has a medical history of hypertension and COPD. Exam shows a frail male with shortness of breath and mild ptosis bilaterally. His bilateral proximal leg strength is 3/5 and distally 5/5. Heart sounds are distant but regular. Lung sounds are diminished with crackles and rhonchi worse on the right.

Lambert-Eaton myasthenic syndrome is caused by antibodies to voltage-gated calcium channels. This decreases acetylcholine release from pre-synaptic neurons and causes muscle weakness.

Colorectal adenocarcinoma most commonly metastasizes to the...

Liver - common site of metastatic disease due to its dual blood supply via the hepatic artery and portal vein allowing for hematologic spread. Also, the liver acts like a filter for most of the blood throughout the body. Therefore, cells from almost any primary cancer site can break off and travel via the bloodstream to the liver

A 55-year-old male, with a 25-year history of chronic hypertension, presents to his primary care physician with complaints of cough and difficulty breathing, especially when exerting himself climbing the stairs. His blood pressure is found to be 150/95 mmHg. Lung examination reveals crackles and rales. An electrocardiogram, done last month, shows left ventricular hypertrophy. What is the most likely mechanism underlying this person's disease process?

Long-standing chronic hypertension often leads to left-sided heart failure and the backup of blood in the pulmonary veins resulting in an increase in hydrostatic pressure and resultant fluid leak into the lungs, causing pulmonary edema.

Botulinum toxin is one short-term pharmacologic treatment for achalasia. It has the greatest therapeutic effect on which anatomical entity?

Loss of neurons in the myenteric plexus of the lower esophageal sphincter causes achalasia. Botulinum toxin injected into this area can relax the LES and relieve signs and symptoms of achalasia for a short period of time.

A 60-year-old male presents to his primary care physician, concerned because he has been coughing up blood for the past two weeks. He has a 40-pack-year history of cigarette smoking and review of medical records reveals the patient has a history of chronic bronchitis, first diagnosed ten years ago. Physical exam shows a tender nodule just lateral to the spinous process of T3. Serum analysis is significant for elevated calcium. Chest radiography is conducted and shows a central lung mass. The most likely additional finding in this case is...

Low PTH - The hypercalcemia is most likely due to tumor secretion of PTH-related peptide, which has the same physiological action as PTH but is not detected in analysis of serum PTH level. PTH increases bone resorption of calcium and phosphate, as well as the reabsorption of calcium in the distal convoluted tubule.

In which lung lobe do you see secondary TB?

Lung apex

Cyclin D1

Mantle cell lymphoma; older males with disseminated disease. t(11;14), cyclin D1-IgH fusion gene. Biopsy: homogenous population of small lymphocytes with irregular deeply clefted nuclear contours

A 25-year-old male is brought to the emergency department following a motor vehicle accident. Intraperitoneal bleeding is suspected, and he is taken to the operating room for an open laparotomy. Which of the following structures is intraperitoneal?

Middle colic artery is a branch of the superior mesenteric artery and travels inside the transverse mesocolon (or transverse mesentery) to supply the transverse colon - Intraperitoneal structures include the stomach, jejunum, ileum, cecum, appendix, transverse colon, sigmoid colon, liver, spleen, and gallbladder. The pancreas, duodenum, and rectum are partially intraperitoneal.

A 46-year-old Caucasian male presents to your office complaining of fever, chills, myalgias, diarrhea and a rash, which have been slowly worsening over the last several weeks. He recalls a similar episode two years ago after returning from a trip to Thailand, except at that time his symptoms were much more severe and required hospitalization. He has a history of diabetes mellitus, for which he takes both regular insulin and insulin detemir, and coronary artery disease, for which he takes aspirin and atorvastatin. Vitals signs are notable for temperature of 38.4°C (101.2°F), heart rate 88/minute, respiratory rate 18/minute, blood pressure 104/78 mm Hg. Physical examination reveals a slightly jaundiced male with moderate abdominal tenderness to palpation, with both hepatomegaly and splenomegaly. There is cervical lymphadenopathy present, and there is a nearby area of erythema and induration containing several small fluctuant nodules as well. A metabolic panel reveals increased transaminases and bilirubin, and a complete blood count reveals mild leukocytosis. A CT scan of the abdomen reveals multiple small abscesses within both the liver and spleen. What describes the most likely pathogen?

Mobile gram negative rods with bipolar "safety pin" appearance - Melioidosis is a tropical disease caused by Burkholderia pseudomallei, a motile Gram-negative rod with a bipolar "safety pin" appearance. Melioidosis frequently progresses to sepsis, causing disseminated microabscesses in the skin, liver and spleen.

A 36-year-old male presents to his primary care physician with gradual-onset dyspnea. The patient says this started two months ago, and has gradually worsened since then. Recently, he has started coughing up an occasional small amount of blood. The patient also states he has gained 6.8 kg (15 lb), unexpectedly, over the last few months. He admits to a 10-pack-year history of cigarette smoking. The physician determines the cause of dyspnea to be related to a neuroendocrine cell origin. This condition is most associated with...

Moon facies and purple striae - Small cell carcinoma is of neuroendocrine cell origin and is associated with numerous paraneoplastic syndromes, including increased ADH and ACTH secretion. See Cushing syndrome signs here.

A 24-year-old female presents to her primary care provider with the complaint of chest pain and progressive difficulty in swallowing over the past two months. She also states that she has been experiencing heartburn, odynophagia, and a weight loss of 4.5 kg (10 lbs). An upper gastrointestinal series is conducted and reveals dilatation of the proximal esophagus with subsequent narrowing of the distal portion. These findings are due to degeneration of inhibitory neurons located in the...

Muscularis externa - Auerbach's plexus, also called the myenteric plexus, is a neural network branching between longitudinal and circular muscle layers of the gastrointestinal tract and allows for coordinated movement along the tract. Loss of these neural cells results in achalasia, which commonly presents with chest pain, heart burn, dysphagia, and regurgitation.

EEG reveals sleep spindles and K-waves

Non-REM Stage 2: only stage N2 of sleep is associated with sleep spindles and K-waves on the EEG; Non-REM stage 1 sleep is characterized as light sleep and is associated with theta waves; Non-REM stage 3 sleep is associated with high amplitude, low-frequency delta waves (This is the deepest levels of sleep); Awake state is characterized by mixed frequency waves and alpha waves; During REM, the brain is awake and active while the body is paralyzed

A 65-year-old patient in the intensive care unit (ICU) on a respirator develops a fever. Laboratory evaluation reveals leukocytosis. Physical examination reveals decreased breath sounds. Chest x-ray shows pulmonary infiltrates. What is the most likely diagnosis?

Pseudomonas aeruginosa is the most common pathogen associated with nosocomial pneumonia due to use of a respirator. - In addition to respirator-associated pneumonia, P. aeruginosa is an important cause of other nosocomial infections including respiratory infections in cystic fibrosis patients and wound infections in burn patients.

A 45-year-old obese male with a history of hypertension, hyperlipidemia, diabetes mellitus and erectile dysfunction presents to your office complaining of fatigue. He states that he never feels rested when he wakes up in the morning, and that he has very little energy throughout the day. On questioning his wife, who is present with him, she states that the patient does snore very loudly, and she says that he sometimes appears as if he is fighting to breathe but is unable to do so. Physical exam reveals a morbidly obese male with a BMI of 42. The nasal passages are clear with normal turbinates and no masses or lesions, and the oropharynx is also clear without tonsillar hypertrophy. Cardiopulmonary exam is also within normal limits. You refer the patient to undergo an overnight sleep study.

Obstructive sleep apnea causes hypoxia, which can trigger pulmonary vasoconstriction and lead to pulmonary hypertension.

A 33-year-old Caucasian male presents to the Emergency Department complaining of a sudden onset of weakness and watery diarrhea of two days' duration that occurred after eating large meals. History reveals that he recently underwent a gastric bypass surgery with no complications. Vitals reveal a blood pressure of 102/76 mmHg, heart rate of 106/min, and respiratory rate of 18/min. The most likely mechanism for his symptoms is...

Osmotic draw of fluid resulting from hyperosmolar contents in the intestine - Dumping syndrome, characterized by watery diarrhea, muscle aches, chills, weakness, and tachycardia. These symptoms usually occur after eating a large meal and are often seen in patients who undergo gastric surgeries for ulcers or, as in this case, gastric bypass. The meal's hyperosmolar content, combined with decreased transit time, acts to draw fluid into the intestinal wall and cause diarrhea. - If diarrhea is severe or chronic enough, depletion of potassium and other important electrolytes ensues, leading to weakness and muscle aches. - The best treatment for this syndrome is prevention by instructing patients to eat smaller meals.

A 35-year-old Caucasian male presents to your office after being diagnosed with primary sclerosing cholangitis. He has recently developed a skin lesion on his right leg that is ulcerated with a purulent base and surrounding erythema.

PSC characteristically involves intra- and extra-hepatic ducts while primary biliary cirrhosis is a T-lymphocyte-mediated attack on small intralobular bile ducts. - Imaging studies with contrast will show a classic "beads on a string" appearance of the biliary ducts. This is due to intermittent sclerosis of the bile ducts causing a stricture and subsequent dilation; usually presents in young men with ulcerative colitis

Retroperitoneal organs

Pancreas, kidneys, ureters, abdominal aorta, inferior vena cava (IVC), duodenum (second, third, and fourth parts), ascending colon and descending colon

A 65-year old African-American male comes into the Emergency Department with a chief complaint of vague abdominal pain. He also reports a 7-pound weight loss in the last 6 weeks. The patient has not had any nausea, vomiting, or diarrhea. He reports no melena or hematochezia. Past medical history includes diabetes mellitus type II; he has not had an episode of acute pancreatitis in the past year. He smokes cigarettes and drinks alcohol occasionally. He was adopted and is not sure about his family's medical history. Vital signs are within normal limits. Physical exam shows jaundice and a palpable non-tender gallbladder in the right upper quadrant of the abdomen. His extremities are also red and tender after palpation. Which of the following most likely describes this patient's disease process?

Pancreatic adenocarcinoma - can see Trousseau's syndrome and/or Courvoisier's sign. Painless jaundice occurs when it involves the head of the pancreas because of obstruction of common bile duct (this patient). Pancreatic cancer is highly invasive and shows moderately to poorly differentiated glandular formation with abortive tubular structures.

An elderly patient in respiratory distress is brought to the hospital by her friend. The patient is unresponsive, and her SpO2 is 83% on non-invasive positive pressure ventilation (NIPPV). Her son, who is her closest living relative, is driving to the hospital but cannot be reached by phone. There is no advance directive on the chart; however, the friend notes that the patient has previously mentioned that she did not want to be on a mechanical ventilator in order to maintain life. What is the most appropriate course of action at this time?

Patients in respiratory distress should be intubated and placed on mechanical ventilation unless otherwise stated in an advance directive or confirmed by the medical power of attorney. - While her friend may have knowledge of her prior stated wishes, there is no way to verify these statements, and the patient has no written advance directive or living will specifying her wishes.

A 45-year-old male presents to the emergency department with right upper quadrant pain. He also states a history of foul-smelling diarrhea. He is subsequently diagnosed with somatostatinomas and informed that he may experience gastritis due to decrease gastrin secretion. The enzyme that is most affected by decreased gastrin secretion is...

Pepsin is produced by the chief cells of the stomach and acts to break down proteins in food. Hydrochloric acid is responsible for the conversion of pepsinogen to pepsin.

A 12-year-old boy with cystic fibrosis presents with generalized fatigue and malaise for one week. His stools have been increasingly greasy and foul-smelling. What enzyme is most likely to be affected?

Phospholipase A2 is the enzyme that breaks down phospholipids to arachidonic acid in inflammatory cells, but it is also secreted by the pancreas to break down phospholipids in the GI lumen. - Pancreatic insufficiency may occur with cystic fibrosis due to decreased bicarbonate secretion. Pancreatic enzymes have a pH optimum of 7-8 and are active upon proteolysis in the small intestine. Affected enzymes include: pancreatic amylase, lipase, colipase, and phospholipases.

A 60-year-old male presents to the Emergency Department with fever, shortness of breath, and productive cough that began last night. Past medical history is remarkable for chronic obstructive pulmonary disease (COPD), hypertension, and diabetes mellitus. Medications include hydrochlorothiazide, losartan, albuterol/ipratropium, and metformin. He smokes one pack of cigarettes each day and drinks three beers per week. Chest x-ray reveals a right middle lobar consolidation. Which of the following would most likely be found on physical examination?

Physical exam findings for pneumonia include dullness to percussion, increased tactile fremitus, and inspiratory crackles. Chest x-rays may demonstrate patchy infiltrates or lobar consolidation. To distinguish between COPD exacerbation and pneumonia in this patient, you should consider the chest radiograph findings. The finding of a lobar consolidation would point you to pneumonia as the best diagnosis.

A 45-year-old male presents to the emergency department with the complaint of abdominal pain radiating to the back. History reveals associated nausea and vomiting, and the pain is relieved by sitting bent forward. Past medical history reveals alcoholism. Physical examination reveals hepatomegaly, mild tenderness in the epigastrium, and an ecchymotic discoloration in the flank. Structural examination is likely to reveal palpatory changes...

Physical examination may reveal signs of hemorrhagic complications such as ecchymotic discoloration of the flank (Grey-Turner sign) or periumbilical region (Cullen sign); this bleeding is due to pancreatic necrosis. The pancreas receives its sympathetic innervation primarily from T5-T9, but it also receives some innervation from T10-T11 as well. Increased nervous system stimulation from the pancreas may result in a reflex response in segmentally related structures and may manifest as tissue texture changes in the paraspinal muscles at T5-T11.

A 3-day-old male is delivered at 32 weeks gestation to a 30-year-old, G1P0, AB Rh- mother. The infant presents with jaundice affecting his eyes, neck, and trunk. He is in no acute distress. Phototherapy is begun, and his appearance returns to normal after 3 days. Which of the following best explains the pathogenesis of the most likely diagnosis?

Physiologic jaundice occurs in premature infants due to liver immaturity and the associated immaturity of UDP glucuronyl transferase production, an enzyme necessary for bilirubin conjugation. Unconjugated bilirubin accumulates in tissues and responds to light therapy.

A 52-year-old Hispanic male presents to the emergency department with dyspnea and left-sided chest pain. Past medical history is positive for a 30 pack-year history of smoking, coronary artery disease, and chronic obstructive pulmonary disease. Physical examination reveals decreased breath sounds over the left chest, blood pressure of 128/82 mm Hg, heart rate of 108/min, and respiratory rate of 34/min. Physical examination also reveals viscerosomatic change from T2-T6 and a flattened left thoracoabdominal hemidiaphragm. What is the most likely diagnosis?

Pneumothorax - occurs when extrapleural air is introduced into the intrapleural space. Patients will present with dyspnea, unilateral chest pain, decreased breath sounds, increased resonance on percussion, and decreased tactile fremitus. Viscerosomatic changes may be palpable in the paraspinal muscles from T2-T6, representing lung pathology. - Classic radiograph findings will reveal a thin white line (pleural line) in the affected lung field with no vascular markings distal to it

Mutation of JAK2 gene

Polycythemia vera is due to a mutation of the JAK2 gene and can cause Budd-Chiari syndrome. Patients with Budd-Chiari syndrome may present with jaundice, ascites, abdominal pain, hepatomegaly, and acute renal failure.

A 25-year-old male on the general medical floor complains of abdominal pain and distention. History reveals the patient is post-operative day 2 after an open appendectomy, and he has not had a bowel movement since before the surgery. Physical exam reveals a mildly distended abdomen devoid of bowel sounds. What treatment would be most beneficial first to this patient given his most likely diagnosis?

Post-operative care, such as the treatment of an ileus, can include paraspinal inhibition at the thoracolumbar junction.

A 38-year-old male presents to the clinic for evaluation of recent onset abdominal pain. He recently emigrated from Southeast Asia to the United States. Stool studies isolate eggs identified as Clonorchis sinensis. The most appropriate pharmacologic treatment is...

Praziquantel - antihelmintic agent that increases cell membrane permeability in helminths leading to disintegration of the parasite. It is used to treat infections caused by Clonorchis sinensis, as well other trematodes and cestodes.

A 50-year-old female with history of inflammatory arthropathy presents with jaundice.

Primary biliary cirrhosis is an autoimmune disease with antimitochondrial antibodies. It is most common in middle-aged females and is usually found in patients with other autoimmune diseases.

A 46-year-old female comes into the office for evaluation of pruritus and generalized fatigue. Past medical history is significant for ulcerative colitis, but she has never received surgery or needed acute hospitalization. She does not smoke, rarely drinks alcohol, and has never used illicit drugs. She has not traveled in the past year. Vital signs are temperature of 37.2°C, heart rate of 80/min, blood pressure of 116/80 mmHg, and respiratory rate of 14/min. Physical exam shows generalized jaundiced and scleral icterus. There are no other abnormalities on physical exam. Aspartate aminotransferase is 240 U/L. Serum alkaline phosphatase is elevated. The atypical perinuclear antineutrophil cytoplasmic antibody is also positive. What is the most likely etiology of this patient's complaints?

Primary sclerosing cholangitis (PSC) - chronic disorder that causes inflammation, fibrosis, and structuring of the medium and large-sized ducts in the intrahepatic and extrahepatic biliary tree. - Elevated alkaline phosphatase, hyperbilirubinemia, and elevated serum aminotransferases; see positive p-ANCA; strong association between ulcerative colitis and PSC.

A 40-year-old male with jaundice has an ERCP demonstrating narrowing and dilation of the bile ducts.

Primary sclerosing cholangitis presents in men in their 40's and has a strong association with ulcerative colitis. On ERCP it shows a "beading" appearance of the bile ducts.

A 22-year-old man presents to clinic complaining of right upper quadrant pain. He is unsure when the pain started exactly but feels that the pain has been increasing for the past several months. His past medical history is negative with the exception of a torn biceps tendon last year. Vital signs show temperature of 37°C, pulse of 110 beats/minute, respirations of 15 breaths/minute, and blood pressure of 140/100 mm Hg. On physical exam, the patient is extremely muscular. His heart exam shows tachycardia. His liver is palpable 4 cm below the costal margin. He has acne across his back, shoulders and chest. Laboratory testing shows low HDL, elevated LDL, and elevated AST and ALT. A liver ultrasound reveals multiple hypoechoic cavitations with turbulent flow. Which of the following is this patient most at risk for?

Prostatic hyperplasia - anabolic steroids interact with the same receptors as natural testosterone. This explains why people taking anabolic steroids may experience prostatic hyperplasia: the prostate is a testosterone dependent gland and may increase in size due to steroid's androgenic effects. - Patient is experiencing signs peliosis hepatitis, a rare condition of blood-filled cysts in the liver parenchyma, it is also associated with tuberculosis, carcinomatosis, and Bartonella henselae infection; rare condition, resolves with cessation of drug use.

A 75-year-old female presents with a two-month history of dyspnea. She recently returned from a trip to South America. History reveals she developed atrial fibrillation 20 years ago, and her cardiologist gave her a medication to convert her to sinus rhythm that she has been taking since that time. On examination, you notice decreased chest wall motion globally, hypertonic scalenes and trapezius muscles bilaterally, and paravertebral hypertonicity from T2-T6 bilaterally.

Pulmonary fibrosis - increased use of accessory respiratory muscles, viscerosomatic changes from T2-T6, and poor chest wall motion secondary to the restrictive nature of this lung disease; the patient has likely been taking amiodarone for the last 20 years and now presents with dyspnea on exertion likely secondary to pulmonary fibrosis.

RDS is caused by impaired surfactant synthesis and secretion, ultimately leading to...

Pulmonary vasoconstriction - Surfactant is produced by type 2 pneumocytes and it decreases alveolar surface tension and increases compliance (C = ΔV/ΔP). Surfactant deficiency leads to atelectasis and ventilation/perfusion mismatch with hypoventilation, which leads to hypoxemia and hypercarbia. This results in respiratory and metabolic acidosis and ultimately, pulmonary vasoconstriction.

A 3-week-old white male is brought to the emergency department by his parents with complaints of persistent vomiting after feedings for the past 4 days. Physical exam reveals an ovoid shaped mass near the distal part of the stomach.

Pyloric stenosis causes persistent emesis and loss of gastric contents. When there is excess excretion of hydrogen ions or retention of bicarbonate metabolic alkalosis occurs.

A 58-year-old male prisoner, who has been incarcerated for the past year, presents with one week of fevers, night sweats, and weight loss. He states that yesterday he started coughing up blood. On examination, you note inhalation somatic dysfunction of rib 1 on the right, myofascial restriction in the supraclavicular fossa bilaterally, and hypertonic paravertebral muscles T1-T4 bilaterally. After reviewing the records, you observe that no one else in the prison has had the same symptoms in the last year.

Reactivation tuberculosis - A patient who is an infected with Mycobacterium tuberculosis will most likely enter into a latent phase where they are asymptomatic and not contagious; transient or permanent reduction in their immune state; caused by HIV, DM, and corticosteroids. Patients present with cough, hemoptysis, fevers, night sweats, and weight loss; typically affects the upper lobes of the lung, often with the right worse than the left.

A 45-year-old woman presents to the emergency department with right upper quadrant abdominal pain and right shoulder pain. Moreover, she reports nausea and vomiting after eating fatty meals. Structural examination reveals somatic dysfunction at T6 to T9. Physical examination reveals an arrest of inspiration during palpation of the right upper quadrant. Her shoulder pain most likely is related to which of the following nerves?

Referred shoulder pain due to an inflamed gallbladder is mediated by the phrenic nerve (C3, C4, C5).

A 78-year-old male presents to his physician after noticing a hard, non-tender lump above his left clavicle. Past medical history includes chronic gastritis. Further work-up reveals adenocarcinoma of the stomach with metastases to the left supraclavicular lymph node. Enlargement of this lymph node can lead to regional lymphatic vessel obstruction and prevent drainage of the...

Right lower extremity- The thoracic duct is responsible for draining most of the body, including the lower limbs, pelvis, abdomen, left thorax, left upper limb, and left side of the head and neck. - The right lymphatic duct drains the right thorax, upper limb, head and neck.

Two hours after falling asleep, the patient experiences rapid eye movements. This stage is associated with...

Rise in acetylcholine: acetylcholine rises and norepinephrine declines. The basal forebrain and brainstem contain large amounts of cholinergic neurons that promote wakefulness and REM sleep and also participate in learning, memory, and cognition. These biochemical changes trigger the onset of REM sleep and promote the fast EEG rhythms via projections to the cortex and hippocampus.

A 40-year-old alcoholic male presents with fever, dyspnea, and a productive cough. Physical examination reveals a temperature of 38.1ºC (100.6ºF), with normal PaO2, and the patient smells of alcohol. Physical examination reveals hypertonicity from T4-T8 and a tender nodule in the fourth intercostal space on the right. A sputum sample is obtained and is noted to be pinkish in color and the pathogen is identified as a Gram-positive organism. A chest radiograph shows a right middle lobe consolidation. Which of the following is the most likely causative organism?

S aureus, a Gram-positive cocci, often resides on the skin, nasal passages, and sometimes the pharynx of the human body. It also is an opportunistic pathogen, which means it can cause disease if it is carried to an area where it can become virulent. Conditions associated with altered or reduced consciousness, such as in alcoholism, increases the risk of aspiration pneumonia.

Retroperitoneal organs

SAD PUCKER: Suprarenal (adrenal) glands, Aorta/IVC, Duodenum (second and third with or without fourth), Pancreas, Ureters, Colon (ascending and descending), Kidneys, Esophagus, and Rectum.

Small cell lung carcinoma histology

SCLC is composed of a pleomorphic population of small cells (with a cell size no larger than the size of three resting lymphocyte nuclei). These may be round, oval, angulated, and with variable amounts of cytoplasm; the classic "oat cell" has virtually no cytoplasm. Small dark blue synaptophysin positive cells are another description for small cell lung carcinoma (SCLC).

A 33-year-old African-American female presents to her primary care physician with blurred vision, generalized weakness, and painful nodules on her legs. Plain radiography of her chest shows enlarged hilar lymph nodes. An additional likely finding would be...

Sarcoidosis is a systemic disease with a restrictive pattern in the lungs. Increased ACE levels are a common finding.

A 64-year-old female presents to the office with preprandial, hunger-like pain that radiates to her back; the pain often wakes her up in the middle of the night. History reveals that she has gained 4.5 kg (10 lbs) in the last two months. Physical examination reveals upper abdominal tenderness. Structural examination reveals a small, tender, firm nodule located at the right medial 8th intercostal space.

See smooth, flat erosion filled with exudate seen on endoscopy; the most common causes of peptic ulcer disease are H. pylori and NSAIDs. Abdominal pain paired with erosions seen on endoscopy supports peptic ulcer disease.

A 70-year-old female underwent total knee arthroplasty five days ago. Prior to surgery, she was given antibiotics to prevent local infection. Post-operatively, she was started on low molecular weight heparin to prevent venous thromboembolism. She presents to the Emergency Department with dyspnea, tachypnea, and chest pain on inspiration. Physical examination reveals swelling and redness of the left lower extremity and hypertonic paraspinal muscles from T12-L2... the Four years later, this woman visits her primary care physician because her knee is swollen, red, and painful. Aspiration of the knee joint shows 100,000 WBC's. Her likely diagnosis is...

Septic arthritis has to be monitored for in patients with total knee replacements. The prosthesis provides a surface for bacteria to adhere to, and this infection needs to be treated aggressively.

A previously healthy 20-year-old male athlete presents to the university clinic with chest pain that began yesterday. He informs the attending physician that he spent the previous 3 days mostly studying for his final exams for his college classes, and his other activities during that time were relatively normal. His exercise regimen during that time consisted of running for 45 minutes in the morning and cycling for 1 hour in the evening. On examination, he has a blood pressure of 110/70 mmHg, heart rate of 75/min, respiration rate of 23/min, and temperature of 37.1ºC (98.8ºF). Auscultation of the breath sounds reveals diminished sounds on the left. The most likely diagnosis is...

Spontaneous pneumothorax - common in tall, thin males between 10 and 30 years of age; pain will often begin at rest; see diminished breath sounds, hyperresonance, and tactile fremitus on the affected side - Primary spontaneous pneumothorax occurs without underlying lung disease, predominantly in young, thin males; thought to be caused by ruptured pleural blebs or bullae - Secondary spontaneous pneumothorax usually occurs in older people with an underlying pulmonary disease like emphysema or asthma, acute or chronic infections, lung cancer, or congenital diseases.

Croup is a clinical diagnosis, but the characteristic finding on anteroposterior radiograph is the...

Steeple sign - narrowing of the subglottic trachea; tracheal edema causes elevation of the tracheal mucosa, resulting in loss of the normal lateral convexities of the trachea (also referred to as shouldering of the trachea)

A 47-year-old female, with no significant past medical history, presents to the urgent care with complaint of fever of two days duration, with a maximum temperature at home of 102.3°F. The patient also complains of shortness of breath, non-productive cough, and mild substernal chest pain. Review of systems is positive for nausea without vomiting as well as myalgias. It is otherwise unremarkable. Her only other significant history is medication allergies to penicillins and tetracyclines. Physical exam shows a well-developed, well-nourished woman who is not in any acute distress. Vital signs reveal temperature of 101.2°F, heart rate 95/minute, blood pressure 132/89 mm Hg, respirations 24/minute, and SpO2 95%. Auscultation of the chest finds the heart to be in a regular rate and rhythm without murmur. The lungs are clear bilaterally, but she does exhibit tachypnea. Normal bowel sounds are heard. The abdomen is soft and non-tender to palpation. The remainder of the exam is normal. You are worried her infection is being caused by an organism she was exposed to during her work in a textile factory handling animal hair and wool. Before prescribing treatment for this condition, you tell her that a common side effect associated with this medication is...

Tendinopathy - Known treatments for non-bioterrorism anthrax include penicillin, doxycycline, and ciprofloxacin. Since this patient has allergies to both penicillin and doxycycline, the only possible antibiotic that can be used is ciprofloxacin or another fluoroquinolone. Fluoroquinolones are known to cause gastrointestinal upset, headaches, dizziness, rash, and pruritus. While these side effects are common among many different classes of antibiotics, fluoroquinolones are unique in their ability to cause tendinopathy.

A 23-year-old male is brought to the Emergency Department with a knife wound in his side. He complains of severe dyspnea and a sharp pain with inspiration. Physical examination reveals absent breath sounds on the right, the right side of the thoracoabdominal diaphragm in an inhaled position relative to the left, and paravertebral hypertonicity from T2-T6. Vital signs reveal a blood pressure of 80/32 mmHg, a respiratory rate of 44/min, and an oxygen saturation of 84%. He has distended neck veins and becomes unresponsive. The most appropriate and immediate action to be performed is...

Tension pneumothorax is an emergency and treatment cannot be delayed. The gold standard therapy for a tension pneumothorax is a chest tube, however, in the presence of unstable vital signs indicative of shock, the most appropriate therapy should be needle decompression at this time. This is because needle decompression is quick and effective in the emergent setting. - Needle insertion is to the second intercostal space in the midclavicular line; chest tube insertion is at the 4th/5th intercostal space at the midaxillary line. The incision for chest tube placement is always one level below the site of chest tube placement such that the tube travels subcutaneously upward towards the site of insertion; this is to prevent air trapping resulting from the procedure.

In which lung lobe do you see primary TB?

The Ghon complex (caseous necrosis) of primary TB favors the upper part of the lower lobe, and lower part of the upper lobe.

Public Health Service Act

The Public Health Service Act, enacted in 1944 provides that the Secretary of The Department of Health and Human Services (HHS) "shall lead all Federal public health and medical response to public health emergencies and incidents covered by the National Response Framework." HHS is the primary agency for Emergency Support Function and covers public health and medical response, including mass care, emergency assistance, housing, and human services

Stafford Act

The Stafford Act authorizes the President to issue a major disaster or an emergency declaration in response to an event (or threat) that overwhelms state or local government." In order to trigger the Stafford Act, the governor of the affected state must respond to the disaster, implement the state emergency plan, and determine that the emergency cannot be managed by the state. The governor then requests that the President declare an emergency. Under the Stafford Act, states have access to emergency funds and the assistance of the Federal Emergency Management Agency (FEMA).

A clinic that specializes in autoimmune diseases is interested in examining the relationship between Crohn disease and rheumatoid arthritis. A case-control study was conducted in 155 patients with Crohn disease and 200 patients without Crohn disease, and hospital records were examined to determine the presence or absence of rheumatoid arthritis. The study concluded that the odds ratio for patients with Crohn disease and rheumatoid arthritis relative to patients without Crohn disease who had rheumatoid arthritis was 1.65 with a 95% confidence interval of 0.80-2.50 (a critical p value of 0.05 was used)

The confidence interval is a range of values in which you could expect the mean of a data set to fall at a given probability. If, when evaluating odds ratios, the confidence interval contains the value 1, the null hypothesis is not rejected.

A 35-year-old female is having an exploratory abdominal surgery. The vessel that traverses the superior portion of the pancreas is noted during the procedure.

The distribution of the splenic artery is to the superior margin of the pancreas, greater curvature and posterior stomach body, and spleen. It originates from the celiac trunk.

An 18-year-old male in surgery has been found to have absent blood flow to his short gastric arteries.

The main supply to the short gastric arteries originates from the splenic artery, which originates from the celiac artery.

Which intervention will most likely reduce mortality in person with COPD?

The only two interventions that have been shown to improve mortality in persons with COPD are smoking cessation and supplemental oxygen administration (if the patient qualifies for it). Criteria for use of oxygen in COPD include PaO2 less than 55 mmHg or less than 59 mmHg with signs of polycythemia or cor pulmonale.

A 45-year-old male presents to his primary care physician with the complaint of shortness of breath for the past 2 months. The patient has a heart rate of 103/min, blood pressure of 142/93 mmHg, and respiratory rate of 24/min. Arterial blood gases show hypoxia and respiratory alkalosis. His body mass index is 26 kg/m2. Results from a pulmonary function test and a helium dilution test show that functional residual capacity, inspiratory capacity, residual volume (RV), vital capacity, and total lung capacity (TLC) are reduced.

The results of the pulmonary function tests in this case scenario suggest that this patient has a restrictive pulmonary disease. In restrictive lung diseases, all of the lung volumes and capacities are decreased, and the flow-volume curve is reduced in width and amplitude and shifted to the right. With restrictive lung diseases, although the lung volumes and flow rates are decreased, the flow in relation to the lung volume is actually normal or greater than normal. - By contrast, in obstructive airway diseases (eg, asthma, chronic obstructive pulmonary disease), there is air trapping, so the flow-volume curve is shifted left; in this case, the RV and TLC are increased. With obstructive lung diseases, there is increased resistance, so both inspiratory and expiratory airflow are reduced. The expiratory flow is reduced more than the inspiratory flow because of dynamic airway compression, the partial collapse of the airways at the end of a forced expiration (due to positive pleural pressure). This partial collapse accounts for the "scooped" appearance of the flow-volume curve for obstructive lung diseases.

A 58-year-old African-American male presents to the community health clinic with the complaint of nausea, vomiting, and diarrhea for the past four days. He has a history of chronic obstructive pulmonary (COPD) disease and physical examination reveals a barrel-shaped chest and a prolonged exhalation phase with decreased bibasilar breath sounds. He states he has been taking a medication for his COPD every day for the past two years. However, his primary care physician started him on a pill last week due to an infection he had between his toes. What is the most likely medication this person has been taking for his COPD?

Theophylline has a narrow therapeutic level and can easily become toxic due to a medication interaction. Some of its many toxic effects involve the gastrointestinal tract and include nausea, vomiting, and diarrhea. - This patient was likely prescribed ketoconazole for his tinea pedis infection. The ketoconazole inhibited the cytochrome P-450 system, resulting in theophylline toxicity. Acute theophylline toxicity usually causes predominately gastrointestinal disturbances. Individuals will complain of nausea, severe and protracted vomiting, diarrhea and abdominal pain

A 10-year-old Asian-American male presents with 1 month of abdominal pain, bloating, and diarrhea. The pain is intermittent and occurs approximately 15-20 minutes after eating meals. The symptoms are especially present after eating ice cream, cheese, chocolate, and drinking milk. The patient's mother states that approximately one month ago the patient was diagnosed with Rotavirus gastroenteritis.

This child has lactase deficiency commonly referred to as lactose intolerance. It is an autosomal recessive deficiency. The patient is experiencing a secondary deficiency of lactase. There is a loss of the brush border of the intestines due to his prior viral gastroenteritis infection.

A 23-year-old male is brought to the Emergency Department with a knife wound in his side. He complains of severe dyspnea and a sharp pain with inspiration. Physical examination reveals absent breath sounds on the right, the right side of the thoracoabdominal diaphragm in an inhaled position relative to the left, and paravertebral hypertonicity from T2-T6. The most likely additional finding in this patient would be...

Tracheal deviation to the left - This patient has a tension pneumothorax, which is commonly caused by a penetrating trauma to the lungs. A flap-like tear, which acts as a one-way valve, allows air into the chest cavity, but does not allow it out. Ultimately, this causes a buildup of intrathoracic pressure on one side. The pressure gets so high it literally pushes the mediastinal structures (trachea, heart, and great vessels) to the opposite side.

A 58-year-old male presents to the clinic to schedule his first screening colonoscopy. He has no complaints and denies changes in bowel habits or blood in stool. You note paravertebral hypertonicity in the upper lumbar area bilaterally; otherwise, the physical exam is normal. A suspicious lesion is discovered during the colonoscopy.

Tubular adenomas are the most common polyps found on colonoscopy, with their characteristic stalk attached to the intestinal wall.

A 72-year-old male with a 40-pack-year history of cigarette smoking presents to his primary care physician with cough, dyspnea, and a 9 kg (20 lb.) weight loss over the past three months. He admits to feeling tired all the time and states that his "bones hurt." Laboratory studies reveal hypercalcemia. Chest radiography is positive for a mass in the left lung. What are the most likely histologic findings of the lung tumor?

Tumor cells that produce keratin - Squamous cell carcinoma can secrete PTHrP, causing hypercalcemia. Histologic diagnosis of squamous cell carcinoma is predicated upon the presence of keratin production by tumor cells and/or intercellular desmosomes (referred to as "intercellular bridges").

A 65-year old male with a history of chronic hepatitis B presents with worsening ascites. On laboratory examination, the patient has a serum ALT of 75 U/L and AST of 80 U/L. His hepatitis B virus (HBV) DNA measures 10,000 copies/mL. An abdominal CT is performed revealing a hepatic lesion with poorly defined margins. His serum alpha-fetoprotein is elevated at 68 µg/L. Liver biopsy confirms the diagnosis of hepatocellular carcinoma. Which of the following best describes the mechanism by which HBV leads to development of cancer?

Viral integration into host genome - HBV can cause HCC in the absence of cirrhosis by integrating into the DNA of hepatocytes and acting as a mutagen; increased chromosomal instability and interference of DNA repair and apoptosis; uncontrolled cellular proliferation and malignant transformation

An 87-year-old male, residing in an assisted living home, presents to an in-house physician reporting repeated episodes of abdominal pain and distention. History of the patient reveals reports of constipation over the past year and previous diagnosis of pancolitis and dolichocolon, for which he has been on mesalazine treatment for the past few years. Physical examination reveals abdominal distension, with tympanic sounds on percussion. The patient has no signs of toxicity. The most likely diagnosis is...

Volvulus - occurs when part of the bowel twists on its mesentery often resulting in bowel obstruction.

A 5-year-old female presents to the clinic for evaluation of diarrhea and a mild cough. She recently returned from Africa with her family. Stool sample and microscopy reveals the presence of Strongyloides stercoralis larvae. This infection could have most likely been prevented by...

Wear appropriate footwear - Strongyloidiasis, a parasitic infection caused by the nematode Strongyloides stercoralis, is most commonly acquired from bare feet on contaminated soil.

A group of researchers in southern California is studying the relationship between alpha-fetoprotein (AFP) and hepatocellular carcinoma. In high-risk patients, an AFP level of 500 ng/mL is diagnostic for the presence of liver cancer. For their project, the researchers have decided to decrease the hepatocellular carcinoma screening threshold level of AFP to 400 ng/mL. What best describes the impact of lowering the screening threshold?

Whenever the threshold of a positive diagnostic or screening test is decreased, it is more likely that a subject in the study will have a positive result on the test. Lowering the test threshold for a disease increases the sensitivity, because TP increases and FN decreases, so TP / (TP + FN) increases. Remember that the total number of people who actually have the disease doesn't change, just the test's ability to detect the disease.

A 66-year-old Caucasian male presents with his wife to his primary care physician complaining of abdominal pain, foul-smelling diarrhea, joint pain, and weight loss for the past few months. His wife says he's also been confused lately. He denied recent travel and sick contacts. On physical exam, adenopathy is present with abdominal distention. He is sent home with a prescription for antibiotics that cover gram positive bacteria. By what mechanism does the suspected organism cause disease?

While in the small intestine, macrophages that phagocytose the organism compress the lacteals, preventing absorption of chylomicrons - Whipple's disease typically presents with a combination of foul-smelling diarrhea, abdominal distention, joint pain, neurological and cardiac problems, as this is a systemic infection

Negligence

not providing the standard of care appropriate to the situation. You expect a different standard of care from a family practice than you do from an emergency department

45-year-old female presents to the ED with an acute episode of dyspnea; admits to asthma, and states that her shortness of breath has developed slowly over the past two days. Her vital signs are as follows: temp 37ºC (98.6ºF), HR of 154/min, RR of 30/min, BP of 164/85 mmHg, and pulse-oximetry at 84% on room air. On physical examination, the patient has decreased breath sounds, labored respirations with subcostal retractions, and extensive rales and wheezing throughout every lung field. The patient's blood work returns from the lab. Her complete blood count with differential shows an elevated white blood cell count of 12,900/mm3 and serum eosinophilia of 22%. The patient's husband informs the medical staff that she complained of right arm pain with numbness and paresthesias yesterday. The remainder of her laboratory findings would include a positive...

pANCA - This patient is most likely suffering from Churg-Strauss syndrome, also known as allergic granulomatous angiitis. Criteria : •Asthma •Eosinophilia > 10% •Sinusitis •Pulmonary infiltrates •Vasculitis •Polyneuropathy

Volunteer Protection Act

provides a minimum level of liability protection for volunteers who are part of large, organized volunteer efforts. The VPA may serve to protect individuals, for example, working on large-scale disaster relief efforts.

Malpractice

to have malpractice, the physician must have a duty to the patient and have either neglected or breached the duty and caused the patient some form of harm

Turcot's syndrome

variant of familial adenomatous polyposis that also presents with CNS malignancies, such as medulloblastoma or malignant glioma. - Glioblastoma is an aggressive form of astrocytoma and medulloblastoma is a type of brain tumor that arises from granular cells in the cerebellum.