Amboss Fam Need-to-Know (12/1-12/5)

1. Marfan syndrome 2. aortic regurgitation ("3/6 diastolic murmur heard along the left sternal border") - the clinician will feel rapid engorgement of the artery followed by a significant, prompt collapse of the vessel. This is due to the incompetent aortic valve failing to maintain adequate diastolic pressure in the arterial system, which also causes a widened pulse pressure. - Other findings of aortic regurgitation include pulse synchronous head nodding (de Musset's sign) and, occasionally, a rumbling, low-pitched mid-diastolic murmur (Austin Flint murmur) that is caused by the regurgitant blood striking the anterior leaflet of the mitral valve, leading to a premature closure of the mitral leaflets.

14 yo teenager with tall stature, scoliosis, pectus deformity, thin extremities, upward displacement of the lenses likely has __1__. - A "water hammer" pulse is a classic finding on cardiovascular examination in patients with __2__, which is common in patients with Marfan syndrome

1. mild ulcerative colitis 2. topical 5-aminosalicylic acid derivatives (like mesalamine)

16 yo patient has __1__, which is defined as having < 4 stools/day (that can occasionally be bloody) and lacking signs of systemic illness (e.g., fever, tachycardia, anemia, and an ESR ≥ 30 mm/h). The first-line treatment for mild UC is __2__, since they are effective in controlling the symptoms of mild UC and have fewer adverse effects than glucocorticoids.

1. vitamin D deficiency 2. Rickets - Defective growth plate mineralization due to vitamin D deficiency - The physical exam findings are also classic for rickets, including erosion of tooth enamel, frontal bossing, widened joints, varus knee deformity (genu varum), and beading of the ribs ("rachitic rosary"). 3. Dietary changes (increased vitamin D, calcium, and phosphate) and adequate sun exposure are the first line treatments for rickets.

18 mo old child presents with a history of exclusive breastfeeding along with lack of supplements. - His clinical features of frontal bossing, beading of the ribs, widened wrists, bowing of the legs, and erosion of tooth enamel are suggestive of __1__ deficiency. - The malnutrition seems to arise from domestic neglect as suggested by the elder sibling's failure to thrive, the lack of medical attention after a seizure, the lack of vaccinations, and improper feeding practices. 2) What condition does this pt have? 3. What is 1st line tx?

1. Allergic contact dermatitis (type IV hypersensitivity reaction) - typically presents 12-48 hours after repeated contact with an allergen. - In this case, the patient is exposed to wire braces that can contain nickel among other substances, leading to allergen sensitization. Nickel allergy is the most common metal allergy (accounting for more allergies than all other metals combined). 2. Nickel allergy is confirmed with a patch test. - If the results are positive for nickel hypersensitivity, the braces should be replaced with braces that are either made of stainless steel with very low nickel content or a titanium molybdenum alloy.

18 yo patient presents with edema, pruritus, vesicles, and ulcers localized to the buccal mucosa directly in contact with recently installed orthodontic braces. - Since stroking of the skin did not cause blister formation, Nikolsky sign is negative in this patient. 1). What is the cause of the symptoms? 2). how do you confirm this?

1. The most common causes of bacterial cervicitis are Chlamydia trachomatis and Neisseria gonorrhoeae. 2. NAAT of vaginal fluid is the test of choice in the diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae. - NAAT provides a rapid result, has a high sensitivity, and can differentiate between C. trachomatis and N. gonorrhoeae infection. It has therefore widely replaced tests such as cultures and Gram staining.

19 yo with yellow mucopurulent discharge with a foul scent, bleeding after sexual activity, and a friable cervix on pelvic examination are all suggestive of bacterial cervicitis. 1). What are the most common causes of this? 2). How do you Dx?

1. congenital toxoplasmosis 2. Combination of pyrimethamine, sulfadiazine, and leucovorin rescue for 1 year.

2 day old newborn with: - chorioretinitis, - diffuse intracranial calcifications, - signs of hydrocephalus (enlarged head circumference, ventriculomegaly), - and sensorineural hearing loss ...are indicative of __1__ - The diagnosis is further supported by the presence of purpuric rash, jaundice, seizures, and signs of intrauterine growth restriction (premature birth, small for gestational age). 2). How is this tx?

1. DiGeorge syndrome - congenital disorder caused by microdeletion on the long arm of chromosome 22. - The clinical presentation is variable and includes features such as congenital heart defects, craniofacial abnormalities, and/or defective development of the third and fourth pharyngeal pouches, resulting in hypoplastic thymus and parathyroids. 2. T cells - important part of cell-mediated immunity, which is especially vital to viral and fungal immunity. - occurs due to hypoplastic thymus

2 yo boy has a history of multiple and chronic infections that seem to be caused by viral and fungal pathogens. -he has a prominent nasal bridge, hypoplastic wing of the nose, shortened chin, and dysplastic ears. 1). What does this child have? 2). this pt has a deficiency in what?

1. iron deficiency anemia - The most important underlying mechanisms for this association are the low iron content of cow milk and the inhibition of iron absorption caused by milk ingredients, especially calcium and casein.

2 yo boy presents with fatigue, conjunctival pallor, angular cheilitis, and a history of drinking large amounts of cow's milk. Altogether, these features are highly suggestive of __1__.

1. anorexia nervosa 2. Inpatient nutritional rehabilitation is indicated in this patient with unstable vital signs, mild hypoglycemia, and anorexia nervosa. -While most complications of anorexia nervosa can be dealt with in an outpatient setting, this patient's bradycardia requires hospitalization to prevent syncope, heart failure, and sudden cardiac arrest or death. - Other criteria for hospitalization include cardiac dysfunction, weight < 70% of ideal body weight or BMI < 15 kg/m2, and acute medical complications of malnutrition such as syncope, seizures, liver failure, pancreatitis, hypoglycemia, or electrolyte disturbances. 3. Bradycardia is a compensatory response to caloric deprivation and generally resolves once the patient's weight is restored by refeeding.

21 yo female has a BMI < 18.5 kg/m2, follows a strict diet and exercise regimen, and presents with lanugo hair, bradycardia, and hypoglycemia, all consistent with __1__. 2). What is the best tx for this pt? 3). Why is this pt bradycardic?

1. incomplete abortion -Passage of some but not all products of conception (POC) before 20 weeks' gestation. 2. Expectant management

22 yo female at 12 wks gestation presents with hours of abd cramping and passing large vaginal blood clots. -Uterus 12 wk size -open cervical os and blood clots within the vaginal vault -TVUS shows an empty gestational sac. 1). What is the Dx? Tx: __2__ is a reasonable treatment option in patients with an incomplete abortion at < 14 weeks' gestation that are hemodynamically stable, show no signs of infection, and do not want to undergo invasive procedures such as this patient. - If expulsion of the remaining products of conception does not occur within four weeks or if signs of infection occur, surgical treatment is indicated. - Medical evacuation (e.g., with misoprostol) is another option in patients that do not want to undergo surgical treatment.

1. premenstrual syndrome 2. premenstrual dysphoric disorder (PMDD) 3. SSRIs - recommended by the ACOG as first-line therapy for PMDD, the severe form of premenstrual syndrome, as they have been shown to be effective in alleviating physical and behavioral symptoms with minimal side effects. Nicotine is a known triggering factor for PMS, the patient may also be advised to stop smoking.

25 yo female patient presents with recurrent episodes of headaches, sleeping and concentration problems, and mood swings. These symptoms occur every month around the same time, preceding her menstrual period, which indicates __1__. Behavioral changes severe enough to cause a disturbance of her daily functional capacity suggests a diagnosis of __2__. 3). What is the Tx?

1. Combined oral contraceptives - decrease pelvic pain, the size of endometriotic lesions, and the recurrence of lesions. 2. Pelvic US 3. Laparoscopy

25 yo pt with endometriosis. -NSAIDs were tried with no relief. 1). What is the next step? 2). And after that? 3). and after that?

1. systemic lupus erythematosus (SLE) 2. SLE is an autoimmune disease characterized by the formation of antibodies and immune complexes that then deposit in different tissues, which causes inflammation and organ dysfunction. These antibodies can activate the complement cascade, leading to low serum levels of C3 and C4, which indicate active disease. 3. Anti-histone antibodies are present in approx. 95% of cases of drug-induced lupus erythematosus (DILE).

26 yo young African-American woman presents with pleuritis (cough, chest pain, dyspnea), nephritis (hematuria), arthritis, facial rash, a low-grade fever, and a history of multiple miscarriages, which should raise suspicion for __1__. 2). Why would you expect to see low serum C3 and C4 in this pt? 3). If this was Drug-Induced SLE, what Antibodies would you expect to see?

1. anemia 2. hemolysis 3. hemagglutinin 4. Warm agglutinin disease 5. Initial treatment with glucocorticoid therapy is effective in most patients, but some may require rituximab or splenectomy. 6. A rare form of autoimmune hemolytic anemia that typically affects elderly women. - Hemolysis is predominantly caused by IgM antibodies that bind to and agglutinate erythrocytes at temperatures of 4-30°C. - Patients often complain of painless cyanosis in the extremities (acrocyanosis). - Cold-agglutinin disease is usually idiopathic but may occasionally be associated with lymphomas and infections such as Mycoplasma pneumonia, infectious mononucleosis, HIV, and viral hepatitis.

27 yo pt with clinical signs of __1__ (fatigue, pallor) and __2__ (increased LDH, undetectable haptoglobin) as a result of __3__ formation (positive direct antiglobulin test). 4). This pt has __4__ = An autoimmune hemolytic anemia caused by circulating IgG antibodies to erythrocytes. 5). What is tx? - The etiology of this patient's autoimmune hemolytic anemia is likely secondary to his recent cephalosporin intake, which is known to precipitate warm agglutinin disease. - Other associated conditions that may precipitate warm agglutinin disease include SLE, immunologic malignancies (e.g., non-Hodgkin lymphoma, CLL), viral infections, and HIV. 6) How is this different from cold agglutinin disease?

1. sarcoidosis 2. Monitoring - Most patients with isolated pulmonary sarcoidosis do not require treatment, as the disease is often asymptomatic and nonprogressive with a high rate of spontaneous remission 3. Glucocorticoids - The first-line treatment for patients with symptomatic pulmonary sarcoidosis (e.g., dyspnea, cough, chest pain) or extrapulmonary manifestations of sarcoidosis (e.g., ocular or cutaneous symptoms) is oral glucocorticoid therapy.

30 yo AA woman presents for routine follow-up, ahe is asymptomatic. -serum Cr, and Ca+ are within noral limits. -ECG is normal. -Tb skin test in negative. -Mother dies of progressive lung disease at 50 yrs old. -patient's x-ray shows bilateral, cauliflower-shaped hilar masses consistent with bilateral hilar lymphadenopathy. This is a classic finding in patients with __1__. 2). What is the Tx with this pt? 3). What if she were symptomatic?

1. Primary polydipsia - Excessive oral intake of fluid in the absence of physiologic stimulus to drink. - May include psychogenic polydipsia secondary to psychoses or other mental disorders or non-psychogenic varieties. - The water deprivation test allows primary polydipsia to be differentiated from diabetes insipidus. Normal values of serum and urine osmolality after the water deprivation test indicate that both the release and effect of ADH are intact, ruling out diabetes insipidus and confirming the diagnosis of primary polydipsia. 2. obsessive compulsive disorder

30 yo female patient presents with polyuria and polydipsia. -After the water deprivation test, the patient's serum and urine osmolality are normal (serum osmolality increases to normal, urine osmolality increases significantly, as it should). 1). What is the Dx? 2). This is commonly associated with what psychiatric diseases?

1. hemolytic anemia 2. autoimmune hemolytic anemia (AIHA) - intravascular and extravascular hemolytic anemia typically caused by IgM or IgG antibodies. Associated with Mycoplasma infection, EBV infection, autoimmune diseases (e.g., systemic lupus erythematosus), and malignancies (e.g., non-Hodgkin lymphoma, chronic lymphocytic leukemia). - Spherocytes are a common finding on peripheral blood smear in AIHA. This is thought to be due to incomplete phagocytosis of the RBC membrane by splenic macrophages resulting in the formation of spherocytes. 3. The direct Coombs test detects antibodies bound to the RBC membrane, thereby confirming autoimmune hemolytic anemia.

30 yo female pt has jaundice, anemia, and dark-colored urine along with indirect hyperbilirubinemia, low haptoglobin, and elevated LDH, indicating __1__. - The occurrence of these features after symptoms of atypical pneumonia (non-productive cough, low-grade fever, and CXR with bilateral patchy infiltrates) indicates __2__. 3). What test will confirm this Dx?

1. hemolytic anemia 2. G6PD deficiency - This key enzyme of the pentose phosphate pathway is especially important for the production of NADPH in RBCs. Without it, NADPH levels sink and glutathione cannot be regenerated, leaving the RBCs more susceptible to the oxidative stress induced by many drugs, including isoniazid.

30 yo man presents with back pain, scleral icterus, dark urine, ↑ unconjugated bilirubin, ↑ LDH, ↓ haptoglobin, and hemoglobinuria. These features, especially in an individual of African, Mediterranean, or Asian descent, are suggestive of __1__, which most likely started following the intake of isoniazid. 2). What condition does this person have?

1. 3-2-1 rule 2. Lynch syndrome - hereditary cancer syndrome caused by a mutation in mismatch repair genes (MLH1 and MSH2). -Individuals have a significantly higher risk of developing colorectal, gastric, and endometrial cancer. 3. endometrial cancer 4. Hysterectomy with bilateral salpingo-oophorectomy

34 yo woman has three family members with gastrointestinal cancers in two different generations, and one relative was under the age of 50 when diagnosed (__1__ rule). This fulfills the Amsterdam II criteria for __2__. The most common extracolonic malignancy associated with Lynch syndrome is __3__. Affected individuals, such as this patient, have a ∼ 40% lifetime risk (depending on the type of mutation) of developing endometrial cancer, with most cases occurring in premenopausal women. __4__ at the end of childbearing age (∼ 40 years) is recommended.

1. nephrotic syndrome 2. hypocalcemia 3. focal segmental glomerulosclerosis (FSGS) - Characterized by segmental thickened glomerular capillary loops on light microscopy, IgG and C3 deposits in the sclerotic regions, and effacement of podocytes on electron microscopy. - most common cause of nephrotic syndrome in black populations - associated with heroin abuse, obesity, sickle cell disease, and HIV infection. - Without immunosuppressive treatment, focal segmental glomerulosclerosis usually leads to end stage renal disease (ESRD). 4. appears as segmental sclerosis under light microscopy

35 yo AA pt with HIV has several features of __1__: i.e., swelling of the face and extremities, hypoalbuminemia, hypercholesterolemia, hypertension, weight gain, symptoms of __2__ (paresthesias, muscle cramping), and heavy proteinuria (4+ on urine dipstick). The most likely diagnosis is __3__: a condition that is more common among patients with HIV infection and also the most common cause of nephrotic syndrome in black populations. 4). How does this appear under light microscopy?

1. sarcoidosis - idiopathic, chronic inflammatory disease characterized by the formation of noncaseating granulomas, typically in the lung and, less commonly, in the liver, eyes, and skin - Biopsy is the gold standard for diagnosis. -First-line treatment is corticosteroids. 2. noncaseating granulomas (shown in pic) - T-cell dysfunction and increased B-cell activity lead to local immune hyperactivity, inflammation, and subsequent formation of noncaseating granulomas. 3. In sarcoidosis and other granulomatous diseases (e.g., tuberculosis), expression of 1α-hydroxylase is increased in macrophages. This enzyme hydroxylates 25-hydroxyvitamin D to its active form and results in chronic, increased calcium resorption.

35 yo female african american patient presents with a 6-month history of cough, exertional shortness of breath, and bilateral ankle pain. - In combination with the finding of hypercalcemia and hilar lymphadenopathy, these features suggest a diagnosis of __1__, which is most common in young, black women. Granulomatous inflammation resulting in __2__ is the hallmark of sarcoidosis. - The lung and the lymphatic system are most commonly affected, although it can affect any organ. 3). Why would this cause hypercalcemia?

1. Propranolol - Beta blockers decrease the adrenergic tone and therefore reduce tachycardia, control hypertension, improve muscle weakness, tremor, and neuropsychiatric symptoms. - Propranolol, in high doses, also decreases the peripheral conversion of T4 to T3 by inhibiting the 5'-monodeiodinase enzyme. 2. Thyroid hormones affect cardiac myocytes directly and also stimulate proliferation of beta-adrenergic receptors, which can cause cardiac arrhythmias

35 yo female patient with anxiety, tremor, digital swelling, retraction of the eyelid, and irregular heartbeats most likely has hyperthyroidism. -__1__ is indicated for the immediate control of symptoms in patients with hyperthyroidism. 2). How does hyperthyroidism cause these cardiac symptoms?

1. Cushing syndrome 2. primary hypercortisolism - typically caused by autonomous overproduction of cortisol by the adrenal gland (most commonly due to adrenal adenoma)--> suppresses pituitary secretion of ACTH, leading to low ACTH levels and ACTH-independent Cushing syndrome, as seen here. 3. Adrenalectomy - The treatment of choice for patients with adrenocortical tumors is laparoscopic or open adrenalectomy. After surgical therapy, patients who develop adrenal insufficiency require lifelong glucocorticoid replacement therapy. 4. This patient's hypernatremia and hypokalemia are most likely due to the mineralocorticoid effect of high levels of cortisol.

40 yo female patient has classic features of __1__, including: - weight gain, - hyperglycemia, - proximal muscle weakness, - menstrual cycle changes, - truncal obesity, striae, - hirsutism, and hypertension. Her low ACTH levels indicate __2__. 3). What is the tx? 4). Why would this pt have elevated Na+ and low K+?

1. rheumatoid arthritis 2. Methotrexate is a disease-modifying antirheumatic drug (DMARD) and the first-line, long-term therapy for moderate-to-severe rheumatoid arthritis. - Early administration of DMARDs is crucial, because damage to the affected joints occurs early in the course of RA. - Methotrexate is highly effective, well-tolerated, and inexpensive but has a slow onset of action (> 6 weeks). For this reason, bridging therapy with glucocorticoids or NSAIDs is normally indicated during acute attacks 3. salvage therapy (leucovorin rescue) - used to treat folic acid deficiency or to prevent adverse effects (e.g., myelosuppression) when administering antifolate drugs such as methotrexate. Administration 24 hours after administration of antifolates

42 yo female pt presents with a history of joint pain in > 2 small and medium size joints for more than 6 weeks. - The x-ray shows joint surface destruction and narrowed joint spaces of the metacarpophalangeal, proximal interphalangeal, and wrist joints. -In addition, the distal interphalangeal joints are spared, which is typical for __1__. 2). What is Tx? The side effects this tx can be reduced by administering __3__ 24- 48 hours after.

1. sicca syndrome 2. Sjögren syndrome 3. SS is diagnosed either via detection of Anti-Ro/SSA antibody and anti-La/SSB antibodies, or evidence of lymphocytic infiltration on salivary gland biopsy.

43 yo female patient has polyarthritis, anemia, a raised ESR, and positive anti-nuclear antibodies, which suggests a rheumatic disease. Additionally, she has xerophthalmia (dry eyes) xerostomia (dry mouth), the combination of which is also known as __1__ syndrome. Xerophthalmia can lead to corneal defects, and xerostomia is a risk factor for dental caries and oral infections. These features are consistent with the diagnosis of __2__. -Anti-Ro/SSA antibody and anti-La/SSB antibody are present in about 70% of patients with this! (target ribonucleoprotein antigens (Ro/La) of epithelial cells, especially those of the salivary glands) 3). How do you Dx this?

1. diffuse systemic sclerosis - systemic sclerosis= an autoimmune disease of connective tissue that causes thickening of the skin from collagen accumulation as well as microvascular dysfunction injury. 2. anti-topoisomerase I antibodies (anti-Scl-70) Anticentromere antibody is the main parameter for limited systemic sclerosis, which may also show positive testing for anti-Scl-70.

43 yo female patient presents with typical clinical findings of __1__, including: - sclerodactyly (skin tightness and thickening, nonpurulent ulcers), - pulmonary fibrosis (fine, inspiratory crackles) - and GERD (chest pain, weight loss) due to esophageal dysmotility. -this is commonly associated with __2__ antibodies, which can be found in up to 70% of individuals and indicates a poor prognosis.

1. Kaposi sarcoma caused by HHV8 - malignant skin tumor associated with HIV infection - presents with multiple rapidly growing, painless cutaneous tumors that typically affect the face, chest, heels, and oral cavity. - The diagnosis is confirmed on detection of spindle-shaped cells, leukocyte infiltration, and signs of angiogenesis in skin biopsies. - originates from endothelial cells and occurs predominantly in patients who are immunosuppressed Causes solitary or multiple nodular, purplish, blue-violet, or reddish-brown, submucosal, and painless skin plaques. Internal organ involvement is possible.

45 yo pt with multiple lesions on lower extremities. -non-painful, non-pruritic -He has HIV -skin biopsy shows multiple spindle-shaped cells and leukocyte infiltration 1). What does this pt have?

1. Whipple's disease - infectious disease caused by the bacteria Tropheryma whipplei. It is notoriously difficult to diagnose because of its variable presentation. Findings often include chronic malabsorptive diarrhea, weight loss, migratory non-deforming arthritis, lymphadenopathy, and a low-grade fever. 2. PAS-positive macrophages in gastrointestinal biopsy specimens are a hallmark finding in Whipple's disease. 3. Whipple's disease is treated with IV ceftriaxone for 2 weeks followed by maintenance treatment with oral trimethoprim-sulfamethoxazole for 1 year.

45 yo pt with symmetric oligoarthritis, loose stools, symptoms of malabsorption, cardiac symptoms (diastolic murmur) and generalized lymphadenopathy indicates __1__. 2). What would be seen on a GI biopsy? 3). How do you tx this?

Viral pathogens can cause activation and degranulation of cutaneous mast cells--> release of histamine and other mediators (e.g., prostaglandin, platelet-activating factor, leukotrienes).--> pruritic, erythematous, and confluent plaques (urticaria), as seen in this patient. - While acute urticaria due to viral illness is very common in children, it is also not a rare occurrence in adults.

48 yo male presents with urticarial rash 4 days after an upper respiratory infection. -rash is nontender and blanchable. Why did this happen?

1. iron poisoning - Presents with hemorrhagic gastroenteritis, dark-colored stools (i.e., false melena), shock symptoms, and possibly renal or liver failure. 2. Deferoxamine - used in acute iron intoxication to chelate excess iron from blood, which is then filtered in the kidneys and excreted in the urine.

5 yo boy who got into pregnant mothers medicine cabinet presents with abdominal pain, dark-colored stools (caused by iron directly and/or gastrointestinal bleeding), vomiting, leukocytosis, and anion gap metabolic acidosis. This indicates __1__ poisoning. 2). What is the tx?

1. hypothyroidism 2. carpal tunnel syndrome (CTS) 3. It is assumed that the excess deposition of glycosaminoglycans, hyaluronic acid, and mucopolysaccharides in hypothyroidism causes myxedema --> depositions subsequently cause compression of the carpal tunnel. 4. thyroid hormone replacement and return to a euthyroid state, symptoms should improve within weeks to months.

50 yo pt presents with classic signs of __1__: constipation, fatigue, bradycardia, hyporeflexia, and lower limb edema (which is usually myxedematous and non-pitting, but pitting edema can also occur due to excessive albumin in extracellular spaces). -She has neuropathic pain along the distribution of the median nerve that is consistent with__2__. 3). Why would this pt be more inclined to developing this? 4). What is the tx?

1. cANCA-titers - autoantibody against proteinase-3 (present in neutrophil cytoplasm) that is found in patients with vasculitides, particularly granulomatosis with polyangiitis. 2. Granulomatosis with polyangiitis (GPA, previously known as Wegener granulomatosis) -a systemic vasculitis that affects both small- and medium-sized vessels. 3. glucocorticoids 4. methotrexate, cyclophosphamide, or rituximab.

52 yo male patient presents with nephritic sediment (hematuria, RBC casts, moderate proteinuria), ↑ creatinine and blood urea nitrogen (BUN), and a productive cough. - Simultaneous involvement of the kidneys and the lungs, as seen here, is characteristic of pulmonary-renal syndrome. -Along with a history of chronic sinusitis, saddle nose deformity, necrotic skin lesions, and ↑ ESR, this case indicates a type of vasculitis that typically presents with elevated __1__ titers. 2). What does this pt have? This is treated with immunosuppressive drugs, typically __3__ combined with __4__.

1. peripheral arterial disease (PAD) 2. Ankle-brachial index -the initial step in the management of PAD because it is a readily available and noninvasive test to diagnose peripheral vascular occlusion. - - values between 0.4-0.9 indicate mild to moderate PAD with claudication - values below 0.4 correlate to severe PAD with resting pain and/or gangrene. 3. Duplex sonography is the best initial test in suspected acute limb ischemia (ALI) - onset of ALI is typically acute, involving severe, acute pain, tingling, and weakness in the leg. This patient has had pain associated with walking for the past two months.

53 yo female with the presence of claudication pain, skin changes, and diminished pulses in a chronic smoker should alarm for __1__ Fontaine stage II. 2). What is the nest initial step in the management of this? 3). Why wouldnt duplex US be indicated?

1. microscopic polyangiitis **look over sketchy** - Patients with this disease can present with chronic cough and hemoptysis in addition to nonspecific symptoms such as fatigue, myalgia, and weight loss. Skin lesions such as palpable purpura are also a common feature. 2. Perinuclear antineutrophil cytoplasmic autoantibodies (p-ANCA), specifically anti-MPO (myeloperoxidase) antibodies are positive in 90% of patients with microscopic polyangiitis (MPA) 3. little or no immune deposits (pauci-immune glomerulonephritis).

53 yo pt presents with cough, bloody sputum, and a urine analysis indicating glomerulonephritis. - The palpable purpura on examination and the skin biopsy findings are indicative of a small-vessel vasculitis. - In the absence of granuloma formation, __1__ is the most likely diagnosis. 2). What antibodies are positive in 90% of pts with this? 3). A kidney biopsy would show what?

1. multiple myeloma (MM) 2. Bone marrow biopsy (as with other hematological malignancies) - Pathological findings consist of either destruction of the bone marrow by malignant clonal "fried-egg" appearing plasma cells or a discrete plasmacytoma--> Malignant expansion --> painful lytic bone lesions (causing hypercalcemia) and loss of bone marrow functionality (i.e., anemia). -Plasma cells in MM are monoclonal and lead to an overproduction of a single antibody or light chain resulting in kidney damage and immunodeficiency.

55 yo male with the presence of unexplained anemia, bone pain, hypercalcemia, and lytic lesions on x-rays in a patient with features of renal failure (i.e., edema, oliguria, elevated urea and creatining) are strongly suggestive of __1__. 2). What is required to Dx this? -In addition to bone biopsy, diagnosis requires one additional finding of end-organ damage (remembered by the acronym CRAB) or biomarker of malignancy. CRAB: Calcium increased > 11 mg/dL, Renal insufficiency (creatinine clearance < 40 mL/min or serum creatinine > 2 mg/dL), Anemia (Hb < 10 g/dL), Bone lesions on MRI.

1. Bisphosphonates (e.g., alendronate) can directly injure the esophageal mucosa in case of prolonged contact and cause drug-induced esophagitis. - condition characterized by esophageal mucosal irritation (e.g., from increased acidity, alkalinity, or osmolality) caused by oral medications. Common causes include antibiotics, anti-inflammatory drugs (e.g., aspirin) and bisphosphonates. 2. Discontinue alendronate - Most cases will then heal without further intervention. To minimize recurrence, medications should be switched to liquid formulations or taken with liquids or meals to minimize the risk of the drug tablet sticking in the esophagus. - Remaining upright for 30 minutes after taking the drug is also effective Other common medications that can cause drug-induced esophagitis include antibiotics (e.g., tetracyclines, clindamycin), NSAIDs, potassium chloride, quinidine, and iron compounds.

60 yo female presents with with retrosternal chest pain and odynophagia. - finding on upper endoscopy is a punched-out ulcer with normal surrounding mucosa, often located at a site of anatomic narrowing (e.g., the gastroesophageal junction). 1). Knowing that this pt is taking alendronate is significant, why? 2). What is the best next step?

1. Paget Disease of the Bone - lowly progressive skeletal disease characterized by increased bone turnover. Causes normal lamellar bone to be replaced by weak, woven bone. Most likely genetic. - Most patients are asymptomatic, and bone pain is a late manifestation of the disease 2. Cortical thickening and prominent trabecular markings - While osteolytic bone lesions may be seen earlier in the course of the disease, late disease is dominated by sclerotic bone with cortical thickening, and microfissures and fractures are also common. 3. bisphosphonates

60 yo pt with progressive pain in his right hip and lower back over past 4 wks. -pain is dull and constant, worse with exertion and at night -Has mild hearing loss and isolated elevation of alkaline phosphatase. (Ca+ and PO4- are normal) 1). What does this pt most likely have? 2). What is be shown on X-Ray? 3). What is tx?

1. aortic regurgitation 2. left ventricular enlargement and myocardial hypertrophy 3. left heart failure 4. increase afterload 5. transthoracic echocardiography

62 yo pt has an early diastolic decrescendo murmur that is heard best on the left sternal border and, therefore, suggests __1__. --> this causes widened pulse pressure with decreased diastolic blood pressures. -Over time, this increase in preload causes __2__. In patients with chronic aortic regurgitation, as seen here, signs and symptoms of __3__ (exertional and nocturnal dyspnea, S3 gallop) occur as soon as the left ventricle becomes unable to maintain a normal cardiac output. -Maneuvers that __4__ (e.g., handgrip) increase the intensity of the associated murmur, as a result of the enlargement of regurgitation volume across the valve. The diagnosis should be confirmed with __5__.

1. rotator cuff tear - This patient is likely to have a chronic degenerative rotator cuff tear, which classically presents in older adults (> 50 years) with no history of trauma. 2. Musculoskeletal ultrasound (MSUS) is the most appropriate next step for the evaluation of rotator cuff tears. - MSUS is cost-effective, comparable to traditional MRI for rotator cuff tear evaluation, and allows for detailed visualization of specific shoulder regions at rest and during movement. - Typical ultrasound findings of rotator cuff tear include focal hypoechoic/anechoic areas, with evidence of fiber discontinuity, juxtaposed with the hyperechoic fibrillar pattern of undamaged tendon.

65 yo male with shoulder pain, tenderness of the greater tuberosity, a positive drop arm test, limitation of external rotation, and negative lidocaine injection test raise suspicion of a __1__. -there is no swelling or erythema -XRAY shows sclerosis of the acromion and humeral head. 2). What is the next step in management? Traditional MRI and magnetic resonance arthrography, which is slightly more sensitive than MRI and ultrasound for partial-thickness rotator cuff tears, are both reasonable next steps to rule out a tear in patients with high clinical suspicion but inconclusive or negative MSUS.

1. nephrotic syndrome - massive renal loss of protein (> 3.5 g/day) resulting in edema and hypoalbuminemia, hyperlipidemia, hypercoagulability (antithrombin III deficiency), and an increased risk of infection (loss of immunoglobulins). 2. proteinuria 3. Chronic inflammatory processes, like this patient's rheumatoid arthritis, can increase the production of serum amyloid A (SAA), an acute phase reactant. The resulting deposition of SAA causes reactive amyloidosis and commonly manifests as nephrotic syndrome due to renal deposition. Reactive amyloidosis = subtype of amyloidosis characterized by systemic deposition of serum amyloid A protein (AA protein) in multiple organs. 4. Likely secondary to chronic methotrexate use and/or anemia of chronic disease.

66 yo presents with fatigue and swelling of his legs/feet for 6 wks. -urine has been frothy - eyes have been puffy in the mornings -has HTN and Rh-factor (+) RA -current meds are amlodipine, methotrexate, and ibuprofen. This patient's history of long-standing rheumatoid arthritis has played an important role in the development of __1__, as evidenced by the pedal and periorbital edema and proteinuria. -His frothy urine is likely secondary to the __2__. 3). How does RA cause these kidney problems? 4). Why would this pt have anemia?

1. an inactive chronic hepatitis B infection 2. HBsAg 3. HBeAg 4. HBcAg (viral core antigen) - The presence of HBcAg antibodies indicate either a recent (anti-HBc IgM) or resolved or chronic (anti-HBc IgG) hepatitis B infection. 5. a chronic hepatitis B infection and low infectivity of this patient.

67 yo pt patient with chronic hepatitis B has a normal ALT level and a hepatitis B DNA load of less than 2,000 IU/mL which suggests __1__. __2__ is a protein on the surface of hepatitis B virus (typically the first evidence of infection). __3__ is a protein secreted by the virus that indicates viral replication and infectivity. __4__ is expressed by infected liver cells. The combination of: - positive HbsAg, - positive anti-HBe, - positive anti-HBc IgG, - and negative anti-HBs antibodies indicates __5__

1. Cardiac Stress test - typically performed to evaluate blood pressure, heart rate, and electrical conduction of the heart (ECG) while the patient exercises (usually on a treadmill). - Given his past medical history (stage 2 PAD) and 45 pack-years of smoking, this patient most likely has coronary heart disease. 2. Especially in older individuals with diabetes mellitus, coronary heart disease may present with gastrointestinal discomfort in the absence of retrosternal pain, as seen here.

68 yo male with 4-month history of nausea and abdominal discomfort that is exacerbated by large meals and exercise is consistent with atypical chest pain. - In addition, the patient's history of smoking, diabetes mellitus, hypertension, obesity, and peripheral arterial disease, are concerning for atherosclerosis as an underlying cause. 1). ECG is normal, what is the most appropriate next step? 2). What may contribute to his abnormal presentation? As in this patient, a resting ECG does not always show evidence of cardiac ischemia. This patient is likely to have an abnormal result on cardiac stress testing (e.g., ST depressions), secondary to inadequate coronary artery perfusion

1. nephrotic syndrome - massive renal loss of protein (> 3.5 g/day) resulting in edema and hypoalbuminemia, hyperlipidemia, hypercoagulability (antithrombin III deficiency), and an increased risk of infection (loss of immunoglobulins). 2. amyloidosis 3. multiple myeloma - Impaired kidney function with nephrotic syndrome is a typical presentation of light chain amyloidosis (AL amyloidosis), which often occurs in association with multiple myeloma. 4). Rouleaux formation - aggregation of erythrocytes with the appearance of a stack of coins on peripheral blood smear. - This aggregation is caused by increased concentrations of plasma proteins (e.g., fibrinogen, immunoglobulins). - Associated with multiple myeloma but is not specific to this condition. Widespread protein deposition due to amyloidosis may affect multiple organ systems like the heart, kidney, gastrointestinal system, and tongue. Therefore, patients may describe a variety of symptoms, like fatigue due to heart failure, edema and foamy urine due to renal failure, malabsoprtion, and macroglossia.

73 yo man presents with pitting edema of upper and lower extremities. -takes ibuprofen for chronic back pain -Labs show: - elevated BUN and Cr - very low albumin - 4+ protein in urine -renal biopsy w/Congo red stain shows apple-green birefringence under polarized light. =This patient presents with __1__ (proteinuria, hypoalbuminemia, edema). --> this along with the findings on renal biopsy (indicating __2__), make __3__ the most likely diagnosis. 4). What would be seen on peripheral smear?

1. Uremic platelet dysfunction. - Abnormal platelet adhesion and platelet aggregation in individuals with uremia is multifactorial and most likely occurs because of the presence of platelet function inhibitors, uremic toxins, and glycoprotein IIb/IIIa dysfunction. - Abnormalities in von Willebrand factor and thrombocytopenia may also play a role in increased bleeding tendency in patients with CKD. 2. bleeding time 3. normocytic

75 yo male presents with fatigue and black sticky stools (melena). -has a h/o polycystic kidney disease (Cr=6.1 respresenting CKD), HTN, and hyperlipidemia. - presents with clinical signs of uremia (flapping tremor, pruritus leading to excoriations) and gastrointestinal bleeding (melena). 1). Why would this pt be at risk for bleeding and anemia? - Laboratory findings that suggest dysfunctional platelet aggregation may include increased __2__ and __3__ anemia. -PT and aPTT are usually normal unless there is concomitant coagulopathy.

1. tinea capitis - dermatophyte infection of the scalp that mainly affects children. - Appears as round, pruritic, scaly plaques with alopecia in affected areas. - Postauricular lymphadenopathy may also be present. 2. Oral griseofulvin is the treatment of choice for tinea capitis. - It deposits in tissues that contain keratin and it is very effective against dermatophytes.

9 yo with itchy rash on the right side of his scalp and progressive hair loss for 1 mo. - patient has scaly plaques with broken hair shafts and loss of hair in the affected area with lymphadenopathy. He most likely has __1__, which typically occurs among children and is a contagious disease. 2). What is the Tx?

1. tenofovir - analog of adenosine-5-monophosphate that functions as a nucleotide reverse transcriptase inhibitor (NtRI). Tenofovir is used to treat chronic hepatitis B infection in patients > 12 years of age and those with HIV-1 infection. 2. emtricitabine - nucleoside reverse transcriptase inhibitor (NRTI) used to treat HIV infection. Interferes with viral RNA-dependent DNA polymerase. Adverse effects include diarrhea, headache, and nausea. 3. and raltegravir (or dolutegravir) - reversibly inhibits HIV integrase, which prevents the HIV genome from integrating into host DNA. Generally well-tolerated, but adverse effects insomnia, dizziness, and increases in serum creatine kinase. Go over HIV drug sketchies!

A phlebotomist's mucous membranes were contaminated by blood from a source patient with risk factors for a bloodborne disease. The combination of __1__, __2__, and __3__ is the preferred three-drug regimen for HIV post-exposure prophylaxis (PEP) following high-risk occupational exposure. - PEP should be given as soon as possible, ideally within a few hours but at least within 72 hours. The overall risk of transmission is very low but depends on multiple factors, including the type of exposure, the viral load of the source patient, and, in the case of a needle-stick injury, the type of needle involved.

1. shingles - Famciclovir may be used to treat herpes simplex and varicella zoster virus infections. It is typically administered within 72 hours of the onset of herpes zoster infection (shingles). It is not used for postherpetic neuralgia. 2. postherpetic neuralgia (PHN) 3. Oral tricyclic antidepressants (TCAs) are the first-line medications for postherpetic neuralgia. 4. TCA's should not be administered in this patient because of his history of myocardial infarction, as they may prolong the QRS and/or QT interval, which may lead to arrhythmias. - Gabapentin would be a more appropriate in a pt with heart conditions. (works via Inhibition of high voltage-activated Ca2+ channels)

A unilateral painful rash in a dermatome pattern indicates that this patient had __1__. Intense pain and increasing skin sensitivity in the same area for 3 months after initial healing suggests __2__, which occurs in up to 15% of herpes zoster cases. 3). What is 1st line tx? 4). Why would it e important to know if this pt has a heart condition?

1. orchitis - Mumps orchitis can result in testicular atrophy and subsequent impaired fertility in up to 50% of cases, making it a feared complication. -Sterility, however, is rare. Mumps =highly contagious viral infection that is transmitted via airborne droplets. It classically manifests with parotitis, low-grade fever, malaise, headache, and possibly swelling of other salivary glands or orchitis in post-pubertal males

An acute mumps infection can affect the testicles, causing __1__. (usually occurs 1-2 weeks after parotitis and is typically unilateral, but can involve both testicles). There is no treatment for mumps orchitis, although corticosteroids and analgesics help with the pain and inflammation. The only way to prevent mumps orchitis is vaccination against mumps virus.

1. benign gastroesophageal reflux. - caused mainly by a transitory insufficiency of the lower esophageal sphincter.

An infant who regurgitates and vomits its feed without any alarming clinical features like poor weight gain or weight loss, irritability, or rectal bleeding most likely has__1__ Maintaining an upright position shortly after feeding and avoiding sitting or supine positions significantly improves symptoms. Since the condition is benign and resolves spontaneously in the majority of cases, no other treatment is needed.

Tramadol

An opioid analgesic that also inhibits serotonin and norepinephrine reuptake.

1. pyloric stenosis - Vasoactive intestinal peptide (VIP) in breast milk may help mediate pyloric relaxation, facilitating gastric emptying. - Infants that are bottle-fed tend to have higher serum gastrin levels, which are associated with pylorospasm, and are at increased risk of pyloric stenosis.

Breast-fed infants have a lower incidence of __1__ compared to infants that are bottle-fed.

1. elevation in transaminases - A true hepatotoxic adverse reaction resulting in transaminitis (> 10 times the upper normal limit of transaminases) is exceedingly rare.

Elevations in __1__ are thought to occur transiently after administration of statins and resolve spontaneously over time. -This uncommon, asymptomatic side effect occurs in up to 3% of patients receiving statin therapy.

1. cortisol 2. calcitriol synthesis (form of vitamin D that becomes hormonally active in the kidneys. Increases calcium absorption in the small bowel and renal tubules and increases calcium release from bones.) - Patients with Cushing syndrome are therefore at increased risk for pathological fractures and avascular necrosis of the femoral head.

Hirsutism, thin, easily bruisable skin (ecchymoses), moon facies (rounded facial shape), flushing of the face, acne, weight gain, irregular menstrual cycles, hypertension, and fatigue can all be explained by excess production of__1__, making Cushing syndrome the most likely diagnosis. In individuals with Cushing syndrome, high levels of cortisol cause inhibition of __2__, leading to decreased bone mineral density and osteoporosis in ∼ 50% of patients.

1. carcinoid tumor (indicated by typical features of carcinoid syndrome) 2. transaminases 3. somatostatin analogs (e.g., octreotide)

Patient most likely has a __1__, presenting with abdominal tenderness and cramps, watery diarrhea, cutaneous flushing (facial redness), telangiectasia (tiny blood vessels), tachycardia (sudden palpitations), and wheezing. - usually occurs in the GI tract and are often asymptomatic due to hepatic metabolism of neuroendocrine substances (particularly serotonin) that the tumors produce. -In the case of extraintestinal carcinoid tumors and tumors that have metastasized to the liver (indicated by elevation of __2__ in this patient), the increased serotonin that bypasses hepatic first-pass metabolism and enters systemic circulation causes the symptoms. The treatment of choice in patients with carcinoid syndrome is surgical resection of the tumor. In inoperable cases, __3__ can be given to relieve symptoms.

1. atrial premature beats (APBs) 2. Idiopathic APBs can occur in otherwise healthy individuals. The diagnosis requires ruling out organic causes such as structural heart disease or electrolyte imbalances, neither of which are found in this patient. - Therapeutic options mainly include counseling to avoid potential triggers, such as caffeine and/or alcohol consumption, stress, and smoking. 3. In symptomatic cases (e.g., tachycardia or ventricular response), electrophysiological evaluation with concurrent ablation or medical therapy with beta blockers can be considered.

The ECG shows several extrasystoles preceded by deformed P waves and no full compensatory pause (RR interval between the preceding and the following normal QRS complexes is less than twice the normal RR interval). - The QRS complexes are narrow. These findings are diagnostic for __1__. 2). What is the tx in asymptomatic pts? 3). What is the tx in symptomatic pts?

1. tinea versicolor - most commonly caused by increased growth of Malassezia globosa or other fungi of the Malassezia genus (e.g., Malassezia furfur), which belong to the physiological flora of the skin. 2. Topical antifungals are the first-line therapy, e.g., selenium sulfide lotion or shampoo, topical ketoconazole, or terbinafine.

The eruption of multiple, nontender, and nonpruritic white macules with fine scaling after traveling to a warm, humid climate should raise suspicion for__1__. - Both higher temperatures and humidity provide an ideal environment for the pathogen, which predisposes to overgrowth. The lesions become more apparent after UV exposure or tanning because the surrounding skin gets darker, which provides greater contrast to the lesions. 2). What is the Tx?

1. bronchiectasis 2). In bronchiectasis, damage to bronchial vessels is caused by transmural inflammation that leads to vessel erosion and rupture of dilated bronchial wall vessels. - Blood leaks into the conducting airways, usually resulting in mild, self-limiting hemoptysis, although severe hemorrhages that require embolization may occur

The features of a chronic cough with copious sputum production in a patient with recurrent respiratory tract infections indicate __1__. - This diagnosis is confirmed by the CT scan of the chest that shows multiple dilated bronchioles as well as the signet ring sign. - Additional CT scan findings of damaged bronchial include dilated terminal bronchioles at the lung base, tram-track lines, honeycombing, and cystic changes. 2). Why would this pt be at risk for damaging bronchial vessels?

1. hemolytic anemia 2. mechanical hemolysis secondary to aortic stenosis - thought to result from high-velocity turbulence occurring at the area of the valve, and is usually considered an indication for valve replacement. (most cases of bicuspid aortic valve are familial and it is associated with premature aortic stenosis). The presence of schistocytes should always raise concern for TTP, DIC, and HELLP syndrome, all of which require prompt diagnosis and treatment to prevent further complications. This patient's normal platelet count makes these diagnoses unlikely, however.

This patient has anemia with low haptoglobin and elevated bilirubin, which is consistent with a diagnosis of __1__. - His peripheral blood smear shows fragmentation of red blood cells (schistocytes). -the pt has a crescendo-decrescendo murmur at right sternal border and a brother with a bicuspid aortic valve. ... this makes __2__ the most likely diagnosis

Propranolol - non-selective beta blocker frequently used for migraine headache prophylaxis. In patients with hypertension and no other comorbidities, thiazide diuretics, ACE inhibitor, calcium channel blockers, and/or angiotensin-receptor blockers should be tried first, before using a beta blocker.

This patient has hypertension and would benefit from antihypertensive medication. She also has a history of increasingly frequent migraine headaches (takes sumatriptan prn). An individualized approach to treating patients is preferred, so is there a way you could treat both conditions?

1. Candida albicans 2. Fluconazole is a first-generation triazole antifungal medication used against Candida, Cryptococcus, dermatophytes, and other dimorphic fungi. This patient has symptoms of esophagitis as well as oral thrush on examination. In HIV-positive patients, 50-70% of cases of esophagitis are caused by Candida albicans. Therefore, it is prudent to give this patient a trial of fluconazole to see if her symptoms improve. - If her symptoms do not improve, she should undergo an upper endoscopy to rule out other causes of esophagitis.

This patient has white plaques that are scraped off easily, indicating oral thrush. Additionally, her dysphagia is consistent with esophagitis. Together, oral thrush and esophagitis in a patient with a positive HIV test is most likely caused by __1__. 2). Aside from anti-retroviral medication,what is the tx?

1. Ischemia of the renal papillae --> renal papillary necrosis etiology is often multifactorial; -chronic NSAID use --> result in analgesic nephropathy due to prolonged reduction in renal blood flow --> papillary ischemia and a decline in GFR. -Sickle cell trait --> transient sickling of RBCs in the renal capillaries --> microthrombotic infarctions and sloughing of necrotic papillae.

This patient's history of chronic analgesic use to manage his back pain and headaches in conjunction with his sickle cell trait put him at significant risk of developing __1__. -The onset can be acute or chronic: -Acute cases can present with gross hematuria and flank pain, as in this patient. -Chronic cases are typically asymptomatic or have only mild symptoms.

1. ankylosing spondylitis 2. acute unilateral anterior uveitis (∼ 25% of cases) seronegative spondyloarthropathy = negative for rheumatoid factor (RF) and have a strong genetic association with HLA-B27. - The most important diseases in this group are: - ankylosing spondylitis, - reactive arthritis, - psoriatic arthritis.

This patient, who presents with a C2 vertebral fracture following a fall, has a 2-year history of lower back pain of the inflammatory type (indicated by morning stiffness and worsening with rest), limited range of motion of the lumbar spine, and evidence of sacroiliitis on MRI. - Altogether, these findings suggest __1__ (especially in a young man), which may lead to osteoporosis and an increased risk of pathological fractures. --> this is a seronegative spondyloarthropathy and is associated with extra-articular manifestations, the most common of which is __2__.

An evidence-based protocol for delivering serious news. It includes the following steps: 1. creating an appropriate SETTING; 2. addressing the patient's PERCEPTION of his/her situation; 3. seeking the patient's INVITATION; 4. giving KNOWLEDGE to the patient regarding diagnosis and prognosis; 5. addressing the patient's EMOTIONS; 6. providing a management STRATEGY and SUMMARY of what had been discussed so far.

What is the SPIKES protocol?

1. A type of chest pain that meets 2 out of 3 of the following characteristics of typical angina: (1) substernal chest pain of typical quality and duration (e.g., transient retrosternal pain), (2) provoked by exertion or emotional stress, and (3) relieved by rest and/or nitroglycerin.

Women < 50 years of age with atypical angina have a low pretest probability (< 10 %) of coronary artery disease (CAD). - Patients with a low pretest probability of CAD should not undergo any further diagnostic testing, as a positive test result in a low-risk patient is likely to be a false positive. 1). What is atypical angina? Other patients considered to be at low risk for CAD (who do not require further testing) include: - asymptomatic men and women of all ages, - men < 40 years of age with noncardiac chest pain, - and women < 60 years of age with noncardiac chest pain.

1. Oral dapsone - antifolate antibiotic used in the treatment of dermatitis herpetiformis, leprosy, toxoplasmosis, and chloroquine-resistant malaria. Also used for Pneumocystis jiroveci prophylaxis. - After symptomatic control and gluten-free diet, dapsone may be slowly tapered and stopped.

__1__ and strict adherence to a gluten-free diet is the first-line therapy in patients with dermatitis herpetiformis (DH) and celiac disease. -Patients usually experience a rapid control of the symptoms (e.g., suppression of skin lesions and itching) within days of initiating this medication.

1. MAOIs (Monoamine oxidase inhibitors) -inhibits monoamine oxidase, an enzyme that breaks down monoamine neurotransmitters such as serotonin and norepinephrine. Usually used to treat atypical depression and Parkinson's disease. The most common side effects include hypertensive crisis (with ingestion of tyramine-rich foods), serotonin syndrome, and CNS stimulation. - MAOIs are considered a third- or fourth-line therapy due to their numerous drug interactions and associated hypertensive crisis with ingestion of foods containing tyramine (e.g., aged cheese, salami, wine). 2. 2 wks

__1__ are particularly effective at treating symptoms of atypical depression (↑ appetite, weight gain, and ↑ sleep). - However, they are contraindicated in patients taking selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine because of an increased risk of serotonin syndrome. -Antidepressants should be discontinued at least __2__ weeks before initiating therapy with MAOIs.

1. Advanced sleep phase disorder 2. treated with timed bright light phototherapy before bedtime to realign the circadian rhythm with the night-day cycle.

__1__ is a circadian rhythm sleep-wake disorder in which the sleep-wake cycle begins and ends earlier than normal. - This causes individuals to feel the need to go to bed early and to wake up early in the morning irrespective of when they go to bed. - A patient who delays going to bed will therefore not get an adequate quantity of sleep, resulting in daytime sleepiness. - frequently associated with older age. 2). Whats the Tx?

1. Cyclosporine - calcineurin inhibitor used as an immunosuppressant for patients who receive organ transplantation. Also used in the treatment of immune-mediated conditions such as rheumatoid arthritis and psoriasis.

__1__ is a drug typically used for transplantation rejection prophylaxis whose side-effect profile includes hypertension, gingival hyperplasia, and hirsutism. - Other common side effects include: - nephrotoxicity, - hyperlipidemia, - hyperglycemia, - tremor, - and an increased risk of malignancies (esp. cutaneous squamous cell carcinomas) and infectious diseases (esp. upper respiratory and urinary tract infections).

1. Pneumococcal conjugate vaccine 13 (PCV13) 2. 65 yrs 3. pneumococcal polysaccharide vaccine 23 (PPSV23)

__1__ is a vaccine that offers protection against 13 subtypes of Streptococcus pneumoniae and related diseases. -it is currently recommended for all individuals ≥ __2__ years and should be followed by __3__ after 1 year.

1. Rheumatoid arthritis (RA) - chronic inflammatory autoimmune disorder of unknown etiology. - Characterized by pain, swelling, stiffness, and destruction of synovial joints. - Predominantly affects women and middle-aged individuals. - Can also cause various extra-articular manifestations such as rheumatoid nodules or pulmonary fibrosis. 2. a Baker cyst. - RA is one of the most common causes of Baker cyst.

__1__ is associated with inflammation of the synovium, which can cause production of excess synovial fluid and, subsequently, formation of __2__ (A mass in the popliteal fossa that becomes prominent when the knee is extended) -This patient presents with subtle features of RA, including polyarticular arthritis affecting the right knee and her finger and wrist joints, as well as a history of low-grade fever and fatigue.

1. Fibromyalgia

__1__ is characterized by: - chronic generalized myalgia, paresthesia, and/or stiffness lasting > 3 months, - multiple tender points on examination (typically at the points of muscular attachments to bone), - and no signs of systemic inflammation or systemic disease on laboratory analysis (e.g., normal CBC, ESR, CRP, and TSH) or imaging. - it is most common in middle-aged women and is often associated with tension headaches, neuropsychiatric disorders (e.g., anxiety, depression), and sleep and cognitive disorders (e.g., insomnia, difficulty concentrating).

1. Endometrial biopsy - Assessment of the biopsy pathology provides a definitive diagnosis of any underlying cause of endometrial neoplasia, including endometrial carcinoma (with 97% sensitivity)

__1__ is indicated as a first-line test in the diagnostic workup of patients with abnormal uterine bleeding who are more than 45 years old, or in patients younger than age 45 who have risk factors for endometrial cancer (obesity, polycystic ovary syndrome, nulliparity, early menarche, diabetes mellitus, tamoxifen therapy) or do not respond to medical management.

1. Enterotoxigenic E. coli (ETEC) - gram-negative rod that produces heat-labile as well as heat-stable enterotoxins. The bacteria is common in Asia, Africa, and Latin America and the most frequent cause of traveler's diarrhea. 2. 3-4 days

__1__ is the most frequent cause of traveler's diarrhea. - Symptoms last __2__ days and patients usually only require supportive treatment. - The clinical presentation of watery stools following a vacation to India is consistent with traveler's diarrhea caused by enterotoxigenic E. coli.

1. Genetic predisposition 2. 10%

__1__ is the strongest predisposing factor for bipolar disorder. -While the lifetime risk of developing bipolar disorder is ∼ 2% in the general population, a first-degree relative of an individual with bipolar disorder has a lifetime risk up to __2__, and monozygotic twins have up to a 70% lifetime risk of developing the disorder.