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These are my notes .The answers have been taken from various websites. 1.Ans.

C Testicular ultrasound is a very close distracter in this Question but one should know when to do a testicular ultrasound as opposed to surgical exploration in a suspected testicular torsion case. Recognize that clinical probability of testicular ultrasound can be estimated by history and physical examination (see the predictive clinical score below). Ultrasound should only be done if the clinical diagnosis is uncertain and if the performance of imaging does not significantly delay the treatment. Doing color doppler in this patient is not necessary since the diagnosis is clinically clear and imaging will further delay surgical intervention ( it is already 5 hrs since onset of pain) Rapid diagnosis is important in order to salvage a viable testis with prompt surgery. The testicular salvage rate is more than 80% if surgery is performed within 6 hours, but the rate decreases to approximately 20% if surgery is done after 12 hours after the onset of symptoms. Testicular Torsion: Clinical features include acute onset pain, absence of cremasteric reflex, negative prehns sign, tender testicle on palpation and a an elevated or horizontal lie of testis ( changed position of testis). Absent cremasteric reflex is the most sensitive physical finding for diagnosing testicular torsion. Three features in the history can serve as predictors of pre-test clinical probability of Testicular Torsion: 1. Onset of pain less than six hours 2. Absence of Cremasteric reflex 3. Diffuse Testicular Tenderness. Presence of all the three features (score: 3) is associated with 87% probability (high probability) of having Testicular Torsion as per a large study. These patients should undergo direct surgical exploration. A score of 1 or 2 indicates moderate to low clinical probability and should first undergo diagnostic ultrasound. A score of 0 favors an alternative diagnosis for acute scrotum rather than Testicular Torsion. Key Concept: Recognize Testicular Torsion clinical score and determine the next step as follows : : 1. Onset of pain less than six hours 2. Absence of Cremasteric reflex 3. Diffuse Testicular Tenderness. Presence of all the three features (score: 3) is associated high probability of having Testicular Torsion as per a large study > Next step, direct surgical exploration. A score of 1 or 2 indicates moderate to low clinical probability > next step, diagnostic ultrasound. A score of 0 favors an alternative diagnosis for acute scrotum rather than Testicular Torsion.

2. Ans. B Lab studies reveal hemoglobin of 9.7, platelets 310, wbc 10k with normal differential, BUN 38, creatinine 1.4, calcium of 11.2. The patient is currently on alendronate for Pagets disease. Which of the lab measure would be expected to be abnormal in this patient? A. Alkaline phosphatase B. Serum Immunoelectrophoresis

Pagets disease history is a distractor in this case. Pagets disease does not cause hypercalcemia unless the patient is immobilized because of poor control. The hypercalcemia in pagets is secondary to prolonged immobilization not because of Pagets per se. This patient is physically very active. The question is asking what is the usual abnormality seen in patients with MM. Because only MM explains his renal insufficiency, punched out lesions in the skull and hypercalcemia.The question also presents a skull radiograph that shows Osteolytic lesions with out any concomitant Osteoblastic process. Such pure osteolytic lesions are hallmark of MM which is why Alkaline phosphatase and Bone scans are often normal in MM. ( Recognize that Osteoblasts are the ones that are responsible for positive bone scan and increased alkaline

phosphatase and hence, these are normal in MM which has no osteoblastic activity in skeletal lesions) .
Serum and Urine electrophoresis with immunofixation may reveal a monoclonal spike and useful for confirmation of the diagnosis. Patient also has hypercalcemia, anemia and renal insufficiency which are associated features in multiple myeloma. Pagets disease, on the other hand, is charecterized by mixed osteolytic and osteoblastic phases. Alkaline phosphatase is typically elevated in patients with Pagets. The skull radiograph will show a cotton wool appearance caused by irregular areas of sclerosis ( mixed lytic areas with blastic areas) The patient does have a history of Pagets disease which is chronic and as a result, he also has hearing deficit. The problem is currently having and his skull x-ray findings are unrelated to Pagets . Pagets history is just a dis tractor. The question aims to test your understanding of clinical presentation of paraproteinemias and MM.

3. Ans. B. The patient presents with fever and possible sepsis. Cloudy urine indicates that UTI is the possible source of sepsis. Recognize that severe sepsis can lead to multi-organ dysfunction such as hypotension, encephalopathy. Disseminated intravascular coagulation and renal insufficiency. The latter three are seen in this patient. Recognize that the important difference between DIC and TTP is that DIC is a consumption coagulopathy i.e; it consumes the entire coagulation factors along with platelets. Hence, PT and PTT are elevated and fibrinogen is decreased in DIC but not in TTP. The intravascular thrombi in DIC are fibrin thrombi the lysis of these lead to increased D-Dimer and Fibrin Split products. TTP is a consumption thrombocytopenia and is composed of platelet thrombi not fibrin so, D-dimer is usually normal in TTP. Increased LDH suggests hemolysis here and is non-specific. MAHA is associated with increased reticulocyte count not decreased retic. The distractors in the question are typical TTP like pentad and scistocytes on the smear. However, realize that severe sepsis can have all these features ( Fever, thrombocytopenia, DIC leading to MAHA, altered mental status and renal failure). So, the entire clinical scenario should be put together in arriving at the diagnosis. The peripheral blood smear shows Schistocytes. Recognize that schistocytes are not specific for TTP. Schistocytes can occur in any condition that is associated with Microangiopathic Hemolysis (MAHA). MAHA can occur in conditions where intravascular thrombi rub against RBC in tiny capillaries leading to RBC fragmentation and hemolysis eg: MAHA can be seen in TTP, HUS, DIC, HELLP Syndrome and Malignant Hypertension. Key Concepts: 1. DIC is a consumptive coagulopathy-thrombocytopenia and occurs secondary to several causes. 2. TTP is non-immune consumptive thrombocytopenia. PT and PTT are usually normal. 3. Severe sepsis can resemble TTP. Full clinical picture should be considered in decision making. Source of

sepsis should be sought and ruled out in suspected cases before making a diagnosis of TTP 4. MAHA is not specific for TTP. Recognize other causes of MAHA are DIC, HUS, HELLP and Malignant Hypertension.

PT and PTT are slightly elevated which indicate consumption of clotting factors. Platelets are also decreased because of their consumption in the clotting process. Presence of this schistocytes and inc LDH are due to microangiopathic hemolysis. Since clotting factors and platelets are consumed its causing bleeding (ecchymosis). It looks like a case of DIC which would show a dec fibrinogen and inc D- dimers. So the answer is B.


Ans. C

The smear shows classic smudge cells. Smudge cells are fragile lumphocytes that get damaged and smudged during the smear preparation. Presence of Smudge cells in a patient like above with absolute lymphocytosis > 5000, is suggestive of CLL. A peripheral blood flow cytometry should be obtained to confirm the diagnosis. CLL is staged based on lymphadenopathy, splenomegaly, anemia and thrombocytopenia. Presence of anemia classifies CLL as stage IV where as thrombocytopenia makes it a Stage V. However, this anemia and thrombocytopenia can occur in a CLL patient because of autoimmune mechanisms and may not be directly secondary to CLL. A direct coombs test must always be obtained to rule out this possibility and hence, to avoid mis-staging of CLL. If direct coombs is positive, a Bone marrow biopsy should be done to check if there is a CLL infiltration of marrow additionally contributing to Anemia. If there is CLL infiltration of marrow possibly causing anemia, that suggests Stage IV CLL. Some of the criteria for therapy in CLL are a) Anemia b) Thrombocytopenia c) Presence of bulky disease d) severe fatigue e) lymphocyte doubling time less than 6 months. . CLL need not be treated unless the above criteria for treatment are present. This patients CLL belongs to Rai Stage V in that he has thrombocytopenia. This patient requires treatment. Choice B is not correct since the CBC is consistent with a lymphoproliferative disorder like CLL not a myeloproliferative disorder like CML. In CML, you expect to see proliferation of myeloid lineage with an increase in immature granulocytes, neutrophils and especially, an absolute increase in basophils and eosinophils. Choice A and D are incorrect as they do not explain the lymphocytosis or smudge cells.

5. Ans. B Ampicillin ( Ans.B) is the most appropriate antibiotic for this pregnant woman with early stage Lymes disease. The patient has erythema chronicum migrans which is pathognomonic of early lymes disease. ELISA may be negative in early stage LYME disease and diagnosis must be based on clinical history. No further testing is necessary in the presence of such strong clinical history. Ans. A is inappropriate and not treating lyme disease can be lethal to the patient.

Ans. C is an appropriate first choice for non pregnant patients with lyme disease. Doxycycline is classified as pregnancy category D. Tetracycline exposure during the second or third trimester can cause permanent discoloration of the teeth. Ans. D is incorrect. Western blot is only used to confirm a positive ELISA test because ELISA is associated with a high rate of false positive results. In the absence of strong clinical suspicion, both ELISA and Western blot must be positive in order to diagnose lyme disease. Such testing is especially useful when someone is suspected to have late lyme disease manifestations. ELISA in this patient is negative. It is not required in this case to diagnose early lyme disease given that she has strong clinical features to support the diagnosis.
Lyme disease is a clinical diagnosis especially, in the presence of classic rash consistent with "Erythema Chronicum Migrans". Obtaining a lyme serology in early lyme's is incorrect because this may be falsely negative in early stages. Her history of a camping trip,tick bite, typical rash , the timing of onset of rash are all suggestive of early Lyme's. Treatment should be started immediately. Since Docycycline is contraindicated in Pregnancy, Ampicillin is the drug of choice to treat Lyme's in Pregnancy

ANS 6. B is the answer Household contacts of patients with meningococcal disease have an attack rate of 4 cases per 1000, which is 500 to 800 times greater than the general population. Antimicrobial chemoprophylaxis is recom-mended for close contacts (household members, day care center contacts, and anyone directly exposed to the patients oral secretions). Antimicrobial chemoprophylaxis ideally should be started within the first 24 hours after the initial case is diagnosed, with prophylaxis starting greater than 14 days after contact offering little benefit. Household contacts includes recent visitors who have stayed overnight in the 7 days preceding the cases illness; those who share the same dormitory, military barracks, hostel bunkroom. Should receive clearance antibiotics and vaccination. 2) Sexual contacts sexual partner(s) of case + intimate kissing partners. Should be treated as household contacts and receive clearance antibiotics and vaccination. 3) Travel contacts seated immediately adjacent to a case on flight > 8 hours in duration. Should receive clearance antibiotics. 4) Childcare contacts children and staff in same room group at a child-care facility attended by index case for one period of 4 hours in 7 days preceding onset of cases illness require clearance antibiotics. 5) School and University contacts depending of the nature of the contact and whether it occurred in relation to a specific outbreak (eg. related to a particular class) then clearance antibiotics may be appropriate. 6) Health care worker contacts only medical personnel who are directly exposed to a cases nasopharyngeal secretions (ie: person who intubated case if facemask) Rifampin 600 mg taken orally twice a day for two days is the recommended antibiotic for chemoprophy-laxis, but should not be used in pregnant women due to its teratogenic effects. Other alternatives include ciprofloxacin 500 mg orally, or ceftriaxone 250 mg intramuscularly.
How do we define a "close contact" ? Definition of a close contact differs from one condition to other depending on infectivity and spread. So, IT IS IMPORTANT TO DEFINE "CLOSE CONTACT" in meningococcal disease before deciding on prophylactic recommendations.

Who are close contacts in meningococcal disease? ( Archer preventive medicine lectures) Close contacts of a patient who has meningococcal disease include household members child-care center contacts persons directly exposed to the patients oral secretions (e.g., by kissing, mouth-to-mouth resuscitation, endotracheal intubation,or endotracheal tube management). (REMEMBER --People in the same household or day-care center, or anyone with direct contact with a patient's oral secretions (such as a boyfriend or girlfriend) is at increased risk of acquiring the infection )

B...only give chemoprophylaxis to those in direct contact with respiratory secretions This question focuses on the mode of N.Meningitidis, as it colonizes in the naso pharynx and the anesthetist who intubates the patient is at the highest risk

ANS 7. Ans. B Oral contraceptive pills can worsen migraine but have also been shown to improve certain types of migraines such as Menstrual migraines. Hence, patients may report variable response in the intensity of migraines after starting OCPills. In our case above, OC pills are clearly responsible for worseing of her Migraine. However, they were started in hercase for a reason she has Endometriosis and also, desires contraception! Hence, benefit vs. risk should always be weighed in making treatment decisions like this. Often, estrogen component of the OCP is responsible for worsening headaches. So, switching to low dose estrogens should be the first step and it often improves the situation. The question also tests the concept of risk factors for stroke. Migraines with aura is a known risk factor for stroke but migraines with out aura are benign. OC pills are an independant risk factor for stroke. Hence, OC pills should not be started in any patient with increased risk of stroke ( eg: severe hypertension, smoking, migraine with aura etc). Key Concept : Migraines in the above patient are with out aura. So, OC pills need not be discontinued. Reducing the dose of estrogen component should be the next step in management. ANS 8. D. This patient does have CLL but CLL itself is not causing anemia here. CLL causes anemia
by a process called "Myelophthisis" i.e; replacement of bone marrow by mature lymphocytes in case of CLL so that erythroid precursors can not normally proliferate. In such cases, you would expect a low reticulocyte count . IHowever, in the case above, the reticulocyte count is increased at 8.0% . Reticulocyte count is increased in cases of acute blood loss, hemolysis or recovery from a nutritional deficiency after nutrient repletion. The above case also has increased LDH. Hence, it indicates that anemia here is from hemolysis rather than CLL itself. Autoimmune hemolysis can occur in CLL patients. It is important to understand the etiology of anemia in a case of CLL because if anemia is secondary to autoimmune hemolysis it should be treated with steroids . If anemia is caused by bone marrow replacement, it should be treated with chemotherapy . In the above case, because lab values clearly indicate autoimmune hemolysis steroid should be used rather than starting chemotherapy

D. auto immune hemolysis supported by evidence of hemolysis increased ldh and rect and decreased haptoglobin, patient with auto immune hemolysis also have CLL assoication hence smudge cell.

Smudge cells : CLL Lab for hemolysis low h/h, increase LDH, increase retic.. but no coombs test or microspherocytes in the question maybe why is confusing. steroids are primary method of treating autoimmune hemolysis. They must be carefully tapered to avoid relapses once reticulocyte count comes down and LDH normalizes. Splenectomy in steroid refractory patients. In patients unwilling to undergo splenectomy, Rituximab or AZA or mycophenolate are the choice in steroid refractory patients. . Unlike in ITP, IVIG is not good enough for autoimmune hemolysis - also, remember that IVIG can by itself cause hemolysis from gamma globulin ( it is one of the side effects of IVIG). Though it may show some response in AIHA , because of its hemolytic side effects and also, due to very transient response , not recommended in AIHA. COLD DOES NOT RESPOND TO STEROIDS. Usual treatment is treating etiology like mycoplasma etc if you can find an etiology. Otherwise, rx with Rituximab. but those drugs take 4 months to act what the tx meanwhile if no response to steroid. IF THE PATIENT IS NOT SEVERELY SYMPTOMATIC, TRANSFUSE AS NEEDED and allow for the drug to act. If very very symptomatic, can use plasmapheresis to remove cold antibody. meaning 1 steroid 2- no respone Transfusion 3- Plasmapheresis 4 until patient do splenectomy or not / or use drug like Rituximab. No use of steroids in Cold AIHA. "Prednisone does not diminish antibody production and any benefit is mediated by downregulation of phagocytosis, which typically requires unacceptably high doses." Avoid cold exposure. Start with rituximab. If rituximab is not working , can go for splenectomy . Most times, cold AIHA spontaneously resloves Plasmapheresis only if SEVERELY symptomatic and massive hemolysis. Transfusion is as needed only in symptoms. ( use warmed blood products).

ANS 9. Ans. D This patient has significant microhematuria defines as 3 0r more RBCs/HPF established on two occassions. He also has high risk factors for having a bladder cancer or urological malignancy. So, both upper tract imaging in the form of CT urogram as well as bladder visualization in the form of cystoscopy are warranted in this patient. A. is incorrect because the patient already had >3RBCs/HPF on two occassions already establishing the diagnosis of significant microhematuria. B. is incorrect because this patients has no symptoms or lab findings suggesting UTI. C. is incorrect because this patient is a high risk patient and requires both upper tract imaging as well as cystoscopy as an initial protocol. IVP is good for upper urinary tract imaging but does not adequately visualize the bladder. More over, recent recommendations favor CT urogram over IVP for upper tract imaging.

E. is incorrect. Rifampin causes red colored urine but does not cause positive dipstick or hematuria.
Hematuria: First step in hematuria ----> Urinanalysis Urinalysis confirms the presence of hematuria, and differentiates extraglomerular hematuria from glomerular hematuria. ----> Red cell casts, dysmorphic red cells, and associated proteinuria are features of glomerular bleeding. Centrifugation of urine allows distinction between hematuria, hemoglobinuria, and myoglobinuria. Patients with glomerular bleeding should be referred to a nephrologist, who will decide if a renal biopsy is required or not All patients with unexplained extraglomerular hematuria should undergo further radiological studies to localize the lesion of kidney, collecting system, ureter, or bladder. -------> Intravenous pyelogram (IVP) is usually the first imaging modality of choice. It is superior to renal ultrasound for better detection of medullary sponge kidney and lesions in the renal pelvis and ureters. Young patients with normal IVP does not require further imaging; However, older patients with normal IVP should be followed by ultrasound or helical CT for the detection of possible malignancy. Older patient with painless hematuria &risk factor---> cystoscopy Note: IVP is superior to detect upper urinary tract malignancy (but C/I in renal failure) and cystoscopy for lower urinary tract. From JasonEVALUATION OF MICROSCOPIC HEMATURIA After microscopic hematuria has been identified (2 of 3 urine samples with 3 or more RBC/hpf), the American Urological Association recommends the following evaluation: _ Infection identified: Treat with antibiotics and repeat urinalysis. _ RBC casts, proteinuria, or elevated creatinine: Begin evaluation for glomerulonephritis and consider referral to a nephrologist. _ No infection or primary renal disease identified in first 2 steps: Urine cytology, bladder cystoscopy (if at risk for bladder cancer based on environmental exposures and/or age _40), and CT scan (helical CT if stones suspected, contrast-enhanced CT if stones not suspected). _ If entire thorough diagnostic evaluation negative: Follow-up urinalysis, urine cytology, blood pressure, and serum creatinine every 612 months.

ANS 10. Ans. C A "false-positive" guaic test is a test result when there is in fact no source of
bleeding. This can occur if the recommended dietary instructions are not followed before Guaic. For example; the heme in red meat or the peroxidase or catalase activity in vegetables, especially if uncooked, can cause analytical false positives. This patient has all the work up done and there is alternative etiology to explain his iron deficiency. Hence, obscure bleeding is less likely and this result is probably, a false positive from excess red meat.

Red meat can lead to false positive guaic as it may oxidize the guaic reagent ( Vitamin C on the other hand, anti-oxidizes it and causes false ve guaic.) Obscure bleeding ( Ans. A) is possible but in this patient the most likely cause for iron deficiency was already established as celiac disease making intermittent obscure bleeding less likely. Celiac disease ( Ans. B) does not cause False +ve Guaic. Iron pills ( Ans. D) can cause black discoloration of the stool but not a false positive guaic.

The fact that the colonoscopy was normal makes bleeding from colon cancer ( Ans. E)unlikely here.

ANS 11. answer B ( post streptrococal glomeruonephritis). antistreptolysin O antibody, to rule out post step. Nephritis
The correct answer is B. Poststreptococcal glomerulonephritis is the most common cause of acute glomerulonephritis in children. It usually follows a streptococcal pharyngitis by 1-2 weeks and a streptococcal skin infection by 2-3 weeks. It most commonly occurs in school-age children and has a male to female predominance of 2:1. It is most commonly characterized by hematuria (microscopic or gross) with red cell casts, proteinuria, hypertension (from fluid overload secondary to decreased glomerular filtration rate), and edema (from retention of salt and water). Laboratory values are usually significant for markedly decreased complement levels (C3 and C4), hypo- or hypernatremia, and a blood urea nitrogen elevated disproportionately to the creatinine. In order to diagnose poststreptococcal glomerulonephritis with certainty, there needs to be evidence of a preceding streptococcal infection such as an elevated ASO or streptozyme. Systemic lupus erythematosus (SLE) nephritis is another cause of hematuria. If this child had persistently low complement levels, an ANA (choice A) would be indicated as one of the first screening tests for SLE. Keep in mind that only 25% of cases of SLE are diagnosed within the first two decades of life, the male-to-female ratio is 1:8, and renal disease is not present in all cases of SLE. Therefore, it is unlikely that this 7-year-old boy has new onset SLE, and other more common causes of glomerulonephritis must be ruled out first. At this time, a renal biopsy (choice C) is not indicated. A renal biopsy is an invasive procedure with inherent risks. As this patient fits the perfect description for post streptococcal glomerulonephritis a renal biopsy would only be indicated if the complement level does not return to normal within 8 weeks, and the gross hematuria does not resolve over several weeks. If one was to do a renal biopsy on a patient with post-streptococcal glomerulonephritis, the findings would be: mesangial and capillary cell proliferation, inflammatory cell infiltration, and granular "humps" of IgG and C3 below the glomerular basement membrane. A renal ultrasound (choice D) is useful in evaluating parenchymal disease, urinary tract abnormalities, or renal blood flow. In the case of post-streptococcal glomerulonephritis, the changes are microscopic and therefore would not be seen on ultrasound. Urinary tract infections are a common cause of hematuria. Therefore, it is a good idea to do a urine culture (choice E) in all cases of hematuria. Unfortunately, the child in this case has red cell casts which indicate the kidneys are the source for the blood. So, although a urine culture should be sent on this child, it will probably not help with the diagnosis.

Answers : Q12) E Q13) A ANS12, E) Tell her that the boy requires follow up monthly urinalysis for at least 3 months in order to make sure there is no heamaturia/ renal dysfunction is the correct answer. The patient has non thrombocytopenic purpura associated with abdominal pain and arthralgias. These features are consistent with the diagnosis of Henoch Schonlein Purpura ( HSP). The initial episode of HSP usually resolves within one month. Renal impairment may be seen at the first presentation. However, some children may manifest with late renal disease. In children with no renal impairment at presentation, Urinalysis and blood pressure monitoring should be followed monthly for three months after presentation. In children presenting with renal involvement at the first presentation, should be followed more carefully i.e; urinalysis every week for first 2 months and then every month for one year. Patients with persistent proteinuria, hypertension, or renal insufficiency should be referred to nephrology for further evaluation and treatment.

Choice A is incorrect because though the disease is self limiting, it needs to be followed for possible development of renal impairment. Choice B is incorrect no admission required because the boy has an initial mild attack of HSP with out any renal impairment at this time. Choice C is incorrect because renal impairment may be seen only in about 20 to 50% cases of HSP. Renal involvement is typically seen with in one month of onset of systemic symptoms. Choice D is incorrect because only 2 to 5% patients progress to End Stage Renal Disease. ANS13) A HSP is IGA mediated vasculitis. IgA nephropathy and Henoch-Schoenlein purpura are two different entities that can lead to renal disease. The mechanism of renal disease in HSP is a vasculitis that is mediated by IgA. Extrarenal manifestations are seen most often in patients with Henoch-Schoenlein purpura where as they are uncommon in IgA nephropathy. HSP associated renal disease tends to be self-limiting in majority of cases where as IgA nephropathy is often associated with persistent or recurrent hematuria and/ or proteinuria. ANS 14. Answer. C High risk jobs ( pilot, bus driver etc) is one of the indications to screen for berry aneurysm in asymptomatic ADPKD patients. Family hx of berry aneurysm (Ans. A) alone does not warrant screening for berry aneurysm in asymptomatic ADPKD patients. Asymptomatic ADPKD patients must be screened if there is a family history of Ruptured berry aneurysm ( history of SAH in the family etc) E. is not the answer because this patient is a school bus driver by occupation and needs to be screened. Key Concepts : Screening for Berry Aneurysms: - MRA of head recommended screening test to detect berry aneurysms. - Screen only if - family history of subarachnoid hemorrhage ( Family hx of a ruptured berry aneurysm) not just a family history of berry aneurysm. - Patients with with high risk jobs (pilots/ bus-drivers) an event during such a job is a risk to others safety as well. - Patients with symptoms suggestive of a berry aneurysm ( severe headache, focal neurological deficits) ANS. Answers : 15. C 16. A 17. C 18. C Increased CPK and leg pain indicate rhabdomyolysis precipitated by alcohol and heavy exercise. Presence of blood on the Dipstick with out RBC or RBC casts indicate that this is a pigment such as myoglobin. The mechanism of renal failure in rhabdomyolysis is pigment deposition in tubules ( Toxic ATN)

Though creatinine is normal, rhabdomyolysis can lead to rapid renal failure if not adequately treated. Aggressive IV hydration is helpful in preventing renal failure. There is no role for diuretics or sodium bicarbonate. Rhabdomyolysis leads to myoglobin release in to the tissues leading to accumulation of fluid in the comparments. Increased compartment pressure may lead to compartment syndrome and this can be llimb threatening if it is not treated with Emergent Fasciotomy. ANS. 19. Answer. E Key Concepts : Recognize the definition of Recurrent UTI . Recognize the difference between colonization and Active Infection Answer. E No need of treatment is the correct choice because this old man has no signs of active infection at this time. He has no fever or tachycardia or any signs of sepsis or infection. Ans. A is incorrect. Cystoscopy and IVP can be performed to evaluate the urinary tract if the patient had severe UTI or recurrent UTI. It is not the appropriate step at this time. Ans. B would be appropriate as a prophylactic therapy if the patient has Recurrent UTI. Understand that the Recurrent UTI is defined as 2 or more episodes in past 6 months or 3 or more episodes in past one year. This patient does not meet the criteria of recurrent UTI since he suffers only one episode every 6 months. Ans. C is not helpful in preventing UTI and is also, not appropriate step at this time. Indwelling catheters may in fact, increase the risk of UTIs. Ans. D would be appropriate if the patient had severe UTI. He has no signs of acute infection at this time Ans. B Ans. A Key concepts : Recognize the etiologies of metabolic alkalosis. Understand the concept of urinary chloride level in identifying the etiology of metabolic alkalosis. If urinary chloride is less than 10meq/L, it indicates Saline responsive alkalosis. A higher than 10 value indicates Saline resistant alkalosis. Ans. B is the correct choice because the patient has hypokalemic, hypocholremic metabolic alkalosis. Urinary chloride less than 10 indicate that this is a saline responsive metabolic alkalosis and hence, should be treated with IV normal saline. NS can correct this metabolic alkalosis. Ans. A incorrect because diarrhea due to laxative abuse should cause non anion gap metabolic acidosis. Ans. C is incorrect. The active component in licorice is glycyrrhizic acid which inhibits 11B-HSD2, the enzyme that inactivates cortisol to cortisone in the collecting duct. Inhibition or deficiency of 11B-HSD2 causes cortisol to remain active and like aldosterone, cortisol binds to aldosterone receptors causing hypokalemia, metabolic alkalosis and low-renin and low-aldosterone hypertension. This is not licorice abuse because this patient does not have hypertension. Also, urinary chloride will be higher than 10 in licorice induced metabolic alkalosis Ans. D is incorrect because it should cause chronic diarrhea and non-gap metabolic alkalosis.

Ans. E is incorrect because hyporeninemic hypoaldosteronism causes hyperkalemia and metabolic acidosis. ANS. Answer: D Colon polyp screening guidelines for repeat colonoscopy : a) Low Risk: 1 to 2 adenomatous polyps, both small 1cm or any adenoma with villous features or high grade dysplasia In this group, repeat Colonoscopy in 3 years. If this is normal or shows only small polyps, repeat colonoscopy every 5 years ( remember 3, 5) c) High risk: - Greater than or equal to 10 adenomatous polyps, colonoscopy at 1 year. - Sessile adenomatous ployp that are removed in pieces > colonoscopy in 3 to 6 months to ensure that it is completely removed - Polyp removed in total and has carcinoma insitu with clear margins > colonoscopy at 1 year and then at 3 years and then, every 5 years ( Remember 1,3 and 5) ANS. 23. guys this question was discussed before and the answer i believe is D EXPLANATION is femoral neck fracture is not a life threatening situation where a physician should consent emergency surgery. In these cases of patient's mental incapacity, two physicians are required to sign consent. His daughter is still there who the patient lives with where substituted judgement can be used in cases like this. Saying a physician can consent on basis on nonmaleficience is easy but the burden completely lies on the physician to prove many things in this case. If this was a pneumothorax or cardiac tamponade, then approach will be different because it is life threatening and no consent is needed. C is wrong in my opinion unless two physicians are listed at least check ACP ethics

The parents have the authority to make a choice of this sort. In general, courts have been reluctant to overrule against parental wishes in most situations where that decision does not place the child at considerable risk. Though failure to start an anti-convulsant may increase the risk of further seizures, this does not pose a substantial enough risk to the child to justify overriding the parents' wishes, especially given the potential risks associated with the medication. Though you may not agree with their decision, the decision is a reasonable one that does not place their child at substantial risk of increased harm.

Parental Decision Making

Objectives: Upon completion of this course the participant will be able to demonstrate an understanding of the following:

Who has the authority to make decisions for children? What is the basis for granting medical decision making authority to parents?

When can parental authority to make medical decisions for their children be challenged? What if parents are unavailable and a child needs medical treatment? Should children be involved in medical decisions even though their parents have final authority to make those decisions? What happens when an older child disagrees with her parents about a medical treatment? Under what circumstances can minors make medical decisions for themselves?

Adult patients have the moral and legal right to make decisions about their own medical
care. Because young children are not able to make complex decisions for themselves, the authority to make medical decisions on behalf of a child usually falls to the child's parents.

Who has the authority to make decisions for children?

Parents have the responsibility and authority to make medical decisions on behalf of their children. This includes the right to refuse or discontinue treatments, even those that may be life-sustaining. However, parental decision making should be guided by the best interests of the child. Decisions that are clearly not in a child's best interest can and should be challenged.

What is the basis for granting medical decision making authority to parents?
In most cases, a child's parents are the persons who care the most about their child and know the most about him. As a result, parents are expected to make the best medical decisions for their children. Furthermore, since many medical decisions will also affect the child's family, parents can factor family issues and values into medical decisions about their children.

When can parental authority to make medical decisions for their children be challenged?
Medical caretakers have an ethical and legal duty to advocate for the best interests of the child when parental decisions are potentially dangerous to the child's health, imprudent, neglectful, or abusive. When satisfactory resolution cannot be attained through respectful discussion and ethics consultation, seeking a court order for appropriate care might be necessary.

What if parents are unavailable and a child needs medical treatment?

When parents are not available to make decisions about a child's treatment, medical caretakers may provide treatment necessary to prevent harm to the child's health.

Should children be involved in medical decisions even though their parents have final authority to make those decisions?
Children with the developmental ability to understand what is happening to them should be allowed to participate in discussions about their care. As children develop the capacity to make decisions for themselves, they should be given a voice in medical decisions.

What happens when an older child disagrees with her parents about a medical treatment?
The wishes of competent older children regarding their medical care should be taken seriously. If the medical caretaker judges a child competent to make the medical decision in question, she should first attempt to resolve the issue through further discussion. If that fails, the medical caretaker should assure that the child's voice has been heard and advocate for the child. In intractable cases, an ethics consultation or judicial hearing should be pursued.

Under what circumstances can minors make medical decisions for themselves?
Minors have the ethical and legal authority to make medical decisions for themselves when they have reached the legal age of majority or become "emancipated." Most states recognize an emancipated minor as a person who meets one of the following criteria: self-supporting and not living at home married pregnant a parent in the military In addition, most states allow treatment without parental consent for sexually transmitted diseases, pregnancy, and drug or alcohol abuse.

Parental Decision Making: Case 1

A 4-year-old with an obviously broken forearm is brought to the emergency department by her baby-sitter. Both the baby-sitter and emergency room staff have attempted to reach her parents without success. Can you treat this child without parental permission?

Parental Decision Making: Case 1 Discussion

Your first duty is to the health and welfare of the child. Having attempted to reach her parents for consent without success, you should proceed with x-rays and treatment of her fractured forearm. Rapid treatment of the child's pain and fracture are clearly in her best

interest. When optimal treatment requires immediate intervention, treatment should not be delayed even if consent has not been obtained.

Parental Decision Making: Case 2

An ill-appearing 2-year-old with a fever and stiff neck appears to have meningitis. His parents refuse a lumbar puncture on the grounds that they have heard spinal taps are extremely dangerous and painful. What are your obligations in this case? How should you proceed?

Parental Decision Making: Case 2 Discussion

A lumbar puncture is the only way to diagnose meningitis and a delay in treatment could cause significant harm to the child. Complications from the procedure are very rare, and the benefit in this case is likely to be substantial. There is not time to obtain an ethics consult or court order. The physician should attempt to address the parents' misconceptions about lumbar punctures and to reassure them about the safety of the procedure and perhaps offer to use appropriate pain control methods. A second opinion from another physician may prove helpful. Should these efforts not result in parental permission, the physician is justified in proceeding with the procedure and treatment of the child. While parental authority to make medical decisions for their children is broad, it does not include choices that may seriously harm their children. As long as the physician has used reasonable clinical judgment in determining the need for the lumbar puncture, legal liability should be minimal.

Parental Decision Making: Case 3

A 5-year-old child has just had his second generalized tonic-clonic seizure in a 4 month period. You have recommended starting an anticonvulsant. The parents have concerns about the recommended medication and would prefer to wait and see if their son has more seizures. How should you respond to the parents request?

Parental Decision Making: Case 3 Discussion

The parents have the authority to make a choice of this sort. In general, courts have been reluctant to overrule against parental wishes in most situations where that decision does not place the child at considerable risk. Though failure to start an anti-convulsant may increase the risk of further seizures, this does not pose a substantial enough risk to the child to justify overriding the parents' wishes, especially given the potential risks associated with the medication. Though you may not agree with their decision, the decision is a reasonable one that does not place their child at substantial risk of increased harm

ANS 24. Answer is E. In these difficult situations where the patient is not able to make their own decisions and when there is disparate views among family members, the most important directing factor should be what the patient would have decided were they able to speak for themselves. Therefore, previously expressed views on what the patient would want if faced with a similar situation could prove invaluable in helping to direct care in the direction that the patient would have wanted. Court appointed legal guardians (choice A) are utilized when a patient has no family or has family members who are not competent to help make medical decisions on behalf of the incapacitated patient. If the patient has a clearly expressed view, this view would supercede any sentiments by the medical team (choice B), the husband (choice C), or a hospital ethics committee (choice D). ANS 25. D. Pap smear should be done after 3 year of first sexual encounter or at the age of 21, which ever comes first. In every doctor patient communication, patients confidentiality and wishes should be respected, unless there is considerable harm to self or the other.