to snoo-finity ... and beyond!to snoo-finity ... and beyond!Goljan had a lecture that mentioned that "If a patient has galactorrhea, review every drug they're taking since many drugs cause galactorrhea."
The only thing of possible relevance in this Q-stem is that she takes a medication, therefore the answer of "drug effect" is the most likely reason for her galactorrhea.
Guyon Canal Syndrome is due to an Ulnar Nerve lesions and is associated with bicycle handlebar use.
Also FINGER abduction and adduction is mediated by ulnar nerve. The patient is having trouble with FINGER abduction and adduction.
The Froment sign is testing ADDUCTOR POLICIS ACTIVITY, which is mediated by the ULNAR NERVE activity. It is NOT testing thumb opposition, which would be mediated by the median nerve.
The reason "do not prescribe antibiotics until testing results are available" is incorrect is because we already have a gram stain that shows gram-negative diplococci in pairs. This is Neisseria gonorrhoeae. So, no need to wait for test results come back.
The Q-stem stating that "Testing for Neisseria and Chlamydia" is ordered" after already having done the Gram stain seems to be a distractor.
Patient's symptoms began 30 min after mowing lawn (i.e. after doing physical activity). He has severe chest pain and is cool, clammy, diaphoretic. He has increased pulmonary artery pressure and increased left atrial pressure. Taken altogether, this is cardiogenic shock.
Cardiogenic shock is a heart pump problem -- the LV isn't working.
When the LV, isn't working, it causes a back up in the direction opposite to how blood normally flows. Therefore, blood will back up in the lungs.
This causes increased capillary hydrostatic pressure --> this drives more fluid into the interstitium --> this causes increased interstitial hydrostatic pressure --> there is now more fluid than normal in the interstitium --> this affects the protein ratio within the interstitum --> this causes decreased interstitial oncotic pressure.
Patient in hypovolemic shock - the clues are low BP and COOL skin. Hypovolemic shock is caused by fluid loss.
The patient has decreased preload b/c of fluid loss, i.e. there is decreased blood volume returning to heart --> thus decreased preload.
Spleen is enlarged. Compare it to CT scan showing normal-sized spleen:
http://www.startradiology.com/uploads/scroll/18/14hiu6b3qot5.jpg
As stated below, the Left crus cerebri was damaged (see what it should normally look like below). This contains the corticospinal tract. Since the corticospinal tract decusates at the medulla, below the midbrain section we're looking at, you would see Contralateral (Right) Spastic Hemiparesis
A little math here.. pH is low --> acidosis pCO2 is high --> respiratory Normal compensation should be roughly a 1 (acute) to 4(chronic) increase in bicarb per every 10 increase in pCO2.. Its lower here, so clearly not compensated and indicated additional drop in bicard --> add on metab acidosis
This is a likelihood ratio. LR+= Sens/1-Specif
Any value greater than 10 (per first aid) indicated "usefulness of diagnostic test" which is comparable to PPV (ruling in a dz). Point "A" is the closest mark to where 10 should be on the Y axis.
Is this saying there is vesicoureteral reflux? I could have sworm this same image was on form 20 or 21 and the answer was Wilms tumor
The description of bilateral lower limb loss of vibration implies DCML damage, and the absent DTRs + Romberg seem to me to be implying that he possibly has tabes dorsalis from syphilis (or something very similar in presentation).
As for the other answers, A is wrong because his motor function is intact, B is wrong because pain and temperature deficits are not mentioned, C is wrong because it implies a specific nerve is entrapped, but he has lost bilateral sensation in his entire lower extremities
D is the trickiest, and I’m not 100% sure, but I would think radiculopathy of the anterior (ventral) roots would cause motor deficits since they carry motor efferents. You might also expect that motor dysfunction to be unilateral, since it would be unlikely to have a problem with the nerve roots on both sides. also the DCML is not located near the anterior roots of the spinal cord, so if the anterior roots were affected you really wouldn’t expect to see vibratory loss.
So basically process of elimination, I do feel like sensory neuropathy is an extremely vague answer though and I wasn’t a fan of the question.
Neoplasia is new tissue growth that is unregulated, irreversible, and monoclonal.
Clonality can be determined by glucose-6-phosphate dehydrogenase (G6PD) enzyme isoforms. G6PD is X-linked.
*For more information check out Ch. 3 Neoplasia in Pathoma
This patient has small cell carcinoma. This type of cancer is associated with paraneoplastic syndromes such as: Cushing Syndrome, SIADH, or antibodies against Ca2+ channels (Lambert-Eaton) or neurons. Amplification of myc oncogenes is also common.
SIADH (Syndrome of inappropriate antidiuretic hormone secretion) is characterized by:
Body responds to water retention with aldosterone and ANP and BNP. That is what causes the increased urinary Na+ secretion which leads to normalization of extracellular fluid volume and the euvolemic hyponatremia.
Case of arteriolosclerosis.
Hyperplastic arteriolosclerosis involves thickening of vessel wall by hyperplasia of smooth muscle ('onion-skin appearance')
As stated below, the Left crus cerebri was damaged (see what it should normally look like below). This contains the corticospinal tract. Since the corticospinal tract decusates at the medulla, below the midbrain section we're looking at, you would see Contralateral (Right) Spastic Hemiparesis
Renovascular disease is the most common cause of 2° HTN in adults. Can be d/t ischemia from renal stenosis or microvascular disease. Can hear renal bruits lateral to umbilicus.
Main causes of renal artery stenosis:
Atherosclerotic plaques—proximal 1/3rd of renal artery, usually in older males, smokers.
Fibromuscular dysplasia—distal 2/3rd of renal artery or segmental branches, usually young or middle-aged females.
Lab values based off:
While I can get on board with Adjustment Disorder, I don't see how this answer is any better than Somatic Symptom Disorder. From FA:
Variety of bodily complaints lasting months to years associated with excessive, persistent thoughts and anxiety about symptoms. May co-appear with illness.
SSD belongs in a group of disorders characterized by physical symptoms causing significant distress and impairment.
Definition of adjustment disorder:
Emotional symptoms (eg, anxiety, depression) that occur within 3 months of an identifiable psychosocial stressor (eg, divorce, illness) lasting < 6 months once the stressor has ended.
If symptoms persist > 6 months after stressor ends, it is GAD.
Zollinger-Ellison syndrome: Gastrin-secreting tumor (gastrinoma) of pancreas or duodenum.
Thought this would be something regarding "bariatric surgery," but nope, just "no starchy foods, because you're pre-diabetic."
Urea cycle: Decreased citrulline and hyperammonemia can differentiate it from orotic aciduria.
The more general principle: endothelia vasodilate in the presence of high CO2; you gotta get rid of that acid somehow! Can’t let it accumulate, as lower pH within a “micro-environment” affects structure/efficiency of enzymes, proteins, etc. The more acidic a local environment, the more you expect nearby vasculature to dilate (as a means of increasing flow rate, thereby ferrying off accumulate acid).
The anesthesiologist can exploit this mechanism. By hyperventilating (blowing off CO2), the brain vasculature senses a low CO2 / “hunky-dory state,” which requires no vasodilation. In other words, the vasculature does not need to continue the ATP-consuming practice of synthesizing Nitric Oxide (NO).
Vomiting blood and cool skin indicates this is a type of hypovolemic shock. To understand shock, remember that 1) BP = TPR x CO 2) CO = SV x HR 3) SV = EDV - ESV In hypovolemic shock, you are losing fluid, so stroke volume is decreased and end diastolic volume is decreased. Decreased EDV means that the "filling volume" is decreased, which also means the preload will be decreased (https://www.cvphysiology.com/Cardiac%20Function/CF007). Also, skin is cool because you're decreasing SV --> decreased CO --> Ang II/ADH/etc is released to vasoconstrict increaseing resistance. Since there is increased resistance, there is less blood flow causing skin to be cold/clammy.
Knowing the LR+ value = 10 does not help to solve this Q because estimating where "10" should fall on an axis is arbitrary. Also, the data points are coordinates -- they have an X-value and a Y-value (X, Y).
The way to approach this Q is to know that a high specificity means that a positive result is very, very likely to be a true positive.
Suppose that the specificity is 0.99 -- this is 99% specificity. Then, you look at the graph. The X-axis is "1-specificity." So, suppose the best test has a specificity of 99%. Then, calculate 1-specificity = 1 - 0.99 = 0.10. You would then chose the datapoint that corresponds to having an "X-value" that is closest to the origin. In this problem, it corresponds to data point "A."
You don't even need to know a specific specificity value to solve this problem. All you need to do is understand that if the specificity is extremely high, you will need to find a datapoint that is closest to the origin -- at least for the value in the X-axis in the coordinate of the data point -- because the X-axis corresponds to a calculation of "1-specificity".