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Welcome to szsnikaaโ€™s page.
Contributor score: 28


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 +3  visit this page (step2ck_form6#17)
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Mildly interesting question but worth taking the time to explore the differentials in this vignette.

Fibromyalgia. Prevalent in young - middle-aged & โ™€ > โ™‚. Chronic widespread pain with tender points. Symptoms of pain & stiffness prevalent but Pain > Stiffness. Associated with IBS, urge incontinence & palpitations. Labs tend to be normal. NSAID won't provide relief. This fits!


Polymyalgia Rheumatica. Just like Fibromyalgia, there are symptoms of both pain and stiffness. However, in polymyalgia rheumatica, Stiffness > Pain. The patients tend to be older (>50yr.) and systemic symptoms (fever, weight loss, night sweats, fatigue) tend to be more prevalent. Not seen in this vignette.

Polymyositis. In this diagnosis, proximal muscle weakness is often the chief complaint +/-- mild pain. Serology would show (+) antinuclear antibodies (ANA). The patient does not complain of weakness in this vignette.

Ankylosing Spondylitis. This is seen in โ™‚ > โ™€ (3:1) so it becomes less likely. While pain/stiffness is seen in the back, neck, shoulders of these patients, tenderness is primarily seen at the sacroiliac joints. Furthermore, activity tends to improve symptoms (of stiffness) & NSAIDS would provide some relief. We don't see that in this case.

Seronegative RA. In this vignette, Labs show (--)ANA & RF but patients with this disease would present with joint pain & stiffness particularly in the hands, elbows, knees, feet and ankles. NSAIDS would also provide some relief.

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 +3  visit this page (step2ck_form6#34)
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This question is a rather interesting one. While pharyngitis with viral or bacterial etiologies have very similar clinical presentations, there are a few subtle hints that make Throat Culture the more likely answer regardless of the CENTOR score in this Vignette.

September. The seasonality of Group A Strep (GAS) pharyngitis is usually between winter & early spring. Viral pharyngitis, although all year round, is more common in the colder months.

The main objective of a primary care physician is distinguishing which patients have a higher likelihood of GAS infection vs. viral and because there is a significant overlap between the 2 etiologies, clinical judgment alone is not accurate in diagnosing GAS infections often leading to overtreatment with antimicrobial therapy.

Throat culture is the gold standard in diagnosing GAS. This is done in this scenario, despite the negative rapid test (Sensitivity 70% - 90%), because of the suspicion of viral etiology as well as the avoidance of overtreatment. Throat culture is the most appropriate next step in this case.

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drdoom  ๐Ÿ˜๐Ÿ˜๐Ÿ˜ +

 +12  visit this page (step2ck_form6#4)
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This patient has a testicular mass. Let's examine a few differentials as we go through the answer choices.

Germinal Cell Tumor (Testicular Tumor)

  • Usually painless but dull/achy/heavy sensation; palpation of SOLID mass
  • No change in size when supine
  • No transillumination

Dilated pampiniform venous plexus (Varicocele)

  • Usually painless; "Bag of worms"
  • Reduced swelling when supine
  • No transillumination

Cystic Dilation of the effect ductules (Spermatocele)

  • Typically painless; fluctuant swelling of upper testicular pole
  • No change in size when supine
  • Does transilluminate

Fluid accumulation within the tunica vaginalis testis (Hydrocele)

  • Often painless; fluctuant swelling of scrotum
  • May/May not change in size wrt position
  • Does transilluminate

Vascular Trauma (Hematocele/Ruptured Testis)

  • Extremely painful & tender; visible hematoma
  • May/May not change in size wrt position
  • No transillumination

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drdoom  your account has been upgraded to: ATTENDING +6
drmohandes  that's how you do an explanation. cheers m8 +4




Subcomments ...

submitted by bharatpillai(40), visit this page
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Oh absolutely not. Primary myelofibrosis ALSO presents with splenomegaly, pancytopenia and immature myeloid cells in the periphery. WBC counts for CML are typically >50,000. WTF is this question?

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stinkysulfaeggs  But he doesn't have pancytopenia, his WBC is 22,000. +1
szsnikaa  lol +
charcot_bouchard  WBC and Platelet in myelofibrosis is variable....Not always dec. i still dont know what was i thinking. should have picked the cml since the rainbow wbc panel that they described from that +


submitted by saffronshawty(30), visit this page
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can someone please explain this answer :D

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szsnikaa  Brain abscesses are secondary to septic emboli via hematogenous spread. Edema often forms around these abscesses leading to a mass effect (+ Babinski & Mild Hemiparesis on the left). +10
kingfriday  Guy has a valve replacement -> he then has a new murmur, fever, and FND - he probably has endocarditis due to staph epidermidis. Carotid artery occlusion wouldn't cause more issues (i think vision in particular would be included) in addition to more severe deficits. There would also be no fever. Venous sinus thrombosis would also not present with fever and also probably include vision problems Encephalitis would probably present with AMS and seizures - may or may not be nuchal rigidity Hydrocephalus: wet wacky wobbly- not seen here +5
tinylilron  So the brain abscess would be due to staph epidermis rather than strep pyogenes, right? +
notyasupreme  ^^ yeah, pretty sure I read on Anki that it's usually S aureus initially that commonly causes it, then becomes epidermitis +


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