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ismailalmokyad's version from 2018-01-09 08:37

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Question Answer
1-Gastroesophagea reflux in infants (happy spitters), why present, c/p adn ttt-it due to relaxed and short lower esophageal sphincter. start early and peak at 4 month old. Resolve by 12-18 months.

-spit-up partially digested yellow milk.
-normal weight gain
-no pain/back-arching

treatment with
-Upright positioning after feeds
-Burping during feeds
-Frequent, small-volume feeds
-if no response and sever can do Nissen fundoplication and endoscopy
2-Radial head subluxation (nursemaid’s elbow), wt is mechanism, physical exam and treatment1-Mechanism
-Axial traction on forearm with elbow extended (child pulled, lifted, or swung by arm)

2-c/p and physical findings
-immediate sudden pain and refusal to move the arm after forearm was pulled is classic.
-most common in age 6 months to 5 years.
-Arm held extended & pronated
-No swelling, deformity, or focal tenderness

3-Treatment
-Hyperpronation of forearm
OR
-Supination of forearm & flexion of elbow
3-can a physicians take any payments for travel expenses from pharmaceutical companies?-if just to attend then no
-if will present yes if it is reasonable and with full disclosure. but he must retain full control over the presentation's content(they cant tell him what to say).
4-wt is dyspepsia and how to manage it ?Dyspepsia is defined as chronic/recurrent pain or fullness in the epigastric area without significant heartburn.

ttt
1-if the patient has symptoms of GERD then treat with empiric ppi
2-if pt is taking NSAIDs then stop the medication with or without adding PPI
3-if the pt has no typical GERD and is not using NSAID or if present from a country with high prevalence of H pylori then T pylori testing is indicated.
4-if the patient is > 55 YO or having alarming symptoms (weight loss, gross or occult bleeding, anemia, dysphagia, or early satiety )then Endoscopy.
5-what is the indication of suprapubic catheterization.1- BPH with urine retention plus on of the following
-genitourinary trauma/surgery
-if urethral catheterization was unsuccessful.

2-in prostatitis
6-how to work-up incidentaloma (Incidentally discovered adrenal mass) and how to treat it.- all adrenal masses require workup for hormone hypersecretion or malignancy.
-essential laboratory studies include
1-serum electrolytes
2-dexamethasone suppression testing
3-and 24-hour urine catecholamine, metanephrine, vanillylmandelic acid and 17-ketosteroid measurement.

ttt
- surgical removal if
1- functional
2-demonstrate a characteristic heterogenous appearance on imaging
3-more than 4 cm
-All other masses can be managed conservatively with serial abdominal imaging, and removed if they increase in size.
7-how to treat alloimmunization Rh(D)-negative mother pregnant with baby who is Rh(D)-positive.Serial ultrasounds monitor the progression of fetal anemia, which can be treated with in utero red blood cell transfusions.
8-what is the cut off to dx Maternal Rh(D) alloimmunizationelevated titer levels (>1:8)
9-what to screen before starting RA pt on anti-cytokine therapy (e.g., infliximab, etanercept)screened for latent TB by PPD skin testing.
10- what is trastuzumab and wt is the associated complicationTrastuzumab is a monoclonal antibody that targets human epidermal growth factor receptor 2 (HER2). It is used in addition to adjuvant chemotherapy for the treatment of patients with HER2-positive tumors.

trastuzumab-associated cardiotoxicity (Low EF) is reversible; there is complete recovery of cardiac function after treatment discontinuation.
11-Kawasaki disease diagnostic criteria1-Dx criteria: Fever >5 days plus >4 of the following findings:
-Conjunctivitis: bilateral, nonexudative
-Mucositis: Injected/fissured lips or pharynx, strawberry tongue
-Cervical lymphadenopathy: >1 lymph node >1.5 cm in diameter
-Rash: Erythematous, polymorphous, generalized; perineal erythema & desquamation; morbilliform (trunk, extremities)
-Erythema & edema of hands/feet
-****** if the patient has >5 days fever and <4 criterion then order ESR and CRP and follow daily (symptoms doesn't happen at the same time).

2-Complications
-Coronary artery aneurysms (after 10 days without treatment)
-Myocardial infarction & ischemia

3-Treatment
-Aspirin plus intravenous immunoglobulin (greatly decrease complication and reduce M&M)
-do echo at diagnosis and again at 2-6 weeks.
-postponed live immunization for 11 months, bc IVIG is pooled antibodies and will interfere with body immune system to life vaccines.
12-Cerebral palsy risk factors, c/p, dx and management ?1-Risk factors
-Prematurity
-Low birth weight

2-Clinical features
-Delayed motor milestones
-start as hypotone, progress to spasticity in few months.
-hyperreflexia and sustained clonus
-Comorbid seizures, intellectual disability
-nonprogressive motor dysfunction(wt ever he has will not worsen)

3-Diagnostic workup
-MRI of the brain ( majority of patients have abnormal findings (eg, periventricular leukomalacia, brain malformation, ischemia).
-± Electroencephalography (if with seizure)
-± Genetic/metabolic testing

4-Management
-Physical, occupational, speech therapies
-Nutritional support (if oromotor dysfunction is severe, gastrostomy feeds may be required)
-Antispastic medications (botulinum and baclofen can help to reduce spasticity and clonus.)
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14-Target blood glucose level in gestational diabetes mellitus.Patients with GDM monitor fasting and either 1- or 2-hour postprandial blood glucose levels. Target glucose levels are:
-Fasting <95 mg/dL
-1-hour postprandial <140 mg/dL
-or 2-hour postprandial <120 mg/dL
15-what is the complication of gestational diabetes mellitus on the baby.-lead to fetal hyperglycemia and hyperinsulinemia, resulting in macrosomia shoulder dystocia, or hypoglycemia.
-long-term complications, including type 2 DM, obesity, and cardiovascular disease in offspring.
16-treatment of gestational diabetes1- dietary modifications and exercise if not enough
2- medications
-insuline
-metformin
-glyburide
17-who is adults that need HBV vaccinationhigh risk who is not immunized or current positive HBVsAg.

***high risk is one of the followin
-Multiple sexual partners or a history of a STD's
-Men who have sexual activity with men
-IV drug users
-Patients with CKD, HCV, or HIV
-Household contacts of patients with chronic HBV

also all pregnant women, health care personnel, and inmates who are not immunized
18-Guillain-Barré syndrome (GBS) cause, c/p, complications, and how to manageOccurs after a GI (eg, Campylobacter) or respiratory infection generates cross-reacting antibodies to peripheral nerve components.

C/P
1-Symmetric muscle weakness that usually begins in the legs
2--Paresthesias
3-Dysautonomia (eg, tachycardia, urinary retention) that may be life-threatening
4-Decreased or absent deep tendon reflexes.

complication: rapid-onset respiratory failure due to respiratory muscle weakness. Approximately 30% of patients with GBS ultimately require mechanical ventilation.

management
1-frequent measurement of vital capacity and negative inspiratory force is required to monitor respiratory status
2-Disease-modifying treatment with plasma exchange or intravenous immunoglobulin (IVIG) speeds recovery and reduces the need for mechanical ventilation.
3-Patients with GBS should receive plasma exchange or IVIG if:
-Nonambulatory
-still <4 weeks since symptom onset
4-Those who are ambulatory and recovering generally do not require treatment.
treatment shorten the course

prognosis:
Guillain-Barré syndrome (GBS) tend to evolve as follows:
-2 weeks of progressive motor weakness that can lead to paralysis
-2-4 weeks of plateaued symptoms
-Slow, spontaneous recovery over months
19- wt is Transverse myelitisc/p and treatment and prognosisManifestations typically include motor weakness, paresthesias, and autonomic dysfunction (eg, bowel/bladder dysfunction). Most patients have a sensory level. treated with high-dose glucocorticoids. typically have incomplete recovery and are at increased risk for multiple sclerosis.
20- how does botulism symptoms presentsymmetric descending weakness(starting in the cranial nerves) with no sensory deficits (except blurred vision)
21-Persons needing antimicrobial prophylaxis
following Neisseria meningitidis exposure.

what antibiotics is acceptable
1-Household members
2-Roommates or intimate contacts
3-Child care center workers
4-Persons directly exposed to respiratory or oral secretions (eg, kissing, mouth-to-mouth resuscitation, endotracheal intubation/management)
5-Person seated next to an affected person for
6-≥8 hours (eg, airline traveler).

Abx acceptable are
1-rifampin BID for a total of 4 doses orally (first line in children)
2-ceftriaxonce IM (safe in pregnancy)
3-ciprofloxacin once orally(avoid in children)
22-how does SLE affect coronary arteries. what cancer has a high risk in SLE ptassociated with accelerated atherosclerosis due to a combination of traditional (eg, hypertension, hyperlipidemia) and disease-related risk factors (eg, chronic inflammation, glucocorticoid use). so SLE pt has 50 fold increase in risk of CAD and it can be fatal early.

it increase risk of non-hodgkin lymphoma, especially diffuse large B-cell lymphoma. present as rapidly enlarging symptomatic mass in the neck or abdomen and may cause airway compression.
23- what is the defferance between mechanical and bioprosthetic valve, wt is the rule of anticoagulation after valve replacement-warfarin for only 3 months following bioprosthetic mitral valve but Aspirin is continued indefinitely.
-lifelong anticoagulation warfarin and aspirin following Mechanical valves.

Mechanical valves have several advantages over bioprosthetic valves, including durability and lower risk of failure. The main disadvantage is the risk of thromboembolism
24-how to manage anticoagulatin during pregnancy(hypercoagulable state)1-LMWH SQ can be use throughout pregnancy but should be avoided in renal insufficiency(cleared renally), preferred during the first trimester.

2-UF SQ or IV should be used only before delivery, ok to use in renal insufficiency (cleared by renal and liver), best for high bleeding risk(surgery, full term pregnancy). it is has more complication as associated with increased bone density loss, bleeding, and thrombocytopenia.

3-warfarin oral (can be use preconception and postpartum (does not accumulate in breast milk), sometime used in 2nd and 3ed trimester for patients with mechanical heart valve. it is teratogenic (bone and cartilage) increase bleeding risk.
25- Paget's disease,Technetium bone scan finding, indication for treatment, and wt medications medications?-Technetium bone scan shows an increased uptake in different part of the body

-Indications:
1-intolerable pain
2-involvement of weight-bearing bones
3-neurological involvement
3-hypercalcemia or hypercalcinuria
4-CHF

-Medications
-Several bisphosphonates (alendronate, risedronate, and pamidronate) for Six months of treatment with oral alendronate and two months of treatment with oral risedronate lead to sustained remission in a large number of patients.
-IV pamidronate can be used in patients with contraindications to the use of oral bisphosphonates.
26-what is the indication and complication of IVC filter placement ?indication:
any contraindications to anticoagulation (eg, recent surgery, hemorrhagic stroke, bleeding diathesis, active bleeding).

complications:
post-procedural complications (eg, acute insertion site thrombosis, hematoma, arteriovenous fistula). The main long-term complication is recurrent DVTs, insertion site thrombosis and IVC filter thrombosis. rarely filter migration and perforation.

NB: filter usually placed below the level of renal vein, so renal and portal veins are protected.
27, what cause Wernicke encephalopathy, C/P, dx, and treatment ?life-threatening disorder of thiamine deficiency seen most commonly in patients with heavy alcohol use and/or severe malnutrition

c/p:
-Encephalopathy - disorientation and confusion
-Oculomotor dysfunction - lateral rectus palsy
-Gait ataxia - wide-based gait or complete gait impairment

dx:no specific test available but may show evidence of alcohol hepatitis (2:1) or synthetic hepatic dysfunction (elevated INR, low albumin).

TTT:
-Intravenous thiamine, usually improves ocular abnormalities within hours, but confusion and gait ataxia may persist for days or weeks; many patients never fully recover.
28-wt is korsakoff syndrome, c/p, dx, tttlate-stage complication of Wernicke encephalopathy (up to 80%)

present with
-significant retrograde and anterograde amnesia
-confabulation.
-cognition, attention, social behavior, and long-term memory are relatively preserved.

Dx
-MRI show mammillary body atrophy.

TTT:
-Unlike WE the neurocognitive changes of KS rarely improve; most patients require long-term supervision and social support.
29-what cause febrile nonhemolytic transfusion reaction and how to avoid it ? how to manage it ?When RBC& plasma are separated, a small amounts of residual plasma and/or leukocyte debris may remain. During blood storage, these leukocytes release cytokines, which when transfused can cause transient fevers, chills, and malaise without hemolysis.

-Management
1-stopping the transfusion to exclude other serious reactions
2-administering antipyretics
3-using leukoreduced blood products for future.

NB:Leukoreduction: is reducing leukocytes through filtering or other methods such as saline washing, freezing and deglycerolizing, or buffy coat removal.
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