Most Sensitive Test: Phalen's
(good for screening)
Nerve conduction studies (electromyography) is the gold standard
1) Night brace (keeps wrist in neutral position)
2) Osteopathic Manipulation directed at UEX, upper ribs, clavicle, and cervical spine
Pregnancy is a common risk factor in the development of carpal tunnel syndrome. (Delivery = tx)
Tinel's test is one of the more common provocative tests used to aid in the diagnosis of carpal tunnel syndrome. The test is performed by tapping over the volar aspect of the wrist at the transverse carpal ligament. Reproduction of the patient's symptoms, such as numbness, tingling, and pain radiating into the thumb and first 3 digits, indicates a positive test. Although Tinel's test is commonly performed and tested on COMLEX, it is not a very sensitive or specific test. Performing other tests such as Phalen's, prayer, and carpal tunnel compression can also provide valuable information.
Dementia is a neurodegenerative disease that is defined as a nonspecific syndrome of reduced cognitive ability in a previous unimpaired person.
1) Alzheimer's disease
2) Vascular dementia
3) Fronto-temporal dementia
4) Dementia with Lewy bodies.
The disease is characterized by a loss of memory, with a marked reduction in the ability to learn, reason, retain, or recall past experiences.
Eventually thoughts, feelings, and activities are affected. Altered mental status and behavioral changes are noted on exam.
1) The Mini-Mental State Exam (MMSE) is the initial step in a patient with cognitive complaints.
Includes simple questions and problems to discern orientation, memory, attention, arithmetic and language skills.
A low score suggests the likelihood of dementia or delirium.
2) Clock drawing
The most sensitive test of cognitive function.
This can be performed as an alternative test to the MMSE. The clock-drawing test requires a patient to correctly draw the face of a clock with the hands at 8:20. If the patient has two or more errors in drawing the clock, then dementia is strongly considered. If there are no errors then a diagnosis of dementia should not be considered.
In a patient with hyperlipidemia, who is not diabetic and has an LDL of <190, the most appropriate next step in management is to counsel the patient on healthy lifestyle changes.
The patient in the above scenario has no cardiovascular risk factors. Cardiovascular risk factors include diabetes (considered to be a CAD risk equivalent), smoking, hypertension, HDL <40 mg/dL, age >45 (males), age >55 (females), and early CAD in first-degree relatives (males <55 and females <65).
The most recent treatment guidelines recommend initiation of statin therapy for primary prevention in two major patient groups: Age >21 with an LDL of >190 and age 45-75 with diabetes and an LDL of >70
In a patient with known CAD or a CAD risk equivalent (ie. diabetes), the goal LDL is <100 mg/dL or ideally <70 mg/dL. In a patient with a CAD equivalent, an LDL >130 mg/dL should be managed with medications. First line therapy for increased LDL is a statin. In a patient with a CAD equivalent and an initial fasting LDL of >100 but <130, a 12-week trial of diet and exercise can be attempted
SEE THE COMAT QUESTION BELOW ON "HLD and statins"
The most likely diagnosis is epiglottitis, a bacterial infection caused most commonly by H. influenzae. Due to the H. influenzae vaccination this is not as commonly seen. It is characterized by rapid onset sore throat, dysphagia, stridor, drooling, hoarseness, tachypnea, chest retractions, it usually occurs in the age range of 2-6 years. This should be treated as an airway emergency. The child should be kept calm and taken to the OR for a controlled mask induction, which is the most common way to proceed. Ideally, ENT should be available for emergent tracheostomy or rigid bronchoscopy if problems occur during induction. Recall that a lateral chest x-ray of acute epiglottitis will show the "thumb-print sign", an indicator of a swollen epiglottis.
Accessory muscle use can result in trapezius muscle spasms. In addition, viscerosomatic reflexes from the head and neck result in paravertebral tissue changes from T1-4
Answer A: Chronic bronchitis is uncommon in pediatric patients and is also a chronic process by definition. This presentation is an acute one that is more consistent with epiglottitis. Chronic bronchitis is defined as a productive cough most days for three consecutive months out of the past two years.
Answer B: Emphysema is uncommon in the pediatric population.
Answer D: A foreign body may present with acute respiratory distress but a fever should be absent.
Answer E: Reactive airway disease can be used to describe asthma, which does not present with fever.
The most common initial symptoms of porphyria cutanea tarda are cutaneous fragility and blistering of the hands, forearms, and, sometimes, the face. Changes in hair growth and pigmentation may be noted spontaneously or only after inquiry.
Patients with porphyria cutanea tarda often do not realize the role of sunlight exposure in the subsequent appearance of lesions. In both familial and sporadic porphyria cutanea tarda, a history of exposure to one or more environmental inducers (eg, ethanol, estrogens, hepatitis) can often be elicited.
The most common presenting sign of porphyria cutanea tarda is fragility of sun-exposed skin after mechanical trauma, leading to erosions and bullae, typically on hands and forearms and occasionally on face or feet.
ADL is defined as self-care activity that a person performs daily. Activities of daily living (ADL) include
5) dressing and
Instrumental activities of daily living (IADL) are activities that are needed in order to live independently. Instrumental activities of daily living include
1) use telephone,
3) food preparation,
6) mode of transportation (public or private),
7) responsibility for own medications, and
8) ability to handle finances.
Laundry is an instrumental activity of daily living. Dressing is an activity of daily living.
Food preparation is an instrumental activity of daily living. Feeding is an activity of daily living
Responsibility for own medications is an instrumental activity of daily living.
age-related macular degeneration (ARMD).
two types of ARMD:
1) atrophic/ non-exudative ("dry") ARMD
2) neovascular/ exudative ("wet") ARMD.
Atrophic ARMD makes up 80% of all cases and is the most common cause of vision loss in developed countries.
It is caused by progressive degeneration of the retina and the choroid in the posterior pole due to either atrophy or retinal pigment epithelium detachment.
-painless loss of central vision over years to decades. -peripheral vision remains intact until late stages of disease.
Patients may complain of problems with night vision, difficulty reading or making out faces, and/or metamorphopsia.
Metamorphopsia is a type of visual field defect that causes distorted vision with wavy lines in the central field.
Patients may also report variability in their symptoms where some days their vision is better than others. The main risk factor for ARMD is advanced age, however, other factors include female sex, smoking, family history, cardiovascular disease, and light colored eyes and skin.
Funduscopic examination reveals confluence of drusen (tiny yellow or white accumulations of extracellular material that build up between Bruch's membrane and the retinal pigment epithelium of the eye) with significant pigment changes and accumulation of pigment in the posterior pole. Atrophy of the retinal pigment epithelium and macular fibrosis may also be present.
-controlling blood pressure
-combination of vitamins and antioxidants.
--> vitamin A, vitamin E, vitamin C, beta-carotene, zinc, and lutein.
1) Meningococcal vaccination
-typically administered as one shot
-MC recommendation is in teenagers starting college due to living in closed spaces like dormitories.
-Also recommended in military personnel as well.
-Other indications include patients with: asplenia and complement deficiencies as well as HIV infection patients.
2) Hepatitis A vaccination
-typically administered as two injections 6 months apart
-typically administered to children--> high likelihood of transmission from children in prior epidemics.
-In adults--> travelers to endemic areas like southeast Asia and Africa.
-Other recommendations include: intravenous drug users and chronic liver disease patients except those with chronic hepatitis B or C infection without liver dysfunction.
(Post-exposure prophylaxis should be offered to all person in close contact with the infected person with no prior vaccination of hepatitis A.)
3) Hepatitis B vaccine
-inactivated vaccine series with 3 injections ( 0 month, 1 month and 6 months).
-hepatitis B titers can be checked prior to administering hepatitis B vaccination series.
-hep B transmission = sexual intercourse and blood or blood contaminated products.
-highly recommended for adults with increased risk of sexual transmission of infections including men who have sex with men, multiple sexual partners, sex partner of a patient with hepatitis B and upon evaluation of any sexually transmitted infection.
-Other indications include all health care workers, co-morbidities (diabetes mellitus, HIV infection, chronic liver disease, end-stage kidney disease), and travelers to countries with endemic hepatitis B.
-hepatitis B vaccination series are recommended for all age groups, since it is one of the leading causes of chronic liver disease and cirrhosis worldwide.
4) Human papillomavirus vaccine (HPV)
-inactivated vaccination administered in a series of 3 injections.
-HPV is the MC sexually transmitted infection in the United states with certain serotypes leading to genital warts and cervical or anal cancer.
-HPV vaccine covers serotypes 6, 11, 16, and 18.
-HPV vaccine is recommended for all females of age 11 to 26 years and males of age 11 to 21 years as well.
-Although this vaccination is highly recommended prior to first sexual intercourse, it is still proven to be effective in individuals with prior intercourse and history of HPV infection due to different serotypes covered by the vaccination.
5) Pneumococcal vaccine
-inactivated vaccination recommended in all adults of age 65 years and older.
-ages 19 - 64 years of age, specific indications include diabetes mellitus, chronic pulmonary disease (asthma and COPD), cigarette smoking, alcoholism, cochlear implant, immunocompromised patients (HIV, multiple myeloma, chronic corticosteroids) and asplenia to list a few.
-Patients who are vaccinated prior to age 65 years, receive a booster dose at age 65 or 5 years after initial vaccination, whichever is later.
6) Varicella vaccine
-live, attenuated vaccination.
-recommended in all persons born after 1980 unless there is a physician documented evidence of either varicella or varicella vaccination.
-live vaccine= contraindicated in pregnancy and used with caution in immunocompromised patients.
-recurrent abdominal pain
-weight loss in a child or young adult is characteristic of inflammatory bowel disease.
Crohn's disease typically present in adolescent patients with:
-weight loss, and
-abdominal pain with frequent, sometimes bloody diarrhea.
[This is the result of chronic transmural inflammation of the bowel, which usually involves the terminal ileum (hence RLQ pain), but may involve any intestinal tissue between the mouth and the anus.] --> Pt had apthous ulcers in her mouth
May also have:
aphthous oral ulcers, and
endoscopic visualization and tissue biopsy of involved intestinal mucosa.
Colonoscopy with intubation of the terminal ileum is used to evaluate the extent of disease, to demonstrate strictures and fistulae, and to obtain biopsy samples.
Look for skip lesions, noncaseating granulomas, transmural thickening and inflammation with narrowing of the lumen, and mesenteric "fat creeping" onto the antimesenteric border of the small bowel.
anti-inflammatory agents (sulfasalazine, prednisone) and/or immunosuppressants (azathioprine, 6-mercaptopurine, methotrexate).
advancing disease and complications (e.g., fistulas, strictures, bowel obstruction) eventually develop, requiring surgery (segmental bowel resection). There is no cure and recurrence usually occurs after surgery.
fat-soluble vitamins (vitamin A, D, E, K),
calcium, phosphorous, and
Close attention should be given to calcium, vitamin D, and iron levels.
Loss of the ileum and proximal small intestine leads to decrease absorption of these key nutrients, leading to increased risk for bone disease and chronic anemia.
Iron deficiency is the most common cause of anemia in IBD and is usually one of the earliest nutritional deficits detected.
Current supplementation recommendations suggest oral iron supplements for initial management of mild to moderate iron deficiency in IBD. However, several studies have shown that intravenous iron may be more effective and safer in this patient population due to the risk of GI upset and oxidative damage to the intestines with oral supplements. Therefore, intravenous iron supplementation should be considered for patients with moderate to severe IBD activity or severe anemia, or for those who do not tolerate or respond appropriately to oral iron.
Bronchiolitis is a lower airway obstructive process that causes small airway obstruction and occurs most commonly in the winter.
Typically it does not respond to humidified air alone.
Affected children are usually less than 12 months old and the most common cause is respiratory syncytial virus (RSV). Cough, coryza, and upper respiratory symptoms are commonly observed.
Signs include fever, wheezing, and dyspnea. Younger children may even have apneic episodes, which are alarming to a parent despite the generally benign nature of this illness. On chest x-ray, one might observed peribronchial cuffing, areas of hyperaeration, and atelectasis. Hypercapnia or hypoxemia may be observed. Treatment is typically supportive with supplemental oxygen for hypoxia, nebulized albuterol for wheezing, and corticosteroids if bronchodilators do not help. Patients are admitted for hypoxia, prematurity, age less than 3 months, or toxic presentation. This may have been a close choice for the most correct answer, however, the age of presentation and lack of lower airway obstructive symptoms (expiratory wheeze vs. inspiratory stridor) make this more likely to be croup.
scattered wheezing is noted on physical exam.
In patients who are stable and do not warrant an endoscopic evaluation, confirmation of H. pylori can best be achieved with serologic studies using the so-called "test and treat" method.
The test-and-treat strategy for H. pylori is a proven management strategy for patients with uninvestigated dyspepsia who are under the age of 55 years and who do not have concerns of bleeding, anemia, early satiety, unexplained weight loss, progressive dysphagia, odynophagia, recurrent vomiting, family history of gastroesophageal cancer, or previous esophagogastric malignancy.
Serology is an ELISA test that detects IgG antibodies against H. pylori antigens. Generally a positive serology represents active infection in approximately 50% of patients, and it is generally reasonable to start triple therapy with a positive result.
Conversion of positive serology to negative after treatment suggests bacterial cure.
After treatment, the best test for eradication of the bacteria is with a urea breath test.
1) Serology if stable
2) EGD + Bx + rapid urease assay if red flags
2) urease breathe test to F/U eradication
Cushing's syndrome can present with new-onset hypertension, truncal obesity, purple striae, posterior cervical fat pad, easy bruising and hirsutism in patient's on chronic steroid therapy.
Iatrogenic glucocorticoid overuse including prednisone is the most common cause of Cushing's disease.
Common clinical manifestations include
- proximal muscle weakness,
-weight gain, and
Common physical examination findings include: -hypertension,
-posterior cervical fat pad, and
Common laboratory abnormalities include:
Hypokalemia is the most common electrolyte abnormality noted in patients with Cushing's syndrome because of increased mineralocorticoid activity in patients with high cortisol levels.
1) functional incontinence
This is a form of incontinence characterized by physical or mental barriers to voiding.
urinary tract infection,
reduced mobility. (post CVA w/ right hemiparesis)
2) Mixed incontinence
This a combination of both stress and urge incontinence. For example, the patient would have leakage with urgency, as well as with stress-producing scenarios (coughing, sneezing, or exertion).
3) Stress incontinence
In this form of incontinence, there is an involuntary loss of urine during a stress maneuver due to weak pelvic floor muscles or insufficient internal urethral sphincter strength. This form is more common in women, though men can develop it after prostate surgery. Nocturnal symptoms are uncommon in stress incontinence and pelvic exam may reveal weak pelvic floor muscle strength or a cystocele. Diagnosis is made by finding evidence of pelvic prolapse. Further, causes of intrinsic sphincter deficiency such as use of alpha-adrenergic antagonists, radiation, or surgical trauma should be considered. If chronic cough is a precipitant, it should be treated. Kegel exercises are often suggested to strength the pelvic floor muscles in the case of mild to moderate stress incontinence. They are often successfully if done diligently, though patients will often become discouraged and give up before maximal benefit can be realized. Pessaries may be of benefit to women with stress incontinence in the presence of bladder or uterine prolapse. Ultimately, surgery offers the highest cure rates, through bladder neck suspension, suburethral slings, or tension-free vaginal tape.
4) Urge incontinence is the most common type of incontinence in geriatric patients and is typically due to detrusor overactivity. In the classic scenario, patients feel an abrupt urge to urinate, but cannot get to the toilet in time. They might also have nocturia. In these patients, pelvic and rectal exams should both be performed. There is no abrupt urge to urinate in this question stem.
5) Overflow incontinence is the unpredictable dribbling of urine or weak urine stream due to underactive bladder and/or outlet obstruction. This is the second most common cause of incontinence in older men. Underactive bladder may be due to medications, specifically calcium channel blockers and anticholinergics, or detrusor denervation, or injury. Outlet obstruction may be due to an enlarged prostate gland, tumors, urethral stricture, or chronic constipation.
Hemoptysis, night sweats, fever, and weight loss are classic for tuberculosis.
Patients with primary TB are usually asymptomatic.
If the immune response is incomplete, the pulmonary and constitutional symptoms of TB may develop and this is progressive primary TB. Secondary (active) TB is characterized classically by fever, night sweats, weight loss, and malaise.
Cough progresses from dry cough to purulent sputum, with hemoptysis suggesting advanced TB.
On exam, we hear rales, indicating possible lung consolidation.
Tuberculosis prefers the upper lobes because of their increased aeration.
Classic findings on CXR are upper lobe infiltrates with cavitations, though definitive diagnosis is made by sputum culture.
1) Akathisia occurs both early and late in antipsychotic drug treatment. It is a subjective feeling of motor restlessness as well as the inability to sit still. This may be manifested by repeated leg crossing, weight-shifting, or stepping in place.
2) Chorea is simply an abnormal involuntary movement disorder, one of group of disorders called dyskinesias. These are quick movements of the feet or hands and take their name from the Greek word for "dance." These movements are often combined with athetosis, which adds twisting and writing movements. Chorea is a primary feature of Huntington's disease and can also be seen in Wilson's disease. Though tardive dyskinesia can present with chorea itself, this patient has lip smacking and head jerking, which is not chorea itself.
3) Dystonias are involuntary contractions of major muscle groups, and are characterized by symptoms such as torticollis, retrocollis, and oculogyric crisis. These are usually rapid in onset and disturbing to most patients. Risk factors for dystonia include young age, male sex, use of cocaine, and history of acute dystonic reaction.
4) Secondary parkinsonism consists of mark-like facies, resting tremor, cogwheel rigidity, shuffling gait, and psychomotor retardation (bradykinesia). Mild parkinsonism is usually not evident unless an examiner observed cogwheel rigidity or diminished arm swing during exam.
5) Tardive dyskinesia (TD) is a hyperkinetic movement disorder that appears with a delayed onset after prolonged use of dopamine receptor blocking agents. TD can present with chorea, athetosis, dystonia, akathisia, stereotyped behaviors and rarely, tremor. The term "tardive" differentiates these dyskinesias from acute dyskinesia, parkinsonism, and akathisia, which appear very soon after exposure to antipsychotic drugs. TD can include a variable mixture of orofacial dyskinesia, athetosis, dystonia, chorea, tics, and facial grimacing. The symptoms involve the mouth, tongue, face, trunk, or extremities. Oral, facial, and lingual dyskinesia are especially conspicuous in elderly patients.
Mastitis is an uncommon complication of breastfeeding due to nipple trauma and infection with S. aureus. Patients present with fever, unilateral breast pain, swelling, erythema, and purulent nipple discharge.
Management includes supportive care, frequent emptying via continued breastfeeding or pumping, and antibiotic therapy. Antibiotic therapy and infection are not contraindications for breastfeeding.
Patients should continue to breastfeed their child during antibiotic treatment for mastitis. However, if they are no longer breastfeeding, they are encouraged to pump regularly to empty the breast of infected material.
Antibiotic therapy is with anti-Staphylococcal agents, most commonly amoxicillin/ clavulanate, dicloxacillin, and cephalexin. Azithromycin or clindamycin can be used in patients with a penicillin allergy. None of these antibiotics require the patient to stop breastfeeding.