By S. Deckard. Delta State University. 2018.

He stated that he had had a bicy- cle accident 1 week earlier but that otherwise he had been doing well generic penegra 100 mg without a prescription. On examination cheap 100 mg penegra with visa, the patient was tachypneic and tachycardic discount 50mg penegra visa; his heart rate was 110 beats/min cheap 50 mg penegra free shipping. With the patient receiving 2 L of oxygen by nasal cannula penegra 50mg fast delivery, the oxygen saturation was 94%. Physical examination revealed some crackles in the left base but was otherwise unremarkable. CBC and blood chemistries were within normal limits, and a chest x-ray was normal. Arterial blood gas measurements were made; the arterial oxygen tension (PaO2) was 60 mm Hg on room air. Ventilation-perfusion scanning showed a large right lower lobe perfusion defect, which was interpreted as indicating a high probability of pulmonary embolism. The patient underwent anticoagulation therapy for 6 months. At follow-up, with the patient off medication, a hyper- coagulable workup is performed. Laboratory results are all within normal limits except for the AT-III level, which is low. Which of the following statements regarding AT-III deficiency is false? AT-III deficiency causes severe arterial thrombosis D. For patients with AT-III deficiency, the risk of thrombosis increases with age Key Concept/Objective: To understand AT-III deficiency AT-III deficiency is an autosomal dominant trait that affects nearly 1 in 2,000 people. There are two types of AT-III deficiency: inherited and acquired. The inherited form has two subsets: quantitative deficiency and qualitative deficiency. In some cases, AT-III defi- ciency may be acquired, as with disseminated intravascular coagulation or severe liver dis- ease or through the administration of I. AT-III normally inactivates factor Xa and thrombin; patients with AT-III deficiency show evidence of continuous factor X acti- vation and thrombin generation. The typical presentation of AT-III deficiency is similar to that of other hypercoagulable states. There is no evidence that AT-III deficiency increases the risk of arterial thrombosis. The two hypercoagulable states more closely related to arte- rial thrombosis are the antiphospholipid syndrome and hyperhomocystinemia. A 26-year-old man presents with new-onset left lower extremity swelling and pain of 6 hours’ duration. He takes no medications and has no history of trauma, immobilization, or prior thrombosis. His family history is remarkable for two “blood clots” in his mother. Compression ultrasonography confirms occlu- sive thrombus in the left superficial femoral vein. Which of the following is the most appropriate sequence of interventions for this patient? Start heparin and warfarin immediately, send tests for the hypercoagu- lable state before warfarin reaches therapeutic levels, and discontinue heparin after the international normalized ratio (INR) reaches thera- peutic levels B. Send tests for the hypercoagulable state, then start heparin and war- farin concurrently, and discontinue heparin after 5 days’ overlap C. Send tests for the hypercoagulable state, then start heparin and war- farin concurrently, and discontinue heparin when the INR reaches therapeutic levels D. Start heparin and warfarin immediately, discontinue heparin after 5 days’ overlap, and evaluate for the hypercoagulable state after warfarin therapy is completed E. Evaluate for the hypercoagulable state, but no anticoagulation is indi- cated for superficial thrombophlebitis Key Concept/Objective: To understand the timing of workup and duration of therapy for patients presenting with a new DVT 5 HEMATOLOGY 39 A 26-year-old man presenting with new-onset thrombosis and a positive family history is highly suspicious for a hereditary hypercoagulable state and should be worked up for this. Because the levels of protein C and antithrombin III can be diminished in the setting of acute thrombosis and because heparin and warfarin also alter these levels, the optimal time for the workup is after the patient has completed therapy. Exceptions to this rule include the antiphospholipid antibody syndrome, in which early diagnosis can affect ther- apy and disorders for which specific genotypic tests are available (e. Because the INR (prothrombin time) is heavily depend- ent on factor VII, which has a short half-life, it rises fairly quickly after warfarin is begun.

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Which of the following drugs would you give this patient to minimize the long-term risk of throm- boembolism? Low-molecular-weight heparin Key Concept/Objective: To understand that patients younger than 65 years who are without risk factors are at low risk for thromboembolism from atrial fibrillation Risk factors such as hypertension generic penegra 50 mg with amex, diabetes generic penegra 100mg fast delivery, previous CVA/TIA generic 50mg penegra amex, and poor LV function order penegra 100 mg line, along with older age (> 65 years) order 100mg penegra overnight delivery, are associated with a yearly risk of thromboembolism from atri- al fibrillation of approximately 5%. This risk can be decreased to approximately 1% with warfarin and 2% to 3% with aspirin. The risk of thromboembolism is 1% without therapy in patients without risk factors and younger than 65 years. This patient has a history of controlled hypertension and has a normal echocardiogram, which decreases the probabil- ity that his hypertension has caused end-organ complications. He has no other risk factors 14 BOARD REVIEW for thromboembolism caused by his atrial fibrillation and likely has “lone atrial fibrilla- tion. Ticlopidine or newer antiplatelet agents may be of benefit when aspirin has failed. In addition, converting patients to sinus rhythm: either with electrical cardioversion or chemically: is a desirable outcome in such situations. Finally, agents to control ventricular rate (beta blockers, diltiazem, or digoxin) should be considered in this patient. A 24-year-old man is brought to the emergency department by the emergency medical service (EMS). He suffered head trauma 20 minutes ago while playing football. Immediately after the event, he lost con- sciousness for 3 minutes and then woke up mildly confused. On physical examination, the patient’s vital signs are stable, his Glasgow Coma Scale (GCS) score is 15, and he has no focal signs on neurologic examination. What interventions would be appropriate in the treatment of this patient? Continue with observation and repeated neurologic examinations; repeat assessment with the GCS periodically; and consider imaging with a CT scan to rule out contusions B. Continue with observation and repeated neurologic examinations; repeat assessment with the GCS periodically; and obtain an MRI C. Admit the patient for prolonged observation; obtain a CT scan to rule out contusions; and start I. Admit the patient to the ICU; obtain an MRI; and consider intraven- tricular monitoring of intracranial pressure (ICP) Key Concept/Objective: To understand the appropriate treatment of mild traumatic brain injury (MTBI) With an incidence of 180 per 100,000 people, MTBI is more common than any other neu- rologic diagnosis except migraine. MTBI is defined as any traumatic brain injury/concus- sion with loss of consciousness of 0 to 30 minutes, a GCS score of 13 to 15 on admission, posttraumatic amnesia or confusion lasting less than 24 hours, and no evidence of contu- sion or hematoma on CT. Although the emergency department evaluation and manage- ment of MTBI is controversial, the principal concern is with identifying evolving surgical lesions such as hematomas and contusions. In addition to history and examination, CT has become the mainstay of evaluation. Prolonged or deteriorating mental status or the presence of neurologic signs or other risk factors are still indications for CT scanning, observation, or both after MTBI. MRI promises to be very useful in the long-term manage- ment of moderate and severe TBI, as well as in the documentation of brain pathology in patients with milder injury. However, it is often impractical and not cost-effective in the acute setting. This patient has MTBI, and observation for a few hours and possibly a CT scan to rule out contusions are appropriate. He does not have severe enough trauma to warrant admission or invasive monitoring of his ICP. A 46-year-old woman is brought to the emergency department by EMS after being involved in a car acci- dent. The accident involved frontal impact, with the car moving at 50 mph. The driver says she has not been awake since the accident, which occurred 30 minutes ago. On admission, the patient’s vital signs are as follows: blood pressure, 100/60 mm Hg; heart rate, 78 beats/min; respiratory rate, 8 breaths/min; GCS score, 7. A CT scan shows a frontal epidural hematoma with mass effect.

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In: Campell WW (ed) Essentials of electrodiagnostic References medicine buy penegra 100mg low price. Williams & Wilkins cheap 100 mg penegra visa, Baltimore order penegra 100 mg free shipping, pp 207–224 Dyck PJB generic 50 mg penegra, Windebank AJ (2002) Diabetic and nondiabetic lumbosacral radiculoplexus neuropathies: new insights into pathophysiology and treatment discount 100mg penegra amex. Muscle Nerve 25: 477–491 Feasby TE, Burton SR, Hahn AF (1992) Obstetrical lumbosacral plexus injury. Muscle Nerve 15: 937–940 Jaeckle KA (1991) Nerve plexus metastases. Neurol Clin 9: 857–829 Kutsy RL, Robinson LR, Routt ML (2000) Lumbosacral plexopathy in pelvic trauma. Muscle Nerve 23: 1757–1760 Mumenthaler M (1998) Pseudoradikuläre Syndrome und andere, nicht radikuläre Schmerzsyndrome. In: Mumenthaler M, Schliack H, Stöhr M (eds) Läsionen peripherer Nerven und radikuläre Syndrome. Thieme, Stuttgart, pp 197–201 Said G, Elgrably F, Lacroix C, et al (1997) Painful proximal diabetic neuropathy: inflamma- tory nerve lesions and spontaneous favorable outcome. Ann Neurol 41: 762–770 Stewart JD (2000) Lumbosacral plexus. Lippincott, Philadelphia, pp 355–374 Thomas JE, Cascino TL, Earle JD, et al (1985) Differential diagnosis between radiation and tumor plexopathy of the pelvis. Neurology 35: 1–7 Wohlgemuth WA, Stöhr M (2002) Percutaneous arterial interventional treatment of exer- cise induced neurogenic intermittent claudication due to ischemia of the lumbosacral plexus. M1 + M2: represent the mobile parts 119 Cervical radiculopathy Genetic testing NCV/EMG Laboratory Imaging Biopsy + Fig. Left hand: C8 radicul- opathy with atrophy in a pa- tient with leukemic infiltration Fig. Meningeal carcinoma- tosis with neoplastic deposits in C6 and C7. Extensor deficits of fingers 3, 4, 5 mimicks partial radial paralysis 120 Anatomy With exception of the upper two, the cervical vertebrae articulate with each other by an intervertrebral disc, plus a pair of smaller joints between articular facets and pedicles. The intervertebral foramina are formed by the pedicles (above and below), anteriorly by intervertebral discs and joints of Luschka, and posteriorly by the facets and facet joints. The transverse processes are (except in the case of C7) foramina for the vertebral arteries. A deep horizontal groove lies on the upper surface of each transverse process. The scalene muscles are attached to the transverse processes. Two important structures are the longitudinal ligaments and the intervertebral discs. The laminae of the vertebral arches are connected by the ligamentum flavum. Rootlets of ventral and dorsal origin form roots (fusing in the intervertebral foramen). The dorsal root ganglia (DRG) lie just dorsal to the fusion. Dura and arachnoid extend around nerve roots into the intervertebral foramina as root pouches or sleeves. In the cervical spine, the nerve roots exit over the vertebral body and are numbered by the vertebral body beneath the root (e. C6 exits between C5–C6, the C8 root exits between C7 and T1). While the cervical roots exit horizontally, there is about a one segment difference (see Fig. Symptoms Classically, the patient with cervical disc rupture complains of neck, shoulder, and arm pain, with or without distally radiating paresthesias. Pain is described as radiating into the shoulder, periscapular, or pectoral regions, or the “whole” arm. C5/6 lesions tend to cause more shoulder pain than C7/8 lesions. Upper medial arm pain is characteristic of C7/8 lesions. Pain radiating into the scapula or interscapular regions points to C7/8. Sensory symptoms (paresthesia, dysesthesia or numbness) may occur in the nerve root distribution.

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When asked purchase 100mg penegra with mastercard, she says that many years ago buy 50 mg penegra with mastercard, she had an illness with rash cheap penegra 100mg with mastercard, fever cheap penegra 50mg fast delivery, and 8 BOARD REVIEW joint pain that kept her in bed for a few weeks penegra 50mg without prescription. On the basis of this history, you make a presumptive diagnosis of rheumatic mitral stenosis. Which of the following constitutes the best immunologic causative mechanism of rheumatic fever? Antistreptocococcal antibodies cross-reacting with myocardial antigens C. Toxins released by group A Streptococcus that cause valvular damage D. Pathogenic autoantibodies directed against the endocardium of heart valves Key Concept/Objective: To understand the mechanism of molecular mimicry In rare cases, the normal immune response to a specific microbial peptide can trigger immunity to a related self-peptide, a phenomenon known as molecular mimicry. This mechanism has been described in rheumatic heart disease and Lyme disease. In the case of rheumatic heart disease, antistreptococcal antibodies cross-react with myocardial anti- gens. Pathogenic autoantibodies have been clearly associated with myasthenia gravis, pemphigus, and a number of endocrinopathies but not rheumatic fever. A 35-year-old woman with a history of asthma and atopic dermatitis presents to your office for follow- up. She was recently hospitalized for community-acquired pneumonia complicated by an acute exacer- bation of her asthma. Which of the following statements most accurately describes the T cell response to allergenic pep- tides in an atopic patient? In the TH2 response, T cells form interleukin-4 (IL-4), IL-5, and IL-13, thereby directing the production of allergen-specific antibodies B. In the TH1 response, T cells produce interferon gamma (IFN-γ), thereby inducing T cell differentiation C. In the THO response, T cells produce IL-12 and IL-18, thereby causing differentiation from THO cells to TH1 cells D. In the TH response, naive helper T cells differentiate into mature T lymphocytes, producing IgG1 and IgG4 antibodies Key Concept/Objective: To recognize T cell response in an atopic host The pathophysiologic response to allergenic peptides such as bacterial DNA sequences dif- fers in a normal person from an atopic patient. Bacterial DNA sequences have immuno- stimulatory regions containing deoxycytidine-phosphate-deoxyguanosine (CpG) repeats. CpG repeats are recognized as foreign by pattern recognition receptors called Toll-like receptor-9 (TLR-9) on antigen-presenting cells. These CpG repeats stimulate macrophages and dendritic cells to secrete inflammatory cytokines, including IL-12 and IL-18. These cytokines then induce T cells and natural-killer (NK) cells to produce IFN-γ, a cytokine known to promote nonallergic, protective responses. This pattern of response by helper T cells is termed a TH1 response, because it is associated with the differentiation of naive T helper (TH0) lymphocytes into mature TH1 lymphocytes. Similarly, the T helper cells of persons without atopy respond to presentation of potentially allergenic peptides by producing IFN-γ and directing the production of allergen-specific IgG1 and IgG4 anti- bodies. This type of T helper cell response is termed a TH2 response. IL-4 and IL-13 share a num- ber of functions, which are mediated through the IL-4Rα/IL-13Rα heterodimer. However, only IL-4 is able to induce the differentiation of TH0 cells to TH2 cells and to antagonize the differentiation of TH0 cells to TH1 cells, resulting in IgE-mediated allergic inflammation. In contrast, both IL-12 and IFN-γ induce the differentiation to TH1 cells; TH2 cell differentia- tion is inhibited by IFN-γ. Differentiation to TH1 cells results in cell-mediated immunity and inflammation. Therefore, the differentiation of TH0 cells to either TH1 cells or TH2 cells appears to be the crucial event that determines which type of immune response will fol- low. A 28-year-old graduate student with a history of chronic allergic rhinitis and asthma presents to your clinic. His symptoms, which are continuous, have been somewhat refractory to the therapies you have tried thus far. He recently ran across a proposed new drug therapy for asthma while reading a scientific journal.

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Which of the following statements regarding neutrophilia is true? Neutrophilia is usually defined as a neutrophil count greater than 1 buy 50 mg penegra free shipping,000/mm3 B discount 100 mg penegra. Thrombocytosis is commonly associated with splenectomy purchase penegra 100mg amex, but splenectomy has no association with neutrophilia C discount 50 mg penegra mastercard. Serious bacterial infections are usually associated with changes in the number of circulating neutrophils generic penegra 100mg amex, as well as the presence of younger cells, but they are not associated with changes in neutrophil morphology D. With serious bacterial infections, characteristic morphologic changes of the neutrophils include increased numbers of band forms and increased numbers of cells with Dohle bodies and toxic granulations Key Concept/Objective: To know the definition and morphologic characteristics of neutrophilia Neutrophilia, or granulocytosis, is usually defined as a neutrophil count greater than 10,000/mm3. Neutrophilia most often occurs secondary to inflammation, stress, or corti- costeroid therapy. Serious bacterial infec- tions and chronic inflammation are usually associated with changes in both the number of circulating neutrophils and their morphology. Characteristic changes include increased numbers of young cells (bands), increased numbers of cells with residual endoplasmic retic- ulum (Dohle bodies), and increased numbers of cells with more prominent primary gran- ules (toxic granulation). These changes are probably caused by the endogenous production of granulocyte colony-stimulating factor or granulocyte-macrophage colony-stimulating factor and are also seen with the administration of these growth factors. A 61-year-old woman visits your clinic for a follow-up visit. She has been coming to you for several weeks with complaints of diffuse rash, intermittent fevers, persistent cough, and dyspnea. Laboratory results were significant only for a WBC count of 15,000/mm3 with 40% eosinophils. You have completed an extensive workup for underlying allergy, connective tissue disease, malignancy, and parasitic infection, with negative results. A bone marrow biopsy revealed hypercellular marrow with eosinophils constitut- ing 50% of the marrow elements. Your working diagnosis is hypereosinophilic syndrome (HES). Which of the following statements regarding HES and eosinophilia is true? The criteria used to diagnose HES are an unexplained eosinophil count of greater than 1,500/mm3 for longer than 6 months and signs or symptoms of infiltration of eosinophils into tissues B. The term HES is often used for patients with chronic eosinophilia resulting from parasitic infection C. Eosinophilia is defined as an eosinophil count greater than 500/mm3 D. Long-term corticosteroid therapy is the only available therapy for HES Key Concept/Objective: To understand HES Evaluation of the patient with eosinophilia (i. The term HES is often used for patients with chronic eosinophilia of unknown cause. The cri- teria used to diagnose HES are an unexplained eosinophil count of greater than 1,500/mm3 for longer than 6 months and signs or symptoms of infiltration of eosinophils into tissues. If symptoms involving the lungs or the heart are present, prednisone at a dosage of 1 mg/kg/day should be given for 2 weeks, followed by 1 mg/kg every other day for 3 months or longer. If this treatment fails or if an alternative is necessary to avoid steroid side effects, hydroxyurea at a dosage of 0. Studies suggest that treatment with imatinib mesylate is effective. Alternative agents include interferon alfa, cyclosporine, and etoposide. A 52-year-old man presents to your office for his yearly physical examination. He is completely asymp- tomatic and is tolerating his single blood pressure medication well. On review of systems, the patient states that for several weeks, he has had severe pruritus after showering and that lately his face has been feeling “flushed. Physical examination is significant only for facial plethora and moderate nontender splenomegaly.

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