absence seizure

absence seizure

A 9 year old boy was Dx with absence seizure. the patent asked you about the long term prognosis.

It is a benign seizure. Majority end by age 20. Very few convert to other forms of seizure

A 23-year-old, previously healthy woman presents with jaundice, confusion, and fever. Initial physical examination is unremarkable except for scattered petechiae on the lower extremities, scleral icterus, and disorientation on mental status examination. Laboratory examination discloses the following: hematocrit, 27 percent; white cell count, 12,000/L; platelet count, 10,000/L; bilirubin, 85 mol/L (5 mg/dL); direct bilirubin, 10 mol/L (0.6 mg/dL); urea nitrogen, 21 mmol/L (60 mg/dL); creatinine, 400 mol/L (4.5 mg/dL). Red blood cell smear discloses fragmented red blood cells and nucleated red blood cells. Prothrombin, thrombin, and partial thromboplastin times are all normal.
The most effective and appropriate therapeutic maneuver is likely to be



A plasmapheresis

B administration of aspirin

C administration of high-dose glucocorticoids

D administration of high-dose glucocorticoids plus cyclophosphamide

E splenectomy

The answer is A
This young woman is suffering from a combination of hemolytic anemia with fragmented red cells in the absence of disseminated intravascular coagulation (DIC), thrombocytopenia, fever, mental status changes, and renal dysfunction, which is essentially pathognomonic of thrombotic thrombocytopenic purpura (TTP). The etiology of TTP is unknown, though immunologic and primary vasculopathic phenomena have been associated with this disorder. Pathologically, arteriolar hyalinization, which is also seen in DIC, may be noted. Seventy percent of patients with TTP improve with exchange transfusion or plasmapheresis. Glucocorticoids, antiplatelet agents, splenectomy, and vincristine have been of benefit to subsets of patients, but each is less effective and probably associated with a greater risk than therapeutic plasmapheresis.

it's gamma-hydroxybutyrate

It's called liquid ecstasy- an endogenous short-chain fatty acid. Often associated with date rape/'raves'.
Intoxication presents with cerebellar features/myoclonus/coma.
It's not detected with standard screen.

Standard Toxic Screen..

A toxicology screen checks a person's blood or urine or both for the presence of drugs or other toxic substances. The screen can determine the type and amount of drugs or other toxic substances a person may have swallowed, injected, or inhaled. The substances, drugs, or medications detected in the bodily fluids or 'screened for' can be legal or illegal.

A healthcare provider may order this test to evaluate for drug overdose, poisoning, or drug abuse. An employer may order the test when drug use may pose a threat to work performance or might endanger others. This test is used to find the causes of acute drug poisoning. The tests can be used for legal proceedings too.

Normal values for toxicology screens depend on the institution performing the tests. In general, the following values apply: There should be no illegal drugs in the blood or urine. There are acceptable levels for over-the-counter medications. These are called therapeutic levels. There should be no alcohol. Cigarette smoking may affect some test results. The presence of nonprescription drugs may show unapproved drug use. Specific tests can show the drug used. High alcohol levels may show intoxication.

Commonly abused drugs that may be detected in the urine include: marijuana, or pot cocaine phencyclidine, or PCP amphetamines morphine, heroin, and codeine barbiturates

If the test is used as a drug screen there is a finite amount of time after ingestion that the drug or any of its metabolites can be detected:

cocaine
2 to 4 days
amphetamines
24 to 48 hours
heroin
1 to 2 days
morphine
1 to 2 days
phencyclidine (PCP)
1 to 8 days
alcohol
3 to 10 hours
benzodiazepines
up to 6 weeks with high level use
hydromorphone
1 to 2 days
tetrahydrocannabinol (THC)
6 to 11 weeks with heavy use
propoxyphene
6 to 48 hours
methadone
2 to 3 days
codeine
1 to 2 days
barbiturates
up to 6 weeks


What abnormal results mean:
The presence of illegal drugs or drugs not prescribed for the person indicates illicit drug use.

Elevated levels of alcohol or drugs can indicate intentional or accidental intoxication and/or overdose.

Carboxyhemoglobin results from the union of hemoglobin and carbon monoxide. Elevated levels may indicate carbon monoxide poisoning.

Methemoglobin results from the oxidation of ferrous iron to ferric iron. Elevated levels may indicate the use of chemicals and drugs such as aniline, chlorates, nitrates, nitrites, phenacetin, or sulfonamides, or may exist as a primary condition.

Sulfhemoglobin results from the combination of hemoglobin with certain drugs such as phenacetin or sulfonamides; it causes cyanosis (blueness of the skin) but few other symptoms.


Commonly found substances on a toxicology screen include:

alcohol
amphetamines
benzodiazepines
antidepressants
barbiturates and hypnotics
hemoglobin derivatives
isopropanol -- isopropyl alcohol, rubbing alcohol
methanol -- methyl alcohol, found in antifreeze and other substances (toxic)
narcotics
non-narcotic analgesics
acetaminophen - oral
anti-inflammatory analgesics - oral
phenothiazines (antipsychotic or tranquilizing medications)
prescription medications, any type

An 80-year-old Asian woman is hospitalized with weight loss, generalized weakness, and a pulmonary mass. Work-up reveals that she has pulmonary tuberculosis. Her family approaches the physician and asks that the patient not be told, stating that in her upbringing in mainland China tuberculosis was considered fatal and to tell her would be like giving her 'a death sentence.'
Should you respect the family's concerns?

This is an interesting cultural issue which often arises in treating migrant population. The principle of full disclosure is applicable in these groups too.
At the same time, sensitive handling/empathizing with patient's anxiety is also essential. A conservative approach will be educating the patient about the illness and it's curability with pschosocial consult if needed

This exam is American (USMLE)exam. So we answer according the medical guidelines of this country. Having said that, it is important to respect
other cultural values, especially the Chinese patient and the patient's family involved. For example, native American Indian population have their 'medicine' man. They rely on him heavily. If a physician can accomodate him without compromising patient care, it should be done so. Here, the physician need to talk with involved family involved and eventully inform patient in such a way not to shock her.

Some cultures hold different beliefs about truth-telling in the medical encounter. Some assert that in some Asian cultures, members of the family unit may withhold the truth about terminal illness from elders out of respect and a desire to protect them from harm. If a patient and their family members hold such beliefs, they should be respected, and a mechanism for informed decision making in collaboration with the family negotiated. One must not, however, assume that every patient of Asian ancestry holds the beliefs described here. The physician should make an attempt to explore the patient's belief system. If he finds that the patient does hold such beliefs about the harmful nature of truthful disclosure of the truth, then it would be justifiable to withhold the diagnosis of tuberculosis.

A 28-year-old woman who uses oral contraceptives comes to the emergency room because when she looked in the mirror this morning, her face was twisted. It felt numb and swollen. While eating breakfast, she found that her food tasted different and she drooled out of the right side of her mouth when swallowing. Neurologic examination discloses only a dense right facial paresis equally involving the frontalis, orbicularis oculi, and orbicularis oris. Finger rubbing is appreciated as louder in the right ear than in the left. The physician should

A: instruct the patient in using a patch over the right eye during sleep
B: recommend that she discontinue the use of oral contraceptives
C: order brainstem auditory evoked potentials to assess her hearing asymmetry
D: inform her that her chances of substantial improvement within several weeks are only about 40 percent
E: order an echocardiogram to rule out mitral valve prolapse as a source of emboli

The answer is A
The abrupt appearance of an isolated peripheral facial palsy, which may include ipsilateral hyperacusis resulting from involvement of fibers to the stapedius and loss of taste on the anterior two-thirds of the tongue resulting from involvement of the fibers of the chorda tympani, is most often idiopathic, as in Bell's palsy. If the patient is unable to close the eye, artificial tears may be helpful during the day to prevent drying, and the eye should be patched at night to prevent corneal abrasion. Excellent recovery occurs in 80 percent of these cases. Oral contraceptives and mitral valve prolapse are not associated with the causes of this clinical picture. Evoked potentials are not helpful diagnostically.

A 14-year-old boy is brought to the walk-in clinic by his father late on Saturday afternoon because his left ear is swollen and painful. The boys ear has been black and blue since he injured it in a wrestling match 3 days ago.
Symptoms have increased significantly following a repeat injury 3 hours ago. On physical examination, his left ear is markedly swollen and tender to palpation. The most appropriate next step is to

(A) reassure him and start aspirin therapy
(B) reassure him and start codeine therapy
(C) recommend that he apply cold packs to the ear for the next 12 hours
(D) recommend that he apply hot packs to the ear for the next 12 hours
(E) refer him to a surgeon for immediate drainage of the lesion

E

this question is from usmle booklet.I dont have explaination

For a pregnant woman in the 26th week of gestation who tested positive for Streptococcus B you should start the treatment:
a.right away
b.one week before delivery
c.24 hours before delivery
d.during delivery

D

Physicians who culture for GBS carriage during prenatal visits should do so late in pregnancy (35-37 weeks gestation); cultures collected earlier do not accurately predict whether a mother will have GBS at delivery.

A positive culture result means that the mother carries GBS -- not that she or her baby will definitely become ill. Women who carry GBS should not be given oral antibiotics before labor because antibiotic treatment at this time does not prevent GBS disease in newborns. An exception to this is when GBS is identified in urine during pregnancy. GBS in the urine should be treated at the time it is diagnosed. Carriage of GBS, in either the vagina or rectum, becomes important at the time of labor and delivery when antibiotics are effective in preventing the spread of GBS from mother to baby.

Most GBS disease in newborns can be prevented by giving certain pregnant women antibiotics through the vein during labor. Any pregnant woman who previously had a baby with GBS disease or who has a urinary tract infection caused by GBS should receive antibiotics during labor.
Pregnant women who carry GBS should be offered antibiotics at the time of labor or membrane rupture.

You diagnose acute pancreatitis in a 45-year-old white male. As you initiate therapy and closely monitor his progress, which one of the following complications is most likely to develop?

a.Hypomagnesemia
b.Hypoglycemia
c.Hypercalcemia
d.Acute hypertension

A

Treatment strategies for pancreatitis vary somewhat and are related to the degree of inflammation. In patients with mild pancreatitis, a therapeutic regimen of avoidance of oral intake, intravenous hydration, and analgesia usually suffices.
However, patients with more severe pancreatitis are likely to develop significant complications, and require closer monitoring. Patients with hypotension and vascular instability frequently require massive fluid resuscitation. Patients with metabolic complications such as hyperglycemia, hypocalcemia, or hypomagnesemia may require insulin, calcium, or magnesium supplementation.

Immediate gastric lavage is contraindicated in treating acute ingestion of which one of the following?


A.Salicylates
B.Strychnine
C.Ethanol
D.Acetaminophen
E.Phenothiazines

B

Ten to 30 minutes after ingestion of strychnine, untoward symptoms begin. Often without any warning the patient falls into violent convulsions. Gastric lavage is postponed until treatment designed to prevent the convulsions is started. Initiation of gastric lavage as soon as possible is indicated in treating poisoning by salicylates, ethanol, acetaminophen, and phenothiazines.