A 46-year-old woman presents to your office complaining of something bulging from her vagina for the past year. It has been getting progressively more prominent. She has started to notice that she leaks urine with laughing and sneezing. She still has periods regularly every 26 days. She is married. Her husband had a vasectomy for contraception. After appropriate evaluation, you diagnose a second-degree cystocele. She has no uterine prolapse or rectocele.

Which of the following is the best treatment plan to offer this patient?

a. Anticholinergic medications
b. Surgical correction with a bladder neck suspension procedure
c. Placement of a pessary
d. Antibiotic therapy with Bactrim
e. Le Fort colpocleisis

The answer is b

Explanation

Surgical therapy for stress urinary incontinence due to cystocele and loss of urethral support involves suspension of the bladder neck via Kelly plication, retropubic suspension (Marshall-Marchetti-Krantz and Burch procedures), or sling procedures (Pererya and Stamey procedures). Placement of a pessary is an option to relieve a cystocele, but is not ideal in this patient, who is sexually active. Antibiotics such as Bactrim would be used to treat a urinary tract infection, but would not affect stress incontinence. A Le Fort procedure is performed in patients with vaginal vault prolapse and pelvic relaxation who are poor surgical candidates and not sexually active. The procedure involves obliterating the vaginal canal to provide support to the pelvic structures. Anticholinergic drugs such as Ditropan (oxybutynin chloride) are used to relax the bladder in the treatment of bladder dyssynergia.

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1-A 45-year-old right-handed man who has been HIV positive for the past 3 years has noticed some sort of visual change over the past 1 to 2 months. It is difficult for him to describe, but it is some sort of distortion of part of his right visual field. There is a 4-cm rim-enhancing lesion in the left occipital lobe that is revealed by MRI.

Which of the following tumor types is common in the brain of patients with AIDS, but otherwise extremely rare?

Lymphocytic leukemia
Metastatic lymphoma
Primary lymphoma
Kaposi’s sarcoma
Lymphosarcoma

ansawer: Primary lymphoma

explanation : Kaposi’s sarcoma is unusually common in patients with AIDS, but it is rarely metastatic to the brain. Metastatic lymphomas producing meningeal lymphomatosis are not especially rare in the general population, but primary lymphomas (i.e., lymphomas apparently arising in the CNS) were rare before the AIDS epidemic. The primary brain lymphoma usually presents as a solitary mass and can occur anywhere in the brain, but it does have a predilection for the periventricular structures.

2-A 9-year-old girl presents with precocious puberty and episodes of uncontrollable laughter.

Which of the following mass lesions might explain her symptoms?

Craniopharyngioma
Choroid plexus papilloma
Giant aneurysm
Metastatic carcinoma
Hypothalamic hamartoma

answer: Hypothalamic hamartoma

explanation : Hypothalamic hamartomas are nonneoplastic malformations involving neurons and glia in the region of the hypothalamus. They may be discovered incidentally, either on imaging performed for other reasons or at autopsy, or they may cause symptoms referable to the hypothalamus. Most often, the latter involves neuroendocrine functions, causing precocious puberty or acromegaly due to overproduction of growth hormone-releasing hormone. Patients may also experience paroxysms of laughter, known as gelastic seizures. They may be cured surgically. Craniopharyngiomas are epithelial neoplasms arising in the sellar and third ventricular regions. They may cause hypopituitarism and visual field disturbances. Choroid plexus papillomas usually develop intraventricularly and do not extend down into the sella turcica. These tumors affect both children and adults, but they are rare. They are benign if they are surgically accessible and are extirpated early in their evolution. Giant aneurysms occur in many locations, but typically do not cause gelastic seizures or precocious puberty. Metastatic carcinoma generally occurs in older patients and would not be expected to cause these symptoms.

3-With an ependymoma of the posterior fossa, the patient is at risk of dying because of which of the following?

Transforaminal herniation
Emboli from the tumor
Vascular occlusion by the tumor
Hemorrhagic necrosis of the tumor
Status epilepticus

answer: Transforaminal herniation

explanation : As a tumor of the posterior fossa enlarges, the contents of the posterior fossa will be compressed and ultimately forced upward or downward. If the herniation is upward, it is called transtentorial because it is across the tentorium cerebelli. If it is downward, it is called transforaminal because it is across the foramen magnum. Ependymomas are not especially vulnerable to hemorrhagic necrosis. Tumors in the posterior fossa generally do not produce seizures.

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Response from William F. Balistreri, MD 
Dorothy M. Kersten Professor of Pediatrics

 University of Cincinnati College of Medicine, Cincinnati, Ohio

 Medical Director, Liver Transplantation Program

 Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio

The hepatitis B virus (HBV) can be transmitted from an infected mother to her infant. In fact, the risk of developing chronic HBV infection after acute exposure ranges from 90% in newborns of hepatitis B e antigen (HBeAg)-positive mothers to approximately 25% in infants and children under 5 years of age, to less than 5% in adults. According to the recently revised guidelines approved by the American Association for the Study of Liver Diseases and endorsed by the Infectious Diseases Society of America,[5] screening is recommended for all pregnant women. Newborns of HBV-infected mothers should receive both hepatitis B immune globulin (HBIG) and the HBV vaccine at the time of delivery and should complete the recommended vaccination series. The guidelines further state that hepatitis B surface antigen (HBsAg)-positive women who are pregnant should be counseled to make sure that they inform their providers of their hepatitis B status so that HBIG and the HBV vaccine can be administered to their newborns immediately after delivery.This has become an established and highly effective practice. Concurrent administration of HBIG and the HBV vaccine to the newborn is 95% effective in the prevention of perinatal transmission of HBV. However, efficacy is lower for maternal carriers with very high serum HBV DNA levels (> 8 log10 IU/mL). Because infants of HBsAg-positive mothers remain at risk for HBV infection, they should be tested for response to vaccination. Postvaccination testing should be performed at 9-15 months of age in infants of carrier mothers.

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CONSISTS OF

15 BOARDS OF 50 QUESTIONS EACH,,,,

TO BE GIVEN 60 MIN FOR EACH OF THEM !!!

&

THEN DETAILED EXPLAINATION OF EACH AND EVERY QUESTION WITH ANSWER ! ! !

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Question 1

After biopsy resection of a lymph node in her neck, a 23-year-old woman notices instability of her shoulder. Neurologic examination reveals winging of the scapula on the side of the surgery. During surgery, she probably suffered damage to which of the following?

Deltoid muscle

Long thoracic nerve

Serratus anterior muscle

Suprascapular nerve

Axillary nerve

*The answer is b, Long thoracic nerve

Answer to Question 1

Winging of the scapula most often occurs with weakness of the serratus anterior muscle. This is innervated by the long thoracic nerve, whose course starts high enough and runs superficially enough to allow injury to the nerve with deep dissection into the root of the neck. The long thoracic nerve is derived from C5, C6, and C7. Winging is elicited by having the patient push against a wall with the hands at shoulder level. With this maneuver, the scapula with the weak serratus

anterior will be pulled away from the back and the vertical margin of the scapula will stick out from the back. Injuries to the long thoracic nerve are usually unilateral and are often due to trauma or surgical manipulation.

Question 2

A 25-year-old woman is involved in a motor vehicle accident. Among her injuries is a lumbar vertebral body fracture. Which of the following most likely contributed to this injury?

Flexion

Extension

Torsion

Spondylolisthesis

Subluxation

* The answer is a, Flexion

Answer to Question 2

Extreme flexion of the lumbar spine is likely in automobile accidents and in falls where the person is upright. Fracture of a lumbar vertebral body may be seen in vehicular accidents when the victim is restrained during a high-speed impact by a seat belt without a shoulder harness. The rapid and extreme forward flexion of the lumbar spine may produce a variety of spinal injuries, ranging from fractures

to dislocations. Fractures suffered during falls in which the person is upright, such as may occur when someone jumps off a building, are usually compression fractures of the vertebral body. Fracture of the vertebral body will usually produce pain coincidental with the injury. Patients with fractures of the vertebral body that occur without trauma or with inconsequential trauma must be investigated for malignant processes, such as metastatic carcinoma, multiple myeloma, and unsuspected osteomyelitis.

Question 3

A 35-year-old man injured his thoracic spine in a motor vehicle accident 2 years ago. Initially he had a bilateral spastic paraparesis and urinary urgency, but this has improved. He still has pain and thermal sensation loss on part of his left body and proprioception loss in his right foot. There is still a paralysis of the right lower extremity as well. This patient most likely has which of the following spinal cord conditions?

Brown-Séquard (hemisection) syndrome

Complete transection

Posterior column syndrome

Syringomyelic syndrome

Tabetic syndrome

Answer to Question 3

Hemisection of the spinal cord results in a contralateral loss of pain and thermal sensation due to spinothalamic damage, and ipsilateral loss of proprioception due to posterior column damage. There is also an ipsilateral motor paralysis due to destruction of the corticospinal and rubrospinal tracts as well as motor neurons. Complete transection of the spinal cord would cause a bilateral spastic paralysis, and there would be no conscious appreciation of any cutaneous or

deep sensation in the area below the transection. Posterior column syndrome would result in a bilateral loss of proprioception below the lesion, with relative preservation of pain and temperature sensation. Syringomyelic syndrome results from a lesion of the central gray matter. Pain and temperature fibers that cross at the anterior commissure are affected, which may result in bilateral loss of these sensations over several dermatomes. However, tactile sensation is spared. The most common cause of this type of syndrome is syringomyelia. Trauma, hemorrhage, or tumors are other possible etiologies. If the lesion becomes large enough, then other spinal cord systems become affected as well. Tabetic syndrome results from damage to proprioceptive and other dorsal root fibers. It is classically caused by syphilis. Symptoms include paresthesias, pain, and abnormalities of gait. Vibration sense is most affected.

A 13-year-old boy has a 3-day history of low-grade fever, upper respiratory symptoms, and a sore throat. A few hours before his presentation to the emergency room, he has an abrupt onset of high fever, difficulty swallowing, and poor handling of his secretions. He indicates that he has a marked worsening in the severity of his sore throat. His pharynx has a fluctuant bulge in the posterior wall.

 Which of the following is the most appropriate initial therapy for this patient?

1-Narcotic analgesics
2-Trial of oral penicillin V
3-Surgical consultation for incision and drainage under general anesthesia
4-Rapid streptococcal screen
5-Monospot test

answer : 3

interpretation :Suppurative infection of the chain of lymph nodes between the posterior pharyngeal wall and the prevertebral fascia leads to retropharyngeal abscesses. The most common causative organisms are Staphylococcus aureus, group A ß-hemolytic streptococci, and oral anaerobes. Presenting signs and symptoms include a history of pharyngitis, abrupt onset of fever with severe sore throat, refusal of food, drooling, and muffled or noisy breathing. A bulge in the posterior pharyngeal wall is diagnostic, as are radiographs of the lateral neck that reveal the retropharyngeal mass. Palpation (with adequate provision for emergency control of the airway in case of rupture) reveals a fluctuant mass. Treatment should include incision and drainage if fluctuance is present.

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Pediatric

All children aged 6 months to 18 years should be immunized against influenza. In the past, only high-risk children were immunized against seasonal influenza. Now, all children, regardless of risk, should receive this immunization. It is estimated that this recommendation means that approximately 50 million children will need the influenza vaccination this year. It is important, particularly in 2009, that clinicians begin to immunize against influenza as soon as the vaccines are received in the office. This will make way for the receipt of the H1N1 vaccine, which is anticipated in October or November of this year. Clinicians can be assured that although we will begin the immunization campaign in early September, much earlier than in the past, it will protect children throughout flu season

Patients aged 6 months to 24 years as well as those at high risk as a result of pulmonary or cardiac conditions should receive the H1N1 vaccination when it becomes available. At the time of this writing, this vaccination will probably be a series of 2 vaccinations, separated by 3 weeks. The first injection may be administered at the same time as the seasonal influenza vaccine, if it has not already been given. The vaccine will be purchased by the federal government and shipped to the states for distribution and administration. Each state is in charge of implementing the distribution and administration of the vaccine. While we are anticipating release of the vaccine in October, clinical trials for efficacy and safety are still under way.

A combination vaccine named Pentacel is now available for infants. This combination vaccine provides protection against diphtheria, tetanus, and pertussis; polio; and Haemophilus influenzae type B. Depending on the state in which you practice and the vaccines to which you have access, this series may decrease the number of injections given to children by up to 7 shots. It consists of 4 injections administered at 2, 4, 6, and 15-18 months.
The restrictions on H. influenzae type B vaccination have now been relaxed. Healthcare providers should attempt to “catch up” the children who missed dose number 4 of the series due to a lengthy shortage of the vaccine.
There are currently 2 rotavirus vaccines available. RotaTeq is a series of 3 oral vaccinations given at 2, 4, and 6 months and Rotarix is a series of 2 oral vaccinations administered at 2 and 4 months. Providers must be aware of which vaccine product they are using to make certain that the correct schedule is followed.

Adolescents

All adolescents age 11-18 years should receive the meningococcal (MCV4 or Menactra) vaccine. In the past, this vaccine was often recommended to be given just before a student went to college. However, the Advisory Committee on Immunization Practices now recommends that all children be immunized with MCV4 to provide protection against 4 strains of Neisseria meningitidis beginning at 11 years. It should be noted that children at high risk due to travel or immunosuppressive conditions may receive the vaccine as early as 2 years of age and may have it repeated, if high risk, 5 years after the initial vaccination.
HPV (human papillomavirus) vaccine is recommended for all young women age 9-26 years as a 3-part series. The series is frequently initiated at 11 years of age but may be given as early as 9 years of age. It is administered according to the following schedule: day 0, 2 months after day 0, and 6 months after day 0. Healthcare providers should observe the recipient for 15 minutes following administration of the vaccine. In addition, the vaccinator may wish to place the child in a semirecumbent position during administration due to reports of syncope after vaccine administration.

Tdap (combined tetanus, diphtheria, and pertussis) should be administered to all adolescents age 11 years and older. This additional pertussis protection should be given once to all adolescents and adults who have not received a pertussis booster. Individuals 65 years of age and older should be given Td only, as the pertussis component has not been deemed safe or efficacious for this age cohort

GREAT NOTES SHADOWING EACH AND EVERY SUBJECT RELATED TO MEDICAL PROFESSION– MAINLY ALL PRE PG SUBJECTS!

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BY
EDWARD GOLJAN

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THESE are  GOLJAN NOTES  ON 4 MAIN TOPICS namely

(4) SYSTEMIC PATHOLOGY

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Apparently, meniscal damage itself is an independent risk factor for OA.

A patient who undergoes surgical removal of a torn meniscus is at above-average risk for subsequent knee osteoarthritis (OA). Whether meniscal damage itself — in the absence of surgery — also predisposes patients to development of knee OA is unclear.

To study the association between meniscal damage and subsequent knee OA, researchers performed this prospective case-control study as part of a larger study of risk factors for knee OA among middle-aged and older adults (age range, 50–79). The 121 case patients had no radiographic knee OA at baseline but developed tibiofemoral OA at 30 months. The 294 controls had no radiographic knee OA either at baseline or at 30 months. On magnetic resonance imaging at baseline, the prevalence of meniscal damage was significantly higher among case patients than among controls (54% vs. 18%). On multivariable analysis that was adjusted for age, sex, body-mass index, physical activity, and knee alignment, meniscal damage remained a highly significant predictor for development of OA.

Comment
Although the possibility remains that other unidentified conditions predispose patients to both meniscal damage and knee OA, this study suggests that meniscal damage itself is an independent risk factor for OA — even among patients who have not undergone meniscectomy. The challenge is to find ways to prevent meniscal tears from occurring in the first place.