Missed Qs

1. Serous otitis media usu self-resolves and should be followed. If the condition does not resolve on its own further evaluation should be done.
2. CXR is best initial step in management of suspected sarcoidosis (hilar lymphadenopathy, granuloma lesions)
   Erythema nodosum, painful joints, vision Δs, ↑vit D, hypercalcemia, ↑ACE.
3. Eye opening

spontaneously 4

to speech 3

to pain 2

none 1

Verbal response

oriented 5

confused 4

inappropriate 3

incomprehensible 2

none 1

Motor response

obeys commands 6

localizes pain 5

withdraws from pain 4

flexion to pain 3

extension to pain 2

none 1

4. Hypertonic saline may be used to rapidly increase serum sodium level in patients with severe acute or chronic hyponatremia, as manifested by severe confusion, coma, seizures, or evidence of brainstem herniation. In general, 200-400 mL of 3% NaCl is reasonable dose in most adult patients with severe symptomatic hyponatremia and should be administered IV over the first 1-2 hours of presentation until resolution of seizures or herniation. As rapid correction may cause central pontine myelinolysis, serum sodium should only be raised enough to halt symptoms. Then, a more gradual correction (no faster than 0.5 mEq/L/h) should be achieved. Seizures due to hyponatremia are unlikely to respond to conventional anticonvulsant therapy (benzodiazepines) making hypertonic saline the preferred initial treatment. Seizures typically occur when serum sodium levels reach 120 mEq/L , and cardiac symptoms result if serum sodium falls below 100 mEq/L.
5. Lifesaving measures should be performed unless there is substantial evidence in writing suggesting the patient prefers otherwise.
6. T1-3: the spinous process is located at the level of the corresponding transverse process

T4-6: the spinous process is located one-half segment below the corresponding transverse process.

T7-9:the spinous process is located at the level of the transverse process below

T10: follows the rules of T7-9

T11: follows the rules of T4-6

T12: follows the rules of T1-3

7. OMM for URIs should be directed at the sphenopalatine ganglion.
8. Physostigmine is a reversible anticholinesterase inhibitor that increases acetylcholine concentration at the sites of cholinergic neurotransmission. Because physostigmine readily crosses the blood-brain barrier, it is preferred over neostigmine for CNS effects. Patients with central anticholinergic syndrome develop dry mucous membranes, urinary retention, and QRS widening on EKG.
   Remember from your Level 1 days the common anticholinergic signs and symptoms, "red as a beet, dry as a bone, blind as a bat, mad as a hatter, and hot as a hare." This mnemonic corresponds to the symptoms of flushing, dry skin and mucous membranes, mydriasis, altered mental status (AMS), and fever, respectively. Sinus tachycardia, decreased bowel sounds, functional ileus, urinary retention, hypertension, tremulousness, and myoclonic jerking may also be present.
9. High doses of beta blockers can elicit bradycardia, hypotension, hypoglycemia, and pulmonary edema. Both glucagon and atropine can be used to treat the effects of profound beta-blockade. Atropine is an anticholinergic whose effect on the heart is a decrease in vagal tone, resulting in an increased heart rate.
10. organophosphate poisoning due to exposure to insecticides, which manifests as excessive salivation, lacrimation, vomiting, diarrhea, polyuria, paralysis and decreased levels of consciousness. Atropine and pralidoxime are two agents used to treat this condition. Atropine works by acting as a competitive antagonist at muscarinic cholinergic receptors, in both the central and peripheral nervous systems.
11. Vitamin B1 (thiamine)

Vitamin B2 (riboflavin)

Vitamin B3 (niacin)

Vitamin B5 (panthothenate)

Vitamin B6 (pyridoxine)

Vitamin B12 (cobalamin)

Vitamin C (ascorbic acid)

Biotin

Folate

12. When there is a high suspicion for PE, in a stable patient, the next step is either a V/Q scan or a contrast enhanced chest CT. The chest X-ray is usually normal for a PE and thus has little diagnostic value. Lower extremity Doppler to look for a DVT is appropriate if the V/Q scan is inconclusive for a patient with high clinical probability. A non-contrast CT plays no role. Contrast is needed to detect the embolism in the blood vessel. Pulmonary angiography is the gold standard for the definitive diagnosis of PE. It is an invasive procedure and is the last resort when all other diagnostic modalities fail to secure the diagnosis.
13. Amaurosis fugax refers to transient monocular blindness involving carotid emboli with occlusion of the ophthalmic artery. Carotid duplex ultrasonography and MRA are the preferred studies for assessing blood flow through the carotid arteries.
14. Cataracts are due to yellowing and hardening of the natural lens. All lenses yellow as we age, but cataracts need surgical attention when it is obscuring vision. Patients will often complain of glare when driving at night. Macular degeneration – is further delineated into “wet” and “dry” but the end results are essentially the same, what varies is the speed of progression and treatment. We are hearing more and more about this disease as the population is living longer. As the macula degenerates a corresponding blind spot forms in the visual field. Risk factors include age and smoking. Closed-angle glaucoma- is a sudden, painful loss of vision due to increased ocular pressure. This is a medical emergency and must be treated immediately to prevent permanent visual loss. Open-angle glaucoma is painless, progressive visual loss due to increased ocular pressure. An increased cup to disc ration can be appreciated on fundiscopic exam. Risk factors include: genetic predisposition, black/latin/hispanic descent, HTN, DM, and thin corneas. Retinal detachment is most likely unilateral and is a painless loss of vision, usually described as a curtain descending over the visual field.
15. Patients who undergo CVS prior to 9 weeks gestation are at an increased risk for developing fetal limb abnormalities.
16. Pathologic vaginal discharge: pruritis, burning, malodorous vaginal discharge; erythema, edema, and friability of vaginal mucosa, cervical tenderness, green/curd-like d/c.
    Copious white/yellow vaginal d/c, nonmalodorous, in absence of other symptoms/findings = physiologic leukorrhea. 2724
17. AV fistula → high-output cardiac failure by shunting blood from arterial to venous side → ↑cardiac preload. Patient develops heart failure despite maintaining normal or ↑cardiac output d/t circulation unable to meet O₂ demand of peripheral tissues. 2396 (also caused by thyrotoxicosis, Paget disease, anemia, thiamine deficiency.) Dx: US of AVF. Tx: surgery.
18. Painless jaundice in a patient w/conjugated hyperbilirubinemia and ↑alkaline phosphatase ← intraabdominal malignancy obstructing the biliary system (pancreatic adenocarcinoma). 522
    The absence of pain distinguishes acute obstruction (choledocholithiasis). Dx: CT abd, US.
19. Herediatary telangiectasia (Osler-Weber-Rendu syn) → pulmonary AVMs a/w hemoptysis, R→L shunt physiology(chronic hypoxemia, reactive polycythemia). A/w recurrent nose bleeds and oral lesions. 2384
20. Opioid withdrawal presents w/N/V/Abd pain, diarrhea, restlessness, arthralgias, myalgias, ↑bowel sounds, mydriasis, piloerection, (no seizures like EtOH or sedative withdrawal). Tx: methadone.
21. Pts w/anorexia nervosa should be hospitalized when there is evidence of medical complications and/or <75% of average body weight for age, sex, height. 230
22. β-blocker overdose → AV block, bradycardia, hypotension, wheezing cardiogenic shock.
    Tx: Atropine and IVF, then glucagon.
    Glucagon → ↑cAMP and ↑intracellular Ca²⁺ → ↑cardiac contractility. 558
23. Actinic keratoses develop in predisposed individuals on chronically sun-exposed areas. Lesions: erythematous papules w/central scale, "sandpaper-like" texture. Convert to squamous cell carcinoma in ~1% of cases. 2347
24. Once the specific causative bacterium of valve bacterial endocarditis is identified change from broad empiric to specific IV antibiotic. 2664

25. CLASSIFICATION	SYMPTOMS	TREATMENT
    Mild Intermittent	Asthma Attack < 2 times a week Nocturnal Attack < 2 times a month	PRN short acting beta 2 agonist
    Mild Persistent	Asthma Attack > 2 times/week Nocturnal Attack > 2 times/month	Daily inhaled low dose corticosteroid OR Leukotriene Modifier + PRN short acting beta 2 agonist
    Moderate Persistent	Asthma Attack daily Nocturnal Attack> once per week	Daily inhaled high dose corticosteroid + long acting beta 2 agonist (Salmeterol) + PRN short acting beta 2 agonist +/- Theophylline
    Severe Persistent	Continuous Asthma Symptoms Frequent Nocturnal Attacks (every or almost every night)	Oral corticosteroid + high dose inhaled corticosteroid + long acting beta 2 agonist + PRN short acting beta 2 agonist

26. Summary of DeBakey Classification of Aortic Dissection:

Type I: Dissection of ascending and descending thoracic aorta

Type II: Dissection of ascending aorta

Type III: Dissection of descending aorta

Tearing chest pain with mid-scapular radiation in an elderly patient with known atherosclerosis and hypertension carries a high index of suspicion for Type III aortic dissection.

27. Panic disorder is commonly associated with agoraphobia, which is the fear of places that are difficult to escape from.
28. According to the AHA CPR guidelines of 2005, before a full minute from birth--if the infant has continued apnea, pulse <100 bpm, and is cyanotic--positive pressure ventilation should be initiated. After 30 sec of positive pressure ventilation, chest compressions should be instituted if the HR < 60 bpm. Pharmacological intervention with epinephrine would be considered if after an additional 30sec conditions have not improved. Overall, the entire resuscitation sequence occurs over 90 sec, and it is noted by the AHA CPR guidelines that the times are approximate.
29. The following coagulation profile is consistent with the diagnosis of hemophilia A: Normal platelet count, normal PT, increased PTT.
30. Felty syndrome is characterized by the triad of rheumatoid arthritis, splenomegaly, and granulocytopenia.
31. ARDS is a common complication in ICU patients and is most commonly caused by sepsis. Its pathophysiology consists of non-cardiogenic pulmonary edema. acute respiratory distress syndrome (ARDS), a common cause of hypoxia in ICU patients. The hypoxia is usually not helped with 100% oxygen because of shunting. His fever and hypotension suggests sepsis which is the most common cause of ARDS in hospitalized patients. Chest X-ray will show bilateral infiltrates with ground-glass appearance suggestive of pulmonary edema. ARDS is diagnosed by having a PaO2/FiO2 ratio (FiO2 is the fraction of inspired oxygen) of less than 200 (B). Elevated pulmonary capillary wedge pressure suggests left-sided heart failure or cardiogenic shock (C). Elevated jugular venous pressure suggests right-sided heart failure (D). Pleural effusion is a non-specific finding that is not generally associated with ARDS (E), but is associated with congestive heart failure.
32. Current recommendations by the American Academy of Pediatrics that toilet training should begin between the ages of 18-24 months.
33. Acetaminophen is the first-line treatment for migraines during pregnancy.
34. Trauma to the chest places patients at risk for serious diagnoses such as tension pneumothorax and cardiac tamponade. Therefore, all patients who present to the hospital following a motor vehicle accident should receive a chest x-ray.
35. Hodgkin's lymphoma: Hodgkin's disease exists in four major subtypes, with the most common being nodular sclerosing Hodgkin's lymphoma, which makes up as many as 80% of all Hodgkin’s-type cases. The most common presentation of Hodgkin's disease is painless lymphadenopathy. Constitutional symptoms such as unexplained weight loss, fever, and night sweats have been shown to be present in up to 40% of patients. Hodgkin's disease is staged using the Ann Arbor classification.

Acute lymphocytic leukemia (ALL): Acute lymphocytic leukemia typically presents with signs of bone marrow failure due to replacement with immature blast cells. The classic picture is a young child between the ages of 2 and 5 years who presents with fatigue, bone pain, pallor, fever, and neutropenia with or without anemia and thrombocytopenia.

Chronic lymphocytic leukemia (CLL): CLL most commonly presents with asymptomatic leukocytosis with WBC counts greater than 50000/mm3 and is typically seen in males over the age of 55. As the disease progresses, patients may develop the following signs: lymphadenopathy, splenomegaly (40%), hepatomegaly (20%), anemia, and recurrent infections.

Acute myelocytic leukemia (AML): AML results from a proliferation of myeloid cells leading to the following symptoms: fatigue, history of recurrent infections, fever, pallor, easy bruising, and hepatosplenomegaly. Pancytopenia is common on laboratory evaluation. Blood smear shows large myeloblasts with notched nuclei and Auer rods.

Chronic myelogenous leukemia (CML): CML is due to the proliferation of mature myeloid cells and is commonly seen in middle-aged adults and is more prevalent among persons with a history of radiation exposure. The presence of the Philadelphia chromosome is pathognomonic for CML. Patients typically present with constitutional symptoms including fatigue, weight loss, night sweats, fever, and splenomegaly. Eventually, blast crisis may develop leading to death.

ALL: children

AML: ages 20-40

CML: ages 40-60

CLL: age >65

36. Macrolide antibiotics, especially erythromycin, have been associated with pyloric stenosis. It is used as post-exposure prophylaxis or treatment of pertussis. Patients treated with macrolide antibiotics within the first two weeks of life are at highest risk for pyloric stenosis.
37. Diabetes can be diagnosed either by a random blood glucose sample of greater or equal to 200 mg/dL or by a fasting plasma glucose of greater than or equal to 126 mg/dL on two separate occasions. If you repeat a fasting blood glucose screen and his level is above 126 mg/dL, type II diabetes mellitus can be diagnosed and you can initiate treatment with oral hypoglycemic agents
38. Know the sequence of ligamentous injury that occurs during inversion ankle injuries.

1) Anterior talofibular

2) Calcaneofibular

3) Posterior talofibular

39. Iron-deficiency anemia can be characterized by the following iron indices:

1) Increased TIBC

2) Decreased serum iron

3) Decreased serum ferritin

4) Increased RDW

5) Decreased RI




Iron deficiency: decreased MCV, decreased serum iron, increased TIBC, decreased % saturation, decreased ferritin, increased RDW, normal Hb electrophoresis

Anemia of chronic disease: decreased MCV, decreased serum iron, decreased TIBC, decreased % saturation, increased ferritin, normal RDW, normal Hb electrophoresis

Thalassemia: decreased MCV, normal serum iron, normal TIBC, normal % saturation, normal ferritin, normal RDW, abnormal Hb electrophoresis (beta-thalassemia only)

40. In addition to low-income coverage, Medicaid is also available to persons who are aged, blind, disabled, or certain people in families with dependent children regardless of financial burden.
41. Uterine synechiae is another name for Asherman’s syndrome leading to scarring and adhesions present in the uterus. This condition can lead to infertility
42. Creatine kinase and aldolase levels are the most commonly elevated enzymes in patients with dermatomyositis.
43. At 9 months of age, children are expected to begin to say “dada/mama” and understand the meaning of “no”. A 4 month-old should be oriented to voice, while a 6 month-old should begin to “babble.” At one year of age you would expect to see a 1-8 word vocabulary with words other than “dada/mama” and one-step commands should be followed. This milestone should be reached by 18 months of age when he/she is then expected to point to body parts when asked.
44. Common side effects for furosemide include: hypokalemic metabolic alkalosis, ototoxicity, hyperuricemia, hypomagnesemia, allergic reactions, and hypercalciuria. Gynecomastia is a common side effect of synthetic steroids such as spironolactone (potassium-sparing diuretic)
45. Graves disease is caused by an antibody that stimulate the TSH receptors in the thyroid. Grave’s disease is characterized as a type-2 hypersensitivity reaction.
46. A) Compression occurs when the sphenoid and occipital bones are forced towards one another at the sphenobasilar synchondrosis (SBS) articulation. This commonly occurs when there is an impact to the back of the head, such as during a high speed motor vehicle accident. The associated clinical finding is a severely decreased (sometimes absent) CRI.

B) A flexion/extension straining pattern occurs when the cranium is restricted in either flexion or extension (named for the direction of ease). This is diagnosed by observing asymmetry while palpating the CRI.

C) Lateral strain occurs when the sphenoid deviates laterally in relation to the occiput. The cranium will feel like a parallelogram during palpation.

D) Torsion occurs when the sphenoid rotates about an anterior-posterior axis relative to the occiput at the SBS. The torsion is named by the side of the more superior greater wing of the sphenoid. Torsion can be a physiological variant if it does not interfere with the CRI.

E) Vertical strain occurs when the sphenoid deviates superior or inferior relative to the occiput. There will not be asymmetry between the greater wings of the sphenoid.

47. Empiric treatment of adult meningitis includes ceftriaxone and vancomycin.
48. The combination of positive inotropes (dopamine) with vasodilators (nitroprusside) is the appropriate treatment for patients suffering from acute aortic regurgitation.
49. The most common symptoms of digoxin toxicity are GI distress, blurry vision and arrhythmia. Hypokalemia can enhance digoxin toxicity.
50. Von Willebrand disease presents with an abnormal ristocetin assay, normal platelet count, prolonged bleeding time and prolonged PTT. Giant platelets are associated with Bernard-Soulier syndrome which also presents with an abnormal ristocetin assay but is associated with thrombocytopenia
51. Chronic mesenteric ischemia is common among the elderly population and, in most cases, is caused by diffuse atherosclerotic disease. The most common clinical presentation is post-prandial pain that can eventually cause anorexia and weight loss. The diagnostic test of choice is angiogram. Treatment options include surgical intervention, stent placements or medical management with anti-coagulants and vasodilators.
52. The mainstay therapy for gonococcal infections is IM ceftriaxone followed by oral doxycycline (or azithromycin) for concomitant chlamydial infection.
53. Warfarin therapy must be initiated for 3-4 weeks prior to cardioversion in patients with atrial fibrillation greater than 48 hours. This treatment plan should also be followed if the length of dysrhythmia is unknown.
54. Children with ADHD are at an increased risk of having antisocial personality disorder.
55. Benzodiazepine withdrawal must be treated and should be addressed with a drug, such as lorazepam, that causes cross-dependence. Antipsychotics lower the seizure threshold and should not be used to treat psychosis that occurs secondary to benzodiazepine withdrawal.
56. Cranial dysfunction affecting CNX can lead to spitting up with feedings. Infants should not spit up every meal, this is not normal and you can address this osteopathically.If this remains untreated it can evolve into frequent GI upset and reflux later in life. Spitting up can also indicate overfeeding, but that is unusual in a breastfed baby as compared to bottle-fed infants. CVII dysfunction can lead to partial facial paralysis as is seen in Bell’s Palsey. CNXI innervates the trapezius and sternoclidomastoid muscles and when it’s nerve root is irritated it can lead to muscle tenderness or weakness. CNXII dysfunction generally leads to poor swallow reflex in an infant of this age.
57. Hypercalcemia may produce ECG findings related to altered conduction time. Shortening of the QT interval is the most common finding. Prolongation of the QT interval is seen cases of hypocalcemia. Occasionally, hypercalcemia may also elicit prolongation (not shortening) of the PR interval as well.
    Multiple myeloma presentation involves the CRAB mnemonic: Calcium (elevated), Renal failure, Anemia, Bone lesions/pain.
58. Hypnotic agents should never be used in conjunction with alcohol as this could lead to increased toxicity and CNS depression.
    
    Benzodiazepines such as estazolam and flurazepam should be avoided in patients with histories of narrow-angle glaucoma or untreated obstructive sleep apnea.
    
    Patients with prior cardiac arrhythmias should not be prescribed amitriptyline to avoid further cardiac arrhythmic potential.
    
    Trazodone has a strong association with priapism (E) and should be avoided in all persons suffering from this diagnosis in both the present or past.
59. History is the quickest way to diagnosis aspiration of a foreign body.
60. Permanent limitations of motion secondary to disease process or injury are referred to as pathological barriers.
61. Ankylosing spondylitis commonly presents in young males with chronic back stiffness, photosensitivity, oral ulcerations, and fatigue.
    The best initial step in management is to order HLA-B27 antigen testing. Although this test is not specific for ankylosing spondylitis, it can be easily demonstrated in a blood test and has a high sensitivity. Other diagnostic tests for ankylosing spondylitis include x-rays of the lumbar spine which show the presence of “bambooing” of the spine, MRI of the SI joints, tomography, and the Schober’s test, which is a useful clinical measure of flexion of the lumbar spine. Treatment with NSAIDs would be a viable option; however, diagnostic work-up should begin prior to therapy.
    

Certain disorders have been found to have a strong association with HLA-B27. These include the following:

1. Ankylosing spondylitis

2. Reiter's syndrome

3. Acute anterior uveitis

4. Iritis

5. Behçet's Disease

6. Psoriatic arthritis

7. inflammatory bowel disease

62. Morphine, hydrocodone, oxycodone cross-react. Fentanyl, meperidine, or methadone are alternative options for opioid allergy.
63. Propylthiouracil (PTU) is the first line treatment for hyperthyroidism in pregnancy during the first trimester. Methimazole is used after the first trimester.
64. Hyperprolactinemia is a known side effect of haloperidol, which occurs due to its dopamine-inhibiting effects thus causing an oversecretion of prolactin.
65. Uncomplicated diverticulitis can be managed conservatively with IV antibiotics and NPO status. It commonly presents with fever, elevated white blood cell count and left lower quadrant pain. After the acute inflammatory phase, a colonoscopy is indicated to rule out cancer. If there is no perforation diverticulitis can be managed conservatively. Abdominal CT can confirm the diagnosis but treatment should begin immediately.
66. An adult male with anemia and a history of constipation, thus it is important to screen for colon cancer. Anemia in an adult male is a GI bleed until proven otherwise.
67. Polycythemia of the newborn is relatively common and involves a central venous hematocrit (Hct) level of greater than 65%. Blood viscosity increases exponentially as the Hct level rises above 42%. Polycythemia is more common in diabetic mothers and newborns can present with irritability, tremor, jitteriness, “ruddiness” (red color), and priapism in males. Treatment is a partial exchange transfusion (PET) using an umbilical venous catheter to reduce the central Hct level.
68. This patient presents with symptoms consistent with gastritis and labs consistent with Hashimoto thyroiditis. The most likely diagnosis is pernicious anemia because it is an autoimmune disease, like Hashimoto, and autoimmune diseases tend to occur together. Pernicious anemia is an autoimmune attack against the parietal cells in the stomach leading to vitamin B12 deficiency, megaloblastic anemia and achlorohydria (low gastric acid production)
69. Salicylate toxicity initially manifests with dizziness and tinnitus, but ultimately leads to loss of consciousness and death.
70. Antidiarrheal agents are generally not recommended in children with diarrhea, per the American Academy of Pediatrics (AAP). A trial of oral rehydration is recommended for mild dehydration in a child who is able to tolerate fluids.
71. Hemophilia A is caused by a deficiency in Factor VIII, which manifests as an ↑ in PTT with normal PT and bleeding time.
    Hemophilia B (Factor IX deficiency) shows ↑PTT, normal PT, and normal bleeding time.
    Bleeding time, PT & PTT are all elevated in Disseminated Intravascular Coagulation because all of the clotting materials are used up in the “Disseminated” clots.
72. Simple febrile seizures are relatively benign events that frequently recur but generally do not pose a significant risk for future neurological sequela.
73. Symptoms of MDD include loss of energy, loss of concentration, changes in sleeping/eating patterns, suicidal ideas and lost of interest in pleasure. These symptoms must persist for at least 2-weeks.
74. Clonidine is an alpha-2 agonist that can be used for hypertension. Depression is a possible adverse effect.
75. Arch supports are used in the primary treatment of plantar fasciitis.
76. Patients with Addisonian crisis (aka: adrenal crisis) commonly present with signs/symptoms similar to shock (i.e. fevers and hypotension) and tend to have polydipsia, GI symptoms, excessive weight loss, dehydration and hyperpigmentation in their palmar creases and other areas of the body. Nausea, vomiting, and diffuse abdominal pain are present in approximately 90% of cases.
77. Renal tubular acidosis type II is associated with defects in proximal tubular reabsorption . This is characterized by low serum bicarbonate and high urine bicarbonate due to defects in proximal tubular reabsorption. Glucose is also reabsorbed in the proximal tubule and thus may be found in the urine (Fanconi syndrome). These patients are also at increased risk for bone diseases like multiple myeloma and osteomalacia.
    All types of renal tubular acidosis are characterized by normal anion gap metabolic acidosis .
    Renal tubular acidosis type I is associated with urine pH greater than 5.5. These patients are therefore at risk for renal stones.

Hyperkalemia is associated with renal tubular acidosis type IV which is due to aldosterone insufficiency or resistance .

78. Ascites is a common sign of ovarian malignancy. The most common cause of an ovarian mass in a post-menopausal woman is a malignant epithelial tumor.
79. Anterior intercostal narrowing occurs in the dysfunction of pump-handle ribs while lateral narrowing occurs in the dysfunction of bucket-handle ribs.
    For an inhalation dysfunction, the key rib is the lowest rib (rib 9 in this case) thus the narrowing will occur above rib 9.
    The superior edge becomes more prominent for inhalation dysfunctions of ribs that move primarily by pump-handle motion .
    Inhalation dysfunctions of bucket-handle ribs cause lateral displacement that can be counteracted by pushing medially during direct muscle energy.
80. Studies have demonstrated that patients with Crohn’s disease are positive for anti-Saccharomyces cerevisiae antibodies (ASCA) and negative for perinuclear antineutrophil cytoplasmic antibodies (p-ANCA). The converse is true for ulcerative colitis.
81. Livedo reticularis is a skin condition that can be triggered by the dislodging of cholesterol emboli during cardiac catheterization.
82. Consent cannot be assumed for subsequent procedures, other than what was discussed and consented to prior to the operation. Calling the family would not be appropriate because on ly the patient can consent to subsequent procedures.
83. A newborn head swelling that stays within suture lines and associated with jaundice is most likely a cephalohematoma. Head imaging is indicated to rule out skull fracture.
84. Inheritance of HNPCC is autosomal dominant, and members of the family should undergo biennial colonoscopy starting at age 25. The average age for adenocarcinoma of the colon is 50 years and the most common site is the proximal colon. Prophylactic colectomy is recommended for patients with familial adenomatous polyposis, an autosomal dominant disorder characterized by small polyps that develop during the second decade of life and undergo malignant transformation before the age of 40.
85. In forward torsions, L5 has good spring and the lumbosacral spring test is negative. In backward torsions, L5 does not have good spring and the lumbosacral spring test is positive.
    A forward sacral torsion on a left oblique axis is the correct diagnosis for patients with a right deep sacral sulcus and a left posterior ILA in the presence of a negative lumbosacral spring test.