Incorrect Qs

1. Mallory bodies (cytoplasmic inclusion bodies containing keratin) are associated with alcoholic hepatitis. This is an acute illness that usually occurs in chronic alcoholics after a bout of heavy drinking.
2. Benzodiazepines are the drug of choice for alcohol withdrawal syndrome. Chlordiazepoxide is a common choice (> carbamazepine)
3. Neonatal respiratory distress syndrome causes hyaline membranes to form around the alveolar sacs secondary to leakage of proteins and cellular debris.
4. Increased GABA will cause sleepiness and difficulty wakening, like what is seen in patients with hepatic encephalopathy, because that is what is occurring.
   Increase in Dopamine often is associated with hallucinations and delusions; this is the reason behind schizophrenia.
   Decrease in dopamine will cause parkansonian like symptoms of slowed movements and rigidity.
   Although depression can cause numerous neurotransmitter defects the most important neurotransmitter in depression is serotonin.
   Decreased melatonin is often a simple and easily correctable problem in people with difficulty sleeping especially those who travel or work in shifts.
5. Acute lymphoblastic leukemia presents in a 2-5-year-old child with fever, pallor, and petechiae.
6. Patients with HELLP syndrome should be managed according to length of gestation and disease severity. Patients symptomatic with headaches or abdominal pain with elevated liver enzymes should undergo immediate induction of labor if they are greater than 33 weeks gestation.
7. Circumferential restricted areas on the limbs of a newborn is most likely to have been caused by amniotic bands.
8. Patients on positive-pressure ventilation are at risk for barotrauma and a simple chest x-ray should be performed if this is suspected.
9. Allopurinol can be used to prevent uric acid stones. Chemotherapy commonly causes a complication known as tumor lysis syndrome, caused by the spillage of break-down products of dying cancer cells into the blood. Complications can include hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia, and acute renal failure. Allopurinol, a xanthine oxidase inhibitor, is given prophylactically before starting chemotherapy to reduce the formation of uric acid stones. Patients are also commonly given IV hydration to promote high urine output to prevent renal complications.
10. Contact the organ-donor network to obtain consent for organ donation
11. Due to recent studies linking the long-term use of long-acting beta agonists to increased mortality, salmeterol should only be used in combination with inhaled glucocorticoids, and never as monotherapy. An alternative to steroid treatment for asthma includes leukotriene receptor antagonists such as montelukast.
12. Squamous cell carcinoma: Squamous cell carcinoma of the lung is associated with smoking, cavitations, and hypercalcemia, which occurs due to secretion of PTH-related protein. Squamous cell comprises 25-35% of all cancers of the lung. Look for a cavitary lesion on chest x-ray that is centrally located. Also be suspicious if “keratin pearls” are mentioned in the stem. Direct extension to hilar lymph nodes is also characteristic of squamous cell cancer of the lung.

Small cell carcinoma: Small cell carcinoma (oat-cell) is the most aggressive type of lung cancer and has a very poor prognosis. It usually metastasizes prior to detection and is, therefore, treated with chemotherapy only. Small cell lung cancer is highly associated with a smoking history. Hyponatremia may occur due to ectopic secretion of ACTH and ADH.

Adenocarcimoma: Adenocarcinoma is the most common lung cancer in non-smokers and is a peripheral tumor-type. Non–small cell lung cancer (NSCLC) accounts for approximately 75% of all lung cancers. NSCLC is divided further into adenocarcinoma, squamous cell carcinoma, and large cell carcinoma, which share similar treatment approaches and prognoses but have distinct histologic and clinical characteristics. Adenocarcinoma has been linked to asbestosis and pleural effusions typically show increased hyaluronidase levels.

Bronchioloalveolar carcinoma: Bronchioloalveolar carcinoma is a subtype of adenocarcinoma, characterized by proliferation along the alveolar walls without invasion. Patients usually present with a chronic productive cough and a chest x-ray that resembles community-acquired pneumonia. Like adenocarcinoma, bronchioloalveolar carcinoma of the lung is also a peripheral tumor.

Large cell carcinoma: Large cell carcinoma is the least common type of lung cancer, comprising 5-15% of all cases. Cells are typically large and undifferentiated. This cancer type carries a very poor prognosis and often metastasizes to the brain.

Solitary pulmonary nodule on chest x-ray.

13. 1) Compare the current x-ray with previous chest films. If the nodule has remained the same size for greater than years, it is generally benign and does not require further immediate work-up.

2) If no old films are available and the patient is older than age 35 or has a smoking history, order a CT scan of the chest.

3) If the CT scan is not definitive, perform a biopsy of the nodule (most commonly by bronchoscopy) for a tissue diagnosis.

4) If the patient is younger than 35, or has no smoking history, the diagnosis is likely infectious (TB or fungi), hamartoma, or collagen vascular disease. These patients should undergo observation and follow-up with repeat CT or chest x-rays.

Stress Incontinence patients present with involuntary losses of small volumes of urine secondary to effort that increases intra-abdominal pressure (coughing, laughing, or sneezes). It is not associated with dementia or gait instability.

Transient Ischemic strokes though having the possibility to present with mental status changes, classically present with ipsilateral blindness (amaurosis fugax) and or unilateral hemiplegia, hemiparesis, weakness, or clumsiness. TIA last minutes to less than 24 hours.

Urge incontinence is the most common cause of incontinence in the geriatric population as it presents with urinary incontinence due to detrusor instability (overactivity). It does not associated with dementia or gait instability.

Overflow Incontinence is most commonly seen in men with prostatic enlargement, or post-prostatectomy (outlet obstruction). TCA antidepressants is the most common medication that causes overflow incontinence.

14. Metformin is contraindicated in renal insufficiency and caution should be used during imaging procedures to reduce the risk of contrast-induced nephropathy.
15. NYHA (New York Heart Association) CHF Classification

Class I (Mild) - No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or dyspnea (shortness of breath).

Class II (Mild) - Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or dyspnea.

Class III (Moderate) - Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or dyspnea.

Class IV (Severe) - Unable to carry out any physical activity without discomfort. Symptoms of cardiac insufficiency at rest. If any physical activity is undertaken, discomfort is increased.

16. IV indigo carmine can be injected peripherally into the patient and then leaking of the blue dye can be searched for in the operative field or cystoscopy can be utilized to visualize blue excretion through each of the ureters.
17. Treatment for acute right ventricular infarction includes fluids to increase pre-load and thus increase cardiac output.
18. The next best step on COMLEX is the most urgent step that is needed to improve the patient's status. In practice many steps may be done simultaneously and timing, not sequence, is more important.
19. Cocaine induced myocardial ischemia should be recognized and treated first-line with benzodiazepines, aspirin, and nitrates. Avoid beta-blockers such as metoprolol since they may precipitate ischemia via unopposed vasoconstriction.
20. Cocaine induced myocardial ischemia should be recognized and treated first-line with benzodiazepines, aspirin, and nitrates. Avoid beta-blockers such as metoprolol since they may precipitate ischemia via unopposed vasoconstriction.
21. This patient is suffering from secondary amenorrhea and should be worked-up in a stepwise fashion, beginning with a pregnancy test.
    If negative, then thyroid function should be assessed, which is stated to be normal in the case.
    Once thyroid dysfunction is ruled out, the next step is to test prolactin levels. If the prolactin is high, the etiology is likely to be prolactinoma.
    If the prolactin level is normal, a progestin challenge should be performed.
    Only if the progestin challenge is negative should an estrogen-progesterone challenge take place.
    If the estrogen-progesterone challenge is negative, the diagnosis is Asherman’s syndrome. If it is positive, however, the next step is to test FSH and LH levels.
    High FSH and LH levels suggest ovarian failure as the cause, where low levels imply hyopothalamic-pituitary dysfunction.
22. A fibular head that is stuck posteriorly and resists anterior spring, a distal fibula that is stuck anteriorly and resists posterior spring, and an internally rotated talus resulting in inversion and plantarflexion of the foot and should be treated in the prone position. Initially the foot should be dorsiflexed and everted to engage the restrictive barrier. The physician should then instruct the patient to plantarflex his/her foot against isometric resistance. This should be repeated approximately three times, each time engaging the new restrictive barrier until full motion is restored.
23. Delayed puberty is defined as no breast development in girls or no testicular enlargement in boys by the time they are 14. The first step of evaluation should be obtaining left wrist X-ray to compare bone age and chronological age.
24. It is recommended to hold metformin for 48 hours before and after contrast exposures in diabetic patients.
25. Suspect cerebral venous thrombus in women taking oral contraceptives and who present with headache, vomiting, papilledema, and focal neurologic weakness. There is typically no alteration in consciousness. The first-line treatment for cerebral venous thrombus is anticoagulation with heparin and warfarin.
26. The diagnosis of an L5 somatic dysfunction can be made by knowing the examination finding of the sacrum. L5 and the sacrum always rotate in opposite directions. Sidebending of L5 engages the ipsilateral sacral oblique axis.
27. An omphalocele is a hernia through the umbilicus that is covered by peritoneum and commonly associated with Beckwith-Wiedemann syndrome.
28. Inspiration – increases right-sided murmurs.

Expiration – increases left-sided murmurs.

Abrupt standing – decreases venous return because increased venous capacity, causes a reflex increase in heart rate.

Valsalva – like standing causes a decrease in venous return.

Squatting – increases venous return and therefore increased preload to the heart.

Handgrip - increased venous return, but more importantly increase afterload. Decreases AS murmurs and increases MR.

29. Thrombocytopenia: decreased platelet count, increased bleeding time, normal PT, normal PTT

Von Willebrand's disease: normal platelet count, increased bleeding time, normal PT, increased PTT

Hemophilia A: normal platelet count, normal bleeding time, normal PT, increased PTT

DIC: decreased platelet count, increased bleeding time, increased PT, increased PTT

30. The general rule for health privacy of minors is that if a minor has the right to control a health care decision, then he or she has the right to control the information associated with that decision. All the other choices do not protect the minors autonomy and privacy.
31. For diseases associated with the prostate, one would expect to find a Chapman’s point located anteriorly along the superior margin of the iliotibial band.
32. All patients regardless of vaccination history should receive a tetanus toxoid booster (Td) every 10 years. Tetanus toxoid should be administered intramuscularly to patients suffering from tetanus-prone wounds (those present greater than 6 hours, deeper than 1 cm, contaminated, infected, exposed to saliva or feces, as well as crush injuries and puncture wounds), if they are less than 7 years of age, or if it has been more than 5 years since their last booster. Tetanus immunoglobulin (TIG) should be administered to patients older than age 60, along with patients who have received fewer than 3 doses of tetanus toxoid in their lifetime. If there is any doubt the patient has had his original series of three tetanus immunizations, add tetanus immune globulin.
33. In ITP if patient is asymptomatic, and the platelet count is >20,000/mm3, treatment can be held off. The mainstay of the treatment in symptomatic patients is glucocorticoids (prednisone) and IVIG. The goal of the treatment is to keep platelets >50,000/mm3.
34. Wilson’s disease is an autosomal recessive liver disease that displays the pathognomonic Kayser Fleischer Rings on the outer periphery of the cornea. Once diagnosed, the patient should be treated with D-Pencillamine.
35. Ascending cholangitis classically presents with a triad of fever, right upper quadrant abdominal pain, and jaundice, which is apparent in greater than 50% of all cases. If hypotension and altered mental status are present, then Reynold's pentad is present which indicates concominant sepsis.