poops

Question 1

CASE  A 37 y/o male HIV+ comes into your office for diarrhea of 1 month duration. The diarrhea is watery without blood. He thinks he has been running fevers for the last month too. He has a 15 lb weight loss. He does not know what his CD4 count is, but says his HIV recently told him he had “late-stage” disease and last week started him on Dolutegravir/ Tenofovir/ Emtricitabine. PE is unrevealing.
-Stool culture is negative
-Stool O&P x 3 are negative
-Stool Giardia antigen and Cryptosporidium DFA stain are negative
-Stool modified AFB stain shows the following:
infection cause
treatment
what are you watching the pt closely for

Answer 1

WHAT IS CAUSING THIS INFECTION?  ISOSPORA (protozoan)
WHAT DO YOU WANT TO TREAT THEM WITH?  TMP-SMX
WHAT ARE YOU GOING TO WATCH THIS PATIENT MOST CLOSELY FOR?  IRIS SYNDROME (worsening of current symptoms, just started HAART in face of an active, uncontrolled opportunistic infection in a patient who likely has a low CD4+ count)

Question 2

A 45 y/o healthy patient of yours went on a mission trip to rural Honduras. She was fine during and after the trip, but starting 1 month after her return to the US, she started having diarrhea, that has now been ongoing for 3 weeks. She has noticed some blood and mucus in her stool, vague abdominal discomfort, low-grade fevers and has a 10 lb weight loss. She says she was seen in an urgent care facility a week ago, and they “did a whole bunch of stool tests that came back negative” and did not know what else to do except “watch her.” She is feeling worse and wants to know what is going on. You send off a bunch of stool tests and refer her to Dr. deMondesert, who does a colonoscopy and sees non-specific colitis. He sends a colonic mucosal aspirate for O&P and you find the following:
WHAT KIND OF INFECTION DOES THIS PATIENT HAVE?

Answer 2

ENTAMOEBA HISTOLYTICA (protozoan)

Question 3

You treat Entamoeba with an antibiotic, and she gets better, and her diarrhea goes away. Three months later, she comes back to see you with return of fever for 2-3 weeks and waxing and waning RUQ pain. On exam, she has a positive Murphy’s sign. You do an ultrasound of her GB which is normal, but it shows the following
GIVEN THIS PATIENT’S HISTORY, WHAT DO YOU THINK YOU COULD USE TO TREAT HER MOST LIKELY DIAGNOSIS?

Answer 3

METRONIDAZOLE FOLLOWED BY PAROMOMYCIN (suspect amoebic liver abscess, this time treat with Metronidazole first to kill the active trophozoites, then next with Paromomycin to kill the luminal cysts)

Question 4

75% have foul-smelling fatty stools, 71% have abdominal cramps, 75% have flatulence, etc….ONE HALF OF INDIVIDUALS CAN DEVELOP CHRONIC SYMPTOMS INCLUDING LOOSE STOOLS AND STEATORRHEA

TX

Answer 4

• TREATMENT  Metronidazole is the most commonly used agent in the US, but often, the preferred agent is Tinidazole

Question 5

WHAT IS THE NEXT BEST STEP TO DO NOW TO CONFIRM YOUR SUSPECTED DIAGNOSIS? cysticercosisTHE PATIENT SHOULD RECEIVE WHICH OF THE FOLLOWING THERAPIES UNTIL FURTHER STUDIES ARE DONE?

Answer 5

DO AN ELISA ANTIBODY FOR THE SUSPECTED PATHOGEN (active Neurocysticercosis, send off Cysticercosis serology, nearly 100% sensitive….new onset seizures in a young Hispanic patient from Mexico of Central America is this diagnosis until proven otherwise)
ALBENDAZOLE/ PRAZIQUANTAL/ DEXAMETHASONE

Question 6

Tx of old calcified asymptomatic cystericircosis

Answer 6

nothing

Question 7

pic of kids shit with worms in it
What kind of womrs
most common tx?

Answer 7

TAPEWORM PROGLOTTIDS (CESTODE INFECTION

PRAZIQUANTEL (drug of choice for most common tapeworm infections)

Question 8

CASE  A 35 y/o sailor from Eastern Europe comes to your office with fatigue, weight loss, peripheral numbness, vague abdominal discomfort, constipation and just “hasn’t’ felt right for more than a year.” PE looks normal, except for pale mucous membranes and pale creases in his palms.
You check a CBC/diff and find:
-WBC 2.8 with 70% polys, 15% lymphs, 10% eos, 5% monos
-Hgb 7, Hct 21, and MCV 112
-Plt 120, 000WHAT’S THE CAUSE OF ALL OF THIS (BEST ANSWER)?

Answer 8

 CESTODE INFECTION (Fish tapeworm, Diphyllobothrium latum, CAUSING B12 DEFICIENCY)

Question 9

A 48 y/o man comes to see you, after moving here recently from rural Georgia (US). He is increasingly weak x several months and has occasionally had dark stool. He has intermittent nausea and some occasional epigastric pain, worse after eating (not related to fatty food however). He has lost 15 lbs this last year, unintentionally. PE just shows him to be pale. The Chem-19 is normal except for an albumin of 2.8. CBC/diff shows the following:
-WBC 8 (65% polyps, 20% lymphs, 15% eos)
-Hgb 6, Hct 18, MCV 71
-Plt 225, 000
Because of the eosinophilia, WHAT IS HAPPENING HERE

Answer 9

NEMATODE INFECTION (Hookworm infection, Necator americanus since from the SE US, causing BLOOD LOSS LEADING TO IRON DEFICIENCY, MICROCYTIC ANEMIA)

Question 10

With regards to indications for nasogastric tube placement, which of the following is NOT correct?

a) treatment of ileus or bowel obstruction
b) administration of medications on patients that cannot swallow
c) gastric lavage during GI hemorrhage to facilitate endoscopy
d) treatment of GI bleeding ulcers by infusion of ice cold saline solution
e) administration of feedings

Answer 10

a) treatment of ileus or bowel obstruction
b) administration of medications on patients that cannot swallow
c) gastric lavage during GI hemorrhage to facilitate endoscopy
d**) treatment of GI bleeding ulcers by infusion of ice cold saline solution (the administration of ICE WATER LAVAGE was used in the past under belief that it caused vasoconstriction but it has no effect in bleeding lesions in the upper GI tract)
e) administration of feedings

Question 11

The following are relative/absolute contraindications to NG tube placement, EXCEPT…

a) esophageal stricture (pose an increased risk for perforation from NG placement but fluoroscopic placement is an option)
b) esophageal varices (may be ruptured by NG placement)
c) basilar skull or facial fracture (intracranial placement (intracranial placement of tubes has been reported in patients with basilar skull or facial fractures)
d) severe bleeding diathesis (patients with coagulopathy may bleed profusely from nasal cavity or develop airway compromise from pharyngeal hematoma due to traumatic NG placement)
e) allergy to latex (most NG tubes are made of Polyvinyl chloride (PVC), polyurethane or silicone and do not contain any latex)

Answer 11

The following are relative/absolute contraindications to NG tube placement, EXCEPT…
a) esophageal stricture (pose an increased risk for perforation from NG placement but fluoroscopic placement is an option)
b) esophageal varices (may be ruptured by NG placement)
c) basilar skull or facial fracture (intracranial placement (intracranial placement of tubes has been reported in patients with basilar skull or facial fractures)
d) severe bleeding diathesis (patients with coagulopathy may bleed profusely from nasal cavity or develop airway compromise from pharyngeal hematoma due to traumatic NG placement)
e***) allergy to latex (most NG tubes are made of Polyvinyl chloride (PVC), polyurethane or silicone and do not contain any latex)

Question 12

hich of the following is a potential complication of NG tube placement?

a) esophageal perforation
b) meningitis from perforation of cribriform plate (rupture of the cribriform plate is a catastrophic but fortunately uncommon complication from NG tube placement)
c) gastric erosions along the greater curvature (it is not uncommon to find “NG induced erosions” along the greater curvature in patients that have had NG tubes for several days)
d) sinusitis (usually associated with long term NG tube placement (weeks))
e) All the above

Answer 12

e

Question 13

Proper technique in placement of NG tube includes the following, EXCEPT….

a) always alert patient or give them a “dry run” of what is about to happen
b) instillation of lidocaine spray to the back of the throat may prevent gagging
c) patient should avoid drinking liquids during the insertion process
d) the tip and distal few inches of the tube should be lubricated with K-Y jelly or similar
e) warming the tube to body temp makes it more flexible and less traumatic on insertion

Answer 13

Proper technique in placement of NG tube includes the following, EXCEPT….

a) always alert patient or give them a “dry run” of what is about to happen
b) instillation of lidocaine spray to the back of the throat may prevent gagging
c) ** patient should avoid drinking liquids during the insertion process  having the patient sip through a straw a small amount of water during NG tube insertion can facilitate the process by taking advantage of the natural swallowing mechanism
d) the tip and distal few inches of the tube should be lubricated with K-Y jelly or similar
e) warming the tube to body temp makes it more flexible and less traumatic on insertion

Question 14

cceptable ways to assess proper NG positioning into the gastric lumen are all of the following, EXCEPT….

a) aspiration of gastric contents from the tube (tested for pH <4 by Nitrazine paper)
b) Injection of air into the tube while auscultating the epigastrium
c) instillation of 20-30 cc of warm water and recovering 70% upon suctioning
d) obtaining CXR including upper abdomen
e) direct endoscopic visualization

Answer 14

cceptable ways to assess proper NG positioning into the gastric lumen are all of the following, EXCEPT….
a) aspiration of gastric contents from the tube (tested for pH <4 by Nitrazine paper)
b**) Injection of air into the tube while auscultating the epigastrium
c) instillation of 20-30 cc of warm water and recovering 70% upon suctioning
d) obtaining CXR including upper abdomen
e) direct endoscopic visualization

Question 15

best way to position a patient (when able to cooperate) for the NG tube placement is:

a) patient seated with head tilted towards the chest
b) patient supine with head tilted towards the chest
c) patient seated with neck hyperextended (looking up)
d) patient supine with neck hyperextended
e) patient in Trendelenburg position with head tilted back like a “sword swallower”

Answer 15

best way to position a patient (when able to cooperate) for the NG tube placement is:
a***) patient seated with head tilted towards the chest (tilting the head forward helps directing the tip of the tube away from the airway and into the esophageal opening. Patient should be sitting up rather than flat in bed in case there is gagging and vomiting during insertion)
b) patient supine with head tilted towards the chest
c) patient seated with neck hyperextended (looking up)
d) patient supine with neck hyperextended
e) patient in Trendelenburg position with head tilted back like a “sword swallower”

Question 16

In a patient with Small Bowel Obstruction that is treated with NG tube placement, a rough measure of adequate fluid replacement should be WHICH of the following?

a) NSS or lactated ringer’s solution at 150 cc/hr
b) Maintenance Fluids of 1.5-2 L/daily PLUS measured NG aspirate volume
c) Maintenance fluids of 1.5-2 L/daily MINUS measured NG aspirate volume
d) NSS or LR at 100 cc/hr
e) NSS or LR PLUS measured urinary output

Answer 16

In a patient with Small Bowel Obstruction that is treated with NG tube placement, a rough measure of adequate fluid replacement should be WHICH of the following?
a) NSS or lactated ringer’s solution at 150 cc/hr
b**) Maintenance Fluids of 1.5-2 L/daily PLUS measured NG aspirate volume (large amounts of fluid can be loss into the GI tract in SBO and those need to be factored in for adequate replacement. Adequate replacement of potassium which is lost in enteric secretions is also very important. Monitoring of daily electrolytes, particularly sodium and potassium levels as well as careful documentation of intake/output is mandatory)
c) Maintenance fluids of 1.5-2 L/daily MINUS measured NG aspirate volume
d) NSS or LR at 100 cc/hr
e) NSS or LR PLUS measured urinary output

Question 17

An 82 y/o first generation Japanese-American female presents to your clinic for fatigue, malaise, nausea, and weight loss. This has been going on intermittently for the last few weeks. Your patient’s daughter has noticed that her eyes have looked “odd” for the last year. Patient denies any pain. Symptoms arise randomly. She has no associated symptoms with anything that she has done or eaten. She does take OTC B supplements and herbal teas. Your patient complains of being so weak that she cannot cook and is afraid of falling. She has lost 9 pounds off of her normal 105 pound frame.
Physical is what you obtained from your patient with the changes below. Labs that you performed are also listed below.
• VS Temp 37 C. BP 104/68. Pulse 72. Respirations 14. Oxygen saturation 97% on room air.
• Skin is jaundiced, eyes are icteric
• CMP shows Glucose 102. Na 136. K 3.9. CL 101. HCO3 25. AST 522. ALT 90. Ca 8.9. T Bili. 5.2. BUN 16 Creatinine 0.9. eGFR >60.
• Hemogram WBC 5.6K. Hgb 11.2 Hct 34.0. MCV 96 Platelets 96 K
• Vit B12 560.
• Retic 2%
• Ferritin 348 ng/ml
• Iron 52 ug/ml
• TIBC 282 ug/dL
• Transferrin 210 mg/dL

WHAT SHOULD DIFFERENTIAL INCLUDE

Answer 17

WHAT SHOULD DIFFERENTIAL INCLUDE? Hepatitis A, B, C, and E along with hepatocellular carcinoma

Question 18

heb B drug starts with an e

Answer 18

entecavir

Question 19

a 52 y/o male presents to the ED with epigastric pain. Symptoms have been present for the last hour. Pain is sharp and severe. Pain radiates straight through to the back. Your patient has a history of drinking and normally drinks a 6 pack of beer and a few shots of whiskey nightly. He has been hospitalized at least 3 times in the last 10 years for alcohol induced pain, that he cannot remember the exact diagnosis. He was prescribed medications to take long-term but cannot recall what they are and has not taken any because he cannot afford them.
Physical Exam findings are what you obtained from your patient with the below exceptions and labs.
• VSS: Temp 37.6 C. Pulse 123. RR 22. BP 90/58, Oxygen saturation is 96% on room air.
• CBC shows a WBC of 10.6 K. CMP shows Calcium of 7.6. Glucose is 423. Na 130. K 4.0. AST 412. ALT 201. Bicarb is 24. BUN 28. Creat 1.2. Lipase 623. LDH is 392. WHAT SHOULD YOUR DIFFERNTIAL INCLUDE

Answer 19

WHAT SHOULD YOUR DIFFERNTIAL INCLUDE? Acute on chronic pancreatitis, acute pancreatitis, chronic pancreatitis, and PUD

Question 20

preferredf imnital stufy of acute vs chronic pancreatitis. “gold standard”

Answer 20

CT, gold standard ERCP, not done as often due to invasive

Question 21

non absotbable

Answer 21

PEES
prolene(polypropylene)
ethibond(polyester)
Ethilon(Nylon)
Stainless
Silk

Question 22

permanent

used extensively before synthetics introduced; still used in some circumstances when permanence is desired

Answer 22

silk

Question 23

used for sternal closure; formerly used for abdominal closure

Answer 23

stainless

Question 24

most commonly used for skin

Answer 24

nylon

Question 25

used extensively for vascular surgery; occasionally used for fascial closure

Answer 25

prolene (polyproylene

Question 26

sed for orthopedics and fascial closure

Answer 26

Ethibond polyester

Question 27

derived from bovine serosa or ovine submucosa (primarily collagen) ; broken down by enzymatic action
-lasts 5-14 days (depending); used less frequently (oral, anal, urologic)

Answer 27

plain and chromic gut

Question 28

degraded by hydrolysis; lasts 7-21 days with widespread applications (bowel, dermis, and other deeper areas)

Answer 28

Vicryl (Polyglactin 910)

Question 29

degraded by hydrolysis; provides support for 14-56 days; used often for bowel, fascia, and urologic applications

Answer 29

PDS-II (Polydioxanone)

Question 30

also hydrolytic degradation; shorter lasting than PDS-II (7-21 days); typically used for subcuticular skin closures

Answer 30

Monocryl (Poliglecaprone)

Question 31

2. What type of surgeries require absorbable material?

Answer 31

• Urinary tract; oral, anal, urologic; bowel, dermis, and other deeper areas; subcuticular skin closures
• NOTE  do not use a permanent suture in the urinary tract  can lead to stone formation
• Can find more info in table under question 1

Question 32

3. What kinds of surgeries do not require absorbable sutures?

Answer 32

• NEVER USE AN ABSORBABLE SUTURE FOR A VASCULAR REPAIR

Question 33

push tissue out of the way as you are going through them

Answer 33

• TAPER POINT

Question 34

has the cutting surface on the inside arc on the concave part of the needle
o has a triangular shape and is better for going through more tenacious material specifically places that have a lot of dense collagen like the epidermis
 when you are suturing the dermis and epidermis, you are going to find out that the round needle just doesn’t want to go through (tapering needle doesn’t want to go through)
o this needle will help force your way through

Answer 34

• CONVENTIONAL CUTTING

Question 35

the cutting surface is on the convex part of the needle (it is on the outside of the curve)
o Prevents it from pulling through the tissue (works a lot better)

Answer 35

• REVERSE CUTTING

Question 36

these needles are usually very large, and they are used for going through large volumes of tissue where you don’t want to cut anything along the way; not used very o Used when suturing the liver because the parenchyma doesn’t have a lot of support to it, and there are deeper structures there that you are hoping to push out of the way as opposed to poking right through the middle of (ex: bile ducts and arteries)
o Ideally, you are not causing as much trauma

Answer 36

• BLUNT POINT

Question 37

• Vestibulocochlear dysfunction o Pathogenesis during LP

Answer 37

reduced CSF pressure may reduce perilymph pressure through the cochlear aqueduct, producing endolymphatic hydrops

Question 38

long term use of blank, can be associated with panc enzyme use in pts with long term panc due to inhibiting of the enzymes to not be degraded

Answer 38

H2 blockers, TELL THOSE FUCKS TO STOP DRINKING