Test 18

Question 1

Carotid artery stenosis

Answer 1

A number of nerve injuries can occur during carotid endarterectomy. Inadvertent retraction or transection of the hypoglossal nerve causes tongue deviation to the side of injury.

Question 2

Depression

Answer 2

Patients with a single episode of major depressive disorder should continue antidepressants at the same dosage for an additional 6 months following acute response to reduce the risk of relapse. Those with recurrent, chronic, or severe episodes should be considered for maintenance tx (1-3 years or indefinitely) to reduce the risk of recurrence.

Question 3

Tuberculosis

Answer 3

Pregnant women who develop active tuberculosis require treatment with multidrug therapy and pyridoxine. Treatment usually involves 3-drug therapy with isoniazid (INH), rifampin (RIF), ethambutol for 2 months followed by INH and RIF for 7 additional months.

Question 4

Tinea

Answer 4

Tinea versicolor is a non-invasive fungal infection of the skin characterized by multiple, often coalescing, small circular maculae that may vary in color (white, pink, or brown). It is often more apparent in the spring and summer months. Diagnosis is confirmed by potassium hydroxide preparation of skin scrapings showing yeast and hyphae.

Question 5

Pleural effusion

Answer 5

Hepatic hydrothorax usually presents as a right-sided transudative pleural effusion in patients with decompensated cirrhosis and ascites. The initial tx is with sodium restriction and diuretic; transjugular intrahepatic portosystemic shunt placement may be pursued in refractory cases.

Question 6

Hirschsprung’s dx

Answer 6

Hirschsprung’s dx causes delayed meconium passage and abdominal distension due to lack of innervation in the rectosigmoid colon. Initial work up typically shows distal bowel obstruction on x-ray and a “transition zone” on contrast enema. Rectal suction bx is the gold standard diagnostic test.

Question 7

Proteinuria

Answer 7

Orthostatic proteinuria is the most common cause of proteinuria in adolescents. The degree of proteinuria is mild and other significant renal abnormalities (hematuria, acute kidney injury, hypertension) are absent. Orthostatic proteinuria can be diagnosed by split (day and night) 24-hour urine collection showing elevated daytime but normal nighttime protein excretion rates.
Orthostatic proteinuria is a benign finding and requires no invasive diagnostic workup (kidney bx) or tx (angiotensin-conveying enzyme inhibitors or oral steroids).

Question 8

Tuberculosis

Answer 8

Patients with suspected tuberculosis meningitis should be initiated on tx prior to bacteriologic confirmation. Tx involves 2 months of 4-drug therapy with isoniazid, rifampin, pyrazinamide, and either a fluoroquinolone or injectable aminoglycoside, followed by 9-12 months of continuation therapy with isoniazid plus rifampin. Patients should also receive adjuvant glucocorticoids to reduce treatment-associated central nervous system inflammation.