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Mary is a 22 year old IV drug user, light alcohol user, and cigarette smoker. She has

developed right upper quadrant abdominal pain , nausea and vomiting along with a mild fever. Ironically, Mary notices a paradoxical distaste for smoking. One week later her skin develops a yellowish hue. On physical exam, she is found to have an enlarged, tender liver. Her laboratory tests show dramatically elevated liver enzymes. Her alpha fetoprotein test is negative. What condition is most likely? a) hepatitis A b) hepatitis B c) Laennec\'s cirrhosis d) Gilbert\'s Syndrome e) hepatocellular carcinoma Hepatitis B infection is transmitted by exposure to blood or blood products. Sharing of needles with drug users and sexual contact are two common routes of transmission. During the prodromal phase of hepatitis, the symptoms include arthralgia, nausea and vomiting. There may also be a fever as well as right upper quadrant abdominal pain. A distaste for smoking can occur during the prodromal phase. During the icteric phase of hepatitis B, jaundice develops. The majority of the cases of hepatitis B demonstrate hepatomegaly. Liver tenderness is a common finding as are dramatically elevated liver enzymes. Primary biliary cirrhosis tends to occur in women age 40-60. There is no association with any of the risk factors given here. Hepatocellular carcinoma is associated with long-standing liver disease, such as cirrhosis or hepatitis B or C, which is not the case here. Alpha fetoprotein would be positive with hepatocellular carcinoma. Laennec\'s cirrhosis is associated with heavy alcohol use over many years. In Gilbert\'s syndrome, there is a mild intermittent unconjugated hyperbilirubinemia and normal liver function tests


A neonate was noted to have adduction and internal rotation of hi left arm with

pronation of the forearm. A chest Xray revealed a raised hemidiaphragm on the same side. These findings are suggestive of a) birth injuiry b) transcervical Infection c) transplacental Infection d) defect in gametogenesis e) sudden infant death syndrome f) familial genetic malformation g) environmental influences during pregnancy h) prematurity i) inborn error of metabolism

In Erb-Duchenne paralysis, the injury is limited to the 5th and 6th cervical nerves. The infant loses the power to abduct the arm from the shoulder, to rotate the arm externally, and to supinate the forearm. The characteristic position consists of adduction and internal rotation of the arm with pronation of the forearm. The power of extension of the forearm is retained, but the biceps reflex is absent; the Moro reflex is absent on the affected side. There may be some sensory impairment on the outer aspect of the arm. The power in the forearm and the hand grasp are preserved unless the lower part of the plexus is also injured; the presence of the hand grasp is a favorable prognostic sign. When the injury includes the phrenic nerve, alteration of the diaphragmatic excursion may be observed fluoroscopically. Trauma to peripheral nerves constitutes a major group of birth injuries. Brachial plexus injuries are caused by stretching of the cervical roots during delivery, usually when shoulder dystocia is present. Upper arm palsy (Erb-Duchenne), the most common brachial plexus injury, is caused by injury to the fifth and sixth cervical nerves; lower arm paralysis (Klumpke) results from damage to the eighth cervical and first thoracic nerves. Damage to all four nerve roots produces paralysis of the entire arm. Outcome for these injuries is variable, with about 15 percent of infants left with significant residual. Horner syndrome may accompany Klumpke\'s palsy, and approximately 5 percent of patients with Erb\'s palsy have an associated phrenic nerve paresis. Facial palsy is another fairly common injury caused either by pressure from the sacral promontory as the infant passes through the birth canal or by forceps. Most of these palsies resolve, although in some infants paralysis is persistent. The most common birth injuiry is cephalhematoma (56.6%). Other findings included scalp and/or facial lacerations (12%) and hematomas (2.3%), facial nerve paresis (8.6%), brachial plexus injuries (5.1%), clavicular (9.1%) and skull fracture (2.9%), nasal septal dislocation (0.6%), and phrenic (1.7%) and laryngeal nerve injuries

A study aims to evaluate the impact of screening for colorectal cancer by means of faecal occult blood testing. It is found that patients detected by this method tend to survive longer than patients presenting with a complication of the tumour. It is concluded that faecal occult blood testing improves the chances of survival. This study demonstrates a) recall bias b) chronologic Bias c) lead-time bias d) publication bias e) selection bias f) p-value bias g) randomisation bias

h) commercial bias i) Confounding bias j) observational bias This study demonstrates overestimation of survival duration among screen-detected cases (relative to those detected by signs and symptoms) when survival is measured from diagnosis. This is an example of Lead-time bias The apparent effects of early diagnosis and intervention (measured in terms of how screening-detected cases compare with cases detected by signs and symptoms) are always more favorable than the real effects (measured in terms of how a population that is screened compares with a population that is not). The comparison between screening-detected cases and others overestimates benefit because the former consists of cases that were diagnosed earlier, progress more slowly, and may never become clinically relevant. This comparison, therefore, is said to be biased. In the figure below (representing one patient), the patient survives for 10 years after clinical diagnosis and survives for 15 years after the screening-detected diagnosis. However, this simply reflects earlier diagnosis because the overall survival time of the patient is unchanged.

A male diabetic patient complains of bilateral breast tenderness. He is taking medication with phenothiazines. The following serum level is likely to be elevated : a) insulin b) thyroxine c) AST d) Prolactin e) Bilirubin f) ionized magnesium g) estriol h) aminotransferase i) antigliadin antibody j) IgE Phenothiazines such as promethazine block dopamine receptors. This effect can lead to increases in blood levels of prolactin, a hormone involved in lactation (formation of breast milk). Many prescription and nonprescription medications can cause breast problems. For example, breast tenderness is not unusual for the first few months after starting birth

control pills or hormone therapy. Some medications may cause a milky discharge (galactorrhea). Medications that may cause nipple discharge include: Antidepressants. o Selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine or sertraline o Tricyclic antidepressants, such as imipramine or amitriptyline Atenolol, such as Tenormin. Birth control pills (oral contraceptives). Butyrophenones, such as Haloperidol. Infertility medications, such as Clomid. Methyldopa, such as Aldomet. Metoclopramide hydrochloride, such as Reglan or Maxolon. Phenothiazines, such as Compazine or Thorazine. Reserpine, such as Deserpidine or Rauwolfia Serpentina. Sumatriptan, such as Imitrex. Verapamil, such as Calan, Isoptin, or Verelan. Medications that may cause breast tenderness include: Birth control pills (oral contraceptives). Corticosteroids, such as prednisone. Hormone therapy, such as HRT. Infertility medications, such as Clomid. Cimetidine, such as Tagamet, may cause nipple discharge and breast enlargement in men (gynecomastia).

Cystadenocarcinoma of the pancreas is most likely to present at a) at birth b) 1-5 months c) 6-12 months d) 1-5 years e) 6-14 years f) 15-20 years g) 20-30 years h) 30-40 years i) 40-60 years j) over 60 years Cystadenocarcinoma generally arises in females between the ages of 40 and 60, and it represents less than 2% of all pancreatic exocrine neoplasms. Cystadenocarcinomas often present as cystic masses in the body and tail of the pancreas, associated with abdominal and back pain. CT scan of the abdomen typically reveals a tumor mass with associated cysts, which may be misinterpreted as representing a pancreatic pseudocyst.

Joint involvement usually develops concurrently with the onset of hypothyroidism, but occasionally antedates the development of clinical myxedema. Approximately one-third of hypothyroid patients have symptomatic synovial effusions. Inflammation is neither common nor severe, with minimal pain and tenderness and only slight warmth and erythema. The arthritis is usually bilateral, most often affecting the knees; the ankles, metacarpophalangeal joints, and small joints of the hands and feet are less frequently involved. Periarticular tissues appear thickened, and the increased intra-articular fluid is reflected in a sluggish \'bulge\' sign. This finding, caused by hyperviscosity, is secondary to an increased concentration of synovial fluid hyaluronic acid. The synovial fluid otherwise is generally noninflammatory, with a leukocyte count less than 1000/mm3 . Radiographs are characteristically normal except for signs of effusions. The disease is Duchenne muscular dystrophy, an X-linked recessive muscular disease usually caused by a deletion involving the dystrophin gene. This defect produces accelerated muscle breakdown leading initially to proximal muscle weakness, then later to generalized weakness that typically begins before age 5. A feature of X-linked recessive diseases is that carrier mothers pass the disease to half their sons; affected fathers can have carrier daughters but not affected sons. Since the mother is presumably normal (because the disease is X-linked), she must be a carrier to have an affected son, and the grandmother must also be a carrier, therefore the mother\'s brother (maternal uncle) may also have the disease. The father\'s (choice A) side of the family, including the father\'s brother (choice B), most likely does not carry the defective gene (since they themselves would be affected, and furthermore since the father cannot pass the gene on to a son). It would be extremely unlikely for a carrier female to marry an affected male (and the question does not mention any similar symptoms in the father). The mother (choice C) and possibly the sister (choice E) are carriers of, but not affected by, the defective gene. This patient has gout, characterized by painful joints due to the precipitation of uric acid crystals caused by excessive production of uric acid (a minority of cases are associated with underexcretion of uric acid). Kidney disease is also seen due to accumulation of uric acid in the tubules. The disease mostly affects males, and is frequently treated with allopurinol, an inhibitor of xanthine oxidase. Xanthine oxidase catalyzes the sequential oxidation of hypoxanthine to xanthine to uric acid. A defect in urea synthesis (choice A) would result in the accumulation of ammonia. Phenylketonuria is a disease in which tyrosine cannot be produced from phenylalanine (choice C). It is characterized by a musty body odor and mental retardation. Defective topoisomerases (choice D) would affect DNA unwinding, and therefore replication. Leukotrienes (choice E) are potent constrictors of smooth muscle and would more likely lead to bronchoconstriction.