By B. Sancho. McPherson College.
No masses are examination is signiﬁcant for an intact neurologic exami- present cheap 100caps geriforte syrup overnight delivery, and the stool is negative for occult blood order geriforte syrup 100caps visa. His Laboratories show a normal white blood cell count order 100 caps geriforte syrup overnight delivery, he- neurologic examination is intact generic geriforte syrup 100caps amex. Microscopic polyangiitis ploratory laparoscopy for acute abdominal pain and pre- D. Polyarteritis nodosa 345 Copyright © 2008, 2005, 2001, 1998, 1994, 1991, 1987 by The McGraw-Hill Companies, Inc. A 58-year-old female presents complaining of right the hospital for congestive heart failure, renal failure, and shoulder pain. Physical examination on admission was notes that she feels that the shoulder has been getting notable for these ﬁndings and raised waxy papules in the progressively more stiff over the last several months. The patient’s past medical history is ocrit was 24%, and white blood cell and platelet counts also signiﬁcant for diabetes mellitus, for which she takes were normal. Further evaluation included right shoulder is not warm or red but is tender to touch. A 44-year-old woman presents for evaluation of dry plaining of painful arthritis that is worse in the mornings eyes and mouth. She was recently evaluated by an years ago and the symptoms have worsened over time. A recent lab- She describes her eyes as gritty-feeling, as if there were oratory report shows an erythrocyte sedimentation rate sand in her eyes. Which of the following will be helpful in dis- that it is difﬁcult to be outside in bright sunlight. In addi- tinguishing relapsing polychondritis from rheumatoid tion, her mouth is quite dry. Relapsing polychondritis will present with high-titer changes, her dentist has had to place ﬁllings twice in the rheumatoid factor. A 66-year-old woman with a history of rheumatoid She takes no medication regularly and does not smoke. Her oral mucosa is dry heart rate is 110 beats/min, blood pressure is 104/78 with thick mucous secretions, and the parotid glands are mmHg, and oxygen saturation is 97% on room air. Laboratory examination reveals posi- left knee is swollen, red, painful, and warm. She has tion, her chemistries reveal a sodium of 142 mEq/L, evidence of chronic joint deformity in her hands, knees, potassium 2. A 32-year-old African-American woman presents to her which the patient states have been there for many months. Which protein do you expect to ﬁnd on immu- about 6 months ago, and at that time, a complete blood nohistochemical staining? Fibrinogen α-chain She has also developed joint stiffness and pain in her hands, C. Immunoglobulin light chain wrists, and knees that is present for about 1 h upon awaken- D. A 41-year-old female presents to your clinic with 3 she intermittently developed painful mouth ulcerations that weeks of weakness, lethargy. She also reports a severe “sun- notes increasing difﬁculty with climbing steps, rising from burn” on her face, upper neck, and back that occurred after a chair, and combing her hair. The patient also notes some past medical history is positive for two spontaneous vaginal dyspnea on exertion and orthopnea. She is taking oral contraceptive pills and has no tions, and the past medical history is otherwise uninfor- allergies. The physical examination is notable for an beats/min, respiratory rate 12 breaths/min, SaO2 98% on elevated jugular venous pressure, an S , and some bibasilar room air. This area has an atrophic center proximal muscle weakness in the deltoids and biceps and with hair loss and is erythematous with a hyperpigmented the hip ﬂexors. Her conjunctiva are pink and no scleral icterus is examination and reﬂexes are normal. The oropharynx shows a single 2-mm aphthous ul- remarkable except for a negative antinuclear antibody ceration on the buccal mucosa. All the following clinical condi- The patient is incapable of closing her hands tightly. In addi- tions may occur in polymyositis except tion, there is warmth and a possible effusion in the right knee and tenderness with range of motion in the left knee. A 64-year-old man with congestive heart failure pre- Mean corpuscular hemoglobin count 32 g/dL sents to the emergency room complaining of acute onset of Platelet 98,000/mL severe pain in his right foot. The pain began during the night The differential is 80% polymorphonuclear cells, 12% lym- and awoke him from a deep sleep. He reports the pain to be phocytes, 7% monocytes, 1% eosinophils, and 1% basophils. She carial lesions, which occasionally leave a residual discol- denies any prior similar episodes. The sedimentation ually active and estimates her last sexual activity to be 8 rate now is 85 mm/h. She has a history of seasonal the correct diagnosis in this case would be rhinitis, but is taking no medications currently. Arthrocentesis is The pain is worse in the morning and when the patient is performed and is consistent with inﬂammatory arthritis barefoot. On examination, pain can be elicited with pal- without crystals or organisms seen on Gram stain. Which of the fol- cal probes for Neisseria gonorrhoeae and Chlamydia lowing is required to make a deﬁnitive diagnosis of trachomatis are negative. Chronic joint symptoms affect 15% of individuals, cine bone scan and recurrences of the acute syndrome may occur. Reactive arthritis is self-limited and should be ex- demonstrating heel spur pected to resolve spontaneously over the next 2 weeks. Which of the following ﬁndings on joint aspiration comes following an initial episode of reactive arthritis. A 54-year-old female with rheumatoid arthritis is treated with inﬂiximab for refractory disease. Fluid, clear and viscous; white blood cell count, 400/ lowing are potential side effects of this treatment except µL; crystals, rhomboidal and weakly positively bire- fringent A. A 26-year-old man presents with severe bilateral 12,000/µL; crystals, needle-like and strongly nega- pain in his hands, ankles, knees, and elbows. He is recov- tively birefringent ering from a sore throat and has had recent fevers to E. Social history is notable for recent unprotected 4800/µL; crystals, rhomboidal and weakly positively receptive oral intercourse with a man ~1 week ago. Physi- birefringent cal examination reveals a well-developed man in moderate discomfort. A 45-year-old woman presents to the emergency with pustular exudates on his tonsils.
Once diuretic use and vomiting are excluded buy 100 caps geriforte syrup amex, the dif- ferential diagnosis of hypokalemia and metabolic alkalosis includes magnesium deﬁciency buy geriforte syrup 100 caps, Liddle’s syndrome generic 100 caps geriforte syrup with amex, Bartter’s syndrome purchase 100caps geriforte syrup otc, and Gittleman’s syndrome. Liddle’s syndrome is as- sociated with hypertension and undetectable aldosterone and renin levels. It may also include polyuria and nocturia because of hypokalemia-induced di- abetes insipidus. Gittleman’s syndrome can be distinguished from Bartter’s syndrome by hypomagnesemia and hypocalciuria. These are associated with a feeling of excess tory of peptic ulcer disease, for which he takes a proton- gas. On physical examination, she is writhing in dis- namically stable and his hematocrit has not changed in tress and slightly diaphoretic. Which of the rate 127 beats/min, blood pressure 92/50 mmHg, res- following ﬁndings at endoscopy is most reassuring that piratory rate 20 breaths/min, temperature 37. Which of the following statements about alcoholic greatest in the periumbilical and epigastric area with- liver disease is not true? There is no evidence of jaun- dice, and the liver span is about 10 cm to percussion. Serum aspartate aminotransferase levels are often phosphatase level 268 U/L, lactate dehydrogenase greater than 1000 U/L. After 3 L of normal sa- room with severe mid-abdominal pain radiating to line, her blood pressure comes up to 110/60 mmHg her back. She has had two episodes lowing statements best describes the pathophysiology of emesis of bilious material since the pain began, but of this disease? She currently rates the pain as a 10 out of 10 and feels the pain is worse in the A. For the past few months, she has had autodigestion and acinar cell injury intermittent episodes of right upper and mid-epigas- B. Chemoattraction of neutrophils with subsequent tric pain that occur after eating but subside over a few inﬁltration and inﬂammation 307 Copyright © 2008, 2005, 2001, 1998, 1994, 1991, 1987 by The McGraw-Hill Companies, Inc. All of the following necessitate sending bacterial 2 stool cultures in patients with diarrhea for 2 days severe A. The pain is mostly in the right ﬂank cur- you see a 70-year-old male patient with multisystem or- rently but began in the periumbilical area. His preoperative laboratory results showed: sodium, She is tender in the right ﬂank without costovertebral an- 133 meq/dL, potassium, 5. The genitourinary and pelvic examina- dL, bicarbonate, 14 meq/dL, blood urea nitrogen 85 tions are normal. Urine analysis had no Urine analysis shows 2 white blood cells per high pow- red cells, white cells, and trace protein. Preoperative troponin I level no past medical history and has never had similar symp- was 0. All the following are causes of diarrhea except 4/µL is admitted to the hospital with several days of epigas- tric boring abdominal pain radiating to the back with asso- A. A 55-year-old white male with a history of dia- sounds, and tender epigastrium without rebound or guard- betes presents to your ofﬁce with complaints of gen- ing. The remainder of the eralized weakness, weight loss, nonspeciﬁc diffuse examination is normal. The examina- The patient is treated conservatively with intravenous ﬂuids tion is signiﬁcant for hepatomegaly without tenderness, and bowel rest, with resolution of symptoms. Skin examination quadrant ultrasound is normal, and calcium and triglycer- shows a diffuse slate-gray hue slightly more pronounced ides are normal. All the following are associated with an increased The patient was treated conservatively, and 1 week after risk for cholelithiasis except ﬁrst presenting, she appeared to have made a full recovery. Inappropriate treatment of initial infection for incision and drainage, which he tolerates well, and he is D. Incorrect initial diagnosis; this patient likely has discharged home with a 2-week course of antibiotics. On examination, he has discrete red swollen nodules on both of his shins without ﬂuctuance. Laboratory data medical records, you note that he has had primarily rectal show a white blood cell count of 12,000 with a normal dif- disease. He is doing well and ﬁnishing anal pain for 2 months that is worse with defecation. He is taking propranolol and patient notes that he occasionally sees small amounts of lactulose; besides complications of end-stage liver disease, red blood on the toilet tissue. He never has had blood he has well-controlled diabetes mellitus and had a basal staining the toilet bowl. He and his wife ask if he is a liver raised edges with a skin tag at the distal end. He can be counseled in which of the bers of the hypertrophied internal sphincter are visible. He is not a transplant candidate now, but may be after resection a sustained period of proven abstinence from alcohol. The patient described above has the following lab- quality of life, though there is no fecal incontinence. A 62-year-old female has a 3-month history of dif- tric folds together with the persistent ulceration in the fuse crampy abdominal pain and watery diarrhea and has duodenal bulb previously detected and the beginning of a lost 14 lb over this period. There is no prior history of ab- new ulceration 4 cm proximal to the initial ulcer. She is on no regular medi- gastrin levels are elevated and basal acid secretion is 15 meq/h. She notes constipation as well as diarrhea, but to the United States from South America presents to a diarrhea predominates. In comparison to 6 months ago, she local emergency room with severe abdominal pain, has more bloating and ﬂatulence than she has had before. She is un- She identiﬁes eating and stress as aggravating factors, and her sure how long her symptoms have been going on, but pain is relieved by defecation. Uncoordinated distal esophageal contractions re- sulting in a corkscrew appearance of the esophagus A. Dilation of the esophagus with loss of peristaltic failure results ﬁrst in congestion and necrosis of contractions in the middle and distal portions of the portal triads, resulting in subsequent ﬁbrosis. Reﬂux of barium back into the distal portion of the seen in acute hepatitis infection or acetaminophen esophagus toxicity. Budd-Chiari syndrome cannot be distinguished apple core–like lesion clinically from cardiac cirrhosis. A 26-year-old woman presents to your clinic and and mortality in patients undergoing liver trans- is interested in getting pregnant. She works as a receptionist ing constrictive pericarditis as a cause of cirrhosis. A patient with known peptic ulcer disease presents is true regarding hepatitis B vaccination? Pregnancy is not a contraindication to the hepatitis tis without manual palpation of the abdomen?
On row of ags at top of antigram discount 100 caps geriforte syrup amex, cross out those that are present on cells that didn’t react in any phase order geriforte syrup 100 caps line. An ab will react with all cells that possess the corresponding ag (except for abs that demonstrate dosage & only react with homozygous cells) discount 100caps geriforte syrup mastercard. Testing with selected cells If other abs can’t be ruled out generic 100caps geriforte syrup otc, further testing with selected cells might be required. Cells selected for testing should be pos for only 1 ag corresponding to abs in question, e. Most often in multiply 2ºF during or shortly or cytokines transfused pts or women with multiple after tf, with no pregnancies. Transfusion-associated Rash, nausea, vomit- Viable T lymphs in None Irradiate components for pre- graft-vs. Transfusion Reaction Investigation Immunohematology Review 478 Signs & symptoms of possible Fever; chills; respiratory distress; hyper- or hypotension; back, ﬂank, chest, or abdominal transfusion reaction pain; pain at site of infusion; hives (urticaria)*; jaundice; hemoglobinuria; nausea/vomiting; abnormal bleeding; oliguria/anuria. Signs of hemolytic reaction Hemolysis in post-tf sample, but not in pre-tf sample. Transfusion Reaction Investigation continued Immunohematology Review 479 Additional tests that may be Haptoglobin (↓with hemolysis). If baby is Rh pos, draw mother’s blood after delivery & perform rosette test to screen for large fetal bleed. If rosette test pos, quantitate fetal bleed by ﬂow cytometry or Kleihauer-Betke acid-elution test. Examples of Equipment/Reagent Quality Immunohematology Review 484 Control Blood storage refrigerators & freezers, System for continuous temp monitoring & audible alarm. Centrifuges Determine optimum speed & time for diﬀerent procedures upon receipt, after repairs, & periodically. Antihuman globulin Check anti-IgG activity each day of use by testing Rh-pos cells sensitized with anti-D. Clean catch Routine, culture Cleanse external genitalia & collect Less contamination. Suprapubic aspiration Culture Needle inserted through abdomen Avoids contamination. Protein Neg–trace Protein error of indicator Possible renal disease Buﬀered to pH 3. Orthostatic proteinuria— benign condition, protein is neg in 1st am specimen, pos after standing. Ketones Neg Sodium nitroprusside rxn ↑ fat metabolism Most sensitive to acetoacetic acid. Urobilinogen 1 Ehrlich unit or 1 Ehrlich’s aldehyde rxn or Liver disease, hemolytic Reagent strips don’t detect absence mg/dL diazo rxn disorders of urobilinogen, only↑. Failure to follow manufacturer’s Erroneous results instructions Failure to dip all test pads in urine False-neg rxns Prolonged dipping False-neg rxns Reagents may leach from pads. Expired strips Erroneous results Highly pigmented urine Atypical colors, false-pos rxns Pigment masks true rxns. Urobilinogen Highly pigmented urine Improperly preserved specimen (oxidation to urobilin), formalin. Sulfosalicylic All proteins, in- Acid precipitation False pos: radiographic dyes, Centrifuge & test supernatant. False neg: highly buﬀered alkaline urine Clinitest Reducing Copper reduction False pos:↑ascorbic acid Watch rxn to avoid missing pass substances False neg: “pass through” through. Lower urethra, Usually none ↑numbers usually seen in Prominent round vagina urine from females. Spherical, Renal pelvis, Seldom signiﬁcant May form syncytia (clumps) pear-shaped, or ureters, bladder, polyhedral. Oval fat body Renal tubular epithe- Renal tubules Same as renal tubular Maltese crosses with lial cell containing fat epithelial cells polarized light droplets. Calcium oxalate Octahedral (8-sided) envelope form is most Occasionally found in slightly alk urine. Triple phosphate “Coﬃn-lid” crystal Ammonium biurate Yellow-brown “thorn apples” & spheres Seen in old specimens. Tyrosine Fine yellow needles in sheaves Severe liver disease Often seen with leucine. Ovoid, colorless, Usually due to vaginal or Add 2% acetic acid to diﬀerentiate from smooth, refractile. Protein/blood/microscopic Large amounts of blood or myoglobin can cause pos protein. Glucose/protein/microscopic Renal disease is common complication of diabetes mellitus. Type of process Noninﬂammatory Inﬂammatory Color Colorless Yellow, brown, red, green Clarity Clear Cloudy Speciﬁc gravity <1. Yellow when long axis of crystal is parallel to slow wave of red compensator; blue when perpendicular. Blue when long axis of crystal is parallel to slow wave of red compensator; yellow when perpendicular. Deliver to lab within Test monthly beginning 2 months after vasec- 1 hr of collection. Abnormalities: double heads, giant heads, amorphous heads, pinheads, tapering heads, constricted heads, double tails, coiled tails, large numbers of spermatids (immature forms). Foam stability index Fetal lung maturity Shake with increasing Index is highest concentration of ethanol (shake test) amounts of 95% ethanol that supports ring of foam after shaking. Lamellar body count Fetal lung maturity Count in platelet channel Number correlates with amount of phos- of hematology analyzers pholipid present in fetal lungs. Amniotic ﬂuid bilirubin Hemolytic disease of the Direct spectrophotometric Bilirubin has peak absorbance at 450 nm. Gene Speciﬁc sequence of nucleotides (1,000–4,000) at particular location on chromosome. Starts at 5’end with promoter region that initiates transcription & ends at 3’end with terminator sequence that ends transcription. Present in nucleus & in cytoplasm where it’s associated with ribosomes (free or attached to endoplasmic reticulum). A pentose sugar with nitrogen base attached to 1’C & 1–3 phosphate groups attached to 5’C. Superscript (prime) diﬀerentiates Cs in sugar from Cs in bases, which are numbered 1–9. Base pairs Purine from 1 strand of nucleic acid & pyrimidine from another strand joined by hydrogen (H) bonds. Composition Repeating nucleotides linked by phosphodiester bonds between 5’ Repeating nucleotides linked by phosphate group of 1 sugar & 3’hydroxyl group of next. Synthesis on 5’–3’template is discontinuous, forming lagging strand of disconnected Okazaki fragments. Hybridization Pairing of complementary strands of nucleic acid, 1 from sample & 1 a reagent. Labeled with ﬂuorescent or chemiluminescent dyes, enzymes, or radioisotopes to produce visible sign of hybridization.
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