Property:Explanation
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This is a property of type Text.
W
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This patient's clinical presentation and positive VDRL are consistent with primary syphilis. However, correct diagnosis should be confirmed with treponemal testing (either FTA-ABS or FTA-TP) before treatment since VDRL and RPR may be turned falsely positive by some autoimmune diseases.
WJG NOTES: This question strikes me as a bit off. Why wouldn't you just treat the patient with penicillin? It's not as though you are giving a toxic chemotherapy - and there are no other signs of autoimmune disease in this patient such as synovitis or joint problems.<br/>
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This patient likely has Roseola or exanthem subitum (meaning sudden rash), also referred to as roseola infantum (or rose rash of infants), sixth disease (as the sixth rash-causing childhood disease) and (confusingly) baby measles, or three day fever. It is a benign disease of children, generally under two years old, whose manifestations are usually limited to a transient rash ("exanthem") that occurs following a fever of about three day's duration.
It is caused by two human herpesviruses, HHV-6 (Human Herpesvirus Six) and HHV-7, also called Roseolovirus.
Typically the disease affects a child between six months and three years of age, and begins with a sudden high fever of 102-104 degrees Fahrenheit (39-40 degrees Celsius). After a few days the fever subsides, and just as the child appears to be recovering, a red rash appears. This usually begins on the trunk, spreading to the limbs but usually not affecting the face. In contrast, a child suffering from measles would usually appear more infirm, with symptoms of conjunctivitis and a cough, and their rash would affect the face and last for several days.
There is no specific vaccine against or treatment for exanthem subitum, and most children with the disease are not seriously ill. Treatment is usually supportive i.e., oral fluids and paracetamol/acetaminophen or ibuprofen to reduce their temperature (but never aspirin, due to the risk of Reye's Syndrome. The rash is not particularly itchy and needs no special lotions or creams.<br/>
'''Educational Objective:''' Roseola is a self-limiting viral illness common among children less than 3 years of age. It usually presents as a maculopapular rash on the trunk, limbs and neck (sparing the face) shortly after an abrupt cessation of high fevers. Treatment is largely supportive, not requiring any antibiotics.<br/>
'''References:''' http://www.wikidoc.org/index.php/Roseola +
The patient in this vignette is most likely diagnosed with silent aspiration pneumonia. Silent aspiration is an important cause of chronic pneumonia in children, as demonstrated in this patient who has focal infiltrates in the right upper lobe. Mineral oil is a viscous oil that depresses cough reflex and consequently facilitates the development of aspiration pneumonia due to deposition of oil in the alveoli. Generally, aspiration pneumonia is characterized by the presence of high lipid content within alveolar macrophages. Most cases of aspiration pneumonia result from the ascending of gastric content that include lipid components. When alveolar macrophages ingest gastric lipids, they are called lipid-laden macrophages. Lipid-laden macrophages are clinically associated with tracheal aspiration in children with gastro-esophageal reflux (GER) and seizures.<br/>
'''Educational Objective:''' Lipid-laden macrophages are commonly observed in the bronchoalveolar lavage (BAL) of patients with aspiration pneumonia. Oral ingestion of mineral oil, a laxative with viscous oil content, may suppress cough reflex and facilitate aspiration pneumonia.<br/>
'''References:''' Bandla HP, Davis SH, Hopkins NE. Lipoid pneumonia: a silent complication of mineral oil aspiration. Pediatrics. 1999;103(2):E19<br>
Naryshkin S, Young NA. Respiratory cytology: A review of non-neoplastic mimics of malignancy. Diagn Cytopathol. 1992;9(1):89-97<br>
Perez-Arellano JL, Losa Garcia JE, Garcia Macias MC, et al. Hemosiderin-laden macrophages in bronchoalveolar lavage fluid. Acta Cytol. 1992;36(1):26-30. +
The correct answer is ST elevation seen in all leads, as well as PR depression. Diffuse ST elevation is due to ventricular current of injury and PR depression is due to concomitant atrial current of injury. These findings are typically seen in stage 1 (initial days) of the disease. After several days the ST elevations return to baseline (stage 2) and T wave inversions begin to appear (stage 3). Eventually in weeks to months the EKG findings will be normal (stage 4).<br/>
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The correct answer is tuberculous pericarditis. Among all of the options given, TB pericarditis is the only cause of bloody pericardial effusion. Malignant pericarditis is another cause of bloody pericardial effusion. Other rare causes are rheumatic fever, post-cardiac injury, post-myocardial infarction and uremic pericarditis.<br/>
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The correct answer is pulsus paradoxus (PP). The patient in this vignette is suffering from cardiac tamponade most likely secondary to uremic pericarditis. Tamponade is strongly suggested by the muffled hear sounds, low voltage EKG, dyspnea and chest pain. The hallmark of cardiac tamponade on physical exam is pulsus paradoxus. Pulsus paradoxus (PP), also called paradoxic or paradoxical pulse, is an exaggeration of the normal variation in the pulse and drop of systolic blood pressure during the inspiratory phase of respiration, in which the pulse becomes weaker as one inhales and stronger as one exhales. It is a sign that is indicative of several conditions including cardiac tamponade and lung diseases (e.g.asthma, COPD).<br/>
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The correct answer is diuretics.This patient has a chronic constrictive pericarditis due to uremia. The diffuse calcification seen on the chest x ray in this scenario is due to the thickened pericardium due to uremic pericarditis. Dietary sodium restriction and diuretics are useful before surgery to relieve the congestive symptoms of constrictive pericarditis and fluid overload. The thickened and calcified pericardium in chronic constrictive pericarditis causes a rise in end diastolic pressures causing pulmonary and systemic congestion. Caution should be maintained while prescribing diuretics as their overuse causes hypotension due to drop in pressures.<br/>
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The correct answer is an EKG. The pain described by this patients suggests a pericardial pathology, but his age and male gender makes him a high risk patient for ischemic heart disease. EKG is the best initial test to evaluate for coronary heart disease as well as for other cardiac conditions. The EKG in acute pericarditis shows ST segment elevation in all leads and PR segment depression.<br/>
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This patient;s presentation is classic for acute pericarditis. NSAIDs, such as ibuprofen, naproxen or indomethacin, are the best initial therapy for acute pericarditis. Management requires treatment for the underlying cause. The majority of cases, the specific cause of pericarditis is not identified, therefore they are assumed to be caused by Coxsackie B virus and treated with NSAIDs. Colchicine has been proved to decreased the recurrences.<br/>
'''Educational Objective:''' NSAIDs, such as indomethacin and aspirin, are the best initial therapy for acute pericarditis.
Colchicine decreases recurrences.<br/>
'''References:''' Master the Boards for Step 2CK, 2013 edition, page 99 +
The correct answer is pericardial effusion. Common causes of pericardial effusion in HIV infection are mycobacterial infections and neoplasms like lymphoma and kaposi’s sarcoma.<br/>
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The correct answer is chronic constrictive pericarditis. Kussmaul’s sign is failure of the central venous pressure to decline during deep inspiration, which causes distended cervical veins, even when the patient is on diuretics. Other conditions that give a positive Kussmaul’s sign are tricuspid stenosis, right ventricular failure and restrictive cardiomyopathy.<br/>
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The correct answer is hypertrophic cardiomyopathy.<br/>
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The correct answer is Dressler’s syndrome. Dressler's syndrome or post myocardial infarction syndrome is a form of pericarditis that occurs in the setting of injury to the heart as a result of myocardial infarction. Dressler's syndrome typically occurs 2 to 10 weeks after the myocardial infarction occurs.<br/>
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The correct answer is diuretics.This patient has a chronic constrictive pericarditis due to uremia. The diffuse calcification seen on the chest x ray in this scenario is due to the thickened pericardium due to uremic pericarditis. Dietary sodium restriction and diuretics are useful before surgery to relieve the congestive symptoms of constrictive pericarditis and fluid overload. The thickened and calcified pericardium in chronic constrictive pericarditis causes a rise in end diastolic pressures causing pulmonary and systemic congestion. Caution should be maintained while prescribing diuretics as their overuse causes hypotension due to drop in pressures.<br/>
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The treatment of choice is high dose enteric coated Aspirin. Acetaminophen may be added for pain management.<br/>
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The correct answer is pulsus paradoxus (PP). The patient in this vignette is suffering from cardiac tamponade most likely secondary to uremic pericarditis. Tamponade is strongly suggested by the muffled hear sounds, low voltage EKG, dyspnea and chest pain. The hallmark of cardiac tamponade on physical exam is pulsus paradoxus. Pulsus paradoxus (PP), also called paradoxic or paradoxical pulse, is an exaggeration of the normal variation in the pulse and drop of systolic blood pressure during the inspiratory phase of respiration, in which the pulse becomes weaker as one inhales and stronger as one exhales. It is a sign that is indicative of several conditions including cardiac tamponade and lung diseases (e.g.asthma, COPD).<br/>
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The correct answer is an EKG. The pain described by this patients suggests a pericardial pathology, but his age and male gender makes him a high risk patient for ischemic heart disease. EKG is the best initial test to evaluate for coronary heart disease as well as for other cardiac conditions. The EKG in acute pericarditis shows ST segment elevation in all leads and PR segment depression.<br/>
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The correct answer is PR depression, as the patient has acute pericarditis. PR depression is an EKG finding which is pathognomonic in acute pericarditis, even though ST elevation is often seen in all leads universally. ST segment elevation is seen in other cardiac conditions such as STEMI, pulmonary embolism, therefore this finding is not pathognomonic.<br/>
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